Long-Term Follow-up of Patients Managed Conservatively for Acute Traumatic CSF Rhinorrhea.

OBJECTIVE: Conservative management of acute traumatic cerebrospinal fluid rhinorrhea (TCR) results in cessation of the leak in most patients. The objective of this study was to estimate the incidence of recurrent cerebrospinal fluid (CSF) rhinorrhea and meningitis in these patients on long-term follow-up and to determine the risk factors associated with them. METHODS: Data on 50 patients with acute TCR who were successfully treated with conservative management between 2013 and 2015 and had long-term follow-up was retrieved from our head injury database. Patient variables were analyzed to determine the risk factors associated with recurrence of CSF rhinorrhea and meningitis. RESULTS: All patients in our series developed CSF rhinorrhea within 48 hours of trauma. The mean duration of follow-up was 6.3 ± 1.3 years. CSF rhinorrhea recurred in 16 (32%) patients, 15 (93.8%) of whom developed it within 3 years of trauma. Meningitis occurred in 5 (10%) patients and 1 died. Sphenoid sinus fractures and features of raised intracranial pressure on computerized tomography of the brain at admission were significantly associated with the development of meningitis. There were no risk factors identified for the recurrence of CSF rhinorrhea. CONCLUSIONS: Patients with acute TCR in whom rhinorrhea subsides with conservative therapy have the highest risk for recurrence of leak or meningitis within 3 years of the trauma. Therefore, we recommend that these patients be counselled about the need for periodic follow-up for several years.

A nested case-control study to determine the incidence and factors associated with unanticipated admissions following day care surgery.

BACKGROUND AND AIMS: Day care surgery offers respite from hospitalisation for specific surgical procedures and has many advantages. However, occasionally patients who undergo such surgery require hospitalisation for unanticipated complications. We aimed to determine their incidence and to identify factors associated with unanticipated admissions in a tertiary care hospital in South India. METHODS: During the 3-month study, 63 cases requiring admission and 126 randomly selected controls were taken from the 776 procedures that were performed were compared. The variables studied were patients' demographic characteristics, pre-operative medical illness, personal habits, American Society of Anesthesiologists status, the diagnosis and surgical procedures, time since last meal, duration of anaesthesia and surgery, experience of the surgeon and anaesthetist, and intraoperative management (techniques, drugs, monitoring, etc.). Univariate and bivariate statistics were used to determine factors associated with unanticipated admissions. RESULTS: The incidence of unanticipated admissions following day care surgery was 8.11%. The reasons for admission were anaesthetic (33.33%), surgical (15.87%), medical (6.34%) and social (44.44%). The factors significantly associated with unanticipated admissions included duration of anaesthesia more than 50 min (odds ratio [OR]: 3.179; 95% confidence interval [CI]: 1.503-6.722), and starting the last case after 3 pm (OR: 10.095; 95% CI: 2.418-42.148). CONCLUSION: Unanticipated admissions following day care surgery occur mainly due to anaesthetic, surgical, medical and social reasons.

Separation of thoraco-omphalopagus twins in a rural secondary hospital: Perioperative management.

Providing anaesthesia for the separation surgery of conjoined twins presents unique challenges to the managing anaesthesiologists. The low incidence of such surgeries and anatomical variations in each type of conjoined twins makes each separation surgery a unique experience. This report features the anaesthetic plan and challenges faced in performing the separation surgery of a set of thoraco-omphalopagus twins in a rural secondary hospital in a remote location in India.

Peri-operative course of peritonitis following tube thoracostomy: A misdiagnosed case of congenital diaphragmatic hernia.

A young adult presented with signs of peritonitis following tube thoracostomy for suspected acute hydropneumothorax. Attempted decompression of the chest by tube thoracostomy had caused gastric perforation, and on surgical exploration, he was found to have a congenital diaphragmatic hernia with herniation of the stomach, spleen and colon. All intensive care doctors and emergency room physicians dealing with the care of patients with acute respiratory failure should be taught to recognize and keep the possibility of a Bochdalek hernia in mind, especially in young adults presenting with unusual respiratory and gastrointestinal symptoms.

Fatal hypoglycemia with levofloxacin use in an elderly patient in the post-operative period.

BACKGROUND AND AIM: Fluoroquinolones are antimicrobial agents with a broad spectrum of activity against gram-positive, gram-negative, and anaerobic organisms. They are widely used in surgical practice and are generally considered safe. Hypoglycemia because of use of levofloxacin is a rarely reported complication. This report of a case of a surgical patient highlights this potentially fatal complication. PATIENT: An elderly, non-diabetic patient with renal impairment presented with a possible duodenal perforation. After successful surgery, the patient developed recurrent hypoglycemic episodes in the post-operative period after use of levofloxacin. Delay in recognition of the cause of hypoglycemia led to irreversible brain damage and death. RESULTS: The calculated Naranjo adverse drug reaction probability scale criteria suggest the possibility that these episodes were related to levofloxacin. The mechanism of hypoglycemia with levofloxacin relates to the potential inhibition of the K(ATP) channel on the pancreatic beta cell by the drug. CONCLUSION: The case report highlights the need to be aware of this potentially fatal complication of a drug commonly used in surgical practice.