Cases reported "Respiratory Paralysis"

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1/227. phrenic nerve injury following cardiac surgery: a review.

    phrenic nerve injury following cardiac surgery is variable in its incidence depending on the diligence with which it is sought. Definitive studies have shown this complication to be related to cold-induced injury during myocardial protection strategies and possibly to mechanical injury during internal mammary artery harvesting. The consequences are also variable and depend to a large extent on the underlying condition of the patient, particularly with regard to pulmonary function. The response of the patient may range from an asymptomatic radiographic abnormality to severe pulmonary dysfunction requiring prolonged mechanical ventilation and other associated morbidities and even mortality. Two cases are presented to demonstrate the variability in clinical responses to diaphragmatic dysfunction secondary to phrenic nerve injury from cardiac surgery. In addition, treatment strategies are reviewed including early tracheostomy and diaphragmatic plication, which appear to be the most effective options for patients who are compromised by phrenic injuries. ( info)

2/227. Chronic aneurysm of the descending thoracic aorta presenting with right pleural effusion and left phrenic paralysis.

    A 62-year-old man was admitted to the emergency department with chronic dysphagia and lower back pain. Chest radiography revealed a wide mediastinal shadow and an elevated left diaphragm, which proved to be secondary to left phrenic paralysis. The patient was diagnosed with an aneurysm of the descending thoracic aorta and was admitted to the hospital. After the patient was admitted, the aneurysm ruptured into the right chest. The patient underwent an emergency operation to replace the ruptured segment with a synthetic graft. Postoperative recovery and follow-up were uneventful. This report describes an unusual presentation of a thoracic aortic aneurysm. Hemidiaphragmatic paralysis caused by compression of the phrenic nerve is an unusual complication that, to our knowledge, has not been previously reported. ( info)

3/227. Diaphragmatic paralysis due to lyme disease.

    lyme disease is a tick-borne spirochaete infection which, in a proportion of patients, can lead to neuropathy. This article describes a case of diaphragmatic paralysis due to lyme disease. A 39-yr-old male presented to the hospital because of an acute left facial palsy. Six weeks prior to admission he had developed a circular rash on his left flank during a camping holiday. He also complained of shortness of breath and arthralgia for 1 week. His chest radiograph demonstrated a raised right hemi-diaphragm. Diaphragmatic paralysis was confirmed by fluoroscopy (a positive sniff test). serology revealed evidence of recent infection by borrelia burgdorferi. On the basis of the patient's clinical presentation, a recent history of erythema migrans, and positive Lyme serology, a diagnosis of neuroborreliosis was made. He received oral doxycycline therapy (200 mg x day(-1)) for three weeks. Facial and diaphragmatic palsies resolved within eight weeks. On the basis of this case, a diagnosis of lyme disease should be considered in patients from endemic regions with otherwise unexplained phrenic nerve palsy. ( info)

4/227. Multivascular trauma on an adolescent. Perioperative management.

    Penetrating vascular injury, in particular at the neck, is a life-threatening trauma not only of the nature and the anatomic proximity of cardiovascular, aerodigestive, glandular and neurologic system but also of the development of early and late complications. The following case report describes our experience with a penetrating wound patient, who was admitted to our emergencies twelve hours after the accident. The only demonstrable objective signs included a large hematoma at the right-side of the neck and distended mediastinum on the chest X-ray. As the patient was cardiovascularly unstable he was immediately transported to the theater without any angiography. The mandatory operative exploration was initially unsuccessful and a median sternotomy with a standard cardiopulmonary bypass and deep hypothermia circulatory arrest was established to restore all the vascular lesions. Actually, the patient was in critical condition with a rupture of the right internal jugular vein, a large pseudoaneurysm of the innominate artery and an avulsion of the ascending aorta with the suspicion of a cardiac tamponade. The postoperative period lasted two full months, while complications appeared. The substantial message from this multivascular trauma is the early diagnosis of the life-threatening complications as exsanguinations, ventricular fibrillation and the ability to minimize postoperative complications, which will impair the normal functional life of the patient. ( info)

5/227. Acute neuromuscular respiratory failure after ICU discharge. Report of five patients.

    OBJECTIVE: To describe a syndrome of acute neuromuscular respiratory failure (NM-ARF) caused by ICU-acquired acute myopathy and neuropathy. DESIGN: Case series. SETTING: General Regional University Hospital in Brescia, italy. patients: Five adult patients with NM-ARF after prolonged ICU stay and successful weaning from the ventilator and ICU discharge. INTERVENTIONS: None. MEASUREMENTS: Clinical signs of NM-ARF, electroneurography and electromyography (ENMG) of peripheral nerves and muscles, and functional assessment of respiratory muscles. RESULTS: NM-ARF was diagnosed at the time of (one case), or 1-3 days after, ICU discharge. Limb weakness alarmed the physicians, while the signs of the NM-ARF were initially undetected. In the first observed case the acute respiratory failure was near fatal, and necessitated ICU readmission, while in the other cases 2 weeks of aggressive chest physiotherapy permitted resolution of the respiratory failure. history, clinical course and ENMG indicated the diagnosis of critical illness myopathy and neuropathy (CRIMYNE). Three patients recovered fully, while two had persisting evidence of axonal polyneuropathy several months after the onset. CONCLUSIONS: Critically ill patients with prolonged ICU stay, sepsis and MOF are at great risk of developing CRIMYNE, which in turn may be responsible for NM-ARF. This latter complication may arise after resolution of the respiratory and cardiac dysfunctions and successful weaning from the ventilator. As NM-ARF may cause unplanned ICU readmission or even unexpected death, strict clinical surveillance and monitoring of respiratory muscle function is recommended after discharge to the general ward of patients with proven NM-ARF. Early intensive chest physiotherapy can resolve the condition. ( info)

6/227. Reversibility of paraneoplastic bilateral diaphragmatic paralysis after nephrectomy for renal cell carcinoma.

    Bilateral diaphragmatic paralysis is usually caused by anatomic lesions of both phrenic nerves (e.g., after cardiothoracic surgery), generalized neurologic diseases (e.g., primary motor neuron disease, amyotrophic lateral sclerosis) or is without a known cause (idiopathic). We report a case of a patient with renal cell carcinoma complicated by an isolated bilateral diaphragmatic paralysis without clinical or electromyographic signs of other muscle or nerve involvement. There has been progressive, though till now partial, recovery of his vital capacity rising from 44% to 72% of predicted values, and maximal inspiratory pressures during the two years following the curative resection of his renal cell carcinoma. We believe this is the first report of a paraneoplastic bilateral diaphragmatic paralysis with actual recovery after tumour therapy. ( info)

7/227. Bilateral diaphragm paralysis secondary to central von Recklinghausen's disease.

    Bilateral paralysis of the diaphragm is either idiopathic or associated with several medical conditions, including trauma or thoracic surgery, viral infections, and neurologic congenital or degenerative disorders. We describe the case of a 36-year-old man with a history of neurofibromatosis who developed severe bilateral diaphragmatic paralysis from involvement of the phrenic nerve roots with neurofibromas. The patient manifested progressive exertional dyspnea and debilitating orthopnea requiring the use of noninvasive mechanical ventilation at night. A review of the literature reveals that neurofibromatosis is an unrecognized cause of diaphragmatic paralysis. ( info)

8/227. Diaphragmatic plication in the extremely low birth weight infant.

    A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed. ( info)

9/227. Diaphragmatic spinal muscular atrophy with bulbar weakness.

    We present the clinical and histopathological features of a child affected by diaphragmatic spinal muscular atrophy. The child was born with mild distal arthrogryposis, mild hypotonia and developed marked diaphragmatic and bulbar muscle weakness in the first week of life. Electrophysiological and pathological investigations performed at presentation were not conclusive, while the investigations performed at 3 months showed a clear neurogenic picture. Genetic studies excluded involvement of the SMN gene, or of other genes located on chromosome 5q, confirming that this syndrome represents a different entity from typical proximal spinal muscular atrophy. ( info)

10/227. Is vecuronium toxicity abolished by hemodialysis? A case report.

    Vecuronium is a curaric agent, largely used in anesthesia. Indications as to its employ in uremic patients appear to be debated because of partial renal elimination of the drug. A 52-year-old hemodialyzed woman required transplantectomy for rejection. At awakeness after general anesthesia (induced with fentanyl, propofol, and 6 mg of vecuronium, repeated with a single 2 mg dose 30 min later), she presented diafragmatic and muscular limb weakeness that lasted 180 min in spite of prostigmine administration. A 2 h 30 min predilutional hemofiltration was then performed, which induced rapid disappearance of neuromuscular blockade. Even if vecuronium can be used in dialysis patients, one should remember its possible side effects, especially with repeated doses, in determining prolonged neuromuscular blockade. Cautious use of this drug in renal failure is mandatory. Low dosage must be employed and repeated administration avoided. neuromuscular blockade seems to be rapidly reversible with dialytic treatment. ( info)
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