Infected Spinal Hematoma After Accidental Exteriorization of an Epidural Catheter: A Case Report.

Optimal treatment and outcome after spinal hematoma remain unclear. Close neurological monitoring is the key to successful treatment. Here, we present a case of an infected spinal hematoma management. We report the case of a 51-year-old male patient, American Society of Anesthesiologists physical status I, admitted to a level I hospital due to right lower limb necrotizing fasciitis. A lumbar epidural catheter was placed for pain control without complications. On the 26th day of hospitalization, three hours after the accidental exteriorization of the epidural catheter, the patient developed severe back pain not relieved by systemic analgesia. Prophylactic low-molecular-weight heparin had been administered less than six hours before. The patient had inflammatory signs and digital pressure pain at the catheter insertion site and a positive Brudzinski sign. Sensory-motor deficits were never felt. An urgent dorsolumbar MRI exhibited a significant hematic collection at the subdural and anterior epidural level, and an infected epidural hematoma was assumed. Empirical antibiotics and hourly monitoring of sensory-motor deficits, meningeal signs, and fever were initiated. The patient remained on absolute bed rest. Low-molecular-weight heparin was stopped. The pain disappeared on the third day after the MRI. Citrobacter koseri was isolated. A re-evaluation CT scan did not show spinal compression. The patient was discharged on the 27th day after an MRI in an asymptomatic condition and was referred to acute pain consultation. Neurological deficits are usually expected at the time of spinal hematoma diagnosis. However, the classic triad of pain, sensory deficits, and motor deficits is only seen in less than half of patients. Our patient only developed severe lumbar pain. In selected cases, diagnostic MRI associated with tight monitoring and conservative management can be applied.

Teeth Damage during General Anesthesia.

INTRODUCTION: Dental injuries during anesthesia, especially when advanced airway management is required, represent a legal problem. Factors such as poor dental condition and excessive pressure during intubation contribute to dental damage. The maxillary central incisors are commonly affected. OBJECTIVE: The objective of this review is to know the incidence of dental injuries in adults undergoing anesthesia that requires airway management. MATERIALS AND METHODS: The search was performed in MEDLINE (through Pubmed), ClinicalTrials.gov, Scopus, LILACS (through the Virtual Health Library Regional Portal), and SciELO for all available literature on the subject up to December 2022. Inclusion criteria involved articles that studied patients aged 18 years or older who underwent general anesthesia requiring airway management with tracheal intubation or insertion of a laryngeal mask airway. RESULTS: Of all the articles, nine report dental injury associated with the type of airway management. Only one article does not have dental injury. DISCUSSION: This study addresses dental injuries related to tracheal intubation during general anesthesia. Although techniques are used to prevent them, these injuries still occur. Laryngoscopy, especially with support on the upper central incisors, can cause damage to the teeth. CONCLUSIONS: It is important that the anesthesiologist is aware of dental trauma and that orotracheal intubation or the placement of the laryngeal mask airway is performed systematically and rigorously, always considering the patient's dentition to choose the best approach in each specific situation.

Recent Myocardial Infarction and Acute Heparin-Induced Thrombocytopenia: A Case Report on Perioperative Management of a Patient for Acute Limb Vascular Surgery.

The optimal alternative anticoagulation regimen for patients with heparin-induced thrombocytopenia (HIT) who need surgical procedures that involve higher levels of anticoagulation, usually performed under heparin, is not yet established. Argatroban has been reported as a safe alternative. Plasma levels and their anticoagulant effects follow a predictable profile. Also, it is easily monitored and its pharmacokinetic profile makes it suitable for patients with renal failure, as it undergoes hepatic elimination. However, its use as a substitute for heparin in HIT patients is not well-documented, especially in vascular surgery. We present a case of a successfully managed patient with acute HIT undergoing limb vascular surgery using anticoagulation with argatroban.

Quality of recovery in elderly patients with postoperative delirium.

BACKGROUND: Our study aimed to evaluate quality of recovery in elderly patients with postoperative delirium (POD). SUBJECTS AND METHODS: An observational prospective study was conducted. Patients aged >60 submitted to elective surgery and admitted to Post Anesthesia Care Unit (PACU) in a tertiary hospital from May to July 2017 were included. POD was evaluated with the Nursing Delirium Screening Scale (NuDESC). Quality of recovery-15 (QoR-15) was used before (T0) and 24 h (T24) after surgery to assess quality of recovery. Data collection include patient's characteristics, respiratory events at the PACU, and other perioperative variables. The Chi-square, Fisher's exact, or Mann-Whitney U-tests were used for comparisons. RESULTS: Of a total of 235 patients, 12.3% developed POD at PACU. POD was more frequently in patients older than 80 years (P = 0.017), patients with neurological disease (P = 0.026), dementia (P = 0.026), peripheral vascular disease (P = 0.016), and diabetes mellitus (P = 0.037). At T0, there were no differences at median total QoR-15, whereas at T24, patients POD scored lower in 10 items (including "severe pain" with P = 0.001 and "nausea or vomiting" with P = 0.009) of QoR-15 and in total median lower scores (P = 0.001). POD patients stayed longer at PACU (P = 0.017) and they stayed longer at hospital (P = 0.002). CONCLUSIONS: POD patients were older and had more comorbidities. POD patients had lower QoR scores at T24 suggesting an adverse impact of delirium in postoperative quality of recovery. POD patients stayed for long in the PACU and at hospital.

Solvatochromic parameters of deep eutectic solvents formed by ammonium-based salts and carboxylic acids.

Deep eutectic solvents (DES) have been studied in a wide range of applications, and despite their potential as sustainable solvents, detailed knowledge on their solvatochromic parameters is still lacking. To overcome this problem, in this work, the Kamlet Taft (KT) solvatochromic parameters, namely the hydrogen-bond acidity, hydrogen-bond basicity and dipolarity/polarizability, of a wide range of DES composed of ammonium-based salts as hydrogen bond acceptors (HBAs), and carboxylic acids as hydrogen bond donors (HBDs), were determined aiming at better understanding the influence of the chemical structure of the DES components on their polarity. It is shown that the high acidity of the DES investigated is mainly provided by the organic acid present in the mixture, and that an increase of the alkyl side chain of both the HBA and the HBD species leads to a lower ability of the solvent to donate protons. On the other hand, the ammonium salt plays the major role on the hydrogen-bond basicity of DES. Contrarily to the hydrogen-bond acidity, an increase in the length of the aliphatic moieties of both the carboxylic acid and salt cation results in solvents with higher ability to accept protons. The dipolarity/polarizability of DES is mainly defined by the ionic species present, and tend to decrease with the increase of the aliphatic moiety of the organic acid. In general, DES composed of ammonium-based salts and carboxylic acids present a higher capacity to donate and accept protons when compared to most of the ionic liquids or organic molecular solvents.

Solid-liquid equilibria of binary mixtures of fluorinated ionic liquids.

Within ionic liquids, fluorinated ionic liquids (FILs) present unique physico-chemical properties and potential applications in several fields. However, the melting point of these neoteric compounds is usually higher due to the presence of fluorine atoms. This drawback may be resolved by, for instance, mixing different FILs to create eutectic mixtures. In this work, binary mixtures of fluoro-containing and fluorinated ionic liquids were considered with the aim of decreasing their melting temperatures as well as understanding and characterizing these mixtures and their phase transitions. Five FILs were selected, allowing the investigation of four binary mixtures, each of them with a common ion. Their solid-liquid and solid-solid equilibria were studied by differential scanning calorimetry and the non-ideality of the mixtures was investigated. Overall, a variety of solid-liquid equilibria with systems exhibiting eutectic behavior, polymorphs with solid-solid phase transitions, and the formation of intermediate compounds and solid solutions were surprisingly found. In addition to these intriguing behaviours, novel FILs with lower melting temperatures were obtained by the formation of binary systems, thus enlarging the application range of FILs at lower temperatures.

Solubility and solvation of monosaccharides in ionic liquids.

Herein, solubility experimental data for six monosaccharides, viz.d-(+)-glucose, d-(+)-mannose, d-(-)-fructose, d-(+)-galactose, d-(+)-xylose and l-(+)-arabinose, in four ionic liquids (ILs), at temperatures ranging from 288.2 to 348.2 K, were obtained aimed at gathering a better understanding of their solvation ability and molecular-level mechanisms which rule the dissolution process. To ascertain the chemical features that enhance the solubility of monosaccharides, ILs composed of dialkylimidazolium or tetraalkylphosphonium cations combined with the dicyanamide, dimethylphosphate or chloride anions were investigated. It was found that the ranking of the solubility of monosaccharides depends on the IL; yet, d-(+)-xylose is always the most soluble while d-(-)-fructose is the least soluble monosaccharide. The results obtained show that both the IL cation and the anion play a major role in the solubility of monosaccharides. Finally, from the determination of the respective thermodynamic properties of solution, it was found that enthalpic contributions are dominant in the solubilization process. However, the observed differences in the solubilities of monosaccharides in 1-butyl-3-methylimidazolium dicyanamide are ruled by a change in the entropy of solution.