Transient severe distributive shock due to early dumping syndrome: a case report

Early dumping syndrome characterized by palpitation, dizziness, cold sweat, feebleness, and abdominal symptoms, occurs within 30 minutes after meals in patients who have undergone gastrectomy. This case report...

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Education in Anesthesia: How to Deliver the Best Learning Experience

No abstract available

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Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions

Anesthetic agents are known greenhouse gases with hundreds to thousands of times the global warming impact compared with carbon dioxide. We sought to mitigate the negative environmental and financial impacts of our practice in the perioperative setting through multidisciplinary staff engagement and provider education on flow rate reduction and volatile agent choice. These efforts led to a 64% per case reduction in carbon dioxide equivalent emissions (163 kg in Fiscal Year 2012, compared with 58 kg in Fiscal Year 2015), as well as a cost savings estimate of $25,000 per month. Accepted for publication August 1, 2018. Funding: K.L.Z. receives nonclinical time for her role as Medical Director of Sustainability for UW Health. 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). Reprints will not be available from the authors. Address correspondence to Karin L. Zuegge, MD, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792. Address e-mail to zuegge@wisc.edu. © 2018 International Anesthesia Research Society

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The Perioperative Management of Ascending Aortic Dissection

Acute aortic syndromes are a distinct group of pathologies involving the wall of the aorta that present acutely and can be potentially fatal unless treated in a timely fashion. The syndrome is dominated by aortic dissections, which comprise ≥95% of all such presentations. Those involving the ascending aorta are particularly lethal and require specific and early surgical treatment compared to dissections involving other parts of the aorta. The surgical repair of an ascending aortic dissection presents multiple challenges to the anesthesiologist. Thoughtful management throughout the perioperative period is critical for minimizing the significant morbidity and mortality associated with this condition. In this narrative review, we provide an overview of the perioperative management of patients presenting for the surgical repair of an ascending aortic dissection. Preoperative discussion focuses on assessment, hemodynamic management, and risk stratification. The intraoperative section includes an overview of anesthetic management, transesophageal echocardiographic assessment, and coagulopathy, as well as surgical considerations that may influence anesthetic management. Accepted for publication July 17, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Madhav Swaminathan, MD, MMCi, FASE, FAHA, Department of Anesthesiology, Duke University Medical Center, Box 3094 DUMC/5691F HAFS, Durham, NC 27710. Address e-mail to madhav.swaminathan@duke.edu. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Trainability of Application of the Correct Cricoid Force: Time to Rely on Devices?

No abstract available

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Short and long-term impact of remifentanil on thermal detection and pain thresholds after cardiac surgery: A randomised controlled trial

BACKGROUND The clinical relevance of the suggested hyperalgesic effects of remifentanil is still unclear, especially in the long term. OBJECTIVE The current study evaluated the impact of remifentanil on thermal thresholds 3 days and 12 months after surgery, measured with Quantitative Sensory Testing. DESIGN A prospective, single-blind, randomised controlled trial. SETTING A tertiary care teaching hospital in The Netherlands, from 2014 to 2016. PATIENTS A total of 126 patients aged between 18 and 85 years, undergoing cardiothoracic surgery via sternotomy (coronary artery bypass grafts and/or valve replacement) were included. Exclusion criteria were BMI above 35 kg m−2, history of cardiac surgery, chronic pain conditions, neurological conditions, allergy to opioids or paracetamol, language barrier and pregnancy. INTERVENTIONS Patients were allocated randomly to receive intra-operatively either a continuous remifentanil infusion or intermittent intra-operative fentanyl as needed in addition to standardised anaesthesia with propofol and intermittent intravenous fentanyl at predetermined time points. MAIN OUTCOME MEASURES Warm and cold detection and pain thresholds 3 days and 12 months after surgery. In addition the use of remifentanil, presence of postoperative chronic pain, age, opioid consumption and pre-operative quality of life were tested as a predictor for altered pain sensitivity 12 months after surgery. RESULTS Both warm and cold detection, and pain thresholds, were not significantly different between the remifentanil and fentanyl groups 3 days and 12 months after surgery (P > 0.05). No significant predictors for altered pain sensitivity were identified. CONCLUSION Earlier reports of increased pain sensitivity 1 year after the use of remifentanil could not be confirmed in this randomised study using Quantitative Sensory Testing. This indicates that remifentanil plays a minor role in the development of chronic thoracic pain. Still, the relatively high incidence of chronic thoracic pain and its accompanying impact on quality of life remain challenging problems. TRIAL REGISTRY REGISTRATION ClinicalTrials.gov identifier NCT02031016. TRIAL REGISTRATION The study was registered at EudraCT (ref: 2013-000201-23) and ClinicalTrials.gov (https://ift.tt/2Mq69Sn). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. https://ift.tt/OBJ4xP Correspondence to Catherijne A.J. Knibbe, Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands Tel: +31 30 609 26 12; e-mail: c.knibbe@antoniusziekenhuis.nl 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/2ylyqmW). © 2018 European Society of Anaesthesiology

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Just Beneath the Surface

In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information by sharing relevant background and reasoning with the reader (regular type). The authors' commentary follows. A 55-year-old man was evaluated in…

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Use of propofol for prevention of post-delivery nausea during cesarean section: a double-blind, randomized, placebo-controlled trial

Abstract

Purpose

Nausea and vomiting are common, undesirable symptoms during cesarean section. We conducted this study to assess the antiemetic properties of propofol for the prevention and immediate treatment of post-delivery nausea and vomiting during cesarean section under combined spinal–epidural anesthesia.

Methods

Eighty women undergoing elective cesarean delivery under combined spinal–epidural anesthesia were randomized to receive either propofol at a plasma concentration of 1000 ng/mL or normal saline immediately after clamping of the umbilical cord. The incidence of post-delivery nausea and vomiting, patients requiring rescue antiemetic, bispectral index, sedation score, and the incidence of hypotension were assessed intraoperatively. Satisfaction and neonatal behavioral neurological assessments were evaluated postoperatively.

Results

The incidence of nausea was significantly lower in the propofol group compared to the placebo group (25% versus 60%, P < 0.001). The incidence of retching and vomiting showed no significant difference between the two groups. Propofol 20 mg as a rescue antiemetic was significantly effective in both the groups. Satisfaction level of patients and obstetricians in the propofol group was higher than in the placebo group. There was no statistical difference in the incidence of hypotension between the two groups both pre- and post-delivery. There was no difference in postoperative neonatal behavioral neurological assessment between groups.

Conclusion

Propofol at a plasma concentration of 1000 ng/mL significantly reduced the incidence of post-delivery nausea compared to placebo, but had no effect on reducing retching or vomiting episodes during cesarean section.

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Atypical case of mucous membrane pemphigoid in a 26-year-old man

A 26-year-old Caucasian man with no previous history of chemical injury presenting with an inability to open his right eye was investigated for mucous membrane pemphigoid and treated. Examination was notable for symblepharon of the right eye and impetigo-like lesions on the face and neck. A biopsy with immunohistochemical analysis was significant for linear deposits of C3 and immunoglobulin G at the level of the epithelial basement membrane, confirming the diagnosis of mucous membrane pemphigoid. Although mucous membrane pemphigoid classically presents bilaterally in women in the sixth and seventh decades of life, our patient was a young man with unilateral cicatrising conjunctivitis who may have been easily misdiagnosed without a high index of suspicion. A biopsy is required in cases of cicatrising conjunctivitis so that even atypical cases such as the one presented herein can be appropriately managed.

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Hit by the wave: a case of painful Horners and intramural haematoma of the carotid

Carotid artery dissection from rupture of the vasa vasorum is under-recognised. We report the case of a 60-year-old woman presenting to our hospital with a 2-week history of right-sided headache, neck pain, unequal pupils and ptosis after being hit by a wave on the beach. She was diagnosed with painful Horner's syndrome. MR angiogram revealed dissection of the right internal carotid artery with an intramural haematoma without an intimal flap. A diagnosis of carotid artery dissection from rupture of the vasa vasorum was made. Initial antithrombotic (aspirin and clexane) were stopped as she was deemed a low stroke risk with no signs of ischaemia on MR brain. Her clinical course was uneventful with resolution of the intramural haematoma seen on repeat MR angiogram.

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Acute gastric volvulus presenting as a pseudo cardiac tamponade

Description 

Gastric volvulus is defined as rotation of the stomach or part of the stomach by more than 180°, creating a closed loop obstruction. Typically, its clinical presentation includes abdominal pain, distension, nausea and vomiting. Diagnosis requires a high suspicion index as it can be easily misdiagnosed with other abdominal problems such as stomach distension or subocclusive syndrome. CT scan has proven to be both highly sensitive and specific when differentiating these processes.1

A woman in their early 80s with no relevant medical background presented at out hospital with nausea and progressive dyspnoea for 3 days. She did not mention chest pain, cough, fever or other symptoms. Physical examination revealed tachycardia (122 bpm), tachypnoea (35 bpm), low arterial pressure (90/67 mm Hg), diminished heart sounds, jugular ingurgitation and basal left hypophonesis. Chest radiography (figure 1) showed massive hiatal hernia and urgent tomography (figure 2) confirmed...

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Enterolithiasis in posterior urethral diverticulum: an uncommon complication following surgery for anorectal malformation

Description 

A posterior urethral diverticulum (PUD) may be formed when a part of the terminal rectal stump is left attached to the posterior urethra during fistula ligation in surgery for anorectal malformation (ARM).

A 13-year-old boy presented with the complaints of burning micturition, postvoid dribbling and vague pain in the left lower abdomen for the last 4 months. The child had high ARM and underwent all three stages of surgery (colostomy, transabdominal pull-through procedure and colostomy closure) elsewhere. On evaluation, the plain X-ray pelvis showed huge, multiple radio-opaque shadows in the region of the bladder (figure 1A). On an ultrasound, these acoustic shadows caused by the stones appeared to be posterior to the bladder and could not be appreciated well in full bladder state. A CT scan further confirmed these radio-opaque shadows to be posterior, but not within the urinary bladder and anterior to the rectum (figure...

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Anaplastic large cell lymphoma in a pregnant Filipino woman successfully treated with prepartum and postpartum chemotherapy

Diagnosis of a malignancy during pregnancy presents a dilemma regarding the work-up and treatment of the patient. This report presents a 42-year-old woman on her 23rd week of pregnancy with multiple enlarging fungating violaceous skin masses. Biopsy of the dominant mass revealed anaplastic large cell lymphoma. Due to the progressive enlargement and increase in number of the masses, the patient was given two cycles of chemotherapy (doxorubicin, vincristine, cyclophosphamide and prednisone) before delivering a live baby boy via spontaneous vaginal delivery, Apgar 9.9, at 37 4/7 weeks. After delivery, she completed four more cycles of treatment. A full-body positron emission tomography scan done 2 months after the last chemotherapy showed no evidence of disease. The patient is doing well with no evidence of disease 9 months after treatment. Her baby is thriving and has no gross deformities and no developmental delays.

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Bladder calculi causing irreducible urogenital prolapse

Over 200 000 surgeries for vaginal prolapse are done annually, and these are rarely urgent. However, when the rare event of bladder stones causes incarcerated procidentia, surgical intervention should not be delayed, due to unrelenting pain and end-organs effects. We present such a case below. A 71-year-old woman presents to our department with massive uterovaginal and rectal procidentia. This massive prolapse was found to be irreducible due to numerous dahllite stones in the bladder, and was causing obstructive uropathy with left-sided hydronephrosis. A multidisciplinary approach was necessary to surgically correct the prolapse and implement complete removal of all the stones. The simultaneous occurrence of uterovaginal prolapse, rectal prolapse and urolithiasis is uncommon. Stone formation is a result of chronically infected urine presenting a nidus for stone formation. This presentation has occurred very rarely over the last 70 years of the world's literature. Surgical cures can be achieved by either the vaginal or abdominal routes but should be treated emergently to alleviate pain, prevent renal impairment from obstructive uropathy and decrease infectious morbidity.

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Invasive mediastinal aspergillosis presenting as superior vena cava syndrome in an immunocompetent patient

Invasive aspergillosis (IA) is a disease of the immunocompromised with a predilection for the lungs, although dissemination to all organs is possible. Its diagnosis remains a challenge due to the absence of specific clinical manifestations and laboratory findings. In most cases, diagnosis is eventually made via invasive methods. It carries with it a high mortality due to late diagnosis and delayed treatment. Here, we report a fascinating case of a young, otherwise healthy, immunocompetent patient that presented to us with superior vena cava syndrome and a mediastinal mass. It was anticipated that a malignancy would be found on further workup but, in fact, what was eventually discovered was a case of IA. Our report accentuates the significance of including IA as a differential while diagnosing a mediastinal mass in an immunocompetent host as patient outcome is determined by timely diagnosis and treatment.

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Emphysematous pyelonephritis: outcomes of conservative management and literature review

Emphysematous pyelonephritis (EPN) is a rare, necrotising infection of the renal parenchyma, predominantly associated with Escherichia coli infection and unless promptly recognised and dealt with, it carries a poor prognosis. The current treatment is one of antimicrobial therapies together with nephrectomy in a majority of patients. We report an elderly man with multiple comorbidities with a diagnosis of EPN whose condition improved with antimicrobial and supportive therapy, and no surgical intervention was required.

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Severe subcutaneous emphysema in a term neonate

Description 

The baby was born by elective caesarean section because of breech presentation, at 38+6 weeks of gestation with an Apgar score of 9 at 1 min, 9 at 5 min and a birth weight of 4.02 kg. She was noted to be grunting at 20 min of age and had O₂ saturations of 55% in air and therefore commenced on O₂ by face mask initially, followed by continuous positive airway pressure (CPAP) at a pressure of 5 cm as O₂ requirements remained high (up to 60%). CPAP pressure did not need to be increased further as the O₂ requirement came down to 40% and remained between 30% and 40% for the subsequent 24 hours. Initial capillary blood gas at 2 hours of age (on CPAP 5 cm, FiO₂ 0.35) showed: pH 7.28; pCO₂ 7.05; pO₂ 7.15 and BE –2. Repeat capillary blood gas at 4 hours (on CPAP 5 cm, FiO₂ 0.35) showed: pH 7.30; pCO₂ 6.95; pO₂...

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When duality of renal duplexity and duplicity coexists

Description 

A 25-year-old male patient presented with complaints of right flank pain and recurrent episodes of urinary tract infections (UTIs) since childhood.

He had no history of fever, haematuria, urinary incontinence or voiding lower urinary tract symptoms. Per abdominal examination was unremarkable, and there was no renal tenderness.

His complete blood haemogram and renal function tests were normal. On evaluation with ultrasound Kidney Ureter Bladder (KUB) and CT urography, there was presence of bilateral duplex kidneys with bilateral duplication of ureter with poorly functioning upper pole moiety of right duplex kidney with gross hydronephrosis and thinned out renal cortex with normal lower pole as shown in figure 1.

Figure 1

Three-dimensional reconstructed CT urography film showing bilateral duplex kidney with duplicated ureters with poorly functioning upper pole of right kidney.

Tc99m-diethylenetriaminepentacetate scan was done which confirmed non-functioning upper pole moiety of right...

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Severe disease due to CCDC40 gene variants and the perils of late diagnosis in primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) can manifest in the neonatal period with severe respiratory distress. We describe a child with PCD who presented at term with severe neonatal respiratory distress, persistent right upper lobe collapse and failure to thrive who underwent lobectomy prior to the diagnosis of PCD at the age of 3 years. This case report illustrates the severe spectrum of lung disease associated with coiled-coil domain containing protein 40 (CCDC40) gene variants in patients with PCD.

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Status dystonicus: a diagnosis delayed

Status dystonicus, also known as the dystonic storm or dystonic crisis, is rare but may prove fatal due to respiratory and bulbar complications. In adults, the condition is rare and possibly under-reported. The lack of awareness of this condition among emergency and acute physicians may lead to an incorrect or delayed diagnosis, which should be avoided. We report a case of a 23-year-old man with athetoid cerebral palsy who presented to a district general hospital with uncontrolled dystonic movements, which were diagnosed as status dystonicus. This was successfully treated with intravenous clonidine, with full recovery returning to baseline functional state.

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An unusual case of intestinal obstruction due to internal herniation from adhesions between two appendices epiploicae

Abstract

Internal hernia of the small bowel is a rare finding especially in previously non-operated abdomen. Such a hernia occurring due to involvement of appendices epiploicae is an even rare instance with less than five reported cases in the literature. We encountered a 75-year-old male who had internal herniation of small bowel through an aperture created by adhesion between two appendices epiploicae in a previously virgin abdomen. Laparotomy and division of adhesion was performed to manage him successfully. Even in a virgin abdomen, a high index of suspicion along with early intervention is the key to reduction in mortality and morbidity in cases intestinal obstruction.

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Cecal volvulus caused by internal herniation after roux-en-y gastric bypass surgery

Abstract

Cecal volvulus is the rotation of a mobile cecum resulting in a large bowel obstruction. We present the case of a 55-year-old female who underwent a roux-en-y gastric bypass in 2003 and presented to the emergency department with worsening abdominal pain, distention and obstipation. Roentgenogram demonstrated a 14 cm colon suggestive of sigmoid volvulus, but CT scan showed rectal contrast abruptly ending in the distal transverse colon, mesenteric swirling and a distended cecum, consistent with cecal, rather than sigmoid, volvulus. Upon surgical exploration the majority of the small bowel, cecum and ascending colon had herniated through the transverse mesocolon defect created during her prior gastric bypass. The bowel was reduced through the mesenteric defect, and an ileocecectomy was performed. This is, to our knowledge, the first reported case of cecal volvulus caused by an internal hernia through a mesocolon defect created during a prior roux-en-y gastric bypass operation.

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A challenging abdomino-scrotal hydrocele—successful resolution with the help of interventional radiology guided sclerosis

Abstract

Abdomino-scrotal hydrocele is a rare condition that presents in male infants. There is no consensus in the literature over treatment. We present the case of a 4-year-old boy with what was thought to be a straight forward congenital hydrocele that persisted despite ligation of a patent processus vaginalis and a Jaboulay procedure. A subsequent Magnetic Resonance Imaging scan identified a large intra-abdominal component connecting to the scrotum. Laparoscopic excision of the intra-abdominal component was performed successfully, but the hydrocele persisted. The hydrocele resolved without complication following two episodes of image intensifier guided sclerotherapy carried out by the interventional radiology team.

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