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Discussion: This 57 year-old male presented with a known history of tricuspid regurgitation for assessment of hepatomegaly. IntroductionThe role of the perfusionist is to perform cardiopulmonary bypass during open heart surgery; therefore improving and understanding clinical practice is an appropriate goal for the perfusion community. Benchmarking involves using a structured method of measurement to identify standards of practice excellence. AimThe aim of this report is to compare three quality indicators for perfusion practice in our baseline procedural cohort and after the introduction of benchmarking.
ResultsSeven thousand eight hundred and seventy-seven procedures were evaluated to compare the incidence of QI before and after the introduction of benchmarking.
ConclusionsWe have defined process of care QI’s and used these to calculate benchmarks for the management of several key aspects of CPB.
A nontraumatic spontaneous extradural hematoma, in a fully conscious 10-year-old male child, caused by a solitary eosinophilic granuloma of calvarium presented as a case of localized painful swelling of the head, which rapidly expanded and decreased in size. Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Kashmir, India. A 10-year-old, fully conscious, boy presented to the accident and emergency room of Neurosurgical Centre, Sher -i- Kashmir Institute of Medical Sciences (SKIMS), Kashmir, with one month history of a gradually appearing almond-sized, swelling on the right side of the head with dull aching pain.
Plain CT-scan of head (bone window) showing lytic area in the right side of the parietal calvarium. NCCT brain showing right parietal extradural hematoma with fresh hemorrhage under lytic inner table of skull.
This pulsed-wave doppler ultrasound examination of the portal vein demonstrates highly pulsatile flow with intermittent flow reversal.
The Perfusion Downunder Collaboration (PDUC) has established a multi-centre perfusion focused database aimed at achieving these goals through the development of quantitative quality indicators for clinical improvement through bench marking.
At the Perfusion Downunder Meeting in 2010, it was agreed by consensus amongst the attendees to report QI’s for glucose, arterial outlet temperature and pCO2 management.

Participation in a multi-centre perfusion database that incorporates quantitative quality indicators facilitates clinical improvement through benchmarking.
A plain CT-scan of the head with bone window revealed eroded right parietal bone with subperiosteal debris and extradural hematoma of mixed density. Abdul Bhat, B-4 Faculty Quarters, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir - 190 011, India.
We report an extradural hematoma in a 10-year-old boy as a complication of solitary calvarial eosinophilic granuloma. The swelling suddenly increased to the size of a walnut with increase in the intensity of pain for last 15 days. Their presentation depends upon the nature of underlying lesion, pain and tenderness locally, swelling of the scalp or rise in the intracranial pressure.
The other findings (not shown) were hepatomegaly and biphasic hepatic vein flow.Tricuspid regurgitation is associated with hepatic congestion and may lead to hepatic fibrosis if severe. Immediate evacuation of the extradural clot and complete excision of the lesion was performed to prevent the deterioration of the patient and to achieve the histological diagnosis for further management. However, for the last one week, the swelling rapidly decreased in size but became pulsatile and at the same time pain continued unabated.
The eosinophilic granulomas (a type of histiocytosis X) are solitary, nonrecurring and moderately vascular lesions of the skull found in older children and young adults. Pulsatile flow in the portal vein (reversed or non-reversed) is associated with tricuspid regurgitation. Pulsatile Portal Vein Flow: A Sign of Tricuspid Regurgitation on Duplex Doppler Sonography.
There was no history of trauma, episodes of unconsciousness, headache, vomiting, drug intake, fever, hemoptysis, hematuria or abdominal pain. Portal vein pulsatility index has been shown to correlate with severity of tricuspid regurgitation.Reversal of flow may also be seen with advanced hepatic cirrhosis, however the portal venous pulsatility is usually not increased.

It is rare for these lesions to bleed extradurally.[9–11] At SKIMS, Kashmir, it was rare for the age (10 years) of our patient to have eosinophilic granuloma and moreover rare for such a lesion to bleed into extradural space.
The arterial blood gas pCO2 was ?35 and ?45 mmHg.These values were chosen based upon published guidelines and regional practices (2,3). An evidence based review of the practice of cardiopulmonary bypass in adults; a focus on neurological injury, glycemic control, hemodulation, and the inflammatory response.
A QI was reported when any of the above conditions were met for an individual procedure, so the best performing centres reported the highest incidence of the QI.
Locally a single, 3 ? 3 ? 4 cm, diffuse, pulsatile, soft and compressible but tender swelling was found on the right parietal region [Figure 1]. The proposed mechanism of extradural hemorrhage (EDH) in paranasal infections and otitis media was infection leading to the vasculitis and thereby rupture of vasculitic vessels and subsequent expansion[3, 14, 19, 20] Although intradiploic epidermoids are believed to cause EDH by erosion of the intradiploic and skull vessels,[7] the possible causes of the EDH of our case at SKIMS, Kashmir are stripping of dura from bone due to rapid tumor growth, expansion (bleeding in tumor), erosion of the intradiploic vessels, erosion of the normal dural surface vessels and bleeding of localized dural neovascularization caused by the eosinophilic granuloma.
We suggest prompt CT-scan of the head in case of pain and tenderness in an existing head swelling or a rapidly expanding and regressing swelling in size with pain. But clinical condition of the patient is the most accurate indication of an investigation, since such a case can turn up as extradural hematoma may not hold true every time. Management During Adult Cardiac Surgery The Society of Thoracic Surgeons Practice Guideline Series: Blood Glucose. The subperiosteal debris and the eroded bone were excised completely after curettage and the EDH evacuated [Figures 5 and 6]. The histopathological examination of the debris, lytic bone and clots revealed eosinophilic granuloma with both eosinophils and Langerhans cells and the lesion infiltrating up to dura [Figure 7].

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