The correct answer is 3. The fact that there is intestinal aeration points to the existence of a fistula of the lower esophageal segment with the trachea or with a bronchus. In this case, pulmonary complications are frequent due to the passage of gastric contents into the airway.

The [HIDDEN] The fact that there is intestinal aeration points to the existence of a fistula of the lower esophageal segment with the trachea or with a bronchus. In this case, pulmonary complications are frequent due to the passage of gastric contents into the airway.

A newborn of 37 weeks gestational age, with no pathological findings in the prenatal ultrasound, presents in the examination performed in the delivery room a "stop" to the passage of the nasogastric tube. Chest and abdominal X-ray showed an atresic esophageal pouch, with normal gastrointestinal pneumatization. After a diagnostic evaluation that ruled out other anomalies and being in a stable respiratory condition, surgical intervention was decided. On what basis was the priority to intervene in this patient based?

Due to the impossibility of swallowing saliva.

Because of frequently associated cardiac malformations.

Because of the risk of aspiration pneumonitis.

Due to the impossibility of enteral feeding.

The prevalence and effects of aspiration among neonates at the time of discharge.

Neonates undergoing heart surgery for CHD are at risk for postoperative gastrointestinal complications and aspiration events. There are limited data regarding the prevalence of aspiration after neonatal cardiothoracic surgery; thus, the effects of aspiration events on this patient population are not well understood. This retrospective chart review examined the prevalence and effects of aspiration among neonates who had undergone cardiac surgery at the time of their discharge. Introduction This study examined the prevalence of aspiration among neonates who had undergone cardiac surgery. Demographic data regarding these patients were analysed in order to determine risk factors for postoperative aspiration. Post-discharge feeding routes and therapeutic interventions were extracted to examine the time spent using alternate feeding routes because of aspiration risk or poor caloric intake. Modified barium swallow study results were used to evaluate the effectiveness of the test as a diagnostic tool. Materials and methods A retrospective study was undertaken of neonates who had undergone heart surgery from July, 2013 to January, 2014. Data describing patient demographics, feeding methods, and follow-up visits were recorded and compared using a χ2 test for goodness of fit and a Kaplan-Meier graph. The patient population included 62 infants - 36 of whom were male, and 10 who were born with single-ventricle circulation. The median age at surgery was 6 days (interquartile range=4 to 10 days). Modified barium swallow study results showed that 46% of patients (n=29) aspirated or were at risk for aspiration, as indicated by laryngeal penetration. In addition, 48% (n=10) of subjects with a negative barium swallow or no swallow study demonstrated clinical aspiration events. Tube feedings were required by 66% (n=41) of the participants. The median time spent on tube feeds, whether in combination with oral feeds or exclusive use of a nasogastric or gastric tube, was 54 days; 44% (n=27) of patients received tube feedings for more than 120 days. Premature infants were significantly more likely to have aspiration events than infants delivered at full gestational age (OR p=0.002). Infants with single-ventricle circulation spent a longer time on tube feeds (median=95 days) than infants with two-ventricle defects (median=44 days); the type of cardiac defect was independent of prevalence of an aspiration event. Aspiration is common following neonatal cardiac surgery. The modified barium swallow study is often used to identify aspiration events and to determine an infant's risk for aspirating. This leads to a high proportion of infants who require tube feedings following neonatal cardiac surgery.

[Congenital Esophageal Atresia].

In this report, we describe the esophageal atresia in terms of current surgical management on the basis of our experience and literatures. Traditionally, infants with esophageal atresia have presented shortly after birth because of an inability to pass an orogastric tube, respiratory distress, or an inability to tolerate feeding. And also, an isolated trachea-esophageal fistula (TEF) usually cases coughing, recurrent pneumonia, or choking during feedings. To ignore these symptoms is to risk a delayed diagnosis. The condition may be associated with other major congenital anomalies such as those seen in the vertebral, anal, cardiac, tracheo-esophageal, renal/radial (VACTER) association, or it may be an isolated defect. Therapeutic strategies for esophageal atresia are a prevention of pulmonary complication by TEF closing and an early establishment of enteral alimentation. We promptly repair healthy infants without performing a gastrostomy and delay repair in infants with high-risk factors such as associated severe cardiac anomaly and respiratory insufficiency. Esophageal atresia has been classically approached through a thoracotomy. The disadvantages of such a thoracotomy have been recognized for a long time, for example winged scapula, elevation of fixation of shoulder, asymmetry of the chest wall, rib fusion, scoliosis, and breast and pectoral muscle maldevelopment. To avoid such disadvantages, thoracoscopic repair was recently reported.

Unilateral pulmonary agenesis associated with oesophageal atresia and tracheoesophageal fistula: A case report with prenatal diagnosis.

We describe herein a case of unilateral pulmonary agenesis (PA) with oesophageal atresia (EA)/tracheoesophageal fistula (TEF) that was diagnosed prenatally and repaired by esophagoesophagostomy with stable postoperative course. The patient was born at 34 weeks gestation, after ultrasonography at 22 weeks gestation showed possible right-sided diaphragmatic eventration or PA and EA was subsequently suspected due to hydramnios. The initial X-ray showed mediastinal shift to the right, and coil up sign of the nasogastric tube, without intracardiac anomaly. Immediately after the diagnosis of EA/TEF and unilateral PA on day 0, the patient was intubated in the operating room, and a gastrostomy tube was placed. After pulmonary status stabilized, at 4 days old, EA/TEF was repaired through a thoracotomy in the right 4 th intercostal space. The right main bronchus was noted to continue into the distal oesophagus; this fistula was ligated and divided, and a single-layer esophagoesophagostomy was performed under mild tension with one vertebral gap. The neonate was maintained on mechanical ventilation and gradually weaned to extubation at 7 days old. The postoperative course was uneventful, with the exception of prolonged jaundice that emerged at 3 months old. Laparoscopic cholangiography at that time excluded biliary atresia, and jaundice resolved spontaneously. The patient has not shown any respiratory symptoms or feeding difficulties as of the 12-month follow-up.

A case series study of therapeutic implications of type IIIb4: a rare variant of esophageal atresia and distal tracheoesophageal fistula.

A wide spectrum of variations can occur in type IIIb esophageal atresia and distal tracheoesophageal fistula [EA-TEF] (Kluth D. Atlas of esophageal atresia. J Pediatr Surg 1976; 11 (6):901-19). The aim of this study was to evaluate the variant anatomy of subtype IIIb4 EA-TEF and its therapeutic implications. We performed a retrospective review of 4 patients of this variant subtype within a series of 259 esophageal atresias, managed over a study period of three years, at our institution. The diagnosis was made at thoracotomy. The overlapping upper and lower esophageal pouches, initially, gave a false impression of esophageal continuity. The long TEF coursed parallel in proximity to the upper pouch (UP) and the trachea needing meticulous dissection. The TEF measured 8-10mm in diameter and was ligated and divided high on the trachea near the thoracic inlet. The patients were followed up by a contrast swallow, radioactive technetium-99m- sulfur colloid scan, echocardiography and bronchoscopy (if indicated). The mean birth weight and gestational age was 2250 g and 38 weeks respectively. The mean follow up was eighteen months (range 5-42 months). An associated anorectal malformation was present in two patients while none had associated congenital heart disease. The Waterston grading was A and B in one patient each and C in two patients. All the patients had muscular UP extending up-to the level of arch of azygous vein (T(3-4)). The lower esophageal pouch (LP) and the fistula extended high, near the thoracic inlet. Tracheal injury occurred in one patient, with thin LP, warranting postoperative elective ventilation. A postoperative barium swallow did not reveal anastomotic leak or stricture in any patient. Follow-up barium swallow showed long LP extending high up in the chest, up to clavicles in all four patients and redundancy of UP in case 1. Severe gastroesophageal reflux was present in two patients. Bronchoscopy revealed tracheomalacia in case 1. Three patients were thriving well at the last follow-up. One patient died at five months of age due to aspiration pneumonia. The knowledge of diagnostic and therapeutic implications of the variant subtype IIIb4 EA-TEF should be in the armamentarium of the treating surgeon to reduce pitfalls in its management.

Esophageal atresia

Diagnosis This condition may be visible, after about 26 weeks, on an ultrasound. On antenatal USG, the finding of an absent or small stomach in the setting of polyhydramnios was considered a potential symptom of esophageal atresia. However, these findings have a low positive predictive value. The upper neck pouch sign is another sign that helps in the antenatal diagnosis of esophageal atresia and it may be detected soon after birth as the affected infant will be unable to swallow its own saliva. On plain X-ray, a feeding tube will not be seen pass through the esophagus and remain coiled in the upper oesophageal pouch. Classification This condition takes several different forms, often involving one or more fistulas connecting the trachea to the esophagus (tracheoesophageal fistula).

Dynamic esophageal patency assessment: an effective method for prenatally diagnosing esophageal atresia.

Esophageal atresia is a major anomaly with a low prenatal detection rate. We propose a sonographic method termed dynamic esophageal patency assessment. This study aimed to assess the feasibility and performance of the dynamic esophageal patency assessment in a high-risk population. A prospective study was conducted in a single tertiary fetal ultrasound unit for 12 months. The study group included pregnant women referred for a targeted scan because of one or more of the following: (1) polyhydramnios; (2) small or absent stomach; (3) vertebral, anal atresia, cardiac, tracheoesophageal fistula, renal, and limb abnormalities; (4) first-degree relative with esophageal atresia; and (5) genetic mutation associated with esophageal atresia. In addition to dynamic esophageal patency assessment, a comprehensive anomaly scan was carried out. The fetal esophagus was observed during swallowing. Cases that demonstrated uninterrupted fluid propagation through the esophagus were classified as normal. Cases that demonstrated interrupted fluid propagation, with the formation of a pouch, were classified as abnormal. Cases with unclear visualization of the esophagus or cases that failed to demonstrate either fluid propagation or a pouch were classified as undetermined. Dynamic esophageal patency assessment results were compared with postnatal findings, considered "gold standard." Test performance indices and intra- and interobserver agreements were calculated. For 12 months, 130 patients were recruited, and 132 fetuses were scanned. The median gestational age (interquartile range) at the time of scan was 31.4 weeks (29.0-35.3). Of 132 fetuses enrolled, 123 (93.2%) were normal, 8 (6%) were abnormal, and 1 (0.8%) was undetermined. Excluded from test performance analysis were 3 cases that were terminated without postmortem autopsy (1 was abnormal and 2 were normal), and a fourth case was excluded as it was classified as undetermined. The detection rate of esophageal atresia was 100%, with no false-positive or false-negative case. Sensitivity, specificity, and positive and negative predictive values of the dynamic esophageal patency assessment were 100%. The Kappa coefficient was 1 for both inter- and intraobserver agreements (P<.0001). The median time (interquartile range) required to complete the dynamic esophageal patency assessment was 6.00 minutes (3.00-13.25). The dynamic esophageal patency assessment is a feasible and highly effective method of ascertaining an intact esophagus and detecting esophageal atresia in suspected cases.

Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula.

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.

Oesophageal atresia.

Oesophageal atresia (OA) encompasses a group of congenital anomalies comprising of an interruption of the continuity of the oesophagus with or without a persistent communication with the trachea. In 86% of cases there is a distal tracheooesophageal fistula, in 7% there is no fistulous connection, while in 4% there is a tracheooesophageal fistula without atresia. OA occurs in 1 in 2500 live births. Infants with OA are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. Associated anomalies occur in 50% of cases, the majority involving one or more of the VACTERL association (vertebral, anorectal, cardiac, tracheooesophageal, renal and limb defects). The aetiology is largely unknown and is likely to be multifactorial, however, various clues have been uncovered in animal experiments particularly defects in the expression of the gene Sonic hedgehog (Shh). The vast majority of cases are sporadic and the recurrence risk for siblings is 1%. The diagnosis may be suspected prenatally by a small or absent stomach bubble on antenatal ultrasound scan at around 18 weeks gestation. The likelihood of an atresia is increased by the presence of polyhydramnios. A nasogastric tube should be passed at birth in all infants born to a mother with polyhydramnios as well as to infants who are excessively mucusy soon after delivery to establish or refute the diagnosis. In OA the tube will not progress beyond 10 cm from the mouth (confirmation is by plain X-ray of the chest and abdomen). Definitive management comprises disconnection of the tracheooesophageal fistula, closure of the tracheal defect and primary anastomosis of the oesophagus. Where there is a "long gap" between the ends of the oesophagus, delayed primary repair should be attempted. Only very rarely will an oesophageal replacement be required. Survival is directly related to birth weight and to the presence of a major cardiac defect. Infants weighing over 1500 g and having no major cardiac problem should have a near 100% survival, while the presence of one of the risk factors reduces survival to 80% and further to 30-50% in the presence of both risk factors.

Surgery_Schwartz

more difficult for the infant to breathe. This leads to further atelecta-sis, which compounds the pulmonary dysfunction. In patients with type C and D varieties, the regurgitated gastric juice passes through the fistula where it collects in the trachea and lungs and leads to a chemical pneumonitis, which further exacerbates the pulmonary status. In many instances, the diagnosis is actually made by the nursing staff who attempt to feed the baby and notice the accumulation of oral secretions.The diagnosis of esophageal atresia is confirmed by the inability to pass an orogastric tube into the stomach (Fig. 39-10). The dilated upper pouch may be occasionally seen on a plain chest radiograph. If a soft feeding tube is used, the tube will coil in the upper pouch, which provides further diagnostic cer-tainty. An important alternative diagnosis that must be consid-ered when an orogastric tube does not enter the stomach is that of an esophageal perforation. This problem can occur in infants

Double aortic arch

Diagnosis Prenatal diagnosis (fetal ultrasound): Today the diagnosis of double aortic arch can be obtained in-utero in experienced centers. Scheduled repair soon after birth in symptomatic patients can relieve tracheal compression early and therefore potentially prevent the development of severe tracheomalacia. Chest X-ray: Plain chest x-rays of patients with double aortic arch may appear normal (often) or show a dominant right aortic arch or two aortic arches . There might be evidence of tracheal deviation and/or compression. Sometimes patients present with radiologic findings of pneumonia.

First_Aid_Step2

Tracheoesophageal f stula Tract between the trachea and esophagus. Associated with defects such as esophageal atresia and VACTERL (Vertebral, Anal, Cardiac, Tracheal, Esophageal, Renal, Limb) anomalies. Presentation: Polyhydramnios in utero, ↑ oral secretions, inability to feed, gagging, aspiration pneumonia, respiratory distress. Diagnosis: CXR showing an NG tube coiled in the esophagus identifes esophageal atresia. The presence of air in the GI tract is suggestive; confrm with bronchoscopy. Treatment: Surgical repair. Congenital diaphragmatic hernia GI tract segments protrude through the diaphragm into the thorax; 90% are posterior left (Bochdalek). Presentation: Respiratory distress (from pulmonary hypoplasia and pulmonary hypertension); sunken abdomen; bowel sounds over the left hemithorax. Diagnosis: Ultrasound in utero; confrmed by postnatal CXR. Treatment: High-frequency ventilation or extracorporeal membrane oxygenation to manage pulmonary hypertension; surgical repair.

Perinatal outcome after ultrasound prenatal diagnosis of persistent right umbilical vein.

Our aim was to describe ultrasound findings and perinatal outcome after prenatal diagnosis of persistent right umbilical vein (PRUV). We performed a retrospective analysis of fetuses with an ultrasound-based prenatal diagnosis of PRUV on record at 2 tertiary centers in Madrid, Spain. We describe clinical, maternal, fetal and perinatal variables for all cases. A total of 20,426 fetuses were delivered between the study centers. We detected 22 cases (0.1%) of PRUV. The male-to-female ratio was 1:1. All cases were intrahepatic type and diagnosed during the second and third trimesters (median, 21 weeks; IQR, 20-29 weeks). Doppler ultrasound revealed normal flow in the ductus venosus in all cases. Nine fetuses (40.9%) had additional ultrasound anomalies but no chromosomal abnormalities. Cardiovascular malformations were the most frequently associated congenital anomalies (4/9), followed by neurological malformations (2/9). In 5 of the cases with no concomitant anomalies, the weight of the newborn was below the tenth percentile for gestational age. Gestational development was normal for the remaining newborns. Delivery was unremarkable, and post-natal evolution was favorable. Our results point to a potential association between PRUV and other fetal malformations and a very low rate of chromosomal abnormalities. Prenatal diagnosis of PRUV should be followed by detailed anatomical evaluation and echocardiography in order to rule out other structural malformations. The indication for a fetal karyotype study must be made on an individual basis considering PRUV type and other ultrasound findings.

[Prognosis assessment of esophageal atresia: our experience of 29 years].

The major advances in neonatal intensive care have made less useful the Waterston's criteria for esophageal atresia (EA) and/or tracheoesophageal fistula (TEF), and other prognostic classifications have been reported. The aim of this study was to determine the influence of various parameters on the outcome of EA-TEF. We reviewed 97 cases admitted in our hospital for 29 years. We divided the cases in two groups in relation to the improvement of our neonatal unit care during the years: 1st. 1971-1982 (n = 46); 2nd. 1983-1999 (n = 51). chi 2 squared test and logistic regression analysis of the influence of several parameters before surgical treatment (Waterston's and Spitz's birth weight groups, pneumonia, ventilator dependence, severity of associated anomalies and cardiac malformations) on mortality was performed. The survival rate increased since 1983, reaching 86.2% in the last 10 years, although the number of neonates with birth weight < 1500 g has increased. Association with a major anomaly increased the mortality significantly in the 2nd. group only (45.5% major vs 7.1% minor and 8.3% none). The cardiac malformations were the most common, not only before 1983 (26.8%), but also since then (31.3%). When the neonate associated a major cardiac malformation the mortality was significantly higher in the 2nd. group (71.4%). The mortality, when pneumonia was present, was significantly higher before 1983 only (75% vs 32.4%), whereas the mortality was significantly increased by the need of ventilator in the 2nd. group only (85.7% vs 9.1%). Before 1983, the best prognostic parameters were the pneumonia and the severity of associated anomalies, whereas only the ventilator dependence was selected between 1983 and 1999. The EA-TEF mortality has decreased in the last years. The associated cardiac malformation is the most common. We think that the ventilator dependence is the most reliable prognostic risk factor, showing a poor physiologic status of the neonate.

Unusual presentation of sacrococcygeal teratomas and associated malformations in children: clinical experience and review of the literature.

Sacrococcygeal teratomas are the most common and best known extragonadal teratomas in neonates and infants, but they sometimes present unique, distinctive features unlike those commonly described, that can be considered exceptional and noteworthy. The Authors reviewed the most significant (Table I, II) clinical, laboratory, radiological and pathologic findings, surgical procedure, and early and long-term results in 5 children, 2 males and 3 females, suffering from sacrococcygeal teratomas. Four of 5 patients were observed and managed in the neonatal age. A prenatal diagnosis had already been made in 2 of them between the 2nd and 3rd trimester of pregnancy. Two patients were also suffering from the Currarino syndrome associated with Hirschsprung's disease and other, multiple malformations and a cloacal anomaly with anal imperforation, respectively. This last developmental anomaly had been prenatally suspected at US scanning, which had demonstrated a severe sacral anomaly and a large abdominal mass with perineal extension and dilated bowel loops. All the infants were born by scheduled caesarean section in a tertiary care hospital and were then referred to the N.I.C.Us. because of a mostly acute clinical presentation, except for case N°4, who was referred at the age of 3.3 years. Laboratory and radiologic investigations confirmed the clinical diagnosis of teratoma on the basis of elevated AFP values and imaging findings. All patients underwent emergency surgical management, in accordance with recommended practice, consisting of complete exeresis of the tumor, including coccygectomy, in 3 of the 5 children. Of the 5 patients, the female newborn affected by the Currarino syndrome, associated with persistence of the common cloacal canal and anal imperforation, died two days after surgery, of cardiovascular and respiratory complications. All the other patients had an uneventful postoperative course. Two years after the first exeresis at birth, relapse was observed in case N° 3, with a malignant component, YST, anticipated by elevated AFP values but negative physical signs and a benign cystic imaging pattern. After adjuvant chemotherapy she underwent a second complete exeresis. So far, 3 years after the second surgery and 5 years after the diagnosis and first treatment, no local recurrence or distant metastases have occurred. The other 3 patients are also all alive, disease-free and with no signs of relapse or distant metastasis, after a follow-up ranging from 2 years to 28 years. None of the 3 cases treated for sacrococcygeal teratoma, operated in 1985, 1984 and 2006, have ever developed functional sequelae such as ano-rectal and/or bladder dysfunction or hypotonia of the lower limbs. From this review of our selected cases and in the light of literature reports, we can draw the following conclusions. Some sacrococcygeal teratomas may have unique characteristics distinguishing them from more common cases, especially those included in the Currarino Syndrome, with or without an association with other malformations such as Hirschsprung's Disease and Cloacal anomalies. Being congenital tumors, prenatal diagnosis by US scan is extremely important in order to decide either for an anticipated delivery or to perform, in critical fetuses, prenatal treatment within highly specialized facilities, or to organize proper perinatal care, always in appropriate facilities where it is possible to define the diagnosis and carry out emergency surgery. An emergency procedure is frequently dictated both by complications related to the mass effect, and by the need to define the histology of the whole mass rather than just small biopsy specimens. Some sacrococcygeal teratomas can hide more or less extensive islands of immaturity or signs of malignant transformation that are clinically evident. The prognosis is generally benign, although AIEOP (Associazione Italiana Ematologia Oncologica Pediatrica) 2004 guidelines pointed out that high levels of circulating markers, including AFP, in children affected by mature or immature teratomas would indicate the presence of micro-foci of YST, marking them out as at high risk. The UKCCSG II (Children UK Cancer Study Group) and the SFOP (Société Française d'Oncologie Pédiatrique) indicated AFP values exceeding 10,000 ng / ml as the threshold identifying a group of patients with severe prognosis. The treatment indicated is early, complete exeresis, followed by a careful, extensive microscopic examination associated, if necessary, with adjuvant chemotherapy, that is indicated before surgery only in infiltrating primary malignant teratomas. Sacrococcygeal teratomas are commonly considered as lesions at particular risk, in which the coccyx must always be removed together with the mass and overlying skin, taking particular care of the deep pelvic fascia to prevent functional disorders of the bladder and anal canal, as well as any motor alterations of the lower limbs, usually due to iatrogenic lesions of the subfascial nerve structures. There is a ananimous consensus that to improve the prognosis, close, long-term clinical, laboratory and imaging surveillance is essential at shorter intervals during the first 5 years after the exeresis and annually thereafter. In newborns or infants suffering from congenital malformations associated with teratomas, definitive surgical correction, if indicated, must obviously be postponed to a proper time, especially in patients with multiple malformations or needing adjuvant chemotherapy, unless a complication arises or the repair cannot be delayed.

Aspiration After Congenital Heart Surgery.

Dysphagia and vocal cord dysfunction are frequent complications after congenital heart surgery. Both are risk factors for aspiration, which can lead to pneumonia, progressive lung disease, and respiratory arrest. A protocol was implemented to promote early detection of aspiration in a high-risk cohort of patients. Retrospective data were collected on all patients under 120 days old who underwent the Norwood procedure, aortic arch repair, Blalock-Taussig shunt placement, or cervical cannulation for extracorporeal membrane oxygenation from 10/2012 to 05/2016 at a single institution. Patients underwent an assessment of symptoms, fiberoptic endoscopic evaluation of swallowing (FEES), and modified barium swallow (MBS) study in the postoperative period prior to initiating oral feeds. Patients with and without aspiration were compared. Of the 96 patients included in the study, one-third (33%) of patients had evidence of vocal cord dysfunction by FEES and just over half (51%) had evidence of aspiration by FEES or MBS. Most (73%) of the patients with aspiration were asymptomatic and a majority (53%) of patients with aspiration had normal vocal cord function. Aspiration is common after congenital heart surgery, and an assessment of vocal cord or swallow function in isolation may lead to underdiagnosis. A comprehensive protocol including MBS and FEES is necessary for the early detection of vocal cord dysfunction and aspiration and may prevent adverse outcomes in high-risk postoperative patients.

Tracheoesophageal fistula

TEF can also occur due to pressure necrosis by a tracheostomy tube in apposition to a nasogastric tube (NGT). Diagnosis TEF should be suspected once the baby fails to swallow after their first feeding during the first day of life. Esophageal atresia can be diagnosed by Ryle nasogastric tube; if the Ryle fails to pass into the stomach, then this indicates esophageal atresia and loss of communication between stomach and esophagus. TEF may be diagnosed by MRI which clarifies the atretic esophagus (if presents) and TEF, as well as its location and anatomy. Gastrograffin contrast swallow should not be used if TEF is suspected, due to its high risk of allergy and severe intractable chest infection. Classification Fistulae between the trachea and esophagus in the newborn can be of diverse morphology and anatomical location. However, various pediatric surgical publications have attempted a classification system based on the below specified types.

Bronchoscopy in newborns with esophageal atresia.

The aim was to evaluate the influence of rigid laryngotracheo-bronchoscopy in newborns with oesophageal atresia (OA) and tracheoesophageal fistula (TOF) in preventing complications, improving diagnosis and surgical treatment. Among 76 consecutive newborns, received in the Paediatric Intensive Care Unit (PICU) from January 1990 to September 2001 with prenatal o perinatal suspected OA, forty-five had one or more other congenital anomalies. They were divided in I Montreal's risk group for 73.7% (56) and in the II one for 26.3% (20). Endoscopic procedure was performed in the operating room with Storz's rigid ventilating bronchoscope just before surgery, in all babies. With bronchoscopic examination we were able to identify the level, number and size of TOF and to visualise anatomical variants in 76 children. 15 children with OA had a gasless abdomen, but an upper pouch fistula was found only in three cases. In another four cases bronchoscopy confirmed the diagnosis of an "H" fistula and cervical surgical approach was established. One case had only oesophageal stenosis. 56 patients had fistula in lower pouch and in the last 38 cases we proceeded with selective transtracheal fistula incannulation and then we provided gastric drainage. One quadriforcation, 2 triforcations, 3 aberrant right upper lobe bronchi, 1 congential subglottic stenosis and 1 associated with a congenital subglottic stenosis and 1 left main bronchus agenesia were detected. No complications were correlated to the procedure and no babies had early pneumonia. Continuous feeding was achieved in 70 out of 76 patients: 46 primary anastomosis with 12 staged repairs (OA I and II type long gap), 4 resections of TEF, 8 oesophagocoloplasty. Nine babies (11.8%) did not survive. Clinical follow-up was possible in all the survivors. Mortality rate in the high-risk patients with OA remains high because of the many complications that may occur. Tracheal endoscopy is useful in improving the diagnostic approach and to prevent pulmonary complications. Fistula incannulation minimizes the risk of gastric distension and its detrimental effect on ventilation, helping the surgeon to identify TEF easily and quickly. Moreover, the endoscopic approach offers obvious advantages for the anaesthesiologist and the surgeon and has proven, in our experience, to be effective.

[A rare case of esophageal atresia type I].

An extremely rare case of type A esophageal atresia is reported. The baby girl patient born spontaneously after a 38-week pregnancy, was diagnosed prenatally with suspected type A esophageal atresia. Diagnosis was confirmed at birth by chest and abdominal X-ray. As per protocol, a naso-esophageal tube was positioned in aspiration and a Stamm gastrostomy made for nutritional purposes. Evaluation of the distance between blind pouches at one month of life showed they were overlapping. At intervention the pouches were found to be united by a fibrous bridge about 1.5 cm long. Anastomosis was carried out with ease. The postoperative course was trouble-free. On the X day the baby girl was being fed completely per os. Histolo-gical examination of the fibrous residue excluded the presence of a mucosa-lined lumen. X-ray examination of the esophageal-gastric passage, one month after the operation, showed the smooth transit of the contrast medium and an adequate anastomotic lumen. At follow-up, at the age of 9 months, the baby was growing normally and being fed per os with a diet appropriate for her age; no oesophageal dilatation was necessary. Type A oesophageal atresias are long-gap forms: they are treated with direct anastomosis after the blind pouches come together spontaneously in the first four months of life. Stress is laid on the rarity of the case. According to Kluth's classification of 1976, this form was described by Mason in 1855 and Jlott in 1905 on the basis of autopsy findings. A review of the literature did not show any similar clinical cases.

Esophageal atresia with distal fistula - unusual case series. Considerations related to epidemiological aspects, malformative associations, and prenatal diagnosis.

Esophageal atresia (EA) is the most frequent and severe congenital anomaly of the esophagus, occurring in 1:2500-1:4500 live births. Five types of EA have been described, EA with tracheoesophageal fistula (TEF) being the most frequent. The aim of this paper is to evaluate epidemiological aspects, malformative associations, and prenatal diagnosis in an unusual case series of EA with distal TEF. The authors are analyzing a series of seven cases of EA with distal TEF. The seven cases of EA with TEF presented occurred during a period of two years, resulting in an unusually increased rate - 1.1:1000 live births. Except a late suspicion of EA (one day before delivery), EA was not diagnosed during prenatal scans despite association with polyhydramnios in two cases and single umbilical artery in four cases. None of the two cases of unilateral renal agenesis or anorectal malformations were diagnosed on prenatal ultrasound scans. In two of the cases, EA was part of VACTERL (vertebral defects, anorectal malformations, heart defects, EA with or without TEF, renal anomalies/dysplasia, and limb defects) association. Despite lack of prenatal diagnosis, postnatal diagnosis of EA was suspected at birth in four cases, at two hours in one case. An increased index of suspicion for congenital structural defects, particularly for EA, should be maintained in the presence of a single umbilical artery and÷or polyhydramnios on prenatal ultrasound scan. Prenatal diagnosis of EA offers the chance for parental counseling, planned birth and transfer for corrective surgery and decreases the risk for postnatal aspiration pneumonia associated with early feedings.

Unusual Cause of Respiratory Distress in a Term Neonate.

<bBackground:</b Respiratory distress is a clinical finding often seen in neonates. Common causes of respiratory distress in this population include respiratory distress syndrome, transient tachypnea of the newborn, infection, aspiration, and cardiac etiologies. We present the case of a neonate who presented with respiratory distress with no identifiable cause on initial workup. The patient was eventually found to have a variant of a genetic mutation that predisposed the infant to this presentation. <bCase Report:</b A term male infant born via spontaneous vaginal delivery was admitted to the pediatric service at 3 weeks of age because of tachypnea. Chest x-ray showed perihilar infiltrates. Septic screen, thyroid function test, sweat test, echocardiogram, intracranial ultrasound, and modified barium swallow were normal. Computed tomography scan of the chest showed ground glass opacities in the upper and lower lobes. Airway evaluation showed no evidence of obstruction or anatomic abnormalities. Bronchoscopy showed no masses or tracheomalacia. Bronchoalveolar lavage was negative for infection. The infant was treated with intravenous antibiotics, steroids, and furosemide but continued to be tachypneic and required supplemental oxygen. Genetic studies were obtained to assess for surfactant deficiencies, and the patient was transferred to another center for a higher level of care. Genetic evaluation was positive for NKX2.1 variance mutation C.190C. The patient's symptoms improved, and he was weaned to room air by 3 months of age. <bConclusion:</b When evaluating a child with unexplained pulmonary disease, clinicians should have a high index of suspicion for interstitial lung disease including surfactant protein mutations.

[Antenatal diagnosis of lung malformations. Apropos of 9 case reports].

The authors report 9 cases of prenatal diagnosis of lung malformations. The diagnoses was performed between 17 to 33 weeks amenorrhea (mean = 25.5 weeks). The clinical findings were: 7 cystic adenomatoid malformations of the lung, 1 intralobar sequestration and 1 bronchogenic cyst associated with extralobar sequestration and esophageal duplication. In two cases of cystic adenomatoid malformation of the lung with polyhydramnios and fetal hydrops death occurred at 27 and 32 weeks amenorrhea. In the seven other cases surgery was performed shortly after birth, before any serious complications occurred. No problems were encountered following the surgical intervention and the remaining lung inflated after a few days. All these children are currently alive and well, without pulmonary or thoracic disorder. The authors first explain the echographic findings in each malformation and later discuss the sonographic criteria of the diagnoses. The antenatal diagnosis permits early recognition and thus adequate management using a team of neonatologists, radiologists and pediatric surgeons. This type management involves: --normal vaginal delivery if there are no obstetrical problems; --if it is possible, artificial ventilation should be avoided as it may increase respiratory distress. If however, it is necessary, the healthy lung should be intubated; --the surgical procedure should be performed as soon as possible, before complications as respiratory distress or recurring pulmonary infections occur; --the major risk of this surgery is respiratory and heart failure when the child is placed in the operating position. A rapid thoracotomy permits the extraction of the compressed lung and the resuscitation of the patient.

Transmediastinal gunshot wound

Previously every stable patient that suffered a TMGSW received extensive evaluation that included chest radiography, oesophagography, esophagoscopy, angiography, bronchoscopy, cardiac ultrasound. Grossman et al. found evidence that the trajectory of the bullet can be delineated with the use of Computed Tomographic Scan (CT). Subsequently other studies demonstrated the use of CT as a screening tool for stable patients who suffered TMGSW is a reliable tool for ruling out, diagnosing and avoiding missed injuries. For example Stassen et al. showed data of 22 stable patients who were screened with CT, chest x ray and abdominal ultrasound; seven patients showed a positive CT scan and required additional evaluation, and of these seven patients, three required surgical management. Additionally the work of Burack et al., whose evaluation of stable patients with penetrating injuries to the mediastinum — this time including stab wounds — relied mostly on CT and ultrasound, showed similar

Recent evaluation of prognostic risk factors in esophageal atresia--a multicenter review of 223 cases.

In this study, 223 cases of esophageal atresia (Type IIIb: 85.7%; Type II: 5.8%; Type IIIc: 4.0%; Type IIIa: 2.2%; Type IV: 2.2%) from 6 pediatric surgery centers of Austria, were retrospectively examined for the following parameters and their influence on the prognosis: Birth weight (2494.7 +/- 702.0 g), gestation week (range 27-42 weeks; mean 37.3 +/- 3.1 weeks), sex (male: n = 128; female: n = 95), long-gap atresia (> or = 2 cm: n = 33), Tracheomalacia (n = 16), associated malformations (n = 122; cardiac 27.4%, renal 17.9%, skeletal 17.0%, anal: 10.3%, intestinal 9.9%, mediastinal 7.6%, chromosomal 2.2%), preoperative aspiration (n = 92), pneumonia (n = 96), anastomotic insufficiency (n = 45), empyema (n = 5), mediastinitis (n = 8), sepsis (n = 32), other medical complications (n = 122, in 80 infants), other surgical complications (n = 57). The mortality rate was 41.3% overall, from 1975 to 1991; however, it was 25% from 1987 to 1991 and 0% in 1991. A statistically significant correlation was found between prognosis and the following factors: Cardiac malformations (p = 0.0001), medical complications except aspiration and pneumonia (p = 0.0001), empyema (p = 0.0081), mediastinitis (p = 0.0214), and sepsis (p = 0.0295). These 5 significant factors were given different points and a prognostic score was calculated by the addition of these points. This score was predictive for survival in 90.6% of cases and for mortality in 94% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prenatal diagnosis of skeletal dysplasia: case report of a fetus with multiple anomalies].

Skeletal anomalies are in the group of anomalies most difficult to be diagnosed antenatally. But, because of high lethality and morbidity rate as well as high possibility to be found again in the next pregnancy, they need to be systematically and actively looked for during every scan. A pregnant woman, aged 18, primigravida, was admitted to the Dept. of Obstetrics and Gynaecology because of polyhydramnios and suspected multiple fetal malformations. Fetal biparietal diameter and abdominal circumference were adequate for 33 weeks gestation, whereas all the long bones were short for the gestational age. A detailed ultrasound morphology check was impossible because of the excessive amount of amniotic fluid, but the skull, brain, lungs, spine and abdomen appeared normal. There was an impression of frontal bossing and left-sided cleft lip. A thoraco-abdominal disproportion was evident. All the extremities were short, feet were normal, and hands were not extended during the whole scan. The woman underwent an uneventful amino-drainage and three days after that she ruptured the membranes, giving birth to a live female, 2150 gr, 46 cm, Apgar score 6/7. The anomalies seen on ultrasound were confirmed after birth. After a series of dyspnea the neonate was transferred to the Dept. of Paediatrics where it underwent a series of further extensive diagnostic procedures and 37 days after birth it passed away. Postmortem examination led to the following diagnoses: Neonatus femininus eutrophicus temporis aetatis. Defectus partis memebranacei septi interventricularis. Ductus arteriosus Botalli persistence. Hypoplasia thymi. Cheliognathopalatoschisis. Low set ears. Extremitates breves. Atelectasis subtotalis pulmonis bilateralis. Foramen ovale apertum cum valvula competent. Oedema cerebri gradus maioris. Majority of fetal skeletal malformations can be relatively easily visualised during ultrasound scans and hence ultrasound is the most sensitive way of prenatal diagnosis of these anomalies. Maternal habitus, fetal position, alteration of amniotic fluid volume and gestational age can be factors that may aggravate check-ups. A prerogative for an early prenatal diagnosis of fetal skeletal anomalies is a well organized scan of each and every fetus that checks all bones, starting with the skull and finishing with hands and feet. Should an anomaly be found an extensive detailed scan by an expert should be performed, as well as karyotyping and a consultation with pediatrician/surgeon. In case of a lethal anomaly, an option of pregnancy termination should be considered and if the parents decide against it, the pregnancy should be closely monitored, with parents fully counseled about the prognosis for the child. In this case the anomaly was noted only after the 30th week of gestation and even then only because the patient came because she had some subjective difficulties because of the excessive amniotic fluid volume. On the other hand, some skeletal dysplasias can be diagnosed only in the late second, early third trimester and sometimes stay unnoticed until the end of pregnancy. This case could not be resolved definitely, for the anomalies were conclusive neither of a specific genetic syndrome, nor of an isolated skeletal dysplasia. Extensive further examination of parents as well as their families is needed in order to be able to give some information about the risks in the next pregnancy. Although skeletal anomalies are extremely difficult to diagnose antenatally, a detailed scan of a complete fetal anatomy between 20 and 32 gestational weeks with special attention given to the entire skeleton, gives certain assurance of excluding majority of major skeletal dysplasias or enables their diagnosis and further adequate plan for pregnancy management.

Tracheoesophageal anomalies in Waterston C neonates: a 30-year perspective.

Two hundred and seventy-eight infants with congenital tracheoesophageal anomalies have been managed at the Columbus Children's Hospital since 1955. Fifty-four (20%) have been classified as high risk using Waterston's criteria of birth weight, associated anomalies, and pneumonitis. The infants have been divided into group I (n = 27, 1955 to 1969) and group II (n = 27, 1970 to 1984) to reflect the onset of mechanical ventilation and effective neonatal intensive care. The mean birth weight of infants in group II was significantly less than in group I (1,753 +/- 390 g v 1,950 +/- 505 g, P less than .05). The incidence of prematurity, measured by gestational age, has significantly increased with 9 of 27 (33%) infants in group II and 2 of 27 (7%) infants in group I less than 32 weeks gestation (P less than .05). The presence or severity of associated anomalies was not significantly different in groups I and II. Twenty patients in group I and 22 patients in group II underwent definitive management of their tracheoesophageal anomaly. Operative survival was 30% in group I and 74% in group II (P less than .05). Long-term survival was 15% in group I and 64% in group II (P less than .05). Early postoperative complications included aspiration pneumonitis, anastomotic leak, or stricture. The most frequent complications in long-term follow-up were recurrent pneumonias, which were observed in 9 of 16 children. Esophageal dysmotility or gastroesophageal reflux was documented in five of these children; four were managed successfully with positional or pharmacologic manipulations while one required an antireflux procedure. Thirty percent (5/16) are asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal atresia

This birth defect arises in the fourth fetal week, when the trachea and esophagus should begin to separate from each other. It can be associated with disorders of the tracheoesophageal septum. Complications Any attempt at feeding could cause aspiration pneumonia as the milk collects in the blind pouch and overflows into the trachea and lungs. Furthermore, a fistula between the lower esophagus and trachea may allow stomach acid to flow into the lungs and cause damage. Because of these dangers, the condition must be treated as soon as possible after birth. Associated birth defects Other birth defects may co-exist, particularly in the heart, but sometimes also in the anus, spinal column, or kidneys. This is known as VACTERL association because of the involvement of Vertebral column, Anorectal, Cardiac, Tracheal, Esophageal, Renal, and Limbs. It is associated with polyhydramnios in the third trimester.

Acute abdomen

Workup Stable patients presenting to A&E (accident and emergency department) or ER (emergency room) with severe abdominal pain will almost always have an abdominal x-ray and/or a CT scan. These tests can provide a differential diagnosis between simple and complex pathologies. However, in the unstable patient, fluid resuscitation and a FAST-ultrasound are done first, and if the latter is positive for free fluid, straight to surgery. They may also provide evidence to the doctor whether surgical intervention is necessary. Patients will also most likely receive a complete blood count (or full blood count in the U.K.), looking for characteristic findings such as neutrophilia in appendicitis. Traditionally, the use of opiates or other painkillers in patients with an acute abdomen has been discouraged before the clinical examination, because these would alter the examination. However, the scientific literature does not reveal any negative results from these alterations. References

[Results of treatment of esophageal atresia].

The aim of the study was to analyze morality, incidence of complications and influence of various prognostic factors on the outcome of patients with esophageal atresia. A retrospective analysis of the records of 109 consecutive cases of esophageal atresia and/or tracheoesophageal fistula operated in 1992-2001 was undertaken. Primary anastomosis was achieved in 68 (62.4%) patients, in 7 (6.4%) procedures aimed at esophageal substitution in future were performed and in 34 (31.2%) delayed anastomosis was primarily planned. Major associated anomalies were found in 55 (50.4%), cardiac anomalies in 19 (17.4%), and more than one associates anomaly in 16 (14.7%) patients. The most frequent surgical complication was anastomotic leak in 11.9%, septic complications were the most frequent and occurred in 66 (60.5%) patients. Gastroesophageal reflux was diagnosed in 30.3% and treated surgically in 14.7% of infants. The overall mortality was 20.2% (22 patients). The most frequent cause of death was sepsis and/or pneumonia. Long gap esophageal atresia was not found to be a significant factor in mortality. Factors significantly increasing mortality were birth weight below 2000g (OR 3.94), cardiac anomalies (OR 3.95), and mechanical ventilation before the operation (OR 2.97). Analysis of the outcome suggests that improved strategy in treating infants with multiple anomalies and more frequent attempts at primary anastomosis even in children in sub optimal general condition at diagnosis could decrease mortality.

Unconventional treatment of neuroenteric cyst in a newborn.

Neuroenteric cysts are uncommon congenital malformations that can require early surgical treatment. The authors report on an unusual treatment of a very large neuroenteric cyst that involved most of the small bowel and extended into the chest. A 1-day-old boy was admitted because of abdominal distension. The prenatal ultrasound results at 8 and 36 weeks had been normal. Examination showed right upper quadrant fullness and mild respiratory distress. A malformed sternum and asymmetric upper thoracic vertebra were seen on the initial x-rays. The possibility of a midthoracic right paravertebral mass was raised. Abdominal ultrasound findings were consistent with a large bowel duplication cyst. Laboratory results were all normal except the bilirubin level, which was (59 mmol/L). During laparotomy, the second part of the duodenum was found to enter a dilated cyst, and the terminal ileum arose from the cyst. The total length of the intact small bowel was 20 cm including a competent ileocecal valve. The site of the biliary duct entering the cyst was not clear. The surgical procedure involved partial resection of the anterior wall of the cyst, creation of an enteric tube from the posterior cyst wall to communicate between the duodenum and the ileum, and addition of another 25 cm of length to the small bowel. An enterocutaneous fistula was created with the proximal portion of the cyst because the site of the papilla of Vater was suspected to enter this part of the cyst. A postoperative HIDA scan showed good uptake with no excretion into the gut or the proximal pouch.(ABSTRACT TRUNCATED AT 250 WORDS)

A Case of the TOF with APV Complicated with Polyhydramnios and Severe Bronchomalacia.

Absent pulmonary valve syndrome (APVS) is a rare congenital heart disease with severe pulmonary insufficiency, characterized with aneurysmal dilation in the pulmonary artery and one or both of its branches. We presented a rare case with APVS and literature review in this letter. Prenatal USG examination of the fetus at the 26th week of gestation revealed severe polyhydramnios, dilatation at right ventricle, and abnormal appearance of the heart. At the 31st gestational week, the baby was born with cesarean section. The newborn had right heart failure but had no hydrops fetalis. Therefore, severe respiratory distress observed in the infant has been associated with pulmonary complications. The infant, who had respiratory acidosis according to blood gas analysis, was intubated and attached to mechanical ventilator. Despite progressively increased respiratory support and other interventions, the infant died on the 3rd day of admission. Compression against bronchial tree and esophagus due to dilated pulmonary artery and its branches may inevitably lead to bronchomalacia and polyhydramnios. In conclusion, presence of polyhydramnios and the possibility of severe bronchomalacia should be kept in mind; and due to the risk of early neonatal mortality, delivery should be performed in a center where pediatric heart surgery is available.

Congenital malformations presenting during the neonatal period.

Discharge of the newborn within 24 to 48 hours after birth makes it more difficult to detect some congenital malformations and increases the need for careful examination and review of the history of the pregnancy, delivery, and nursery course. Progressive physiologic changes after birth, especially in the cardiovascular system, precede the development of signs indicative of disease for certain congenital malformations. Discharge before these changes occur may delay their detection because the newborn is not being monitored by medical or nursing caregivers. The AAP Committee on the Fetus and Newborn has published guidelines for criteria for safe discharge and follow-up evaluation to help create a safe situation for such early discharges. Some specific observations at birth may lead to earlier diagnosis. Careful attention to subtle differences between the initial and follow-up examination, such as a changing cardiac murmur or quality of pulses or abdominal fullness, may provide clues to the diagnosis of congenital malformations. Coordinated suck and swallow with successful feeding and passage of stool and urine within 24 hours after birth should occur before discharge. Reports of feeding difficulties should be reviewed. Although a thorough examination is facilitated by a sleeping infant, documentation of a normal pitched cry helps in the evaluation of the upper airway. Parents should be counseled about signs of illness that warrant medical attention, and early follow-up is needed to detect problems early enough to intervene effectively. In addition, although passage of a feeding tube through each nare and to the stomach with aspiration and measurement of gastric volume is not a routine procedure in the well, term newborn, this may be a useful early diagnostic tool in infants with signs or a maternal or nursery history suggestive of nasal or GI obstruction.

Abdominal trauma

Diagnosis Ten percent of people with polytrauma who had no signs of abdominal injury did have evidence of such injuries using radiological imaging. Diagnostic techniques used include CT scanning, ultrasound, and X-ray. X-ray can help determine the path of a penetrating object and locate any foreign matter left in the wound, but may not be helpful in blunt trauma. Diagnostic laparoscopy or exploratory laparotomy may also be performed if other diagnostic methods do not yield conclusive results. Ultrasound Ultrasound can detect fluid such as blood or gastrointestinal contents in the abdominal cavity, and it is a noninvasive procedure and relatively safe. CT scanning is the preferred technique for people who are not at immediate risk of shock, but since ultrasound can be performed right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning. A normal ultrasound does not rule out all injuries.


We are dealing with a case of severe lithium intoxication (lithemia > 3.5 mEq/L is life threatening), therefore, the therapeutic option of choice is to start hemodialysis urgently. Remember that activated charcoal is NOT indicated in lithium intoxication.

We are dealing with a case of severe lithium intoxication (lithemia > 3.5 mEq/L is life threatening), therefore, the therapeutic option of choice is [HIDDEN]. Remember that activated charcoal is [HIDDEN].

A 46-year-old man with bipolar disorder is brought to the emergency department after an over-ingestion of lithium carbonate. Examination reveals severe tremor, ataxia, dysarthria, myoclonus and fasciculations. Lithemia is 4.1 mEq/L (toxicity > 1.6 mEq/L). Which of the following therapeutic options would be most indicated?

Aminophylline associated with a cathartic.

[Acute intoxication with sustained-release lithium carbonate tablets. A propos of a case].

To describe the case of a patient who ingested 50 sustained release lithium carbonate 400 mg tablets, and reached a late peak concentration above 3 mEq/L. A 32-year-old male with bipolar mood disorder ingested 50 sustained-release lithium carbonate tablets. Upon admission to the emergency room, a gastric wash was performed,from which several tablet remnants were obtained, as well as an intestinal lavage using activated carbon. good general status, no fever, blood pressure 160/90 mm Hg, no edemas. Neurologic, pulmonary, and cardiac examinations were normal. CBC and the chemistry panel were normal. The patient's psychopathological examination suggested a stable status with no apparent manifestations arising from a decompensated mood disorder. Five hours after his massive lithium ingestion the drug's plasma levels were 0.75 mEq/L. At 22 hours post-ingestion a chemistry panel was obtained, which showed serum creatinin at 1.38 mg/dL and a lithium plasma concentration of 3.15 mEq/L. A hemodyalisis trial was attempted for 4 hours. At 73 hours post-ingestion, lithium plasma levels were 0.6 mEq/L, that is, within therapeutic range. The patient was hemodynamically stable and serial blood tests were normal; he was discharged. Acute lithium intoxication with plasma levels above 3 mEq/l can be fatal or result in irreversible neurologicsequelae in almost one third of cases, with persistent cerebellar dysfunction in association with dementia of variable degree, andrenal, blood, and liver disturbances. Sustained-release tablets may prolong absorption and delay peak plasma concentrations. In such cases, therefore, it is recommended that drug plasma concentrations be monitored during 48-72 hours post-ingestion.

Lithium intoxication presenting as altered consciousness and arrhythmia with cardiogenic shock: A case report.

Lithium has been used to treat bipolar disorder. Lithium has a narrow therapeutic index, with a therapeutic level between 0.6 and 1.5 mEq/L. The possible complications of lithium overdose include altered mental status, hand tremor, muscle weakness, nausea, vomiting, diarrhea, seizure, syncope, and arrhythmia. Lithium intoxication can be fatal and is difficult to diagnose in patients without a history of lithium intake. The occurrence of serious cardiac arrhythmias is rare in lithium intoxication. An 81-year-old man was brought to the emergency department because of consciousness disturbance for 2 days. According to his daughter, he had a history of hypertension and diabetes. Recently, his family also observed slurring of speech and easy choking. The physical examination findings were unremarkable. Blood examination only revealed impaired renal function. Twelve-lead electrocardiography revealed sinus rhythm with first-degree atrioventricular block. Chest radiography revealed mediastinal widening. The blood pressures obtained from the 4 limbs showed no significant differences. Subsequently, brain computed tomography revealed no obvious intracranial lesion. A neurologist was consulted, and a recent ischemic stroke could not be ruled out. While in the observation area, his systolic blood pressure decreased to <90 mm Hg and he showed bradycardia, and 12-lead electrocardiography revealed an AV block and long pulse. Contrast-enhanced chest computed tomography revealed no evidence of aortic dissection. Another family member reported a history of lithium intake for bipolar disorder for >30 years. Blood examination revealed a lithium concentration of 2.65 mEq/L. A nephrologist was consulted, and emergency hemodialysis was indicated. Dopamine was administered for his shock status via a right neck central venous catheter. His lithium level gradually declined after the hemodialysis, and blood pressure and consciousness level improved subsequently. The patient was discharged 9 days later in a stable condition. If an emergency physician encounters a patient with altered consciousness and arrhythmia with cardiogenic shock, the patient's drug intake history should be carefully reviewed to rule out cardiovascular problems on the basis of the patient's clinical condition.

Prolonged neurological burden in severe lithium intoxication.

A 53-year-old woman was brought to the Emergency Department for a persistent state of stupor, tremors, fever and oliguria. The patient had been under treatment for depression. The electrocardiogram showed a wider QRS complex; laboratory tests were as follows: urea 110 mg/dL, creatinine 3 mg/dL, sodium 135 mEq/L, potassium 4.5 mEq/L, and lithium 8.0 mEq/L. Renal replacement was initiated to normalize plasma lithium levels; both stupor and speech impairment persisted for several days after dialysis. Complete recovery was achieved several days afterwards.

[Difficulty in determining when to end continuous hemodialysis for lithium intoxication: case report].

The patient was a 26-year-old woman who ingested a total of 230 tablets, including 160 lithium carbonate tablets (200 mg), in a suicide attempt, and was brought to our hospital 5 hr later. After arriving at the hospital, her only complaint was mild nausea, and no neurological abnormalities or renal dysfunction was observed. We were unable to learn the blood concentration of lithium immediately. A forced diuresis was performed after admission, but the nausea persisted. Continuous hemodialysis (CHD) was performed for 23.5 hr starting 19 hr after ingesting the tablets because the patient had ingested a large amount of lithium carbonate, 32,000 mg. Since the nausea resolved after the CHD was started and no manifestations of lithium intoxication had developed as of 91 hr after ingestion, the patient was discharged. The blood lithium concentrations (mEq/L) revealed at a later date showed that the concentration 5 hr (at the time of the initial examination), 19 hr (start of CHD), 44.5 hr (end of CHD), and 91 hr after ingestion (at the time of discharge) was 4.08, 3.30, 1.09, and 0.38, respectively. Blood purification is said to be effective in treating serious lithium intoxication, but it is difficult to judge when to stop. A favorable outcome of treatment of acute lithium intoxication in a patient with normal renal function appears to have been achieved by performing CHD guided by the clinical manifestations, intravascular redistribution times, etc.

Lithium toxicity precipitated by thyrotoxicosis due to silent thyroiditis: cardiac arrest, quadriplegia, and coma.

Lithium is widely used to treat bipolar disorders. Lithium toxicity is generally caused by inappropriately high doses of lithium or impaired lithium excretion. Most lithium is eliminated via the kidneys and, since thyroid hormone increases tubular reabsorption of lithium, thyrotoxicosis could contribute to the development of lithium toxicity. We report a case of severe lithium toxicity that was apparently precipitated by the onset of thyrotoxicosis resulting from silent thyroiditis and dehydration. The patient was a 64-year-old woman who was admitted for muscle weakness in the lower extremities, diarrhea, and palpitations. She had bipolar disorder and was being treated with lithium carbonate, which she discontinued one week before admission. Her circulating lithium levels had been monitored yearly. Early in her admission she was dehydrated and had febrile episodes, paroxysmal atrial fibrillation, and muscle weakness. Initially, fluid therapy was started, but she lost consciousness and had a cardiac arrest for 2 minutes due to prolonged sinus arrest. Chest compression and manual artificial ventilation were performed, and body surface pacing was started. Serum lithium was markedly elevated to 3.81 mEq/L (therapeutic range, 0.4-1.0 mEq/L), and thyroid hormone levels were increased (free triiodothyronine, 8.12 pg/mL; free thyroxine, 4.45 ng/dL), while thyrotropin (TSH) was suppressed (<0.01 μIU/mL). Hemodialysis was performed, and a temporary pacemaker was inserted for severe sinus bradycardia. The serum thyroglobulin was 4680 ng/mL (reference range, <32.7 ng/mL). A TSH receptor antibody test was negative. Glucocorticoid therapy and inorganic iodine (100 mg) were administered and continued until day 11. However, her neurological symptoms deteriorated with floppy quadriplegia and deep coma. She gradually recovered. On day 36, she was discharged without any neurological symptoms or thyrotoxicosis. A 64-year-old woman taking lithium for bipolar disorder developed lithium toxicity in the setting of what seemed likely to be a recent onset of thyrotoxicosis due to silent thyroiditis. Thyrotoxicosis may be a contributing cause of lithium toxicity, particularly if it is abrupt in onset and even with cessation of lithium therapy if renal function is compromised. Thyroid function should be assessed immediately in patients with suspected lithium toxicity.

[Reversible choreoathetosis associated with lithium intoxication].

Several reports have been published in the literature of choreoathetosis associated with lithium intoxication, but little is known about choreoathetosis without concurrent antipsychotic treatment. We report a 65-year-old woman with lithium intoxication whose choreoathetosis completely recovered without sequela following decrease of her serum lithium level. She had been treated elsewhere for bipolar II disorder and also for hypertension, chronic hepatitis type C and diabetes mellitus. As she became hypomanic, lithium carbonate at 600 mg/day was commenced, which was increased to 1200 mg/day due to unfavorable therapeutic response. She began to manifest disorientation and abnormal involuntary movement and was therefore referred to our Department of Psychiatry. Her clinical symptoms at admission included consciousness disturbance with marked bilateral symmetrical slow-wave activity in her EEG and choreoathetosis was observed in her face and upper and lower extremities. Cerebellar symptoms were minimal with only mild ataxic gait and finger-to-nose test did not show dysmetria or intention tremor. Her serum lithium level was 3.52 mEq/L, which was clearly in the toxic range. She demonstrated no metabolic abnormalities including hyperglycemia, and was diagnosed with lithium intoxication and treated with water loading and mannitol for forced diuresis. On the 14th day after admission her consciousness disturbance and choreoathetosis resolved, but EEG abnormalities still persisted. On the 23rd day after admission, she was discharged with clinical remission and normal EEG background activity. Although she developed mild renal dysfunction, hemodialysis was not indicated. Hypersensitivity of dopamine receptor in the nigrostriatal pathways may contribute to choreoathetosis in association with the patient's vulnerability. Choreoathetosis can be a sign of lithium intoxication and prompt treatment is required following careful differential diagnosis.

[Lithium sulfate poisoning treated with hemodialysis in a patient with normal renal function: a case report].

Lithium is the milestone of psychiatric patients' therapy, in particular in bipolar disorder. Despite its high therapeutic efficacy, there are several side effects (renal, thyroid, parathyroid, dermatological) and management problems linked to its narrow therapeutic range, which exposes patients to a high risk of toxicity. We describe the case of a male patient with bipolar disorder in therapy with lithium sulfate who developed a severe acute-on-chronic intoxication. He came to our attention in a somnolent state with lithemia >3 mEq/L and therefore underwent hemodialysis. In view of the high toxicity of lithium, a timely and correct therapeutic choice is important to improve the patient's outcome. In this context, considering lithemia, but also kidney function and the patient's clinical status, it is necessary to consider extracorporeal treatments, of which hemodialysis is the most preferable.

Lithium toxicity

Gastric lavage and whole bowel irrigation may be useful if done early. Activated charcoal is not effective. For severe toxicity hemodialysis is recommended. The risk of death is generally low. Acute toxicity generally has better outcomes than chronic toxicity. In the United States about 5,000 cases are reported to poison control centers a year. Lithium toxicity was first described in 1898. Signs and symptoms Symptoms of lithium toxicity can be mild, moderate, or severe. Mild symptoms include nausea, feeling tired, and tremor occur at a level of 1.5 to 2.5 mEq/L. Moderate symptoms include confusion, an increased heart rate, and low muscle tone occur at a level of 2.5 to 3.5 mEq/L. Severe symptoms include coma, seizures, low blood pressure and increased body temperature which occur at a lithium concentration greater than 3.5 mEq/L. When lithium overdoses produce neurological deficits or cardiac toxicity, the symptoms are considered serious and can be fatal.

Treatment of bipolar disorder

Potential side effects from lithium include gastrointestinal upset, tremor, sedation, excessive thirst, frequent urination, cognitive problems, impaired motor coordination, hair loss, and acne. Excessive levels of lithium can be harmful to the kidneys, and increase the risk of side effects in general. As a result, kidney function and blood levels of lithium are monitored in patients being treated with lithium. Therapeutic plasma levels of lithium range from 0.5 to 1.5 mEq/L, with levels of 0.8 or higher being desirable in acute mania. Lithium levels should be above 0.6 mEq/L to reduce both manic and depressive episodes in patients. A recent review concludes that the standard lithium serum level should be 0.60-0.80 mmol/L with optional reduction to 0.40-0.60 mmol/L in case of good response but poor tolerance or an increase to 0.80-1.00 mmol/L in case of insufficient response and good tolerance.

Antacid-induced hypermagnesemia in a patient with normal renal function and bowel obstruction.

To report a case of severe hypermagnesemia caused by magnesium hydroxide in a woman with normal renal function. A 42-year-old Hispanic woman with schizophrenia and bipolar affective disorder was transported from jail to the emergency department with confusion, abdominal pain, vomiting, and constipation. She had been treated in jail with magnesium hydroxide, ordered as milk of magnesia 30 mL po each night and Maalox 30 mL po three times daily. Additional medications included lithium carbonate 300 mg po three times daily, chlorpromazine 150 mg po three times daily, benztropine mesylate 1 mg po twice daily, and docusate sodium 100 mg po each morning. Her temperature was 35.1 degrees C, blood pressure 108/58 mm Hg, heart rate 112 beats/min, and respiratory rate 24 breaths/min. She would respond only briefly to voice or painful stimuli. Her abdomen was distended and diffusely tender. Laboratory tests included serum magnesium concentration 9.1 mEq/L (normal 1.3-2), blood urea nitrogen 16 mg/dL (8-22), creatinine 0.9 mg/dL (0.5-1.1), calcium 3.9 mEq/L (4.2-5.2), and lithium 1.0 mEq/L. A laparotomy was performed, and an adhesive band from a previous oophorectomy was found to be compressing the sigmoid colon. Hypermagnesemia, hypothermia, and hypotension continued in the intensive care unit. Despite successful treatment of the hypermagnesemia with calcium, intravenous fluids, and furosemide, the patient's cardiac rhythm degenerated into fatal, pulseless electrical activity on postoperative day 2. This case of severe hypermagnesemia from magnesium hydroxide ingestion illustrates many of the risk factors for hypermagnesemia in patients with normal renal function. People using magnesium-containing medications for relief of gastrointestinal distress may be at increased risk for hypermagnesemia. A brief review of magnesium physiology, clinical effects, and treatment is provided. Frequent use of the laboratory to identify hypermagnesemia is encouraged because it is often a clinically unexpected finding and responds well to early treatment.

[Diagnostic trap: Lithium neurotoxicity with normal lithemia].

We describe here the case of a 54-year-old bipolar woman, followed in psychiatry and treated with lithium and a selective serotonin reuptake inhibitor (escitalopram) and lamotrigine, presenting a lithium poisoning with an altered state of consciousness caused by a supposed mismanagement of her treatment. Lithium poisoning was suggested based on neurological clinical features, but the blood test brought out a lithium concentration within the therapeutic values at 1,2 mmol/L (N: 0,6-1,2 mmol/L). The classic biological complications related to lithium poisoning (hypercalcemia, diabetes insipidus) confirmed the diagnosis. The patient has been transferred to our nephrology department where she got two hemodialysis sessions conducting to clinical and biological improvement, confirming the diagnosis of lithium poisoning despite the normal blood levels. Later, she was transferred to the psychiatry department for follow-up and for treatment adjustment.

InternalMed_Harrison

A 63-year-old man was admitted to the intensive care unit (ICU) with a severe aspiration pneumonia. Past medical history included schizophrenia, for which he required institutional care; treatment had included neuroleptics and intermittent lithium, the latter restarted 6 months before admission. The patient was treated with antibiotics and intubated for several days, with the development of polyuria (3–5 L/d), hypernatremia, and acute renal insufficiency; the peak plasma Na+ concentration was 156 meq/L, and peak creatinine was 2.6 mg/dL. Urine osmolality was measured once and reported as 157 mOsm/kg, with a coincident plasma osmolality of 318 mOsm/kg. Lithium was stopped on admission to the ICU. On physical examination, the patient was alert, extubated, and thirsty. Weight was 97.5 kg. Urine output for the previous 24 h had been 3.4 L, with an IV intake of 2 L/d of D5W.

Lithium intoxication-induced acute parkinsonism complicated with hyperparathyroidism and nephrogenic diabetes insipidus: report of a case.

To describe a patient with lithium intoxication presenting as acute parkinsonism, adverse metabolic effects and nephrogenic diabetes insipidus (DI). We report a case of a 67-year-old woman with a bipolar affective disorder who was treated with lithium for 10 years. Under concomitant renal insufficiency and urinary tract infarction, she experienced progressive hand tremor, bradykinesia, and unsteady gait. Laboratory results revealed hypercalcemia and hypermagnesiemia. A high serum lithium level (3.6 mEq/L) was found; thus lithium was discontinued. She was found to have a high serum level of intact parathyroid hormone: 135.0 pg/ml and a suspicious parathyroid adenoma. Polyuria with hypernatremia was also noted. A water deprivation test confirmed nephrogenic diabetes insipitces. After correction of electrolyte imbalance and reduction of lithium level, her consciousness recovered. Her parkinsonian features were responsive to levodopa 400 mg/day in 2 divided doses. One month later, apart from the residual extrapyramidal symptoms and mania, her condition was otherwise stationary. Tremor is the most frequent movement disorder associated with lithium therapy, while severe parkinsonism has been rarely reported. It should be kept in mind in differential diagnosis of acute parkinsonism especially in elder patients who receive a chronic lithium carbonate therapy.

[Reversible alterations in the dentate nuclei and rapid-onset cerebral atrophy due to neurotoxicity caused by lithium].

Treatment with lithium can cause several neurological side effects, even at therapeutic levels. We report the case of a 49-year-old woman, with bipolar disorder and depression, undergoing treatment with lithium, antidepressants and antipsychotics, who was admitted to hospital due to a clinical picture of visual hallucinations with an elevated lithaemia of 2.1 mEq/L (therapeutic range: 0.6-1.2 mEq/L). The patient developed a severe encephalopathy that required the use of assisted ventilation in the intensive care unit. Initial magnetic resonance imaging showed a reversible bilateral symmetrical hyperintensity in the dentate nuclei in T2 and T2-FLAIR sequences. Over the following months she gradually developed a pancerebellar syndrome with evidence of a marked loss of bilateral volume in the cerebellum, above all at the expense of the vermis, which was accompanied by a permanent and disabling cerebellar syndrome. Although treatment with lithium can cause a variety of neurological side effects, they are usually reversible. However, they occasionally give rise to permanent and disabling sequelae, as in the case of the patient reported here, with a marked and progressive cerebellar atrophy, accompanied by permanent sequelae in the form of a disabling cerebellar syndrome. The cerebellar neurotoxicity of lithium must be taken into account in the broad differential diagnosis of cerebellar ataxia in adults.

Use of the anion gap and intermittent hemodialysis following continuous hemodiafiltration in extremely high dose acute-on-chronic lithium poisoning: A case report.

A 35-year-old woman intentionally took 40,000 mg of lithium carbonate, and she was transferred to our hospital with nausea, vomiting, and diarrhea. She was diagnosed as having bipolar disorder 10 years ago and was receiving oral lithium therapy. Blood test results on arrival were remarkable for a negative anion gap of -2.1 and later, the serum lithium level turned out to be as high as 15.4 mEq/L. Intubation was required because of disrupted consciousness, and continuous hemodiafiltration (CHDF) was immediately started in the intensive care unit to obtain constant removal of lithium. After adding intermittent hemodialysis (IHD) twice during the daytime to accelerate the lithium clearance, CHDF became unnecessary on day 4, and she was extubated on day 6 with complete recovery of consciousness. Close monitoring of the patient data showed recovery of the decreased anion gap as indicator of the serum lithium level reduction. On day 36, she was discharged without any complication and sequela. The current case highlighted the effective use of CHDF between IHD sessions to prevent the rebound elevation of lithium and the role of the anion gap as a surrogate marker of serum lithium concentration during the treatment.

Mood stabilizer

Mineral Lithium – Lithium is the "classic" mood stabilizer, the first to be approved by the US FDA, and still popular in treatment. Therapeutic drug monitoring is required to ensure lithium levels remain in the therapeutic range: 0.6 or 0.8-1.2 mEq/L (or millimolar). Signs and symptoms of toxicity include nausea, vomiting, diarrhea, and ataxia. The most common side effects are lethargy and weight gain. The less common side effects of using lithium are blurred vision, a slight tremble in the hands, and a feeling of being mildly ill. In general, these side effects occur in the first few weeks after commencing lithium treatment. These symptoms can often be improved by lowering the dose.

Lithium (medication)

Lithium concentrations in whole blood, plasma, serum or urine may be measured using instrumental techniques as a guide to therapy, to confirm the diagnosis in potential poisoning victims or to assist in the forensic investigation in a case of fatal overdosage. Serum lithium concentrations are usually in the range of 0.5–1.3 mmol/L (0.5–1.3 mEq/L) in well-controlled people, but may increase to 1.8–2.5 mmol/L in those who accumulate the drug over time and to 3–10 mmol/L in acute overdose. Lithium salts have a narrow therapeutic/toxic ratio, so should not be prescribed unless facilities for monitoring plasma concentrations are available. Doses are adjusted to achieve plasma concentrations of 0.4 to 1.2 mmol /L on samples taken 12 hours after the preceding dose. Given the rates of thyroid dysfunction, thyroid parameters should be checked before lithium is instituted and monitored after 3–6 months and then every 6–12 months.

Lithium toxicity

Gastric lavage. A tube is placed through the nose or mouth into the stomach. The tube is used to remove lithium that has not been digested yet. It may also be used to put medicines directly into the stomach to help stop lithium from being absorbed. Use of an artificial kidney to clean the blood (dialysis). This is usually done only in the most severe cases. Diuretic medications such as furosemide and hydration via intravenous normal saline appear to be effective in speeding the removal of lithium and also rehydrate patients who've lost fluids. Hemodialysis. Hemodialysis is widely advocated as a means of reducing the risk of permanent neurological sequelae following lithium poisoning. Although hemodialysis clearly enhances the elimination of lithium, it is unclear whether this translates into improved patient outcomes. People may be sent home once their lithium level is less than 1.5 mEq/L and they have no symptoms. See also

InternalMed_Harrison

A stuporous 22-year-old man was admitted with a history of behaving strangely. His friends indicated he experienced recent emotional problems stemming from a failed relationship and had threatened suicide. There was a history of alcohol abuse, but his friends were unaware of recent alcohol consumption. The patient was obtunded on admission, with no evident focal neurologic deficits. The remainder of the physical examination was unremarkable. Na+ 140 meq/L K+ 5 meq/L Cl− 95 meq/L HCO3− 10 meq/L Glucose 125 mg/dL BUN 15 mg/dL Creatinine 0.9 mg/dL Ionized calcium 4.0 mg/dL Plasma osmolality 325 mOsm kg/H2O Urinalysis revealed crystalluria, with a mixture of envelope-shaped and needle-shaped crystals.

Neurology_Adams

With blood levels of lithium in the upper therapeutic range (therapeutic 0.6 to 1.2 mEq/L), it is not uncommon to observe a fast-frequency action tremor or asterixis, together with nausea, loose stools, fatigue, polydipsia, and polyuria. These symptoms usually subside with time. Above a level of 1.5 to 2 mEq/L, particularly in patients with impaired renal function or in those taking a thiazide diuretic, serious intoxication becomes manifest—clouding of consciousness, confusion, delirium, dizziness, nystagmus, ataxia, stammering, diffuse myoclonic twitching, and nephrogenic diabetes insipidus. Vertical (downbeating) nystagmus and opsoclonus (see Chap. 13) may also be prominent. A variety of skin problems is common including worsening of acne vulgaris. An uncommon toxic effect is the development of goiter but most patients remain euthyroid although the thyroid-stimulating hormone (TSH) levels may increase slightly. The goiter usually requires no treatment but it is possible to

Neurology_Adams

becomes effective, usually a matter of 4 or 5 days. The usual dosage of lithium is 1,200 to 2,400 mg daily in divided oral doses, which produces a desired serum level of 0.9 to 1.4 mEq/L. The serum level of lithium must be checked frequently, both to ensure that a therapeutic dose is being taken and to guard against toxicity (see later).

InternalMed_Harrison

In the treatment of acute mania, lithium is initiated at 300 mg bid or tid, and the dose is then increased by 300 mg every 2–3 days to achieve blood levels of 0.8–1.2 meq/L. Because the therapeutic effect of lithium may not appear until after 7–10 days of treatment, adjunctive usage of lorazepam (1–2 mg every 4 h) or clonazepam (0.5–1 mg every 4 h) may be beneficial to control agitation. Antipsychotics are indicated in patients with severe agitation who respond only partially to benzodiazepines. Patients using lithium should be monitored closely, since the blood levels required to achieve a therapeutic benefit are close to those associated with toxicity. Valproic acid may be better than lithium for patients who experience rapid cycling (i.e., more than four episodes a year) or who present with a mixed or dysphoric mania. Tremor and weight gain are the most common side effects; hepatotoxicity and pancreatitis are rare toxicities.

InternalMed_Harrison

A 32-year-old man was admitted to the hospital with weakness and hypokalemia. The patient had been very healthy until 2 months previously when he developed intermittent leg weakness. His review of systems was otherwise negative. He denied drug or laxative abuse and was on no medications. Past medical history was unremarkable, with no history of neuromuscular disease. Family history was notable for a sister with thyroid disease. Physical examination was notable only for reduced deep tendon reflexes. Sodium 139 143 meq/L Potassium 2.0 3.8 meq/L Chloride 105 107 meq/L Bicarbonate 26 29 meq/L BUN 11 16 mg/dL Creatinine 0.6 1.0 mg/dL Calcium 8.8 8.8 mg/dL Phosphate 1.2 mg/dL Albumin 3.8 meq/L TSH 0.08 μIU/L (normal 0.2–5.39) Free T4 41 pmol/L (normal 10–27)

[Origin and treatment of the hypokalemic paresis (author's transl)].

The abuse of laxatives and a prolonged treatment with diuretics has to be brought into consideration as the most common cause for renal or intestinal loss of potassium. Besides characteristical alterations at the E.C.G. and besides intestinal disturbances there do occur again and again acute, life-threatening aspects of cases connected with tetraplegias and a respiratory failure. By means of 3 cases from our hospital and 27 casuistics in literature symptomatology and dynamic in the development of hypokaliemia is discussed. The mean of potassium in the serum of the 16 patients, those having quadriplegias, ran up to 1,7 mval/l (range 1,4-2,5). Paralysis develops peracutely in 4 of the cases within hours and in 12 of the cases within days. In the anamnesis symptoms of adynamia could be traced with nearly every patient. A functional psychosis (reversible physically founded psychosis) couldn't be detected in any of the cases. With the help of a administration of potassium one could achieve a total retrogression of the symptoms. Besides this a normalisation of the acide-base equilibrium is required because of a metabolic alkalosis, detectable in most of the cases.

[Aetiologies of lithium overdose: 10-year experience of Marseille poison centre].

Lithium is used for control of bipolar disorders. In order to precise the different circumstances at the origin of poisonings, the authors present the cases of lithium intoxication observed in the Marseille poison centre between January 1991 and December 2000. Retrospective study. Three hundred and four cases were observed during the studied period (1 patient a case), concerning 6 different circumstances. For 3 of them, the symptoms were mild: accidental ingestion with children (13 cases); mistakes on the quantities of ingested tablets (43 cases); elevation of lithium blood level due to diuretic therapy (8 cases). For 2 other circumstances, the clinical signs were more severe: treated patients who developed renal failure (15 cases, 6 patients managed in intensive care unit [ICU], 1 death) or dehydration (35 cases, 8 patients treated in ICU and 1 death). Finally, the most severe cases were collected with suicide attempts. Fifty-six percent of the patients were managed in ICU, 5% needed haemodialysis, 10% had cardiac (repolarization disturbances) or neurological (seizures) complications, 2% died. The severity of lithium poisonings depends of the circumstances. Ingestion of high quantities of sustained released tablets is the most dangerous situation. Accidental ingestion, even with children, must be considered as less severe situations.

Neurology_Adams

The myoclonic state, particularly when combined with confusion and sharp waves in the EEG, may mimic Creutzfeldt-Jakob disease (see Chap. 32) but there should be no problem in diagnosis if the setting of the illness and the administration of lithium are known. At blood lithium concentrations above 3.5 mEq/L, these symptoms are replaced by stupor and coma, sometimes with convulsions, and may prove fatal. Discontinuing lithium in the intoxicated patient, which is the initial step in therapy, does not result in immediate disappearance of toxic symptoms. This may be delayed by a week or two, and the diabetes insipidus may persist even longer. Fluids, sodium chloride, aminophylline, and acetazolamide promote the excretion of lithium. Lithium coma may require hemodialysis, which has proved to be the most rapid means of reducing the blood lithium concentration.

Lithium carbonate

Lithium carbonate is used as a psychiatric medication to treat mania, the elevated phase of bipolar disorder. Prescription lithium carbonate from a pharmacy is suitable for use as medicine in humans while industrial lithium carbonate is not since the latter may, for example, contain unsafe levels of toxic heavy metals or other toxicants. After ingestion, lithium carbonate is dissociated into pharmacologically active lithium ions (Li+) and (non-therapeutic) carbonate, with 300 mg of lithium carbonate containing approximately 8 mEq (8 mmol) of lithium ion. According to the Food and Drug Administration (FDA), 300–600 mg of lithium carbonate taken two to three times daily is typical for maintenance of bipolar I disorder in adults, where the exact dose given varies depending on factors such as the patient's serum lithium concentrations, which must be monitored by a physician to avoid lithium toxicity and potential kidney damage (or even failure) from lithium-induced nephrogenic diabetes

Lithium -- Toxicity -- Recommendations

The guidelines established by EXtracorporeal TReatments In Poisoning (EXTRIP) are listed below. Initiate extracorporeal treatment for patients with severe lithium poisoning presenting with coma, myoclonus, convulsions, or cardiopulmonary collapse. Initiate extracorporeal treatment when impaired kidney function is evident, and the lithium concentration surpasses 4 mEq/L. Hemodialysis is also indicated in patients with altered consciousness, seizures, or life-threatening dysrhythmias, regardless of the lithium concentration. Consider extracorporeal treatment if the lithium concentration exceeds 5 mEq/L, significant confusion is evident, or the projected duration for reducing the lithium concentration below 1 mEq/L extends beyond 36 hours. Continue extracorporeal treatment until clinical improvement or lithium concentration drops below 1 mEq/L. In cases where lithium concentration measurement is unattainable, maintain extracorporeal therapies for at least 6 hours.

Lithium toxicity

Lithium toxicity, also known as lithium overdose, is the condition of having too much lithium. Symptoms may include a tremor, increased reflexes, trouble walking, kidney problems, and an altered level of consciousness. Some symptoms may last for a year after levels return to normal. Complications may include serotonin syndrome. Lithium toxicity can occur due to excessive intake or decreased excretion. Excessive intake may be either a suicide attempt or accidental. Decreased excretion may occur as a result of dehydration such as from vomiting or diarrhea, a low sodium diet, or from kidney problems. The diagnosis is generally based on symptoms and supported by a lithium level of greater than 1.2 mEq/L.

Case report on lithium intoxication with normal lithium levels.

An 18-year old female was admitted to a psychiatric hospital with an initial episode of mania. Treated with routine dosages of lithium bicarbonate, her symptoms resolved after two weeks; she was discharged on a dosage of 250mg lithium bid. Five days after discharge she was taken to the emergency department of a general hospital with loss of appetite and disturbed consciousness. The general hospital physicians were unable to diagnose the problem so she was transferred back to the psychiatric hospital. At that time she had a lithium blood level of 0.57 mmol/L (i.e., at the lower end of the therapeutic range) but was, nevertheless, clearly experiencing lithium intoxication with anuria, trembling extremities, blurred speech, muscle rigidity and hyperactive tendon reflexes. Treated with intravenous mannitol, her acute symptoms resolved quickly. The case highlights the need to monitor clinical symptoms of intoxication in all patients taking lithium, regardless of their blood level, and to inform patients, family members, and general physicians about the symptoms and management of lithium intoxication.

[Analysis of the poisonings by lithium in a department of internal medicine].

Lithium salts have been mainly used in the treatment of bipolar disorder. Because of its narrow therapeutic range, and several well characterised adverse effects, serum lithium levels must be monitored regularly in patients given lithium treatment in order to prevent intoxication. To describe the clinic and toxic characteristics in inpatients at our Clinic Toxicologic Unit. Descriptive and retrospective study of lithium intoxications in 150 inpatients between 2003 and 2006. Patients were classified based on their neuropsychiathric symptom profile and serum lithium levels. Sixteen of 150 inpatients had lithium intoxication: 58.3% women and 43.8% men; 49.19% +/- 18.49% years old. Lithium was used as treatment of bipolar disorder in 87.5% of cases. The most frequent cause of intoxication was attempted suicide. Using neuropsychiatric parametres, intoxication was moderate in 50% of cases, and mild in 25% and severe or very severe in 25%. Using serum lithium levels, intoxication was very severe in 31.35%, severe in 25%, and slight-moderate in 43.7%. Conservative measures were used as the most frequent treatment (50%), and haemodialfiltration was needed in 37.5%. Mean stay was 4,8 days in acute intoxication, and 11.2 days in chronic. Sequelaes were found in two patients (ataxia). Death was not present. Lithium intoxications can involve severe complications, even death. Narrow control is encouraged in polymedicated and elderly patients, and in concommitant treatment with antidepressant and neuroleptics.

Lithium toxicity with prolonged neurologic sequelae following sleeve gastrectomy: A case report and review of literature.

Lithium is the first-line medication for bipolar disorder, given a narrow therapeutic window of 0.8 to 1.2 mEq/L. Change of lithium pharmacokinetics following bariatric surgery may lead to lithium toxicity, which is particularly concerned. We presented a 39-year-old man with morbid obesity and bipolar affective disorder for 20 years, who was treated with lithium. He developed serious lithium toxicity following sleeve gastrectomy and prolonged neurologic sequelae. He suffered from persistent watery diarrhea, general weakness, and then drowsy consciousness. Lithium level was checked immediately to be 3.42 mEq/L and lithium toxicity was diagnosed. After 3 courses of hemodialysis, his serum lithium level subsequently declined to 0.63 mEq/L, while his consciousness returned normal. Lithium was replaced by lamotrigine. The patient was discharged thirty-five days after admission, while his serum lithium declined to 0.06 mEq/L. Neurologic sequelae were noted by muscle weakness and pain sensation in both feet. The nerve conduction test revealed sensorimotor polyneuropathy with conduction block. He was advised to keep a passive range of motion exercise. Although the consensus guideline remains lacking, our report reviewed cases of relevance in the literature and highlighted the awareness of the potential risk of lithium toxicity following bariatric surgery. We suggest close monitoring of the lithium levels and perhaps a dosage adjustment for the postoperative period.