Delayed CSF rhinorrhea presenting as a lethal acute bacterial meningitis 5 years post trauma.

Key clinical message: Delayed presentation of cerebrospinal fluid rhinorrhea is rare following head trauma. It is frequently complicated by meningitis if not addressed in time. This report highlights the importance of its timely management, the lack of which can lead to a fatal outcome. Abstract: A 33-year-old man presented with meningitis in septic shock. He had a history of severe traumatic brain injury 5 years back following which he had a history of intermittent nasal discharge for the past 1 year. On investigation, he was found to have Streptococcus pneumoniae meningitis, and CT scan of his head showed defects in the cribriform plate which established the diagnosis of meningoencephalitis secondary to cerebrospinal fluid rhinorrhea. The patient did not survive despite appropriate antibiotics.

Hepatic Encephalopathy Induced Transient Cortical Blindness.

Hepatic encephalopathy describes a spectrum of potentially reversible neuropsychiatric abnormalities seen in a patient with severe liver dysfunction with porto-systemic shunting. Cortical blindness can be a rare presentation of hepatic encephalopathy and can even precede the onset of altered sensorium. We report a case of 57 years female with chronic liver disease who presented with bilateral loss of vision, with no focal neurological deficits. From clinical and laboratory examination, a diagnosis of hepatic encephalopathy with cortical blindness was proposed. Her visual disturbances gradually improved with the treatment of hepatic encephalopathy. Keywords: Cortical blindness; end stage liver disease; hepatic encephalopathy; papilledema.

Potential Drug-drug Interaction among the Patients Admitted in Intensive Care Units of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Drug interactions are one of the major contributors to increase hospital stay, inflate health care expenses, and cause serious adverse events and end-organ damage. Patients admitted to the intensive care unit are already critically sick and are at greater risk of these adverse outcomes. The study aimed to find out the prevalence of potential drug-drug interactions in the Intensive Care Units of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among the patients admitted in the Intensive Care Unit of a tertiary care hospital from April-June 2019. Ethical approval was taken from the Institutional Review Board at the institute (Reference number: 399). Convenience sampling method was used. Data was collected using proforma and potential drug-drug interactions were identified using Lexicomp® drug-interactions version 1.1 (Wolters Kluwer). All the drug interactions identified were classified and the severity scale of interactions was also defined. Statistical Package for the Social Sciences version 17.0 was used for data analysis. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean, standard deviation, and mode. Results: Out of 101 patients, the prevalence of the drug-drug interaction was found to be 90 (89.11%) (83.04-95.18 at 95% Confidence Interval). A total of 490 drug-drug interactions were identified. In severity scale, it was seen that 311 (63.46%) were of moderate severity and 303 (61.83%) of drug interactions were categorised as category C in risk rating. Conclusions: Prevalence of potential drug-drug interactions was higher compared to similar published literature. The most common drug with potential interaction was fentanyl and among pairs was fentanyl plus paracetamol. Keywords: drug interactions; intensive care units; Nepal; software.

Massive Middle Cerebral Artery Ischemic Stroke Associated with Severe Acute Respiratory Distress Syndrome in H1N1 Influenza: A Case Report.

Influenza has a common occurrence during its peak seasons. It usually causes disease of the respiratory tract including severe acute respiratory distress syndrome. However, it may also cause disease and complication of other organ systems. We present a rare complication of influenza in which a patient secondary to influenza developed massive middle cerebral artery ischemic stroke. The patient however survived following recovery of both severe acute respiratory distress syndrome and ischemic stroke after decompressive craniectomy and a prolonged intensive care unit stay. This case report is to highlight the importance of influenza related complications besides the pulmonary infliction which can lead to morbidity and even mortality if not managed on time.

Recurrent Ischemic Stroke in a Patient with Atrial Myxoma: A Case Report.

Cardiac myxoma is an infrequent but curable cause of ischemic stroke. There are no guidelines addressing the timing of surgery to excise the tumour or for the use of thrombolysis or thrombectomy. We present a case with an ischemic stroke which was diagnosed to have atrial myxoma. She was planned for surgical excision of the tumour but suffered from a second ischemic stroke while awaiting surgery. This article aims to highlight vital aspects of this rare phenomenon and discuss the prospects of the timing of surgery and neurosurgical intervention. The importance of a proper cardiac evaluation in all cases of stroke is highlighted. Keywords: cardiac tumour; myxoma; cardiac surgery; ischemic stroke.

Characteristics and Outcome of Patients with COVID-19 Undergoing Invasive Mechanical Ventilation for Respiratory Failure in a Tertiary Level Hospital in Nepal.

BACKGROUND: Corona virus disease 2019 has become a global health issue. The goal of this study was to investigate the characteristics and outcomes of patients with corona virus disease 2019 undergoing invasive mechanical ventilation and identify factors associated with mortality. METHODS: Ninety four consecutive critically ill patients with confirmed corona virus disease 2019 undergoing invasive mechanical ventilation were included in this retrospective, single-center, observational study. The outcome variable was mortality of patients undergoing invasive mechanical ventilation and factors associated with it during intensive care unit stay. RESULTS: Seventy nine (84%) out of 94 patients with confirmed corona virus disease 2019 who underwent invasive mechanical ventilation didn't survive. Ninety four percent of patients who had Type 2 Diabetes Mellitus did not survive in comparison to 72 percent of patients who didn't have Type 2 Diabetes Mellitus. Similarly, 48 (94.1%) out of 51 patients with a positive C-reactive protein value didn't survive in comparison to 31 (72%) out of 43 patients with a negative C-reactive protein. CONCLUSIONS: The presence of Type 2 Diabetes Mellitus and a positive C-reactive protein value were strongly associated with mortality. Patients with a Sequential organ failure assessment score of more than eight at intensive care unit admission and peak D-dimer level of more than or equal to two during intensive care unit stay didn't show significant association with mortality. These findings need further exploration through larger prospective studies.

Superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome, though rare, should be considered in patients with duodenal obstruction with no other causes. History of recent weight loss and imaging modalities help in the diagnosis. Conservative management can be tried before going for surgery.

Management of nitrobenzene poisoning with oral methylene blue and vitamin C in a resource limited setting: A case report.

Nitrobenzene can cause life threatening methaemoglobinemia. Its management includes the use of intravenous methylene blue to reduce the iron moiety from its ferric to ferrous state. Due to unavailability of intravenous preparation, enteral methylene blue was used in our case. This case report is to highlight that even oral preparations can be successfully used in a resource limited setting where often intravenous preparations are unavailable.

Topical nitroglycerin for management of peripheral extravasation of vasopressors: a case report.

Peripheral route for administration of vasopressors is often opted due to resource limitations or as a rescue until central venous access is established. This, however, is not devoid of complications, the most common being extravasation and tissue injury. Phentolamine is the only drug approved for management of vasopressor extravasation; however, successful use of other agents has been reported. Here we report a case of peripheral extravasation of vasopressors, successfully managed with topical nitroglycerin in intensive care unit in Kathmandu. To our knowledge, this is the first report of such kind from Nepal.

Acupuncture induced pneumothorax: A case report.

Various forms of alternative medicinal practices are gaining popularity. With this, there will be rise in the complications arising from these practices. Acupuncture is also such practice which though safe can rarely cause life-threatening complications.

Clinical impact of lung ultrasound monitoring for diagnosis of ventilator associated pneumonia: A diagnostic randomized controlled trial.

PURPOSE: Studies have shown that lung-ultrasound may be superior to chest x-ray (CXR) in diagnosing ventilator-associated pneumonia (VAP). This study investigated whether the use of lung-ultrasound monitoring could detect VAP earlier and improve patient outcome. METHODS: This was a single-center diagnostic randomized controlled trial. In the control group, VAP was diagnosed using a combination of CXR and clinical findings. In the intervention group, VAP was diagnosed using a combination of lung-ultrasound and clinical findings. The primary outcome measured was ventilator free days (VFD). Secondary outcomes were ICU mortality, length of stay in ICU, change in Sequential Organ Failure Score at day 4 compared to day 0 (delta SOFA), antibiotic duration and ventilator days. RESULTS: We randomized intubated patients until 44 VAP diagnosis was made in each group. VFD was higher in the intervention group than in the control group (7.80+/- 9.7 days versus 3.7+/- 6.4 days, p = .044). There were no differences between the groups in terms of ICU mortality (p=.104), ICU length of stay, (p = .058), ventilator days, (p = .081), delta SOFA (p = .10) and antibiotic duration (p = .70). CONCLUSION: The use of lung-ultrasound monitoring for diagnosis of VAP improves patient outcome when compared to the standard diagnostic strategy that relies on CXR.

Delayed Neurological Recovery After Ultrasound-Guided Brachial Plexus Block: A Case Report.

INTRODUCTION: Brachial plexus blocks are frequently practiced and safe mode of anaesthsia. Although minor complications may occur, major complications are a rarity. However, we report a rare case of prolonged supraclavicular brachial plexus block which required almost 4 months to recover without a perceivable cause. CASE PRESENTATION: A 22-year-old gentleman posted for open reduction and internal fixation of both forearm bones was administered an ultrasound-guided supraclavicular brachial plexus block. The intra-operative period was uneventful. However, the block persisted for a very prolonged period of time. All perceivable causes were ruled out. A total of 19 weeks was required for the entire block to regress with no residual neurological deficits thereafter. CONCLUSION: Although peripheral neuropathies are known complications of peripheral nerve blocks, such a prolonged brachial plexus block is a rare event. The only plausible cause for the patient's condition could have been the prolonged drug effect; however, it has been rarely documented.

Influence of Arterial Blood Gas to Guide Extubation in Intensive Care Unit Patients after Spontaneous Breathing Trial.

BACKGROUND: Arterial blood gas is required for extubation decision after spontaneous breathing trial in most of intensive care unit. This study was conducted to assess the influence of arterial blood gas for extubation after successful spontaneous breathing trial in intensive care unit patients planned for extubation. METHODS: It was prospective observation study conducted in all patients of age greater than eighteen year admitted in intensive care unit of tertiary care hospital for one year. It was done in 108 patients who were planned for extubation. Patients were assessed by intensivist clinically and decided whether a patient can be extubated on clinical grounds. Spontaneous breathing trial was done for 2 hours by t-piece in patients who met clinical and objective criteria. Arterial blood gas was done in all patients who successfully completed spontaneous breathing trial. Patients with successful spontaneous breathing trial, acceptable arterial blood gas were extubated. Independent Student's t test and paired t test was used for data analysis. RESULTS: Out of 108 patients who passed the spontaneous breathing trial, 96(88.88%) patients had acceptable arterial blood gas and were extubated and 12(11.11%) patients did not have acceptable arterial blood gas level and were chosen to have other mode of weaning. CONCLUSIONS: This study demonstrates that arterial blood gas level has changed decision for extubation after successful spontaneous breathing trial. Further, arterial blood gas might help in identification of patients who can undergo extubation failure when rapid shallow breathing index failed to predict outcome of extubation.

Colistin and tigecycline for management of external ventricular device-related ventriculitis due to multidrug-resistant Acinetobacter baumannii.

Acinetobacter baumannii is an important cause of nosocomial ventriculitis associated with external ventricular device (EVD). It is frequently multidrug resistant (MDR), carries a poor outcome, and is difficult to treat. We report a case of MDR Acinetobacter ventriculitis treated with intravenous and intraventricular colistin together with intravenous tigecycline. The patient developed nephrotoxicity and poor neurological outcome despite microbiological cure. Careful implementation of bundle of measures to minimize EVD-associated ventriculitis is valuable.

Successful lumbar puncture with Taylor's approach for the diagnostic workup of meningitis in a patient with Ankylosing spondylitis.

Meningitis and encephalitis are the neurological emergencies. As the clinical findings lack specificity, once suspected, cerebrospinal fluid (CSF) analysis should be performed and parenteral antimicrobials should be administered without delay. Lumbar puncture can be technically challenging in patients with ankylosing spondylitis due to ossification of ligaments and obliteration of interspinous spaces. Here, we present a case of ankylosing spondylitis where attempts for lumbar puncture by conventional approach failed. CSF sample was successfully obtained by Taylor's approach.

Apnea testing with continuous positive airway pressure for the diagnosis of brain death in a patient with poor baseline oxygenation status.

Apnea testing is a key component in the clinical diagnosis of brain death. Patients with poor baseline oxygenation may not tolerate the standard 8-10 min apnea testing with oxygen insufflation through tracheal tube. No studies have assessed the safety and feasibility of other methods of oxygenation during apnea testing in these types of patients. Here, we safely performed apnea testing in a patient with baseline PaO2 of 99.1 mm Hg at 100% oxygen. We used continuous positive airway pressure (CPAP) of 10 cm of H2O and 100% oxygen at the flow rate of 12 L/min using the circle system of anesthesia machine. After 10 min of apnea testing, PaO2 decreased to 75.7 mm Hg. There was a significant rise in PaCO2 and fall in pH, but without hemodynamic instability, arrhythmias, or desaturation. Thus, the apnea test was declared positive. CPAP can be a valuable, feasible and safe means of oxygenation during apnea testing in patients with poor baseline oxygenation, thus avoiding the need for ancillary tests.