Background/Objectives: Descending necrotising mediastinitis (DNM) is a severe, life-threatening infection that originates from the oropharyngeal or odontogenic regions and spreads to the mediastinum. It poses significant challenges due to its rapid progression and high morbidity. Methods: This monocentric, retrospective study analysed the records of 22 patients treated for DNM between 2008 and 2022. Diagnosis relied on characteristic clinical, radiological, and intraoperative findings linking oropharyngeal or cervical infections to mediastinitis. Contrast-enhanced computed tomography (CT) was used in all cases for diagnosis. Data collected included demographics, comorbidities, surgical interventions, time from diagnosis to surgery, re-operations, and complications. Microbiological analyses targeted aerobic and anaerobic pathogens. Results: The study included 22 patients (mean age 60 ± 9 years, 59% male) with DNM. The primary sources of infection were oropharyngeal (77%) and odontogenic (23%). Hypertension (86%), diabetes (68%), and cardiac arrhythmias (59%) were common comorbidities. Thoracotomy with mediastinal drainage and debridement was performed in 95% of patients, while 45% underwent cervicotomy and 82% required tracheostomy. The median intensive care unit (ICU) and hospital stays were 21 and 30 days, respectively. Delayed surgery (>24 h) significantly prolonged hospital stays (median: 62 vs. 28 days, p = 0.05). Re-operations were required in 82% of patients, with longer ICU stays observed in this group (median: 25 vs. 7 days, p = 0.003). Sepsis occurred in 55% and was associated with a higher tracheostomy rate (100% vs. 60%, p = 0.029). The mortality rate was 9%. Conclusions: Early recognition and prompt aggressive surgical intervention are paramount in managing DNM to mitigate complications and improve survival.

BACKGROUND: Remifentanil is an effective drug in peri-operative pain therapy, but it can also induce and aggravate hyperalgesia. Supplemental administration of N₂O may help to reduce remifentanil-induced hyperalgesia. OBJECTIVE: To evaluate the effect of 35 and 50% N₂O on hyperalgesia and pain after remifentanil infusion. DESIGN: Single site, phase 1, double-blind, placebo-controlled, randomised crossover study. SETTING: University Hospital, Germany from January 2012 to April 2012. PARTICIPANTS: Twenty-one healthy male volunteers. INTERVENTIONS: Transcutaneous electrical stimulation induced spontaneous acute pain and stable areas of hyperalgesia. Each volunteer underwent the following four sessions in a randomised order: 50 to 50% N₂-O₂ and intravenous (i.v.) 0.9% saline infusion (placebo); 50 to 50% N₂-O₂ and i.v. remifentanil infusion at 0.1 μg kg⁻¹ min⁻¹ (remifentanil); 35 to 15 to 50% N₂O-N₂-O₂ and i.v. remifentanil infusion at 0.1 μg kg⁻¹ min⁻¹ (tested drug) and 50 to 50% N₂O-O₂ and i.v. remifentanil infusion at 0.1 μg kg⁻¹ min⁻¹ (gas active control). Gas mixtures were inhaled for 60 min; i.v. drugs were administered for 30 min. MAIN OUTCOME MEASURES: Areas of pin-prick hyperalgesia, areas of touch-evoked allodynia and pain intensity on a visual analogue scale were assessed repeatedly for 160 min. RESULTS: Data from 20 volunteers were analysed. There were significant treatment and treatment-by-time effects regarding areas of hyperalgesia (P < 0.001). After the treatment period, the area of hyperalgesia was significantly reduced (P < 0.001) in the tested drug and in the gas active control (30.6 ± 9.25 and 24.4 ± 7.3 cm², respectively) compared with remifentanil (51.0 ± 17.0 cm²). There was also a significant difference between the gas active control and the tested drug sessions (P < 0.001). For the area of allodynia and pain rating, results were consistent with the results for hyperalgesia. CONCLUSIONS: Administration of 35% N₂O significantly reduced hyperalgesia, allodynia and pain intensity induced after remifentanil. It might therefore be suitable in peri-operative pain relief characterised by hyperalgesia and allodynia, such as postoperative pain, and may help to reduce opioid demand. TRIAL REGISTRATION: EudraCT-No.: 2011-000966-37.

The long-term stability of drugs under normal laboratory storage conditions (−20°C) for years is important for research purposes, clinical re-evaluation, and also for forensic toxicology. To evaluate the stability of the analgesic opioid hydromorphone, 44 human frozen plasma samples of a former clinical trial were reanalyzed after at least three years. Blood samples were disposed using solid-phase extraction with an additional substitution of stable isotope labelled hydromorphone as an internal standard. Hydromorphone concentrations were determined by ultra-performance liquid chromatography (UPLC) with gradient elution, followed by tandem mass spectrometry with electrospray ionization. Calibration curves demonstrated linearity of the assay in the concentration range of 0.3–20 ng/mL hydromorphone. The limit of detection of the hydromorphone plasma concentration was 0.001 ng/mL, and the lower limit of quantification was 0.3 ng/mL. Intra- and interassay errors did not exceed 16%. The percentage deviation of the measured hydromorphone plasma concentrations between the reanalysis and the first analysis was −1.07% ± 14.8% (mean ± SD). These results demonstrate that hydromorphone concentration in human plasma was stable when the samples were frozen at −20°C over three years. This finding is of value for re-evaluations or delayed analyses for research purposes and in pharmacokinetic studies, such as in forensic medicine.

Key Clinical Message: During the COVID 19 pandemic, advanced age, scoring systems, and a shortage of ICU beds were used as cut‐offs for ICU admission. This case report describes the epicrisis of an elderly patient who was almost mistakenly not treated in an ICU.

Although beta‐lactam antibiotics are widely used in intensive care, rare but potentially fatal anaphylactic reactions can occur due to cross‐reactions between penicillins and cephalosporins. We report the case of a 68‐year‐old man who suffered perioperative cardiac arrest following the administration of cefuroxime. During the postoperative period, the patient received ampicillin/sulbactam without any signs of hypersensitivity. Following a switch to piperacillin/tazobactam prior to a procedure, the patient suddenly developed cardiovascular arrest and died. The autopsy revealed no macroscopic cause of death, but immunohistochemistry showed mast cell degranulation (“starry sky pattern”) in the tissue, suggesting anaphylaxis. We present the clinical and histopathological findings of a case with severe allergic reactions to both cefuroxime and piperacillin/tazobactam, as a result of either cross‐reaction or isolated sensitization to both antibiotics. This case report highlights the potential risks of cross‐reactivity between beta‐lactam antibiotics and the importance of autopsy in ambiguous cases. Clinicians should be aware of cross‐reactivity or cosensitization to multiple beta‐lactams in patients with a beta‐lactam allergy and consider non–beta‐lactam alternatives in high‐risk cases.