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The patient did not have a prior medical or surgical history. He reported heavy smoking and, in the review by systems, he reported difficulty breathing while lying on his back and explained that he slept with several pillows or, occasionally, even in a sitting position.

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He was scheduled for placement of endobronchial stents by the pulmonology and interventional radiology services. During the preanesthetic assessment, the patient was classified as ASA-PS 4, with no predictors of difficult intubation. Based on the findings of the chest CT scan and the flow-volume curve, he was considered as having a high risk of intraoperative complications associated with airway compromise due to compression fig.

It was decided to perform the procedure under sedation and local endotracheobronchial anesthesia with fiber optic bronchoscopy, and the use of fluoroscopy for stenting. Basic monitoring was set up using continuous electrocardiography, non-invasive blood pressure monitoring, pulse oxymetry and capnography. The patient was placed in anti-Trendelemburg position. Total collapse of the right main bronchus and partial left bronchial obstruction was reported during fiber optic bronchoscopy.

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It was necessary to place the patient in a supine position in order to proceed to stenting because of reasons associated with the use of the fluoroscopy equipment. After a few seconds in that position, the patient developed significant arterial desaturation of oxygen and bradycardia, requiring the interruption of the procedure and returning to the anti-Trendelemburg position.

However, the signs of respiratory distress, desaturation and bradycardia persisted, requiring the use of positive pressure ventilation and pharmacological treatment with intravenous atropine. In view of impeding ventilatory failure, intravenous induction without muscle relaxant was given, using orotracheal intubation with a ring-design tube.

During mechanical ventilation, peak pressures in the airway reached 50 cmH2O but no adequate effective ventilation was achieved. There was marked hemodynamic deterioration and the cardiac rhythm changed progressively from sinus rhythm to bradycardia and then asystole.

Resuscitation maneuvers were initiated, the orotracheal tube was repositioned by introducing it through the fiber optic bronchoscope down to the left main bronchus beyond the partial obstruction reported initially.

Ventilation improved, followed by improved output rhythm and oxygen saturation. The patient was again placed in the anti-Trendelemburg position, improving ventilation further. This, together with the recovery of spontaneous ventilation, improved the hemodynamic performance. The patient was taken to the intensive care unit, where he died twelve days later from sepsis originating in the lung.

Discussion Multiple reports have been published for over 30 years of cases of anterior mediastinal masses causing serious complications, with occasional fatal outcomes.

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Complications are associated mainly with hemodynamic changes and airway obstruction, and they may occur at the time of induction, during extubation, or even days after the procedure. Manifestations appear when there is a mass effect on the neighboring structures, creating the characteristics signs and symptoms of nervous, cardiovascular o respiratory involvement. Moreover, this test did not show a good correlation with the degree of airway obstruction.

For this reason, imaging studies are now considered more adequate for assessing the compromise created by the lesion, when used together with the clinical history of associated signs and symptoms such as orthopnea, stridor, dyspnea, etc. Patients with anterior mediastinal masses must be taken to preoperative chest CT in order to determine the site, severity and degree of airway obstruction.

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Case reports Retrospective review of hospital records of pediatric patients under 14 years diagnosed with AAC in our hospital from January to December We collected epidemiological age and sexclinical underlying disease and clinical characteristicsdiagnostic special emphasis on ultrasound and therapeutic drugs employed, complications data after informed consent was obtained.

Ultrasound studies reviewed by two radiologists in all children who met clinical criteria. Ultrasonographic diagnostic criteria 8,11 were divided into major gallbladder wall thickening over 3. Adiagnosis was considered positive if it included either a minimum of two major criteria or one major and two minor criteria, in the appropriate clinical setting.

Seven patients were included Table I: The ultrasound showed wall thickening and hypervascularity in the absence of lithiasis in all cases without pericholecystic fluid. Treatment was conservative with fluid therapy, parenteral nutrition, analgesia and antibiotics, adding vitamin K, lactulose and ursodeoxycholic acid in the patient with ALL and in neonates. The most used combination of antibiotics was third generation cephalosporin and antianaerobe agents mainly metronidazole. The evolution was satisfactory without surgery in all patients.

Discussion As for the typical age of presentation, according to Imamoglu 8it predominates at school age mean 7. AAC has been associated with intercurrent infections, metabolic disorders, vascular problems, burns, injuries and malignancies in children.

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AND Micrococcus cholecystitiswhich showed only one previous case of acute gallstone cholecystitis by Kocuria kristinae, belonging to genus Micrococcus, a 56year old Chinese woman.

It must be also pointed out the case of the AAC as a complication of systemic brucellosis, since only 21 cases have been described to date after a MEDLINE search from towith one pediatric patient, being, therefore, our case number 22 worldwide, the second pediatric patient The clinical presentation of the AAC is variable, and depends on the predisposing conditions 13, In all of our patients sonographic criteria were met: Conservative treatment would be adequate hemodynamic stabilization, suppression of drugs that might hinder the gallbladder emptying, fluid therapy, parenteral nutrition, analgesia and use of antibiotics active on gram negative, anaerobes and Enterococci, which in turn reach therapeutic concentrations in the biliary tract.

So, all of our patients were treated conservatively, adding vitamin K, lactulose and ursodeoxycholic acid in the patient with ALL and in neonates who attended E.

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According to the data of our study and the literature reviewed, we draw several conclusions: Although the AAC is a rare entity in children, it must be considered by the pediatrician among the causes of abdominal pain, especially in critically ill children that are often intubated and sedated, with detection of vague abdominal discomfort, fever and jaundice besides, and where the source of infection is not entirely clear.

Ultrasound is the most reliable method for diagnosis Fig. In children, conservative treatment is effective in solving this disease, although it does require close clinical, analytical and ultrasound monitoring, able to detect complications.

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Glenn F, Becker CG. Acalculous cholecystitis in children. J Pediatr Surg ; Acute acalculous cholecystitis in a teenager with hepatitis A viral infection: Braz J Infect Dis ; Am J Gastroenterol ; Clinical features of acute acalculous cholecystitis. J Clin Gastroenterol ;