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    Cerebrospinal Fluid - Cutaneous Fistula After Combined Spinal Epidural Anesthesia in a Non-Obstetric Patient Treated With an Epidural Blood Patch: A Case Report
    (Anestezi Dergisi, 2023) Karka, Ö.E.; Demiraran, Y.; Sobcali, G.
    Background: We aimed to discuss the successful treatment of cerebrospinal fluid (CSF)-cutaneous fistula which is caused by combined spinal epidural anesthesia (CSE), with an autologous epidural blood patch (EBP), further investigation and antibiotherapy. Case: CSE was applied for a total hip replacement. Since CSF was seen in the first attempt, CSE was achieved in the second attempt using the same Tuohy needle. Postoperatively epidural catheter was used for analgesic purposes for 2 days. After the catheter removal, anesthesia consultation was requested due to the patient's wet back. A clear fluid leak at the needle insertion point was observed. A sample was taken and the differential diagnosis of CSF-skin fistula was made biochemically with the presence of glucose and chloride. The patient denied headaches. Neurological examination was normal. With patient's consent, EBP was performed. During the injection CSF leak was slowed down, the last drops were macroscopically hemorrhagic and eventually the leak stopped. Headache, dizziness, and nausea occurred on the 2nd day after EBP. Neurological examination was normal. No dural defect or CSF collection was observed in brain CT, brain diffusion MR and contrast-enhanced MR myelography. Ceftriaxone, metronidazole and a pneumococcal vaccine were added for meningitis prophylaxis in consensus with infection and neurology consultants. 1-month follow-up was performed telephonically and the patient was completely cured. Conclusion: Cerebrospinal fluid (CSF)-cutaneous fistula is a rare complication of neuraxial anesthesia techniques. Since there are no sufficient guidelines for management, the decision on the treatment method depends on the clinician's aspect. We consider that it would be advantageous to prefer EBP primarily in cases with CSF-skin fistula and that the benefit/harm ratio is higher than the complications to be caused by a subarachnoid space that is fistulized to skin and opened out to cutaneous flora. In the literature, the development of meningitis has been reported in some cases followed up under conservative treatment or skin sutures. Although prophylactic use should be avoided as possible due to increasing antibiotic resistance, our opinion is that clinicians should decide for each case, taking into account the conditions such as hospital infection surveillance and the flora of inpatient service. © 2023 Anestezi Dergisi. All rights reserved.
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    Sepsis Multi Organ Damage Due To Secondary Immune Failure After Spondylodiscitis
    (Anestezi Dergisi, 2023) Şenoglu, G.D.; Demiraran, Y.; Yazar, Z.
    Background: Surgical trauma may affect immunity and pave the way for septic complications. In our case, the intensive care follow-up of a patient who developed spondylodiscitis and diagnosed with immunodeficiency and ARDS-Sepsis was presented, and the literature was reviewed. Case: A 36-year-old male patient became immobile with severe pain after a lumbar disc hernia repair twenty-eight days ago. Antibiotherapy was started after the diagnosis of Spondylodiscitis by MRI (Figure 1). Due to his clinical deterioration, he was transferred to our intensive care unit with the preliminary diagnosis of ARDS-sepsis and acute renal failure. There were tachycardia, hypotension, hypoxia, anuria, with no infective findings in the operation area. Continuous venovenous hemodialysis and cytokine filter were applied to the patient. The cytokine filter was terminated on the third day with the regression of ARDS and infective parameters (Table 1), and the patient was followed up with high flow (fi0,:100 flow:60L/min). Hypoxia became evident on the seventh day, and the patient had to be intubated on the tenth day. Antibiotherapy was expanded due to acinetobacter and hyphae in deep tracheal aspirate. Deepening of thrombocytopenia was thought to be related to antibiotics. IgG level was 569 mg/dL (700-1600 mg/dL). Intravenous Ig (IVIG) was administered. As the cytopenia continued, it was thought that infection-related immune thrombocytopenia might have been added, and IVIG was planned again, the treatment was completed with clinical response. After sixty days of intensive care follow-up, the patient was removed from the intensive care unit by closing the tracheotomy. Conclusion: Spondylodiscitis is usually bacterial and occurs after surgery. Complications, constant source of infection, and prolonged antibiotic therapy may lead to multiple organ dysfunction syndrome (MODS) due to uncompensated excessive and prolonged proinflammatory responses in patients. Long-term hospitalization after surgery, immobility, malnutrition are predisposing factors to sepsis; it also reveals the imbalance of inflammatory and anti- inflammatory processes. Thus, prolonged immunodeficiency findings can be observed. The patient, who developed MODS and secondary immunodeficiency, was discharged after meticulous multidisciplinary follow-up. In conclusion, it should be kept in mind that the immune system may be suppressed in young and low-risk patients and the resulting sepsis may cause multi-organ damage. © 2023 Anestezi Dergisi. All rights reserved.