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We report the perioperative course of a patient with long standing ankylosing spondylitis with severe dysphagia due to large anterior cervical syndesmophytes at the level of the epiglottis. He was scheduled to undergo anterior cervical decompression and the surgical approach possibly precluded an elective pre-operative tracheostomy. ⋯ We discuss the role of nasal intubations and the use of both the modified nasopharyngeal airways we used to facilitate tracheal intubation. This modified nasal fibreoptic intubation technique could find the application in other patients with cervical spine abnormalities and in other anticipated difficult airways.
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Case Reports
Case report: severe myoclonus associated with oral midodrine treatment for hypotension.
Midodrine is widely used in the treatment of hypotensive states, there have been no reports of myoclonus associated with midodrine use in hypotension with chronic kidney disease. ⋯ Oral midodrine is widely used in the treatment of orthostatic hypotension, recurrent reflex syncope and dialysis-associated hypotension and the adverse effects are mostly mild. However, clinicians should be alert for midodrine-induced myoclonus, especially in patients with CKD.
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The role of stress ulcer prophylaxis in increasing the risk of pneumonia in ventilator patients was analyzed prospectively in 142 artificially ventilated patients at a medical and surgical intensive care unit (104 males, 38 females, mean time of ventilation 7.9 days, mean age 46.5 years). The pH of gastric aspirate and bacterial counts in gastric fluid and tracheal secretions were investigated daily. Identical isolates from gastric aspirates and tracheal secretions were typed by agglutination, bacteriocin, or phage typing. ⋯ Only 20% of all migrations of Gram-positive organisms from stomach to respiratory tract lead to pneumonia, as compared with 60% of Gram-negatives. At a gastric pH below 3.4 the incidence of ventilation pneumonia was 40.6%; above pH 5.0 the incidence was 69.2% (P less than or equal to 0.05). As pH increased, the organism causing pneumonia was significantly more often isolated first from the gastric aspirate and 1 to 2 days later from the tracheal secretion of the same patient.