Cases reported "Iatrogenic Disease"

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11/177. Contribution of magnetic resonance imaging for the diagnosis of median nerve lesion after endoscopic carpal tunnel release.

    Deterioration of pre-existing signs or appearance of a nerve deficit raise difficult problems during the complicated course following endoscopic carpal tunnel release. One possible explanation is transient aggravation of nerve compression by passage of the endoscopy material, but these signs may also be due to incomplete section of the flexor retinaculum or an iatrogenic nerve lesion. Each case raises the problem of surgical revision. The authors report three cases of open revision in which MRI allowed a very precise preoperative diagnosis of the lesions and all of the MR findings were confirmed during surgical revision. In the first case, MRI showed section of the most radial branches of the median nerve (collateral nerves of the thumb, index finger and radial collateral nerve of the middle finger). The proximal origin of the nerve of the 3rd web space, above the retinaculum, an anatomical variant, was also identified. Section of 2/3 of the nerve of the 3rd web space, proximal to the superficial palmar arch, was observed in the second case. Simple thickening of the nerve of the 3rd web space, without disruption after opening of the perineurium, was observed in the third case. MRI therefore appears to be an examination allowing early and precise definition of indications for surgical revision in this new iatrogenic disease.
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12/177. Iatrogenic main pulmonary artery-left atrial fistula in a child.

    A 14-month-old boy who underwent operation for ventricular septal defect patch closure and debanding of the pulmonary artery presented with arterial desaturation in the early postoperative period. angiography confirmed the echocardiographic findings of hemodynamically significant main pulmonary artery-left atrial fistula. This communication was successfully closed surgically.
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13/177. Detection of iatrogenic cardiac tamponade by transesophageal echocardiography during vena cava filter procedure.

    PURPOSE: To present a patient who developed cardiac tamponade during insertion of an inferior vena cava (IVC) filter. Intraoperative transesophageal echocardiography (TEE) was used as a means to diagnose the cardiac tamponade and to facilitate guiding of pericardiocentesis. CLINICAL FEATURES: A 45-yr-old man with protein s deficiency complicated by repeated attacks of deep vein thrombosis and pulmonary thromboembolism was scheduled for insertion of an IVC filter. He had history of chronic renal insufficiency, heart failure, and cerebral infarction with mild left hemiparesis. Current medication included diltiazem (30 mg, I tab tid ), prednisolone (5 mg, 2 tabs qd ), and warfarin (2.5 mg daily). Preoperative transthoracic echocardiography demonstrated bilateral pleural effusions, moderate mitral regurgitation and tricuspid regurgitation, left atrial appendage thrombus and severe generalized hypokinesia of left ventricle. Nuclear medicine examination by (99)Tc showed ejection fractions of left ventricle and right ventricle as 20% and 22%, respectively. Under the impression of protein s deficiency with multiple attacks of thromboembolism and failure of anticoagulant therapy, he was arranged for the procedure of vena caval filter insertion. Unfortunately, iatrogenic cardiac tamponade occurred during the course of the procedure with rapid hemodynamic deterioration. Because of the expedient of routine monitoring of cardiac condition with TEE, a prompt diagnosis was made. We successfully improved the patient's hemodynamic status after transthoracic echo-guided pericardiocentesis. CONCLUSION: Intraoperative TEE is recommended to be used routinely in patients undergoing vena cava filter procedures. The availability of echocardiographic monitoring in the operation room allows the confirmation of the diagnosis and facilitation pericardiocentesis.
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14/177. Iaterogenic injuries during retrograde delivery of cardioplegia.

    During last eight years, retrograde delivery of cardioplegia was used on a regular basis, utilizing a DLP INC (Grand Rapids, MI) or a research Medical INC (Salt Lake City UT) delivery systems, in almost an equal number of patients. This method resulted in a high pressure rupture, or perforation of the coronary sinus, its radicals or the right ventricle (RV) in 0.06% (5/7886) of patients. Intraoperative diagnosis of these injuries were confirmed on abnormal haemodynamic tracings and trans oesophageal echocardiography (TOE), and appearance of cardiac contusion or leakage of cardioplegia. A low incidence of these iaterogenic injuries may be attributed to: (1) a regular use of this method and (2) use of TOE guided manipulations in select high risk and reoperative patients. Repair of these injuries, as described, resulted in salvage of 4/5 (80%) patients.
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15/177. Iatrogenic burn caused by an alcohol lamp.

    Iatrogenic injury is an intrinsic risk of all medical procedures. Various kinds of iatrogenic complications have been extensively reported and recognized. Two patients were referred to the Prince of wales Hospital for iatrogenic flame burn caused by the breakage of an alcohol lamp during ENT examination. They were 8 and 9 years old and sustained 12 and 17% intermediate to deep dermal burns respectively. There was no eye or inhalation injury. They were treated initially at the referring hospital. Despite having the best possible treatment, the parents were hostile to and demanding of the medical attendants and the patients were uncooperative throughout the whole treatment period. rehabilitation of the two children was jeopardized. The situation was very difficult when they were first seen at the Prince of wales Hospital. The burn surgeon at the Prince of wales Hospital, as a third party, managed to act as a bridge between the referring hospital and the patients and their families. Several meetings were held and the best interests of the two patients was addressed. The compensation issue was also settled without formal legal prosecution.
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16/177. 'Iatrogenic' Wernicke's encephalopathy in japan.

    'Iatrogenic' Wernicke's encephalopathy has appeared to occur more frequently in japan, probably induced by the change of our Japanese national health insurance policy in 1992. We report 4 nonalcoholic patients with such Wernicke's encephalopathy, which occurred during the early postoperative oral food intake period following intravenous nutrition without vitamin supplements. We analyzed the medical records of 4 patients, 3 men and 1 woman, aged between 55 and 71 years, who were admitted to our hospital between 1992 and 1995. Three patients underwent gastrointestinal surgery and 1 suffered chronic pyothorax. We diagnosed our patients as having Wernicke's encephalopathy based on typical neurological abnormalities, in addition to typical cranial magnetic resonance image findings, low serum vitamin B(1) levels, or both. Although all of the patients were treated with vitamin B(1) and showed some improvement, 1 patient developed korsakoff syndrome, 2 made incomplete neurological recovery, and 1 died. We speculated that the body vitamin B(1) stores had been decreasing in our patients who did not receive any vitamin supplements during intravenous hyperalimentation or hydration. Subsequent administration of high calorie and high carbohydrate oral diets increased the demand for vitamin B(1), further depleting the vitamin stores, thereby causing 'iatrogenic' Wernicke's encephalopathy. The change of our national health insurance policy in 1992 discouraged the routine administration of vitamins, probably causing Wernicke's encephalopathy in our patients.
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17/177. Perioperative deaths: a further comparative review of coroner's autopsies with particular reference to the occurrence of fatal iatrogenic injury.

    INTRODUCTION: In previous triennial reviews of Coroner's perioperative autopsies conducted during the periods 1989 to 1991 and 1992 to 1994, it was observed that the necropsy incidence of such deaths rose from 2% to 2.6% (P < 0.05). Concurrently, the rate of iatrogenic deaths had nearly doubled from 15.2% to 28.8% (P < 0.02). These findings spurred a review of the subsequent triennium (1995 to 1997), in order to monitor the apparent rise in these trends and to study the frequency and occurrence of iatrogenic deaths in relation to the number of invasive procedures performed, as well as during emergency and elective procedures. MATERIALS AND methods: A retrospective (descriptive and comparative) study, comprising a clinico-pathological review of a series of 270 perioperative deaths (defined as deaths occurring during or after invasive therapeutic or diagnostic procedures, up to a week after discharge, and excluding cases of major trauma from suicides, homicides, as well as road and industrial accidents) reported to the Coroner, for which autopsies were conducted at the Department of forensic medicine from 1995 to 1997. RESULTS: The necropsy incidence of 4.4% (270/6074) represented a significant rise over the previous triennia (P < 0.01). As in previous years, there was a predominance of males (M:F = 1.65:1) and middle-aged to elderly patients (range 0 to 92 years, mean 55.8 years, median 63 years), most of whom had died after a variable, but usually brief, postoperative interval [0 to 97, 4.2, 1 day(s)] and a more variable period of hospitalisation (< 1 to 289, 12.6, 7 days). A total of 408 invasive procedures were performed, amounting to an average of 1.5 per patient; 101 patients (37.4%) underwent multiple (> 1) interventions, which were initially classified as elective procedures in 27 cases. There were 66 (24.4%) iatrogenic deaths, of which 2 (0.7%) were due to anaesthetic mishaps; 18/64 iatrogenic deaths, unrelated to anaesthesia, occurred after the first postoperative day. The proportions of such deaths amongst patients subjected to multiple interventions, or initial elective procedures, were more than twice as high as amongst those undergoing single procedures, and those initially classified as emergencies (35.6% versus 16.6% and 33.3% versus 13.2%, respectively; P < 0.01). Only 51/66 (77.3%) iatrogenic deaths received Coroner's verdicts of misadventure; no verdict of criminal negligence was recorded during the period in question. CONCLUSIONS: There appears to have been a steady increase in the number of perioperative deaths reported to the Coroner over the previous triennia (1989 to 1997) for which autopsies were conducted. While this observation may not denote an increase in perioperative morality rates per se, it may be indicative of an increasingly "aggressive" or defensive approach to the clinical management of seriously ill patients, particularly over the past decade. Although the rate of iatrogenic deaths appears to have stabilised, it is too early to say whether this apparent trend will persist in the future. It is perhaps not surprising that the risk of iatrogenic injury appears to increase with the number of interventions performed; however, it is not clear why initial, supposedly elective, interventions should be associated with an apparently greater risk of iatrogenic injury than those classified as emergency procedures. The substantial divergence between the autopsy finding of an iatrogenic death and the corresponding Coroner's verdict of misadventure may be comforting to clinicians, but certainly warrants further examination.
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keywords = operative
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18/177. Corneal iron ring associated with iatrogenic keratectasia after myopic laser in situ keratomileusis.

    A 23-year-old woman had bilateral myopic laser in situ keratomileusis (LASIK). Two months postoperatively, she reported decreased visual acuity. Biomicroscopic examination revealed a corneal epithelial iron ring around the central keratectasia on both corneas. The appearance of the ring pattern was similar to the iron deposits of the Fleischer ring of keratoconus.
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19/177. Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair.

    PURPOSE: To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter. CASE REPORT: A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year. CONCLUSIONS: latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.
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ranking = 2
keywords = operative
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20/177. Postoperative retroperitoneal hemorrhage due to a bleeding ureteric artery: treatment by transcatheter embolization.

    We report a case of a postoperative retroperitoneal haemorrhage due to an iatrogenic perioperative injury of an ureteric artery. Transcatheter embolization using microparticles stopped the bleeding and the patient stabilized immediately. Ureteric artery injury is a very rare condition but can be managed successfully by percutaneous interventional techniques.
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