Intravenous Mannitol Research Articles

Acute primary angle-closure in Sturge-Weber syndrome

PurposeSturge-Weber syndrome (SWS) is a neurocutaneous disorder characterized by facial cutaneous venous dilatation (port-wine stain), leptomeningeal angioma, and ocular abnormalities. Here we report a case of SWS who experienced acute primary angle-closure in the same side of the nevus flammeus. ObservationsA 64-years-old female patient with SWS port wine stain on the left side of her face was referred to our ER for acute primary angle-closure (PAC). The IOP was 64 mmHg in the left eye (12 mmHg in OD) and the visual acuity was 20/100. The acute PAC was aborted after medical treatment with intravenous Mannitol and oral Acetazolamide, but laser iridotomy (LI) was not performed because of the risk of bleeding. After the acute episode, her IOP remained stable in midteen under 3 topical medications. However, the patient reported several subacute attacks in the following month. We arranged phacoemulsification and intraocular lens (IOL) implantation two months after the initial PAC attack. The post-op condition was smooth with 20/20 visual acuity, and the angle opened dramatically on anterior segment optical coherence tomography (AS-OCT). Her IOP was around 13 mmHg without medication and there was no more acute PAC attack. ConclusionsSWS with ipsilateral acute PAC has seldom been reported. Lens extraction and IOL implantation can be an option in treating such patients since conventional laser iridotomy may cause bleeding.

Intravenous Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function: A Double-blind, Clinically-integrated, Randomized Trial

BackgroundMannitol is currently used as a renal protective agent to mitigate the effects of renal ischemia during nephron-sparing surgery (NSS). This routine practice lacks rigorous methodological study. ObjectiveTo assess the effect on renal function outcomes after surgery of mannitol infusion prior to renal ischemia during NSS. Design, setting, participantsThis prospective, randomized, placebo-controlled, double-blind trial included 199 patients with a preoperative estimated glomerular filtration rate (eGFR) >45ml/min/1.73m2 scheduled for NSS; the trial was conducted between July 2012 and July 2015. InterventionPatients undergoing NSS were randomized to receive mannitol (12.5g) or placebo intravenously within 30min prior to renal vascular clamping. Outcome measurements and statistical analysisThe primary outcome was the difference in eGFR (renal function) between the two groups at 6 mo following surgery assessed with an analysis of covariance model using preoperative eGFR, treatment group, and surgical approach as covariates. Results and limitationsAt baseline, the median age of the patients was 58 yr, and the median eGFR was 88ml/min/1.73m2. Comparing placebo with mannitol infusion, the adjusted difference of 0.2 eGFR units at 6 mo was not significant (p=0.9), with the upper bound of the 95% confidence interval (–3.1 to 3.5) excluding a clinically relevant effect of mannitol. Limitations include evaluation of a single mannitol dose and patients all had excellent preoperative renal function. ConclusionsIntraoperative 12.5g mannitol infusion during NSS has no demonstrable clinical benefit when compared with standardized fluid hydration in patients with normal preoperative renal function, and its use in this setting is not warranted. Patient summaryIn this randomized trial, patients with normal kidney function who received mannitol during surgery to remove part of their kidney had no better kidney function 6 mo after surgery than those who did not receive mannitol. We conclude that this routine practice should be discontinued.

Intravenous mannitol in status migrainosus treatment: a clinical case series

Status migrainosus (SM) is defined as a severe migraine attack, usually poorly responsive to treatments, lasting more than 72h. Recurrent SM predicts chronic migraine (CM) development in 83.7% of cases. There is evidence that in most unresponsive CM patients a sinus stenosis-associated raised intracranial pressure is causatively involved in migraine chronification. To test the hypothesis that SM may reflect a sustained rise in intracranial pressure, we tested the efficacy of a 3-day treatment with intravenous mannitol 18% 250ml b.i.d. in seven subjects presenting with a SM unresponsive to common treatments, showing unilateral or bilateral sinus stenosis at magnetic resonance venography. Mannitol infusion induced the abrupt reduction or the disappearance of pain in all patients, at least along the 3days of treatment. While the benefit was only observed during the days of treatment in two subjects, in the remaining five patients the time to the next headache was delayed between 20days to 5weeks after mannitol infusion. Due to the lack of any analgesic property of mannitol, our data indicate that in this series a rise in intracranial pressure was involved in SM causative mechanisms.

Acute angle closure attack after an intravitreal bevacizumab injection for branch retinal vein occlusion: a case report

BackgroundIntravitreal injection is widely used to treat retinal vein occlusion, and acute angle closure (AAC) is an exceptional complication of intravitreal injection. The authors report a case of AAC that occurred immediately after administering intravitreal bevacizumab to treat branch retinal vein occlusion (BRVO).Case presentationA 65-year-old woman was referred to the retina clinic of a tertiary referral center for the treatment of macular edema secondary to BRVO. On slit lamp examination, anterior chamber (AC) depth was shallow (3 corneal thicknesses centrally, 1/4 corneal thicknesses peripherally) in both eyes. Intraocular pressure (IOP) was 19 mmHg in both eyes, and refractive error was +1.00 diopter sphere in both eyes. A gonioscopy exam demonstrated narrow angle of over 180° in both eyes. To treat the macular edema, bevacizumab was injected into her right eye intravitreally. After two bevacizumab injections, the macular edema regressed but recurred 5 months later, and thus, a third injection was performed. The next day, she visited our emergency department complaining of persistent ocular pain in her right eye. The right pupil had dilated to 6 mm diameter and was fixed. Slit lamp exam revealed diffuse corneal edema in her right eye, which had an IOP of 56 mmHg. After administration of intravenous mannitol, the IOP fell to 14 mmHg and the corneal edema disappeared. Subsequently, a glaucoma specialist performed laser iridotomy on the right eye.ConclusionsAlthough AAC is a rare complication of intravitreal injection, it can occur in a patient with risk factors such as hyperopic eye or narrow angle.

213 - Phase 3 randomized trial of intravenous mannitol versus placebo prior to renal ischemia during partial nephrectomy: Impact on renal functional outcomes

213 - Phase 3 randomized trial of intravenous mannitol versus placebo prior to renal ischemia during partial nephrectomy: Impact on renal functional outcomes

Abstract WP351: No Effect of Mannitol on the Course of Perihemorrhagic Edema After Intracerebral Hemorrhage

Introduction: In patients with intracerebral hemorrhage (ICH) perihemorrhagic edema (PHE) seems to play a predictive role besides initial hematoma size, clinical status and intraventricular bleeding (IVH). PHE may exceed the initial hematoma volume by up to 600% thereby leading to increased intracranial pressure (ICP) which may cause severe clinical deterioration. EUSI and ASA guidelines recommend the use of intravenous mannitol or hypertonic saline (HS) in order to reduce elevated ICP. However, clinical data suggest that HS may be superior to mannitol in lowering ICP and clinical data concerning the effect of mannitol on PHE as a cause of elevated ICP is limited. We aimed to investigate the effect of mannitol on PHE after ICH. Methods: Patients with supratentorial spontaneous ICH treated with 20% intravenous mannitol solution (125-250ml every 6h) for 5-10 days and controls matched for ICH volume, age and IVH who did not receive any osmotic agents during the course of treatment were identified retrospectively from our institutional ICH database. PHE volume was calculated on diagnostic CT scans performed on days 1, 2-3, 4-6, 7-9 and 10-12 using a validated volumetric algorithm. Frequency of elevated ICP up to day 12 (ICP burden), modified Rankin Scale (mRS) after rehabilitation (approx. day 90) and PHE evolution were assessed as outcome variables. Results: 44 ICH patients treated with mannitol and 43 controls were included. Basic characteristics did not differ between groups (median ICH volume day 1: 32.9 mL (IQR 16.3 - 54.0) and 27.7 mL (IQR 22.4 - 37.1), p=0.786; median age 71 y (IQR 61.5 - 77) and 72 y (IQR 66 - 81), p=0.269; median PHE volume day 1: 24.3 mL (IQR 16.0 - 38.8) and 24.3 mL (IQR 17.1 - 32.1), p=0.592, respectively). In the mannitol group PHE volume exceeded to a greater extent than in controls (PHE on day 10-12: 60.1 mL (SD 33.6) vs. 36.8 mL (SD 23.2), p=0.005). Median ICP burden was higher in the mannitol group (0 (IQR 0 - 7.75) vs. 0 (IQR 0), p=0.016). Median mRS did not differ between both groups (4 (IQR 4-6) vs. 4 (IQR 3-6), p=0.321). Conclusions: We found no effect of mannitol use on the general evolution of PHE and ICP. Other underlying mechanisms may explain the short-term effect of mannitol bolus administration on ICP in patients with spontaneous supratentorial ICH.

A Possible Case of Neurogenic Pulmonary Edema in a Sheep following Intracranial Surgery

Abstract Objective: To describe presentation, treatment and outcome of a sheep that developed acute respiratory distress after intracranial surgery. Case summary: A 3-year-old female crossbred sheep weighing 64 kg was anaesthetized for intracranial surgery as a part of a research project. Premedication and induction of anesthesia were uneventful as well as tracheal intubation. Anesthesia was maintained with isoflurane in a 50% mixture of oxygen and air, fentanyl (5-15 μg kg-1h-1) and lidocaine (1.8 mg kg-1h-1). During anesthesia, an increased alveolar-arterial oxygen gradient was calculated on the basis of arterial blood gas analysis: inspiratory fraction of oxygen was increased and a recruitment manoeuvre was performed. After 210 minutes of anesthesia, the sheep was let recover with oxygen supplementation under monitoring of pulse-oxymetry, capnography, inspired and expired oxygen, temperature and invasive blood pressure. At tracheal extubation no signs of regurgitation or aspiration were noticed. Twenty-five minutes later, the sheep showed deterioration of neurological status and clonic seizure responsive to diazepam. After transient tachycardia, blood pressure rose acutely and sinus bradycardia followed. Severe tachypnea started in few minutes accompanied by loud respiratory noises and harsh diffuse crackles on both sides of the thorax. Foamy blood nasal exudates discharged from the nostrils. Neurogenic pulmonary edema as a sequel of increased intracranial pressure was suspected and treated with intravenous mannitol (0.5 gkg-1) and furosemide (4 mgKg-1). Hypoxemia was successfully managed with oxygen supplementation. Motor and cognitive functions improved progressively and were deemed normal within 12 hours from the episode, when arterial partial pressure of oxygen was 11.7 kPa (88 mmHg) at room air. New information provided: Severe pulmonary complications may be observed after iatrogenic neurological injury in sheep. Neurogenic pulmonary edema should be taken into account among the differential diagnoses of abrupt respiratory distress following seizure.

Clinical characteristics and risk factors of symptomatic central venous catheter-related deep vein thrombosis in children

Objective To investigate the clinical features and risk factors in children with symptomatic central venous catheter-related deep vein thrombosis, and to provide guidence for clinical therapy. Methods The clinical data of 105 children with central venous catheter were retrospectively analyzed.According to the thrombosis or not, these children were classified into two groups: thrombosis group and non-thrombosis group.The risk factors influencing symptomatic central venous catheter-related deep vein thrombosis forming were identified by Logistic regression analysis. Results Among the 105 cases with central venous catheter, the male to female ratio was 68∶37; age ranged from 8.5 months to 13 years old with average age(5.5±4.0)years old.There were 98 cases in non-thrombosis group and 7 cases in thrombosis group.Factors such as age[(5.7±4.1)years old vs.(2.5±1.8)years old], central venous catheter dwell time[(6.1±2.3)d vs.(8.9±2.1)d], more than 7 days parenteral nutrition application(11/98 cases vs.5/7 cases)and more than 7 days intravenous application of mannitol(7/98 cases vs.4/7 cases)were found significantly different between the thrombosis group and non-thrombosis group(P<0.05). Multivariate Logistic regression analysis showed that more than 7 days parenteral nutrition application and intravenous mannitol were the risk factors of symptomatic central venous catheter-related deep vein thrombosis[OR=50.703(95%CI 3.258-789.056), OR=15.590(95%CI 1.196-203.146), P<0.05]. Conclusion Symptomatic central venous catheter-related deep vein thrombosis is a common complication of deep venous catheterization.It cause acute pulmonary embolism and some critical diseases, and influence the prognosis and prolong hospital stay.Application of intravenous nutrition more than 7 days and intravenous mannitol more than 7 days are the risk factors of symptomatic central venous catheter-related deep vein thrombosis. Key words: Central venous catheter; Deep vein thrombosis; Children

Treatment of Acute Liver Failure in Resource-Constrained Settings without Transplantation Facilities Can Be Improved.

Treatment of Acute Liver Failure in Resource-Constrained Settings without Transplantation Facilities Can Be Improved.

Effect of Intravenous Mannitol on Intraocular Pressure in Vitrectomized Silicone-Oil-Filled Eyes

ABSTRACTPurpose: To evaluate the effect of intravenous mannitol (IVM) on intraocular pressure (IOP) in vitrectomized eyes. Methods: Thirty-one patients with raised IOP after retinal surgery with silicone oil injection were included. Patients were administered IVM (20% solution, 1g/Kg, over 30 minutes) and IOP was noted at regular intervals. IOP reduction in vitrectomized eyes (Group 1) was compared with the normal eyes (Group 2). Result: Percentage IOP reduction was higher in Group 1 than in Group 2 at all time intervals, 24.5% vs. 19.2% at 15 minutes (p=0.34), 22.6% vs. 9.8% at 45 minutes (p=0.003), 19.1% vs. 9.9% at two hours (p=0.023), and 16.1% vs. 7.8% at four hours (p=0.04), respectively. In Group 1, 40% eyes had an IOP reduction of 2–6 mmHg while 30% eyes had IOP reduction >6 mmHg at four hours post-IVM. Conclusion: IVM is useful for short-term IOP reduction in vitrectomized eyes. IOP reduction is independent of baseline IOP, and sustained and higher as compared to normal eyes.

Comparative study between hydrocortisone and mannitol in treatment of postdural puncture headache: A randomized double-blind study

BackgroundPostdural puncture headache (PDPH) is a common complication after lumbar puncture. Anesthesiologists are the most likely to be consulted for the treatment. PDPH may be debilitating for a patient and can interfere with daily activities and quality of life.MethodsFifty patients of both sexes, aged 18–50 years and ASA I and II undergoing elective lower abdominal and pelvic surgery under spinal anesthesia were included in this randomized double-blind study. Patients were randomly divided into 2 groups 25 each: hydrocortisone group received intravenous hydrocortisone 100 mg every 8 h for 48 h and mannitol group received intravenous infusion of mannitol 20% 100 ml over 30 min followed by 100 ml every 12hours. Mean (±SD) of headache intensity at 0, 6, 12, 24 and 48 h after beginning of treatment was assessed using visual analogue scale.ResultsThere was no significant difference regarding headache intensity between two groups before beginning of treatment. The VAS was significantly reduced in hydrocortisone group than in mannitol group at 6, 12, 24 h with P-value 0.030, 0.007, 0.004 respectively. At 48 h, both groups had nearly the same VAS of headache intensity, with P-value 0.305.ConclusionBoth intravenous hydrocortisone and mannitol intravenous infusion were efficient in reducing postdural puncture headache within 48 h. Hydrocortisone showed earlier and significant relief of headache.

Efficacy of Intravenous Mannitol in the Management of Orbital Compartment Syndrome: A Nonhuman Primate Model.

To report the efficacy of intravenous mannitol in the treatment of orbital compartment syndrome. An experimental study was conducted on 4 nonhuman primates (8 orbits). Orbital compartment syndrome was simulated by injecting autologous blood into both orbits of each nonhuman primate until a pressure of 80 mm Hg was reached (time 0). After 10 minutes, nonhuman primates were randomized to receive an infusion of either mannitol or saline, given over 15 minutes. Five minutes after the infusion was complete, lateral canthotomy and cantholysis was performed on both orbits in isolated steps every 5 minutes. During the study protocol, orbital and intraocular pressures were recorded every 5 minutes, with a final set of measurements at 60 minutes. The primary outcome measures were the mean change in pressure from time 0 to 60 minutes, as well as the mean change in pressure during the infusion period. There was no statistically significant difference in the mean changes in orbital or intraocular pressure from time 0 to 60 minutes of the protocol. However, during the infusion period there was significantly greater decrease in both orbital and intraocular pressure in the mannitol compared with saline group (-34.0 vs. -9.3 mm Hg for orbital pressure [p = 0.03]; -34.8 vs. -9.7 mm Hg for intraocular pressure [p = 0.04]). While the definitive treatment of orbital compartment syndrome is lateral canthotomy and cantholysis, mannitol results in a rapid and clinically meaningful drop in orbital and intraocular pressure. The authors believe that their data support the routine use of mannitol in orbital compartment syndrome, especially when there is a delay in timely surgical management.

Venous Malformation and Localized Intravascular Coagulopathy in Children.

Aim Localized intravascular coagulopathy (LIC) has been described in adults with venous malformation (VM) but rarely reported in children. This study aims to determine the prevalence of LIC in children with VM and associated risk factors. Methods Patients younger than 18 years with VM from 2010 to 2014 were reviewed. Diagnosis was confirmed by Doppler ultrasound and/or magnetic resonance imaging. Demographics data and VM characteristics including volume, site, extension, painful symptoms, and palpable phleboliths were studied. Plasma D-dimer level of greater than 500 ng/mL was considered as abnormal. Results Total 24 children were included, of whom 8 were boys. Median age of presentation was 9 months (range: 0-12 years). Head-and-neck VM occurred in 17 (70.8%) patients and 3 (12.5%) had multifocal lesions. Seven (29.2%) patients had VM volume greater than 10 mL. Five (20.8%) patients had painful symptoms. Palpable phleboliths were found in two patients. Plasma D-dimer was raised in eight cases (33.3%). One patient with Klippel-Trenaunay syndrome (KTS) had D-dimer level of 5,000 ng/mL. Raised D-dimer was found in 23.5% of small VM (volume < 10 mL) and 57.1% of large VM (p = 0.167). D-dimer was significantly raised in multifocal VM (p = 0.028) and showed increasing trend in lesions with palpable phleboliths (p = 0.101). All patients had sclerotherapy performed with indications (cosmesis 41.7%, enlarging lesion 29.2%, pain 20.8%, bleeding 8.3%). Perioperatively, bolus intravenous fluid and mannitol were given to selected patients. All patients had VM volume reduction after sclerotherapy. There were no major thromboembolic complications. Conclusion LIC with raised D-dimer level occurred in one-third of pediatric VM. It was more common in large, multifocal VM and in those with palpable phleboliths or KTS.

Preoperative mannitol infusion improves perioperative cerebral oxygen saturation and enhances postoperative recovery after laparoscopic cholecystectomy.

Objectives:To test the effect of preoperative mannitol infusion on perioperative decreased cerebral oxygen saturation (rSO2) during laparoscopic cholecystectomy.Methods:Forty patients scheduled for laparoscopic cholecystectomy were enrolled in this study conducted at Dammam Hospital of the University, Dammam, Kingdom of Saudi Arabia from December 2013 to June 2014. Patients received either 0.5 g/kg of 20% intravenous mannitol infusion over 10 minutes before induction of anesthesia (group M), or an equal volume of normal saline instead (group C). Primary outcome variable was rSO2. Other variables included extubation time, clinical assessment of consciousness recovery using the Modified Observer’s Assessment of Alertness/Sedation Scale (OAA/S), and the mini-mental state examination (MMSE) for cognitive evaluation.Results:Anesthesia induction increased rSO2 in both groups. Pneumoperitoneum decreased rSO2 in group C, but not in group M. This drop in rSO2 in the group C reached its maximum 30 minutes after extubation, and was significantly less than the preinduction value. Time to extubation in group M was significantly shorter compared to group C (p=0.007). The OAAS in group M at 10 min after extubation was significantly higher compared to group C. No differences were found between the 2 groups in cognitive function as measured by MMSE score.Conclusion:Preoperative mannitol infusion maintains perioperative rSO2 during laparoscopic cholecystectomy and shortens extubation time with earlier resurgence of OAAS.

Glaucoma agudo bilateral secundário al uso de topiramato como tratamiento para la perdida de peso

Topiramate is a drug used in the treatment of epilepsy, migraine, bulimia and other pathologies. We report a case of a 40-years-old woman, presented to the emergency department of ophthalmology with blurred vision in both eyes and bilateral acute angle closure. Her medications included topiramate started 6 days before Secondary angle closure glaucoma due to topiramate was diagnosed. The medication was discontinued and she was treated with topical antiglaucoma medications, intravenous mannitol and cyclopegics. At the 5-days follow-up visit, vision, intraocular pressure, and angle anatomy had returned to normal. The acute angle-closure glaucoma occurs due to edema of the ciliary body and uveal effusion that produces an anterior motion of the iris-lens diaphragm , with ocular hypertension and acute myopia .

113 Phase 3 randomized trial of intravenous mannitol versus placebo prior to renal ischemia during partial nephrectomy: Impact on renal functional outcomes

113 Phase 3 randomized trial of intravenous mannitol versus placebo prior to renal ischemia during partial nephrectomy: Impact on renal functional outcomes

Successful treatment of a case of primary amoebic meningoencephalitis: How important is history taking.

Sir, Naegleria fowleri is a rare cause of meningoencephalitis leading to a fatal fulminant primary amoebic meningoencephalitis (PAM) acquired after diving, swimming in warm fresh water. Very few patients are reported to survive after acquiring this infection.[1,2] Timely diagnosis requires a high index of suspicion in any individual presenting with a sub-acute onset meningitis after exposure to standing water in lakes and pools. A 6-year-old male child presented with a history of high grade fever, headache, vomiting for 10 days and altered sensorium for 1-day. There was no history of seizures, any other complaints or contact with tuberculosis. There was a history of playing and swimming in water stored in a cement tank, collected from a stream of water (Koohl). On examination, the child was in delirium, febrile with stable vitals. Central nervous system (CNS) examination revealed signs of meningeal irritation with the early papilledema. Rest of the systemic examination was normal. On admission possibilities of acute pyogenic meningitis, rickettsial meningoencephalitis, as this region is endemic for scrub typhus and tubercular meningitis, was kept. Intravenous (IV) ceftriaxone, azithromycin, mannitol, maintenance fluid and supportive care were started. Cerebrospinal fluid (CSF) analysis after lumbar puncture that was done next day, showed 415 cells/mm3 with 30% neutrophils and 70% lymphocytes. Gram-staining did not reveal any bacteria, but the wet mount smear showed plenty of motile, amoeboid flagellate organisms, 15-20 μm in size, Naegleria species. The water that was later on collected from water tank and koohl also showed similar Naegleria. CSF culture was negative for bacteria and computed tomography head done on 2nd day showed mild cerebral edema. The child was started on IV amphotericin B (1 mg/kg/d IV for 21 days), fluconazole (12 mg/kg/d PO on day 1 followed by 6 mg/kg/day for total of 21 days), oral rifampicin (15 mg/kg/d PO for 21 days) and supportive care for 3 weeks. The child showed gradual improvement with normal sensorium in 3 days, afebrile and disappearance of neck rigidity after 6 and 8 days of treatment respectively. He was discharged and followed-up for 3 months with no residual CNS abnormality. Primary amoebic meningoencephalitis is a fulminant and rapidly fatal disease that principally affects children and young adults caused by N. fowleri, an amoeba-flagellate found in most soil and freshwater habitats. Most of the cases reported in children as well as in adults has been fatal.[1,3] One of the key and most important factors for a successful outcome is the promptness in diagnosis and treatment of the patient. Delay in diagnosis and the fulminant nature of the disease results in few survivors.[4] In our case, the child presented with features of meningitis and altered sensorium with sub-acute course with history of swimming in stored fresh water. In a case of meningitis, we routinely do not perform wet mount microscopy but in our case history of swimming in stored fresh water with a sub-acute course of meningoencephalitis led to the investigation and early diagnosis, which is the most important factor for successful treatment of PAM. Early treatment was started, and the child recovered completely. Vargas-Zepeda et al.[2] also successfully treated a 10-year-old boy of PAM with IV amphotericin B, fluconazole, rifampicin, and dexamethasone. So, history taking that is perhaps a dwindling art can create a difference perhaps between death and survival and wet mount microscopy should be routinely done in a case of meningitis or meningoencephalitis with sub-acute course.

Acute onset of intracranial subdural haematoma 2 days after spinal anaesthesia.

Sir, Spinal anaesthesia (SA) is widely used for surgeries but serious complication such as intracranial subdural haemorrhage (ICSH) can rarely occur.[1] The incidence of ICSH after SA has been reported to be 1 in 500, 000.[2] During literature review, 35 cases were identified, and most had a chronic course and associated with post-dural puncture headache (PDPH).[1] We report a case of acute onset of ICSH 2 days after SA with no history of trauma. The 21-year-old young male presented with fistula in ano, and was scheduled for an elective surgery in our hospital. Patient belonged to American Society of Anaesthesiologists physical status 1 with no comorbid conditions. He had no history of any pre-existing brain pathology. The anaesthetic procedure was completed with ease in a single attempt with lumbar puncture at the L 2/3 level using 25-gauge Quincke's needle; there was free flow of clear cerebrospinal fluid (CSF) and 0.5% heavy bupivacaine was injected. T12 level of block was achieved, and surgery completed uneventfully. On 2nd post-operative day patient suddenly developed severe headache, and 2 h later he developed generalised tonic clonic seizure and became unconscious. Patient was immediately intubated and administered intravenous phenytoin and mannitol as advised by neurologist. Computed tomography (CT) scan was obtained, which showed right subdural haematoma (SDH) with midline shift of 1.3 cm [Figure 1]. Patient was shifted to operation theatre where craniotomy with evacuation of haematoma was done. Post-craniotomy, patient was shifted to neuro-intensive care unit and after 48 h of ventilator support, was extubated. On the third post-operative day, non-contrast CT was done, which showed complete resolution of SDH [Figure 2]. Post-operatively during his stay in hospital patient remained apathetic and aphasic for which psychiatrist opinion was taken, and he advised thyroid function tests. He was found to be hypothyroid and hence he was put on the tablet thyroxine 100 μg once daily. On 7th post-operative day, sutures were removed, and wound was found to be healthy. On discharge, patient was conscious with left residual hemiparesis. He was discharged on Ryle's tube feed and indwelling Foley's catheter. Fifteen days later, his left residual hemiparesis resolved and his Glasgow coma scale became 15. Sixty days later patient came back to our hospital for duraplasty, which was done, and he was discharged after 3 days.Figure 1: Right acute subdural haematomaFigure 2: Computed tomography scan after evacuation of right acute subdural haematomaVery few data exist about the consequences of SA-induced ICSH. As symptomatology frequently mimic PDPH, a number of them are frequently missed.[3] According to the literature, its prevalence ranges between 1/500,000 and 1/1,000,000.[45] A Swedish retrospective study published in 2004 and covering a decade (1990–1999) mentions 127 cases of neurological complications following SA, of whom the risk was assessed to be 1/20,000–1/30,000, among which two cases of SA-ICSH were reported.[6] A French study reported 4 such cases of SA-ICSH over a period of 9 years in a medium size centre.[7] The physiopathogenic mechanisms of SA-ICSH are poorly understood. A leak of CSF at the level of arachnoid tear probably induces a lowering of intraspinal and intracranial pressure. The resulting dynamic alteration of CSF flow leads to a relative ventricular collapse and a rostrocaudal movement of central nervous system. As a consequence sensitive meningeal structures or meningeal pain sensors, cranial nerve and bridging-veins that link the encephalon to the meninges and drain into the dural sinuses are stretched.[8] Electron microscopic data on human bridging veins show thin walls of variable thickness, circumferential arrangement of collagen fibres and lack of the outer reinforcement by arachnoids trabecules. All these render the subdural portion of the vein more fragile than its subarachnoid portion. These features explain the laceration of veins and the subdural location of resulting haematomas, which can evolve in various ways, acute or chronic. Cerebral SDH is a serious complication of SA that must be kept in mind and may mimic PDPH. History of lumbar puncture, prolonged non-postural PDPH and development of neurological symptoms should be regarded as a warning sign of an intracranial haematoma and initiate immediate diagnosis and treatment of the same.

Albumin and Furosemide versus Mannitol and Furosemide in the Treatment of Diuretic Resistant Oedema in Childhood Nephrotic Syndrome

Background: To treat resistant oedema in childhood nephrotic syndrome is a therapeutic dilemma. This study was carried out to compare the efficacy of mannitol &amp; furosemide with that of albumin &amp; furosemide in the treatment of diuretic resistant oedema in childhood nephrotic syndrome. Methodology: Forty children with “resistant oedema” due to idiopathic nephrotic syndrome at Paediatric Nephrology Department, Bangabandhu Sheikh Mujib Medical University (BSMMU) from September 2006 to April 2008 were enrolled in this descriptive cross sectional study. `Resistant oedema` was considered based on failure to achieve therapeutic response to diuretics or a weight loss of &lt;1% body weight daily. All nephrotic syndrome patients with anasarca, age 1 year to 15 years of both sexes were hospitalized and were managed with fluid restriction, salt restriction and bed rest. Beside these 2 mg/kg/day oral furosemide or combination of furosemide and spironolactone, were given for 3 days to achieve desired diuresis. Those patients who did not get response were divided into two groups (Group-A, Group-B) in consecutive fashion. The Group- A study population, was with intravenous mannitol 0.5-1 gm/kg/day in single daily dose over 1-2 hrs followed by intravenous furosemide 1 mg/kg/day for 5 days. The Group-B study population was with intravenous albumin, 0.5 – 1 gm/ kg /day in single daily dose over 1-2 hrs followed by intravenous furosemide 1 mg/kg/day in every alternate day, total 3 doses. Efficacy of both groups of drugs was observed day to day by recording the follow-up chart. Results: Efficacy of treatment was evaluated by measuring weight loss and increment of urine volume. Much more increment of urine volume was occurred after albuminfurosemide infusion (1383±949.45ml vs 139.17±88.84ml) than in mannitol-furosemide infusion (928.13±359.61ml vs 151.88±67.15ml). But the difference between the two groups was not statistically significant. Body weight was reduced 13.74% in Mannitolfurosemide group. All other parameters like abdominal girth and complications of oedema reduction were similar with albumin &amp; furosemide group. Conclusion: It is concluded that response to mannitol-furosemide combination is as effective as albumin with furosemide in the treatment of diuretic resistant oedema in children with nephrotic syndrome. However, new combination is less costly and may be more useful in our society. DOI: http://dx.doi.org/10.3329/bjch.v38i2.21139 Bangladesh J Child Health 2014; VOL 38 (2) : 68-73

Epidemiology and Clinical Features of Ciguatera Fish Poisoning in Hong Kong

In the present review, the main objective was to describe the epidemiology and clinical features of ciguatera fish poisoning in Hong Kong. From 1989 to 2008, the annual incidence of ciguatera varied between 3.3 and 64.9 (median 10.2) per million people. The groupers have replaced the snappers as the most important cause of ciguatera. Pacific-ciguatoxins (CTX) are most commonly present in reef fish samples implicated in ciguatera outbreaks. In affected subjects, the gastrointestinal symptoms often subside within days, whereas the neurological symptoms can persist for weeks or even months. Bradycardia and hypotension, which can be life-threatening, are common. Treatment of ciguatera is primarily supportive and symptomatic. Intravenous mannitol (1 g/kg) has also been suggested. To prevent ciguatera outbreaks, the public should be educated to avoid eating large coral reef fishes, especially the CTX-rich parts. A Code of Practice on Import and Sale of Live Marine Fish for Human Consumption for Prevention and Control of Ciguatera Fish Poisoning was introduced from 2004 to 2013. The Food Safety Ordinance with a tracing mechanism came into full effect in February 2012. The Government would be able to trace the sources of the fishes more effectively and take prompt action when dealing with ciguatera incidents.