Letters to the Editor
operation for breech presentation as an etiological factor. As the patient was hemodynamicaly unstable, the decision of laparotomy was chosen. Unicornuate uterus with rudimentary horn is associated with increase rate of abortions and miscarriages. However, missing the diagnosis can lead to fatal complications, while early detection can save the life of the patient. Lata Indu, Kapoor Deepa1, Agarwal Shalini1, Niyaz Zafar2
Departments of Maternal and Reproductive Health, 1Obstetrics and Gynaecology, and 2Radiodignosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
REFERENCES 1. 2. 3.
Daskalakis G, Pilalis A, Lykeridou K, Antsaklis A. Rupture of noncommunicating rudimentary uterine horn pregnancy. Obstet Gynecol 2002;100:1108‑10. Schmied R, Sentilhes L, Baron M, Grzegorczyk V, Resch B, Marpeau L. Recurrence of a rudimentary uterine horn rupture at 25 weeks of gestation: A case report. Gynecol Obstet Fertil 2008;36:296‑8. Reichman D, Laufer MR, Robinson BK. Pregnancy outcomes in unicornuate uteri: A review. Fertil Steril 2009;91:1886‑94. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124172
Address for correspondence: Dr. Lata Indu, Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E‑mail: [email protected]
Post‑traumatic perineal necrotizing fasciitis Sir, Necrotizing fasciitis of the perineum and external genital area, also known as Fournier’s Gangrene, is an infection with a polymicrobial etiology and with rapid progression that causes severe tissue destruction. It represents an important surgical emergency, with early diagnosis and early instauration of a treatment being essential.[1,2] We report an unusual case of a patient who developed perianal necrotizing fasciitis extending to lower extremities and chest wall, due to a laceration in the anoderm after trauma. A 54‑year‑old male who met a traffic accident was admitted. A full body computerized tomography (CT) scan was performed that showed a stable fracture with coining in the body of the fourth lumbar vertebra and comminuted fracture of tibia and right perone, without pathological findings at the thoracic‑abdominal level. After 48 hours of admission, the patient developed fever, hypotension, testicular edema, and smelly anal secretions. An abdominal CT scan was performed that showed air at subcutaneous tissue in the perianal area, right gluteus, scrotum, and right thoracic‑abdominal wall and, free liquid in presacral space and right ischiorectal fossa [Figure 1]. With the diagnosis of Fournier’s Gangrene, broad‑spectrum antibiotics were prescribed and he was taken to the operating room, where multiple surgical incisions were made (in perineum and abdominal wall) to drain purulent material [Figure 2]. During the intervention, the point of origin of the infection, a laceration in anoderm, located at 10 o’clock in gynecological position, was observed and laparoscopic colostomy was made on left flank. Cultures with isolated Escherichia coli producing broad‑spectrum
Figure 1: Images of abdominal computerized tomography (CT) scan where air is observed at subcutaneous tissue in the perianal region, right gluteus, scrotum, and right thoracic‑abdominal wall, and free liquid in presacral space, right ischiorectal fossa
Figure 2: Multiple surgical incisions performed to drain purulent material and the extensive dissection of the perineum
beta‑lactamases were reported. The patient remained in the ICU in a septic shock clinical situation, but with good clinical outcome. He was transferred five days later at the Trauma
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
285
Letters to the Editor
Department and discharged 30 days after the trauma. Necrotizing fasciitis after rectal perforation due to trauma is not widely reported in the literature.[3] Most cases described are secondary to perianal diseases, such as complicated abscesses, complex fistulas, and fissures. Other causes include genitourinary infections as those postoperative of the urogenital area. The diagnosis is imminent clinically, which can be supported by imaging, where CT scan shows subcutaneous emphysema as hypodense areas, subcutaneous collections, and also provides excellent information of the locoregional extension of the disease. The most frequently isolated bacteria is Gram negative E. coli, among aerobes, and Bacteroides, among anaerobes. The treatment should be introduced early and be based on empirical antibiotic therapy, together with aggressive removal of necrotic tissue, and even the use of other therapies such as hyperbaric oxygen.[4] Colostomy should be considered in those cases where the origin is colo‑proctological; in those patients with extensive lesions to prevent contamination of infected lesions or of drainage incisions made. In doubtful cases it will be preferred to be performed the procedure as both the absence and the delay in its implementation are factors shown to increase mortality.[5]
Juan Ramón Hernández -Hernández
Departments of Surgery and 1Intensive Care Unit, Insular Universitary Hospital of Gran Canaria, Las Palmas of Gran Canaria, Spain Address for correspondence: Dr. Luciano Santana-Cabrera, South Maritime Avenue n/n. Las Palmas of Gran Canaria, Canary Islands, Spain. E-mail: [email protected]
REFERENCES 1. 2.
3. 4. 5.
Fu WP, Quah HM, Eu KW. Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb. Singapore Med J 2009;50:e270‑3. Koukouras D, Kallidonis P, Panagopoulos C, Al‑Aown A, Athanasopoulos A, Rigopoulos C, et al. Fournier’s gangrene, a urologic and surgical emergency: Presentation of a multi‑institutional experience with 45 cases. Urol Int 2011;86:167‑72. Basoglu M, Ozbey I, Atamanalp SS, Yildirgan MI, Aydinli B, Polat O, et al. Management of Fournier’s gangrene: Review of 45 cases. Surg Today 2007;37:558‑63. Ooi A, Chong SJ. Use of adjunctive treatments in improving patient outcome in Fournier’s gangrene. Singapore Med J 2011;52:e194‑7. Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier’s gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg 2009;15:342‑6.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124174
Julián Favre-Rizzo, Luciano Santana-Cabrera1, Eudaldo López-Tomasetti Fernández, Cristina Rodríguez Escot1,
Outcome for tracheostomized patients who requiring prolonged stay in intensive care unit Sir, The association between tracheostomy and outcomes reported in the studies of tracheostomized patients remains unclear.[1,2] There is no proven benefit of the procedure itself or related care and it might be that, after several days of mechanical ventilation (MV), intensive care unit (ICU) physicians adequately select candidates for tracheostomy, based on the highest probability of MV weaning failure associated with a reasonable probability of ICU survival.[3] The objectives of this study was to evaluate the effect of tracheostomy on ICU and in‑hospital mortality for patients requiring prolonged (>14 days) stay in ICU. We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 286
to December 2010, with prolonged stay (>14 days). We analyzed outcomes of tracheostomized and non‑tracheostomized patients using univariable and multivariable logistic‑regression analyses. Of the 707 patients requiring prolonged ICU stay, 448 were tracheostomized. The results of the predictive model of survival in ICU show the performing a tracheostomy define survival (odds ratio 2.445, 95% confidence interval 1.520‑3.918, P = 0.000). However, these patients will have a better outcome at discharge from the hospital when a tracheotomy was not performed (odds ratio 0.331, 95% confidence interval 0.139‑0.768, P = 0.011). Kaplan–Meier estimates of the cumulative probability of survival as a function of the number of days after ICU admission differed significantly between the two groups, with better outcome for tracheostomized patients [Figure 1].
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
operation for breech presentation as an etiological factor. As the patient was hemodynamicaly unstable, the decision of laparotomy was chosen. Unicornuate uterus with rudimentary horn is associated with increase rate of abortions and miscarriages. However, missing the diagnosis can lead to fatal complications, while early detection can save the life of the patient. Lata Indu, Kapoor Deepa1, Agarwal Shalini1, Niyaz Zafar2
Departments of Maternal and Reproductive Health, 1Obstetrics and Gynaecology, and 2Radiodignosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
REFERENCES 1. 2. 3.
Daskalakis G, Pilalis A, Lykeridou K, Antsaklis A. Rupture of noncommunicating rudimentary uterine horn pregnancy. Obstet Gynecol 2002;100:1108‑10. Schmied R, Sentilhes L, Baron M, Grzegorczyk V, Resch B, Marpeau L. Recurrence of a rudimentary uterine horn rupture at 25 weeks of gestation: A case report. Gynecol Obstet Fertil 2008;36:296‑8. Reichman D, Laufer MR, Robinson BK. Pregnancy outcomes in unicornuate uteri: A review. Fertil Steril 2009;91:1886‑94. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124172
Address for correspondence: Dr. Lata Indu, Department of Maternal and Reproductive Health, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E‑mail: [email protected]
Post‑traumatic perineal necrotizing fasciitis Sir, Necrotizing fasciitis of the perineum and external genital area, also known as Fournier’s Gangrene, is an infection with a polymicrobial etiology and with rapid progression that causes severe tissue destruction. It represents an important surgical emergency, with early diagnosis and early instauration of a treatment being essential.[1,2] We report an unusual case of a patient who developed perianal necrotizing fasciitis extending to lower extremities and chest wall, due to a laceration in the anoderm after trauma. A 54‑year‑old male who met a traffic accident was admitted. A full body computerized tomography (CT) scan was performed that showed a stable fracture with coining in the body of the fourth lumbar vertebra and comminuted fracture of tibia and right perone, without pathological findings at the thoracic‑abdominal level. After 48 hours of admission, the patient developed fever, hypotension, testicular edema, and smelly anal secretions. An abdominal CT scan was performed that showed air at subcutaneous tissue in the perianal area, right gluteus, scrotum, and right thoracic‑abdominal wall and, free liquid in presacral space and right ischiorectal fossa [Figure 1]. With the diagnosis of Fournier’s Gangrene, broad‑spectrum antibiotics were prescribed and he was taken to the operating room, where multiple surgical incisions were made (in perineum and abdominal wall) to drain purulent material [Figure 2]. During the intervention, the point of origin of the infection, a laceration in anoderm, located at 10 o’clock in gynecological position, was observed and laparoscopic colostomy was made on left flank. Cultures with isolated Escherichia coli producing broad‑spectrum
Figure 1: Images of abdominal computerized tomography (CT) scan where air is observed at subcutaneous tissue in the perianal region, right gluteus, scrotum, and right thoracic‑abdominal wall, and free liquid in presacral space, right ischiorectal fossa
Figure 2: Multiple surgical incisions performed to drain purulent material and the extensive dissection of the perineum
beta‑lactamases were reported. The patient remained in the ICU in a septic shock clinical situation, but with good clinical outcome. He was transferred five days later at the Trauma
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
285
Letters to the Editor
Department and discharged 30 days after the trauma. Necrotizing fasciitis after rectal perforation due to trauma is not widely reported in the literature.[3] Most cases described are secondary to perianal diseases, such as complicated abscesses, complex fistulas, and fissures. Other causes include genitourinary infections as those postoperative of the urogenital area. The diagnosis is imminent clinically, which can be supported by imaging, where CT scan shows subcutaneous emphysema as hypodense areas, subcutaneous collections, and also provides excellent information of the locoregional extension of the disease. The most frequently isolated bacteria is Gram negative E. coli, among aerobes, and Bacteroides, among anaerobes. The treatment should be introduced early and be based on empirical antibiotic therapy, together with aggressive removal of necrotic tissue, and even the use of other therapies such as hyperbaric oxygen.[4] Colostomy should be considered in those cases where the origin is colo‑proctological; in those patients with extensive lesions to prevent contamination of infected lesions or of drainage incisions made. In doubtful cases it will be preferred to be performed the procedure as both the absence and the delay in its implementation are factors shown to increase mortality.[5]
Juan Ramón Hernández -Hernández
Departments of Surgery and 1Intensive Care Unit, Insular Universitary Hospital of Gran Canaria, Las Palmas of Gran Canaria, Spain Address for correspondence: Dr. Luciano Santana-Cabrera, South Maritime Avenue n/n. Las Palmas of Gran Canaria, Canary Islands, Spain. E-mail: [email protected]
REFERENCES 1. 2.
3. 4. 5.
Fu WP, Quah HM, Eu KW. Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb. Singapore Med J 2009;50:e270‑3. Koukouras D, Kallidonis P, Panagopoulos C, Al‑Aown A, Athanasopoulos A, Rigopoulos C, et al. Fournier’s gangrene, a urologic and surgical emergency: Presentation of a multi‑institutional experience with 45 cases. Urol Int 2011;86:167‑72. Basoglu M, Ozbey I, Atamanalp SS, Yildirgan MI, Aydinli B, Polat O, et al. Management of Fournier’s gangrene: Review of 45 cases. Surg Today 2007;37:558‑63. Ooi A, Chong SJ. Use of adjunctive treatments in improving patient outcome in Fournier’s gangrene. Singapore Med J 2011;52:e194‑7. Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier’s gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg 2009;15:342‑6.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124174
Julián Favre-Rizzo, Luciano Santana-Cabrera1, Eudaldo López-Tomasetti Fernández, Cristina Rodríguez Escot1,
Outcome for tracheostomized patients who requiring prolonged stay in intensive care unit Sir, The association between tracheostomy and outcomes reported in the studies of tracheostomized patients remains unclear.[1,2] There is no proven benefit of the procedure itself or related care and it might be that, after several days of mechanical ventilation (MV), intensive care unit (ICU) physicians adequately select candidates for tracheostomy, based on the highest probability of MV weaning failure associated with a reasonable probability of ICU survival.[3] The objectives of this study was to evaluate the effect of tracheostomy on ICU and in‑hospital mortality for patients requiring prolonged (>14 days) stay in ICU. We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 286
to December 2010, with prolonged stay (>14 days). We analyzed outcomes of tracheostomized and non‑tracheostomized patients using univariable and multivariable logistic‑regression analyses. Of the 707 patients requiring prolonged ICU stay, 448 were tracheostomized. The results of the predictive model of survival in ICU show the performing a tracheostomy define survival (odds ratio 2.445, 95% confidence interval 1.520‑3.918, P = 0.000). However, these patients will have a better outcome at discharge from the hospital when a tracheotomy was not performed (odds ratio 0.331, 95% confidence interval 0.139‑0.768, P = 0.011). Kaplan–Meier estimates of the cumulative probability of survival as a function of the number of days after ICU admission differed significantly between the two groups, with better outcome for tracheostomized patients [Figure 1].
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
