Severe Pleural Effusion Research Articles

Epidural Anesthesia for a Cesarean Section in a Parturient Patient with Congestive Heart Failure and Respiratory Insufficiency - A case report -

We report a case in which epidural anesthesia was successfully administered during a cesarean section of a 35 years old parturient patient with severe congestive heart failure and respiratory in sufficiency at 33 weeks of gestation. The patient had a past history of mitral regurgitation and mitral valve prolapse treated by mitral valve replacement ten years prior. When limited motion of the prosthetic mitral valve developed, congestive heart failure recurred and was aggravated by the pregnancy. In addition, the patient presented with symptoms of respiratory insufficiency including NYHA III dyspnea, orthopnea, severe pulmonary hypertension (systolic pulmonary arterial pressure: 112 mmHg) due to severe aortic regurgitation, pleural effusion and pulmonary edema on admission. Four-days after admission, with premature labor pain and fetal distress, the patient underwent an emergency cesarean section. Due to the orthopnea, the patient could not breathe in the supine position, and we chose to give epidural anesthesia at a sitting position for preserving self-respiration and to prevent a ventilation-perfusion mismatch that would possibly develop during general anesthesia. Moreover, we could control postoperative pain and maintain a minimal, gradual hemodynamic change throughout the epidural anesthesia. During surgery, the hemodynamic instabilities were controlled by the use of dopamine, dobutamine, ephedrine and milrinone. We safely finished the cesarean section under epidural anesthesia and the patient was sent to the intensive care unit postoperatively to manage congestive heart failure and respiratory insufficiency. (Korean J Anesthesiol 2007; 53: 656～9)

Metastatic Ovarian Adenocarcinoma in a Dog Treated with Ovariohysterectomy and Intracavitary Chemotherapy

10歳、雌のシーズーに重度の胸腹水が認められた。試験開腹で両側性の卵巣腫瘤を認め、卵巣子宮摘出術を実施した。病理組織学的には、腹膜転移をともなう卵巣の乳頭状腺癌と診断された。手術後に胸水と腹水は消失したが、9ヵ月後に再発し、腹膜と胸膜の病理組織検査で腫瘍の再発が認められた。シスプラチンの体腔内化学療法によって胸水と腹水は4ヵ月間消失したが、その後は治療に反応せず疾患が進行し、初回手術の23ヵ月後に死亡した。

Human factor XIII reduces severe pleural effusion in children after open heart surgery

Objective: Chylus effusions occur after open-heart surgery. Factor XIII (FXIII) is discussed being essential for wound healing. The aim of this retrospective study was to evaluate, if the application of FXIII results in a reduction of chylus.

Human factor XIII reduces severe pleural effusion in children after open heart surgery

Objective: Chylus effusions occur after open-heart surgery. Factor XIII (FXIII) is discussed being essential for wound healing. The aim of this retrospective study was to evaluate, if the application of FXIII results in a reduction of chylus.

Human factor XIII reduces severe pleural effusion in children after open heart surgery

Objective: Chylus effusions occur after open-heart surgery. Factor XIII (FXIII) is discussed being essential for wound healing. The aim of this retrospective study was to evaluate, if the application of FXIII results in a reduction of chylus.

Successful Use of Rituximab To Treat Central Nervous System Lymphoma in a Patient with B-Cell Post-Transplant Lymphoproliferative Disorder (PTLD).

A 27 year old male with end-stage renal failure secondary to IgA nephropathy received a living related renal transplant in 10/2002, complicated by severe cellular and humoral rejection. Immunosuppression included steroids, OKT3, cyclosporine A, rapamycin, thymoglobulin, antithymocyte globulin, and plasmapheresis. He developed multiple complications including severe pancytopenia, pleural effusions, Pseudomonas sepsis, and Vancomycin resistant enterococcus cystitis. Transplant nephrectomy was required 2/2003 for intractable rejection with blood clots in the urine, revealing large nodules of monomorphous B-cell PTLD throughout the renal parenchyma, along with type 2 acute cellular rejection. The B-cells were CD20 positive, and in situ hybridization for EBER was positive in the majority of the cells. PTLD staging was negative in other sites including brain and bone marrow. All immunosuppression was discontinued shortly following the nephrectomy, and he was placed on acyclovir for 3 months until he developed progressive cytopenias. In 8/2003 he underwent open brain biopsy following 2 grand mal seizures and an MRI showing multiple bilateral nonenhancing cortical and subcortical lesions up to several centimeters, with enhancing right temporal and parietal lesions with surrounding vasogenic edema and regional mass effect. Right temporal lobe biospy showed extensive high grade monomorphous B-cell PTLD with necrosis and vascular involvement. Lymphoma staging including lumbar puncture was otherwise negative and LDH was normal. He received a brief course of steroids and valacyclovir in the perioperative period. His performance status remained extremely poor, on hemodialysis, and thus he was not considered a good candidate for systemic chemotherapy, brain radiotherapy, or intrathecal chemotherapy. We elected to give a total of 8 courses of rituximab at 375 mg/m2 intravenously weekly. Although systemic rituximab does not generally penetrate the central nervous system very well, it was presumed that the blood brain barrier in this patient was broken down due to extensive lymphomatous cerebral disease. By 9/2003 there was improvement in the brain parenchymal lesions, and since 11/2003 there has been complete stabilization of residual involuted nonenhancing lesions. He remains in complete clinical remission, off rituximab for 22 months. This excellent response suggests that systemic rituximab can be an effective treatment in selected cases of PTLD in which extensive brain disease is present.

A Rare Case of Primary Amyloidosis, Presenting with Severe Pulmonary Hypertension and Bilateral Pleural Effusion.

Pulmonary arterial hypertension secondary to vascular deposition is a rare presentation of Primary Amyloidosis. The natural history of pulmonary hypertension and concomitant right-sided cardiac failure is not very well understood and is associated with a very short median survival. This syndrome is a marker of advanced Amyloidosis Persistent pleural effusion is another much rarer presentation of pulmonary involvement in Primary Amyloidosis and is secondary to pleural infiltration, which sometimes is difficult to distinguish from the cardiomyopathic causes. The incidence of pleural effusion in primary Amyloidosis is 1–2%. This syndrome also has a very poor prognosis, and has limited response to treatment, however, pleurodesis has been temporarily useful in some cases.Case report: A 74 year old African American female, non-smoker, with history of hypertension, who presented with shortness of breath and persistent productive cough and 18 pounds weight loss for the last six months. The initial chest x-rays showed bilateral pleural effusion and a transudate fluid on analysis. Cardiac workup for an atypical chest pain revealed moderate to severe pulmonary hypertension without myocardial infiltration on 2-D echocardiogram, and normal coronary arteries on cardiac catheterization. Extensive workup did not show any secondary cause of pulmonary hypertension, however, the patient gradually developed nephrotic range proteinuria and kidney biopsy showed infiltration of 10 nm fibrils, involving 3+ segmental mesangium, and 2+ segmental glomerular basement membranes. This was consistent with renal Primary Amyloidosis, AL Lambda type. A random urine and serum sample for immunofixation also revealed an M- spike of 23 mg/dl in gamma region. A concomitant bone marrow biopsy revealed presence of monoclonal IgG lambda plasma cell (CD38 bright) population, without any B-cell or T-cell markers.Conclusion: Pulmonary hypertension and pleural effusion are two rare and lethal presentations of pulmonary involvements in Primary Amyloidosis, and it should be considered in the differential diagnosis of any patient presenting with pulmonary symptoms. There is no definite treatment of these syndromes, although combinations of steroids and melphalan, along with colchicines, vincristine, adriamycin, and thalidomide have been used with minimum satisfactory outcomes. Autologous stem cell transplantation (SCT) provides the opportunity to give higher doses of chemotherapy and may be of benefit in some cases.

Outcome of fetal pleural effusions treated by thoracoamniotic shunting

Fetal pleural effusions are uncommon, and treatment options for moderate or severe effusions include drainage and thoracoamniotic shunting. However, relatively few records of effusions treated by thoracoamniotic shunting are available in the literature, so our objective was to study the outcome after thoracoamniotic shunting in our unit. We searched the database of our tertiary fetal medicine unit for all cases of fetal pleural effusion treated by thoracoamniotic shunting between 1997 and 2003 inclusive, and studied the maternal and neonatal records. Ninety-two cases of fetal pleural effusion were studied, of which 21 had undergone a thoracoamniotic shunt. Sixteen of these 21 fetuses (76%) had associated hydrops, of which seven (44%) survived and, of the five (24%) without associated hydrops, three (60%) survived. There were two procedure-related losses. No shunted cases were associated with abnormal karyotype or proven maternal infection, but it is probable that three cases had been caused by an underlying genetic syndrome. The survival of fetuses with severe pleural effusions after thoracoamniotic shunting in this study was 48%.

The clinical value of daily routine chest radiographs in a mixed medical–surgical intensive care unit is low

IntroductionThe clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients.MethodThis was a prospective observational study conducted in a 28-bed, mixed medical–surgical ICU of a university hospital.ResultsOver a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care.ConclusionIn the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.

Fenestration in Extracardiac Conduits in Children After Modified Fontan Operation by Implantation of Stent Grafts

Three patients (ages 3, 5, and 8 years) with various forms of functionally univentricular heart lesions received a total cavopulmonary connection with an extracardiac conduit as a final reconstructive procedure. Failure of the Fontan circulation occurred immediately after surgery because of spontaneous closure of surgical fenestrations in two children and absent fenestration in one. As an emergency procedure, in all patients the conduit was perforated by transcatheter intervention in order to create a connection to the anatomical right atrium. Following balloon dilatation of the perforated conduit, in all three patients covered stent grafts were placed in the newly created defect to attain a reliable communication. Patency of the fenestration was demonstrated by angiogram and any leakage was ruled out. Cardiac output improved and severe pleural effusion and ascites subsided. Right-to-left shunt could be demonstrated by echocardiography at follow-up after 7 months (median) in all three patients. Oxygen saturation remained stable between 85 and 90%. These preliminary results suggest that stent graft fenestration can serve as a valuable tool in failing Fontan circulation, particularly in patients with an extracardiac conduit. Covered stents have the potential to reduce the acute risk of bleeding and they help to prevent early spontaneous closure of the newly created fenestration.

犬のエプスタイン奇形の1例

A 3-year-old female Labrador retriever was presented because of dyspnea caused by severe pleural effusion. Cardiac auscultation revealed a grade III/VI systolic murmur over the tricuspid-valve area. Echocardiographic examination demonstrated typical tricuspid-valve malformations, dilation of the right atrium and severe tricuspid-valve regurgitation. On the basis of these results, the dog was diagnosed as having Ebstein's anomaly and was treated with orally administered vasodilators, β-adrenergic receptor blockers and diuretics. Clinical signs improved immediately. The patient was doing well and demonstrating no clinical signs 13 months after diagnosis. In this case, medication successfully treated congestive heart failure caused by Ebstein's anomaly

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome

Recovery from renal failure in malignant hypertension associated with primary aldosteronism: effect of an ACE inhibitor

Sir, Primary aldosteronism is one of the most common causes of secondary hypertension. However, it is rare for this disease to induce malignant hypertension associated with vascular organ damage including renal failure.1 One of the reasons for this is that, even in the malignant phase, renin activity and subsequent angiotensin II production remain suppressed in primary aldosteronism. Here, we report a case with aldosterone‐producing adenoma and increased renin activity complicated by malignant hypertension and renal failure, which required haemodialysis therapy. This case is noteworthy, because medical therapy with angiotensin‐converting enzyme (ACE) inhibitor effectively improved renal function, allowing discontinuation of dialysis. A 40‐year‐old woman consulted a physician on 2 January 2000, complaining of dyspnea, general fatigue, anorexia and headache. The patient appeared drowsy and her blood pressure was 260/140 mmHg. Serum creatinine was 7.1 mg/dl and severe pleural effusion was detected on chest X‐ray. Optic fundi exhibited papilloedema and haemorrhage (Keith‐Wagener's grade IV). She was admitted to hospital and treated with antihypertensive drugs and intermittent haemodialysis, which was needed three times a week thereafter. Blood pressure was managed by continuous intravenous infusion of nicardipine, which effectively lowered blood pressure to 170/80 mmHg. As renal function had not improved, the patient was transferred to our hospital …

A case of successful fetal therapy for congenital chylothorax by intrapleural injection of OK-432

A 38-year-old multiparous woman was referred at 19 weeks' gestation because of hydrops fetalis. Ultrasonic examination revealed severe pleural effusion, ascites and skin edema. Detailed examination of the amniotic fluid, fetal blood and intrathoracic fluid led to a diagnosis of congenital fetal chylothorax. Repeated thoracocenteses were not effective in improving the hydrops fetalis. We introduced fetal treatment for the pleural effusion by an intrapleural injection of OK-432 at 23, 24 and 25 weeks' gestation. The pleural effusion was reduced by adhesion of the intrathoracic space and resulted in the delivery of a neonate who was healthy except for right renal dysfunction. Pulmonary hypoplasia was successfully prevented by OK-432.

Successful management of pleuritic pain with thoracic paravertebral block

Background and Objectives: Thoracic paravertebral block (TPVB) is a unilateral analgesic technique that has been advocated in both acute and chronic thoracic and abdominal pain. Other blocks such as interpleural and epidural can be effectively used in pleuritic pain. This report illustrates that TPVB could also be effective for this kind of pain. Methods: A 45-year-old man with acute pancreatitis was referred to the critical care unit 11 days after emergency admission with severe left pleural effusion and acute respiratory failure. His medical history revealed hypertension and chronic obstructive pulmonary disease (COPD); in addition, he was a heavy drinker and smoker. A pleuritic pain that only slightly improved with nonopioid analgesics and opioids resulted in the patient's increasing inability to eliminate bronchial secretions. In an attempt to avoid endotracheal intubation, the pain unit recommended a continuous paravertebral block. The block was performed at T9 on the left side. An initial bolus of 15 mL bupivacaine 0.25% was administered and a continuous infusion, initially at 5 mL/h, was increased up to 10 mL/h to achieve the desired analgesic effect. Results: After the block the verbal analogue scale decreased from 9 to 3, and this level of pain relief was maintained until the end of the treatment 48 hours after the block. The patient improved and was discharged to the ward without the need for endotracheal intubation. Conclusions: This case report supports the notion that, in practice, the paravertebral block could be an effective and safe alternative to relief of pleuritic pain. Reg Anesth Pain Med 2000;25:651-653.

P40Fetal treatment for hydrops fetalis assisted by interventional ultrasound

BackgroundFetal hydrops has many causes including hydrothorax and cardiac abnormality. Our fetal treatment experience with such disorders associated with hydrops fetalis is reviewed and the efficacy of new interventional ultrasound is presented.Methods Case 1. A case of fetal lung tumor. Color Doppler analysis and MRI were introduced for differential diagnosis. Case 2. A case of severe pleural effusion. Detailed examination of intrathoracic fluid led to a diagnosis of congenital fetal chylothorax. Fetal treatment by intrapleural injection of OK‐432 was introduced. Case 3. A case of fetal tachyarrhythmia. We introduced transmaternal‐abdominal fetal ECG and administered transplacental medication.Results Case 1. Color Doppler analysis revealed an anomalous arterial supply from the aorta to tumor, leading to a diagnosis of pulmonary sequestration. Only reduction amniocentesis was repeated, with the circulatory failure spontaneously improving. Case 2. The pleural effusion was reduced by adhesion of the intrathoracic space, with pulmonary hypoplasia successfully prevented by OK‐432. Case 3. Transmaternal‐abdominal fetal ECG led to a diagnosis of fetal PSVT. Transplacental propranolol stopped fetal PSVT quickly, while digoxin slightly improved fetal cardiac function.ConclusionsOK‐432 may be considered as an alternate intrauterine therapeutic option to shunt insertion for severe fetal hydrothorax. Fetal ECG was also useful for the diagnosis of fetal tachyarrhythmia. Since some untreated cases show spontaneous improvement, the indications for fetal treatment should be reconsidered.

Potential role of high-frequency ventilation in the treatment of severe congenital pleural effusion.

Newborns with severe congenital pleural effusions often present with respiratory failure at birth. We describe two premature infants born at 31 and 33 weeks of gestation with bilateral pleural effusions. Both were drained prior to delivery under ultrasound guidance. The first infant had severe bilateral congenital chylothorax with pulmonary hypertension; the second infant had severe nonimmune hydrops fetalis. Both could be adequately oxygenated but failed to respond to conventional mechanical ventilation (CMV) and chest tube drainage, so that CO(2) elimination could not be accomplished. Both infants were successfully treated with high-frequency ventilation (HFV). We suggest that HFV may be of significant value in establishing adequate ventilation in cases of severe congenital pleural effusions.

The prevalence of cardiomyopathy in the Irish wolfhound: a clinical study of 500 dogs.

The prevalence of cardiomyopathy in Irish wolfhounds was evaluated by retrospective review of the results of cardiovascular examinations carried out in 500 dogs presented for veterinary services at the author's practice. Abnormalities were found in 209 (41.8%) of the dogs examined. Dilated cardiomyopathy (DCM) was diagnosed in 121 (24.2%) of the dogs and was accompanied by atrial fibrillation in 106 dogs. Seventeen dogs were suffering from advanced congestive heart failure (CHF), and 55 dogs were suffering from mild to moderate CHF as a result of DCM. Congestive heart failure was most commonly characterized by mild to severe pleural effusion due to right-sided heart failure in addition to pulmonary edema. Rhythm disturbances without evidence of DCM were detected in 48 dogs. Forty dogs had echocardiographic abnormalities without signs of DCM. Soft to moderate mitral regurgitations were diagnosed in 13 (2.6%) of these 40 dogs examined. In 39 dogs that died as a result of DCM, the median survival time from the time of diagnosis was 5.1 months, and in 59 dogs with DCM that are still alive, the median survival time is 15.7 months.

Intrapartum drainage of fetal pleural effusion

Our objective was to describe our experience with intrapartum thoracocentesis in fetuses with severe bilateral pleural effusion. We describe the outcome of four consecutive cases of fetal pleural effusion due to chylothorax that were managed by intrapartum thoracocentesis. These fetuses were not candidates for pleuro-amniotic shunting either because of the need for prompt delivery (three fetuses) or because of advanced gestational age (one fetus). Thoracocentesis was performed in the operating theatre under ultrasound guidance prior to Caesarean delivery. Gestational age at the time of diagnosis and thoracocentesis ranged between 26-34 weeks and 31-34 weeks respectively. Bilateral thoracocentesis was performed in two fetuses and unilateral in the remaining two fetuses. All four infants were born in a relatively good condition; however, all eventually required intubation, ventilation and chest tubes. Chest tubes were introduced between 2 h and 5 days after delivery in three infants, and immediately after birth in one infant who was hydropic. Two infants survived and are developing normally. One infant died from sepsis following successful pleurodesis and one from aspiration on day 51. Our conclusions are that intrapartum thoracocentesis seems to be a relatively simple procedure, that allows newborns with pleural effusion, to breathe spontaneously or be more easily ventilated. This in turn, reduces the need to introduce chest tubes in an emergency situation.

Dengue haemorrhagic fever: ultrasound as an aid to predict the severity of the disease.

In a prospective study, the relationship between the clinical severity of dengue haemorrhagic fever (DHF) and the sonographic findings was examined. The study comprised 73 cases classified as mild (grades I-II) and 75 as severe (grades III-IV). Ultrasonography in the mild group revealed pleural effusions in 30%, ascites in 34%, gallbladder wall thickening in 32%, hepatomegaly in 49%, splenomegaly in 16%, and pancreatic enlargement in 14%. In the severe group, pleural effusions, ascites and gallbladder wall thickening were found in 95%, pararenal and perirenal fluid collections in 77%, hepatic and splenic subcapsular fluid collections in 9%, pericardial effusion in 8%, hepatomegaly in 56%, splenomegaly in 16%, and pancreatic gland enlargement in 44%. Ultrasound may be useful for early prediction of the severity of DHF in children.