Stevens Johnson syndrome following paraquat poisoning: a case report

Paraquat is a herbicidal agent used extensively, mainly in developing countries where there is a high incidence of its poisoning. It causes damage to kidneys, lungs and liver. Reports of mucocutaneous manifestations following paraquat ingestion are rare. Here we describe a case of Stevens-Johnson syndrome(SJS) presenting in a case of paraquat ingestion. A 22 year old male was admitted to our hospital for difficulty in swallowing and micturation since ingestion of 10-15 ml of paraquat 7 days before. He had multiple hemorrhagic crusted erosions over lips and left maxillary area with diffuse erythematous erosions over bilateral buccal mucosa, palate, labial mucosa and urethral mucosa with whitish slough over them. Upper GI endoscopy revealed oral, esophageal and fundal sloughing. Patient was treated with oral corticosteroids and antibiotics which caused complete resolution of skin lesions within 15 days.Paraquat dichloride exerts its toxicity by generation of reactive oxygen species. Skin lesions following topical application of paraquat are common, but very few cases have been reported of the same after oral ingestion. SJS is caused by a variety of drugs and commonly presents with muco-cutaneous tenderness, hemorrhagic erosions and erythematous macules with 90% developing oral, genital and gastrointestinal mucosal involvement. As the oral and genital manifestations in our patient developed the day after paraquat ingestion, possibility of SJS developing due to the same are the highest. Paraquat should not be ruled out as a drug causality if mucocutaneous manifestations of SJS/TEN appear in a patient of paraquat ingestion.

Knowledge Gaps in Anesthetic Gas Utilization in a Large Academic Hospital System: A Multicenter Survey

Inhaled anesthetics account for a significant portion of the greenhouse gases generated by perioperative services within the healthcare systems. This cross-sectional study aimed to identify knowledge gaps and practice patterns related to carbon dioxide (CO2) absorbents and intraoperative delivery of fresh gas flows (FGF) for future sustainability endeavors. Secondary aims focused on differences in these knowledge gaps based on the level of training. Surveys were distributed at five large academic medical centers. In addition to site-specific CO2 absorbent use and practice volume and experience, respondents at each institution were queried about individual practice with FGF rates during anesthetic maintenance as well as the cost-effectiveness and environmental impact of different volatile anesthetics. Results were stratified and analyzed by the level of training. In total, 368 (44% physicians, 30% residents, and 26% nurse anesthetists) respondents completed surveys. Seventy-six percent of respondents were unaware or unsure about which type of CO2 absorbent was in use at their hospital. Fifty-nine percent and 48% of respondents used sevoflurane and desflurane with FGF ≥1 L/min, respectively. Most participants identified desflurane as the agent with the greatest environmental impact (89.9%) and a greater proportion of anesthesiologists correctly identified isoflurane as a cost-effective anesthetic (78.3%, p=0.02). Knowledge gaps about in-use CO2 absorbent and optimal FGF usage were identified within the anesthesia care team. Educational initiatives to increase awareness about the carbon emissions from anesthesia and newer CO2 absorbents will impact the environmental and economic cost per case and align anesthesia providers toward healthcare decarbonization