Acute liver failure secondary to ABVD use

Hodgkin's lymphoma (HL) is a type of cancer originating in the lymph nodes. The preferred therapy for advanced HL is a combination of chemotherapies including doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). ABVD has been standard therapy for advanced HL. It is generally considered as safe and rarely has been reported to cause acute liver failure. We present a case of 79-year-old woman with HL, who developed acute liver failure secondary to first cycle of ABVD chemotherapy.

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Recurrent invasive group A streptococcal infection with four-limb amputation in an immunocompetent child

We report a previously well paediatric patient with two distinct presentations of invasive group A streptococcus (GAS) infection resulting in significant morbidity. The first episode, following GAS pharyngitis, involved multiorgan dysfunction syndrome. This included cardiorespiratory and acute hepatorenal failure and purpura fulminans that eventually necessitated four-limb amputation. The second episode occurred 12 months later, from undetermined aetiology, and resulted in septic shock. Molecular analysis of the emm gene and PCR for Serum Opacity Factor revealed that the initial isolate was M Type 4 and sof gene positive while the second isolate was M Type 1 and sof gene negative. Immunological investigations, including CH50, quantitative IgA, IgM and IgG, and flow cytometry measuring lymphocyte subsets, and vaccine response to measles, mumps, rubella and pneumococcus were normal. This is the first report of recurrent bacteraemia from different strains of Streptococcus pyogenes infection in an apparently immunocompetent child.

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Primary renal angiosarcoma

An older male patient with a history of tachycardia treated with atenolol presented to an outside hospital on 22 February 2017 with acute right flank pain. He had a CT scan which revealed a large right renal mass with acute haemorrhage. He was initially managed with interventional radiology guided embolism on 25 February 2017 due to the ongoing bleeding and haemodynamic instability. He was then transferred to our institution. He underwent right radical nephrectomy on 13 March 2017. His pathology revealed a 12.5x6x4.5 cm mass consistent with angiosarcoma of the right kidney with negative margins. Final pathology was pT2b with extension of the mass into the renal vein and perirenal adipose tissue. He was discharged soon after surgery. He was recommended to undergo adjuvant chemotherapy.

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Extensive Mongolian spots and normocephaly: an uncommon presentation of infantile Sandhoffs disease

Description 

A 10-month-old male infant was brought to us with developmental stagnation since 5 months of age. He attained age-appropriate developmental milestones until 5 months of age, however over the next 2 months, he did not gain any new milestones followed by subsequent developmental regression in the form of loss of neck holding ability, social smile, mother regard, visual fixation and cooing. He was a first born to non-consanguineous parents, at term by caesarean delivery (due to non-progression of labour). The antenatal and perinatal periods were normal. There was no history of seizures, exaggerated startle response and extrapyramidal symptoms. The family history was unremarkable. On examination, he had normal head size (46.2 cm, 50th centiles), dysmorphic facial features (flat nasal bridge, hypertelorism, thick upper lip and upturned nose), bilateral cherry-red spots, extensive Mongolian spots (figure 1) and hepatomegaly. He also had generalised hypotonia, hyperactive muscle stretch reflexes and bilateral...

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Platypnoea-orthodeoxia syndrome exacerbated by kyphosis progression

This is a case of an 86-year-old woman with gradually progressive dyspnoea and hypoxaemia that occurred after a cardiac surgery. It was underdiagnosed for several years, but diagnosis was triggered by the finding of hypoxaemia even during supplemental oxygen administration when in the upright position, such as when taking a shower, that rapidly improved when the patient returned to the supine position. A thorough workup disclosed platypnoea–orthodeoxia syndrome (POS) associated with right-to-left shunting through a patent foramen ovale (PFO). Percutaneous closure of the PFO was performed. After treatment, the patient's arterial oxygen saturation gradually recovered to 98% on room air while she was in the sitting position and her symptoms disappeared. Reviewing this case retrospectively, we determined that the deviation of the spine with kyphosis progression had apparently proceeded as POS worsened over time. We therefore hypothesised that kyphosis progression had played a major role in the POS progression.

https://ift.tt/2vihBch

Liver failure associated with mahogany seed extract consumption

A 45-year-old woman presented to the emergency department with jaundice of 2 weeks' duration. This was associated with mahogany seed extract (Skyfruit supplement) consumption for 6 months prior to admission. Examination was normal apart from scleral icterus and grade 2 encephalopathy. Liver function tests showed a hepatocellular pattern of derangement: alanine transaminase, 1267 U/L (10–36); aspartatetransaminase, 1255 U/L (10–30); alkaline phosphatase, 124 U/L (22–104); bilirubin, 258 µmol/L (3–21) with a prolonged prothrombin time of 16.8 s (9.2–11.0). Viral hepatitis work-up was largely unremarkable and liver biopsy showed moderate inflammatory infiltrates (mostly lymphocytic with scattered eosinophils) in the periportal region and lobule with bridging necrosis, favouring drug-induced liver injury. Withdrawal of the drug resulted in normalisation of liver function.

https://ift.tt/2LB74np

Posterior shoulder dislocation: its worth another look

A 40-year-old woman presented to the emergency department with a painful left shoulder following a fall from a mountain bike. A radiograph of the clavicle and shoulder was carried out. A diagnosis of fractured left clavicle was made, which was treated conservatively in a sling. On day 3, she was reviewed in the fracture clinic and was found to still be in pain with reduced movement of the shoulder joint. A repeat radiograph of the shoulder joint showed a posterior dislocation. This required a closed reduction under general anaesthesia.

https://ift.tt/2vh4vMq

Unusual case of bilateral haemotympanum after endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA)

We present a case of bilateral haemotympanum (HT) during endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA). A 64 year-old-man underwent EBUS-TBNA for mediastinal lymph nodes (LN) staging. Medical history included emphysema and angina. Medication included aspirin until the day before procedure. Full blood count and clotting screen were normal. He received sedation (5 mg midazolam, 1000 mcg alfentanil) and topical anaesthesia (16 mL 1% lignocaine) but coughed excessively throughout the procedure. Left hilar LN was the only area sampled. Spontaneous bleeding ensued from both ears towards the end of the procedure. Patient remained haemodynamically stable. The procedure was aborted and otolaryngology consult sought. Otoscopy showed bilateral haematoma from anterior ear canal with normal tympanic membranes and no hearing loss. Nasendoscopy revealed erythematous ostium of both Eustachian tubes. Bleeding stopped spontaneously and patient required no further imaging or treatment. We report this case to increase awareness of this very rare complication resulting from excessive coughing during EBUS-TBNA.

https://ift.tt/2LzHL5g

MYH9-related disorders: a rare cause of neonatal thrombocytopaenia

Myosin heavy chain 9-related disorders (MYH9RD) are a genetic condition characterised by large platelets and thrombocytopaenia. The May-Hegglin anomaly (MHA), an uncommon condition with a potential risk of bleeding complications once thought to be separate, is now known to be part of MYH9RD.

There are very limited data on the clinical course and neonatal/paediatric outcome in children with MHA. We present the case of a newborn with a normal physical examination whose mother had MHA. Peripheral blood examination revealed a platelet count of 16x10⁹/L with giant platelets and neutrophils containing Döhle bodies. Neonatal brain ultrasound examination showed no haemorrhage. The infant received three platelet transfusions during the first 29 days of life, remaining asymptomatic. The genetic molecular test was positive for MYH9RD. It is important to identify at-risk infants with this condition and to initiate therapy to prevent related complications, if needed, in a multidisciplinary team approach.

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Fatal case of macrophage activation syndrome (MAS) in a patient with dermatomyositis and cytomegalovirus (CMV) viraemia

We describe a case of an adult with dermatomyositis (DM) who presents with a rash, high fevers, tachycardia and hypotension, initially concerning for an infectious aetiology or a DM flare. She was found to have cytomegalovirus viraemia which improved after starting valganciclovir. After extensive workup and lack of improvement with broad-spectrum antimicrobial therapy, intravenous immunoglobulin and steroids, the patient was diagnosed with macrophage activation syndrome after bone marrow biopsy and levels of soluble CD25 (soluble interleukin (IL)-2 receptor) and IL2 were obtained. Unfortunately, despite therapy with dexamethasone, anakinra and etoposide, the patient decompensated and the patient's family opted for comfort care. The patient subsequently expired in the intensive care unit.

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Florid hyperandrogenism due to a benign adrenocortical adenoma

A 26-year-old woman with a history of polycystic ovarian syndrome presented with secondary amenorrhea, worsening hirsutism, acne, deepening of voice and unexplained 10–20 kg weight gain. Her Ferriman-Gallway hirsutism score was 12 with cystic facial acne and increased masculine phenotype. Urine Beta-Human Chorionic Gonadotropins (bHCG) was negative. She had elevated serum testosterone of 551 ng/dL, androstenedione at 7.46 ng/mL and dehydroepiandrosterone sulfate (DHEAS) at 4243 µg/L. Overnight dexamethasone suppression test showed mildly unsuppressed cortisol (2.89 µg/dL). Urinary free cortisol along with paired serum cortisol and adrenocorticotrophic hormone (ACTH) tests were normal (55.4 µg/24 hours, 13.44 mcg/dL, 30.4 pg/mL respectively). Her leutinizing hormone (LH) was low(<0.1 mIU/mL), follicle stimulating hormone (FSH) low/normal (1.41 mIU/mL) with sex hormone binding globulin (SHBG) level 45nmol/L and the rest of the pituitary and adrenal workup was unremarkable. Thyroid stimulating hormone (TSH) was 2.15mU/mL. MRI revealed a 3.1 cm, indeterminate but well-defined left adrenal lesion and polycystic ovaries without abdominal lymphadenopathy. Given radiological appearances and despite biochemical concerns for adrenocortical malignancy, a multidisciplinary team meeting decision was made to proceed with laparoscopic adrenalectomy. Histology was consistent with a benign adenoma. Postoperatively, there was clinical and biochemical resolution of the disease.

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Unusual case of a small bowel leiomyoma presenting as an adnexal mass

This case report will discuss an interesting case of a premenopausal woman who presented with an adnexal mass consistent with a leiomyoma on imaging. However, intraoperatively, the mass was thought to be a gastrointestinal stromal tumour but histological diagnosis subsequently confirmed a leiomyoma arising from the small bowel.

https://ift.tt/2OukL5s

Acute liver failure and hepatic encephalopathy in exertional heat stroke

A 31-year-old man was brought to Accident & Emergency after collapsing during a race. On presentation, the patient had a temperature of 41.7°C (rectal). External cooling was started immediately. The patient was intubated in view of a Glasgow Coma Scale of 7 and was transferred to theintensive therapy unit. Laboratory results revealed an acute kidney injury, rhabdomyolysis, disseminated intravascular coagulopathy and acute liver failure. The patient was encephalopathic, jaundiced and difficult to sedate. His liver function continued to deteriorate with alanine aminotransferase (ALT) levels reaching 9207 U/L. King's Hospital Liver Centre, London was contacted for a possible liver transplant, and they advised an infusion of N-acetylcysteine. The following day liver function tests improved; thus, transplantation was not performed. The patient failed multiple sedation holds and required a tracheostomy. He continued to spike a fever. Despite no source of sepsis being found, the patient remained on broad spectrum antibiotics to cover for any potential infective causes until day 27. After 15 days, the patient's encephalopathy gradually improved. He was weaned off the ventilator and underwent intense physiotherapy. The patient was discharged from hospital one month after admission.

https://ift.tt/2vc6BNs

Spinal myoclonus: a rare presentation of cervical myelopathy

Myoclonus describes a movement disorder characterised by brief, abrupt and involuntary contractions of muscles or groups of muscles, usually associated with intracranial lesions, with limited evidence linking it to spinal pathologies. The pathophysiology of spinal myoclonus is extensive and multifactorial. Infection, intramedullary and extramedullary space-occupying lesions, trauma, vascular abnormalities, degenerative processes and cervical spondylosis have been implicated with the disease, the latter been associated with cervical stenosis with no reported cases linking it to an underlying cervical disc herniation. Although medical therapy with clonazepam, levetiracetam, valproate, tetrabenazine hydrochloride and spinal block injections has been equivocal, spinal myoclonus secondary to disc herniation requires surgical intervention. This report describes a case of segmental spinal myoclonus, secondary to a herniated cervical intervertebral disc. After corpectomy and a cage-augmented fusion technique, the myoclonic symptoms resolved. To our knowledge, this was the first report to describe the successful management of discogenic spinal myoclonus with spinal surgery.

https://ift.tt/2Ost95t

Blast from the past: a novel complication of bronchopulmonary dysplasia

Description 

A 43-year-old Caucasian woman presented to her primary care physician for a retirement physical exam. She endorsed mild dyspnoea on exertion, but denied chest pain, cough or shortness of breath at rest. On physical exam, lungs were clear bilaterally with good air movement in all fields. Chest radiograph was normal except for a 6 mm nodular density noted in the right lower lobe. A non-contrast CT scan of the chest was performed revealing a 2 mm calcified granuloma. In addition, there were global, mild and uniform paraseptal emphysematous changes throughout the pleural surfaces of the lungs and the fissures (figures 1 and 2). Pulmonary work-up including spirometry, carbon monoxide diffusing capacity and testing for alpha-1 antitrypsin deficiency was normal. Further investigation revealed a history of premature birth, supported with mechanical ventilation (MV). We attributed her radiographic findings and symptoms to sequelae of bronchopulmonary dysplasia (BPD).

https://ift.tt/2vj6nUC

Cardiac memory: an under-recognised cause of deep T wave inversion in a patient presenting with chest pain

T wave inversion (TWI) has many differential diagnoses with acute myocardial ischaemia being the highest on the list of potential causes. Cardiac T wave memory is a benign, under-recognised and clinically important phenomenon seen after periods of altered ventricular conduction. After normal ventricular conduction is restored, the T wave 'remembers' and mirrors the direction of the wide QRS complex. Therefore, negative T waves are seen in leads that had negative wide QRS complexes. We describe the case of a 60-year-old truck driver with chest pain, deep TWI and traditional cardiovascular risk factors. After ruling out significant myocardial ischaemia, it was crucial to determine the cause of his T wave changes to provide reassurance and provide commercial license medical clearance. While it is currently a diagnosis of exclusion, it remains an important clinical entity for clinicians to recognise to provide an explanation for certain T wave changes to avoid future unnecessary cardiac testing.

https://ift.tt/2OvaVA3

Primary lymphoedema

Description 

A 32-year-old woman presented with a 20-year history of slowly progressive leg oedema with recurrent cellulitis. She was referred from her primary care physician. Her mother had the same condition. Physical examination revealed non-pitting bilateral leg oedema (figure 1). Stemmer's sign was positive. Lymphoscintigraphy showed non-visualisation of inguinal nodes 30 min postexercise and dermal backflow in the lower limbs (figure 2). Compression garments were used but failed. She underwent bilateral lower limb supermicrosurgical lymphaticovenular anastomosis (two times anastomosis and four times incisions) and her oedema markedly improved. Four years after the operation, she was well without relapse.

Figure 1

Non-pitting bilateral leg oedema.

Figure 2

Preoperative lymphoscintigraphy. Lymphoscintigraphy revealed no migration of radiopharmaceutical agent in the lower limbs.

Primary lymphoedema is due to a congenital and/or inherited condition associated with pathological development...

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Strangulated adnexa due to adhesion band after hysterectomy

Description

A 50-year-old woman was admitted to our hospital with a 2-day history of cramping pain of the lower abdomen. She also reported an episode of nausea and vomiting prior to admission. The patient had undergone total abdominal hysterectomy for uterine myoma. Her blood pressure was 100/60 mm Hg, pulse rate of 70 beats/min and axillary temperature of 36.5°C. The patient had mild direct tenderness of the lower abdomen, especially at the right lower quadrant, with no rebound tenderness or muscular guarding. Laboratory data showed a white cell count of 10 100/mm³ (normal limit of 4000–10 000/mm³) and a C reactive protein concentration of 17.25 mg/L (normal limit of 0–10 mg/L). A plain chest X-ray revealed no free air under diaphragm. Pelvic ultrasound demonstrated smooth bilocular cystic tumour within the right adnexa that has no colour flow on Doppler.

Contrast-enhanced abdominal CT showed a hypodense area measuring 4x3x3 cm in the region of right adnexa and a...

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Endovascular treatment of an aorto-oesophageal fistula caused by oesophageal cancer

Description 

Aorto-oesophageal fistula (AOF) is commonly the product of aortic aneurysms or iatrogenic injuries during endovascular aortic procedures; despite that, AOF is an uncommon medical condition. In rare cases, it can be the product of an oesophageal carcinoma. It is a fatal condition, and its treatment options are scarce due to its low incidence.1 2 The case presented herein aims to show an endovascular treatment for AOF.

A 50-year-old male patient presented with odynophagia, progressive dysphagia and weight loss for 4 months prior to the consultation. The patient sought the emergency healthcare service due to haematemesis and melena for 6 days. He was submitted to haemodynamic recovery, blood transfusion and to an upper gastrointestinal tract endoscopy, which revealed an ulcerative and vegetative tumouration on his oesophagus 25 cm below his upper dental arcade. Biopsy confirmed the hypothesis of a malignant oesophageal carcinoma with moderate cell differentiation. Despite the...

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Pleural coccidioidomycosis presenting as spontaneous pneumothorax

Coccidioides is a fungus endemic to Southwestern USA and Northern Mexico which can be asymptomatic or result in a well-defined clinical syndrome of community-acquired pneumonia. On rare occasion, coccidioidomycosis may have atypical presentations as in our patient, a 25-year-old man admitted with a 2-month history of progressive dyspnoea and cough. He was found to have a large right-sided pneumothorax with exudative pleural effusion which did not resolve following thoracentesis. Decortication was performed which revealed a dense rind of inflammatory tissue covering all lobes of his right lung. Histopathology demonstrated hyphae resembling Aspergillus, but culture and serology confirmed Coccidioides immitis. Following several months of antifungal therapy, he achieved complete clinical recovery with near-complete resolution of radiographic findings.

https://ift.tt/2LCdGlB

Congenital Rhabdomyosarcoma Presenting as a Neck Mass at Birth

Rhabdomyosarcoma is a malignant tumor of the soft tissues which preferentially affects the pediatric population. Neonatal rhabdomyosarcoma is rare, and much of the published literature concerning this entity consists of isolated case reports and small case series. Recent work involving the classification of rhabdomyosarcoma has helped to delineate prognostic information based on gene rearrangements. Here, we present a case of congenital rhabdomyosarcoma seen in utero which manifested as a neck mass at birth and was found to harbor a favorable gene fusion.

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Effect of Intravenous Dexamethasone on the Regression of Isobaric Bupivacaine Spinal Anesthesia: A Randomized Controlled Trial

The effect of intravenous dexamethasone on the regression of sensory and motor block after isobaric bupivacaine spinal anesthesia is unknown. We conducted a prospective, double-blind, randomized controlled trial on 60 patients who received intravenously either placebo (group P) or 8-mg dexamethasone (group D) during the intrathecal injection of 12-mg isobaric bupivacaine 0.5%. Primary outcome was the time from bupivacaine injection to regression of 2 dermatomes in relation to the highest dermatome blocked by the spinal local anesthetic. Time to 2-dermatome regression was 85 minutes (74–96 minutes) in group P versus 87 minutes (76–98 minutes) in group D (P = .79). Accepted for publication June 18, 2018. Funding: Internal. The authors declare no conflicts of interest. Clinical Trials identifier: NCT03078062. Protocol available at: https://ift.tt/2OsukBR NCT03078062. Reprints will not be available from the authors. Address correspondence to Stephan R. Williams, MD, PhD, Département d'anesthésiologie, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC H2L 4M1, Canada. Address e-mail to stephan.williams@umontreal.ca. © 2018 International Anesthesia Research Society

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Laryngeal Mask Airway Versus Other Airway Devices for Anesthesia in Children With an Upper Respiratory Tract Infection: A Systematic Review and Meta-analysis of Respiratory Complications

There is an association between upper respiratory tract infection (URTI) and an increased incidence of perioperative respiratory adverse events (PRAEs), which is a major risk for morbidity during pediatric anesthesia. The aim of the present study was to compare the risk of PRAEs among different airway devices during anesthesia in children with a URTI. A systematic review according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Only randomized clinical trials evaluating anesthesia in children with a URTI and who were submitted to any of the airway devices were included. From 1030 studies identified, 5 randomized clinical trials were included in the final analysis. There were no statistical differences between laryngeal mask airway (LMA®) and endotracheal tube (ETT) regarding breath holding or apnea (risk ratio [RR], 0.82; 95% confidence interval [CI], 0.41–1.65), laryngospasm (RR, 0.74; 95% CI, 0.18–2.95), and arterial oxygen desaturation (RR, 0.44; 95% CI, 0.16–1.17). The quality of evidence was low for the first outcome and very low for the 2 other outcomes, respectively. The LMA use produced a significant reduction of cough (RR, 0.75; 95% CI, 0.58–0.96, low quality of evidence) compared with ETT. The ideal airway management in children with a URTI remains obscure given that there are few data of perioperative respiratory complications during anesthesia. This systematic review demonstrates that LMA use during anesthesia in children with URTI did not result in decrease of the most feared PRAEs. However, LMA was better than ETT in reducing cough. Further research is needed to define the risks more clearly because cough and laryngospasm have similar triggers, and both bronchospasm and laryngospasm trigger cough. Accepted for publication June 18, 2018. Funding: This research was carried out without funding. A.L.R.C. was granted a scholarship from Coordination of Improvement for Higher Academic Staff (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior [CAPES]). P.T.S.S. received a scholarship from São Paulo Research Foundation (Fundação de Amparo à Pesquisa do Estado de São Paulo [FAPESP]; #2014/16734–6). CAPES and FAPESP are Brazilian governmental agencies dedicated to promoting scientific research. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Preliminary data for this study were presented as European Society of Anaesthesiology (ESA) Best Abstract Prize Competition at the ESA Euroanaesthesia May 30, 2015 to June 2, 2015, Berlin, Germany. LMA is a registered trademark of Teleflex Incorporated or its affiliates. Reprints will not be available from the authors. Address correspondence to Ana Lygia R. de Carvalho, MD, PhD, Departamento de Anestesiologia, Universidade Estadual Paulista, UNESP, Faculdade de Medicina de Botucatu, Av. Prof. Mário Rubens Guimarães Montenegro, s/n, Bairro: UNESP, Campus de Botucatu, Botucatu, SP, Brazil. Address e-mail to analygiacarvalho@yahoo.com.br. © 2018 International Anesthesia Research Society

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Perioperative Blood Pressure Monitoring in Patients With Obesity

Blood pressure monitoring plays a key part in the preoperative, intraoperative, and postoperative care of all patients. In patients with obesity, hypertension indicates increased metabolic and surgical risk and may signal the presence of significant medical comorbidities, including obstructive sleep apnea. Avoidance of hypertension postoperatively is necessary to minimize bleeding risk after surgery. Hypotension in the postoperative period may be the first sign of significant complications that require urgent management. With the problem of being overweight or obese now affecting two-thirds of adults in Western countries, the proportion of patients with obesity in perioperative environments is similarly increasing. Detection of aberrations in blood pressure is contingent on the accuracy of blood pressure measurement methods. Patients with obesity tend to have a large arm circumference and "cone-shaped arms." Standard blood pressure cuffs fit such patients poorly, and this compromises the accuracy of measurements. Alternatives to arm blood pressure cuffs, some made specifically for individuals with obesity, have been evaluated but are not widely available to clinicians. This focused narrative review will discuss the relevance of hypertension management in the care of patients with obesity, highlight the currently available methods for perioperative monitoring of blood pressure, and explore the opportunities that exist to improve the perioperative blood pressure care in patients with obesity undergoing surgical procedures. Accepted for publication June 6, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Victoria A. Eley, PhD, Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, QLD 2006, Australia. Address e-mail to va_eley@hotmail.com. © 2018 International Anesthesia Research Society

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Postoperative Hypotension and Surgical Site Infections After Colorectal Surgery: A Retrospective Cohort Study

BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection. Hypotension on surgical wards, while usually less severe than intraoperative hypotension, is common and often prolonged. In this retrospective cohort study, we tested the hypotheses that there is an association between surgical site infections and low postoperative time-weighted average mean arterial pressure and/or postoperative minimum mean arterial pressure. METHODS: We considered patients who had colorectal surgery lasting ≥1 hour at the Cleveland Clinic between 2009 and 2013. We defined blood pressure exposures as time-weighted average (primary) and minimum mean arterial pressure (secondary) within 72 hours after surgery. We assessed associations between continuous blood pressure exposures with a composite of deep and superficial surgical site infection using separate severity-weighted average relative effect generalized estimating equations models, each using an unstructured correlation structure and adjusting for potentially confounding variables. RESULTS: A total of 5896 patients were eligible for analysis. Time-weighted mean arterial pressure and surgical site infection were not significantly associated, with an estimated odds ratio (95% CI) of 1.03 (0.99–1.08) for a 5-mm Hg decrease (P = .16). However, there was a significant inverse association between minimum postoperative mean arterial pressure and infection, with an estimated odds ratio of 1.08 (1.03–1.12) per 5-mm Hg decrease (P = .001). CONCLUSIONS: Postoperative time-weighted mean arterial pressure was not associated with surgical site infection, but lowest postoperative mean arterial pressure was. Whether the relationship is causal remains to be determined. Accepted for publication June 12, 2018. Huseyin O. Yilmaz, MD, is currently affiliated with the Department of Critical Care, Turkish Ministry of Health, Health Sciences University, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Izmir, Turkey. Rovnat Babazade, MD, is currently affiliated with the Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas. Wael Saasouh, MD, is currently affiliated with the Department of Anesthesiology, Detroit Medical Center, Detroit, Michigan. Funding: Institutional and/or departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Alparslan Turan, MD, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, P-77, Cleveland, OH 44195. Address e-mail to turana@ccf.org. © 2018 International Anesthesia Research Society

https://ift.tt/2LwWNZs

In Response

No abstract available

https://ift.tt/2vdEwW4

Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery

BACKGROUND: Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels on discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG). METHODS: We retrospectively evaluated 1552 patients undergoing isolated CABG at our institution from January 2013 to May 2016. We evaluated 2 Hb cohorts: "high" (above) and "low" (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (12 g/dL), "mild anemia" (10–11.9 g/dL), "moderate anemia" (8–9.9 g/dL), and "severe anemia" (

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Preventing Adverse Events in Cataract Surgery

No abstract available

https://ift.tt/2vfk9Yr

Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

https://ift.tt/2Orw3aD

World Health Organization Surgical Safety Checklist: Compliance and Associated Surgical Outcomes in Uganda’s Referral Hospitals

BACKGROUND: A pilot study on the World Health Organization (WHO) Surgical Safety Checklist (SSC) showed a reduction in both major complications and mortality of surgical patients. Compliance with this checklist varies around the world. We aimed to determine the extent of compliance with the WHO SSC and its association with surgical outcomes in 5 of Uganda's referral hospitals. METHODS: A multicentre prospective cohort study was conducted in 5 referral hospitals in Uganda. Using a questionnaire based on the WHO SSC, patients undergoing surgical operations were systematically recruited into the study from April 2016 to July 2016. The patients were followed up daily for 30 days or until discharge for the purpose of documentation of complications. Logistic regression and linear regression were used to assess for association between compliance and perioperative surgical outcomes. RESULTS: We recruited 859 patients into the study. Overall compliance with the WHO SSC was 41.7% (95% confidence interval [CI], 39.7–43.8) ranging from 11.9% to 89.8% across the different hospitals. Overall compliance with "sign in" was 44.7% (95% CI, 43–45.6), with "time out" was 42.0% (95% CI, 39.4–44.6), and with "sign out" was 33.3% (95% CI, 30.7–35.9). There was no association between compliance and perioperative surgical outcomes: length of hospital stay, adverse events, and mortality. CONCLUSIONS: This study revealed low levels of compliance with the WHO SSC. There was a statistically significant association between this level of compliance and the incidence of pain and loss of consciousness postoperatively. Accepted for publication June 18, 2018. Funding: None. The authors declare no conflicts of interest. Study registration number: NCT03252860. Registry URL: ClinicalTrials.gov. Reprints will not be available from the authors. Address correspondence to Elizabeth N. Igaga, MBChB, Department of Anaesthesia, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda. Address e-mail to lyzaigaga@gmail.com. © 2018 International Anesthesia Research Society

https://ift.tt/2veeiCR