En bloc corpectomy for late gastrointestinal stromal tumor metastasis: a case report and review of the literature

Spinal metastases of gastrointestinal stromal tumors are rare; however, the incidence has been increasing since the introduction of tyrosine kinase inhibitors, which have improved overall survival. Due to the ...

https://ift.tt/2QNzR6q

Testicular adrenal rest tumour in an adult patient with congenital adrenal hyperplasia: a case report and review of literature

Abstract

Late presentations of testicular adrenal rest tumours (TART) are rarely seen in males with congenital adrenal hyperplasia, and are often misdiagnosed as primary testicular germ cell tumours. We report a case of bilateral TART in an adult patient with congenital adrenal hyperplasia who had defaulted treatment. He presented with a gradually increasing swelling of the left testis and genital examination revealed a large hard indurated swelling of both epididymes more prominent on the left side. As imaging was inconclusive, a biopsy was performed which showed features in favour of TART rather than Leydig cell neoplasm and he had good response to steroids. Histopathological evaluation is helpful in cases where there is a strong need for excluding a malignancy. Optimal steroid replacement is the treatment of choice and leads to regression of the lesion in the majority.

https://ift.tt/2pWxYZI

Cholecystocolonic fistula with a giant colonic gallstone: the mainstay of treatment in an acute setting

Abstract

A cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis with cholecystitis. Cholecystocolonic fistulas (CCFs) account for 8–26.5% of all CEFs. CCFs can cause colonic bleeding, obstruction or perforation, with such complications being mainly reported in the narrower sigmoid colon. Colonic biliary ileus, or obstruction due to the colonic gallstone impaction, is extremely rare in the proximal colon and its best management is yet to be elucidated. We present the case of a 73-year-old male patient with multiple comorbidities and previous abdominal surgeries who presented with hematochezia and intestinal obstructive symptoms. Imaging revealed a giant 5 × 7 cm² gallstone in the proximal transverse colon. Laparotomy and stone extraction via colotomy were performed. Complicated proximal colonic gallstones are exceedingly rare with several operative and non-operative treatments already described. A time-saving surgery in a patient with serious comorbidities is reasonable when compared to a more extensive procedure including enterolithotomy, cholecystecomy and fistula closure.

https://ift.tt/2NIYS0w

Tracheopleural fistula after thoracoscopic esophagectomy: novel therapeutic approach with pericardial and intercostal muscle flaps

Abstract

Tracheal rupture following thoracoscopic esophagectomy is a dangerous event requiring primary repair with flap reinforcement. If the injury is not diagnosed during the surgery, morbidity and mortality increase significantly. Meanwhile, primary repair in such cases is not feasible due to the inflammation and difficulty in approximating the defect. Here, we report a case of tracheal injury during thoracoscopic esophagectomy with primary repair failure. We successfully repaired the injury by covering the defect first by a pericardial flap, then reinforcing it with an intercostal muscle flap. To our knowledge, there are few reports of such novel surgical techniques.

https://ift.tt/2pUbOY3

A giant duodenal diverticulum causing Lemmel syndrome

Abstract

An 80-year-old female, with a known periampullary giant duodenal diverticulum, presented to the emergency department with general deterioration. While not clinically icteric, her laboratory investigations revealed an obstructive jaundice. MRCP demonstrated mild distension of the gallbladder with several calculi. There was intra- and extra-hepatic biliary dilatation to the level of the ampulla. A giant fluid and air filled periampullary duodenal diverticulum measuring ~8 cm in the long axis was noted. The CBD was dilated to the level of this diverticulum and the cause of the patient's biliary dilatation and obstruction. A rare pancreaticobiliary complication of duodenal diverticula is Lemmel syndrome. Lemmel syndrome is defined as an obstructive jaundice caused by a periampullary duodenal diverticulum compressing the intra-pancreatic portion of the common bile duct with resultant dilatation of the extra- and intra-hepatic bile ducts. Recognition of this condition is important, as delayed diagnosis can result in unnecessary further investigations.

https://ift.tt/2NJNL7D

The relationship between seizure in electroconvulsive therapy and pupillary response using an automated pupilometer

Abstract

Objectives

Seizure duration and morphology, postictal suppression, and sympathetic nervous system activation are all recommended as assessments of adequate seizure in electroconvulsive therapy (ECT). However, blood pressure and heart rate are not typically assessed as part of sympathetic nervous system activation because of the administration of anesthetic or cardiovascular agents during ECT. Although the pupils are known to reflect to the activity of autonomic nervous system and the degree of brain damage, previous studies have not examined the relationship between seizure of electroconvulsive therapy and pupillary response.

Methods

We conducted 98 sessions of ECT with 13 patients, divided into two groups according to seizure quality: (1) adequate or (2) inadequate. Pupillary light reflex [% constriction = (maximum resting pupil size {MAX} − minimum pupil size after light stimulation)/MAX × 100] was measured using a portable infrared quantitative pupilometer before anesthesia induction and immediately after electrical stimulation.

Results

The number regarded as adequate was 67 times and as inadequate was 31 times. Maximum pupil size at the control and immediately after electrical stimulation was similar between the adequate and inadequate groups. Pupillary light reflex was similar at the control between both groups, but significantly smaller immediately after stimulation in the adequate group (2.5 ± 3.6%) compared with the inadequate group (10.6 ± 11.5%). Receiver operating characteristic curve analysis revealed that pupillary light reflex (> 5.5%) predicted adequate seizure.

Conclusions

The current findings suggest that pupillary constriction immediately after ECT could provide a helpful method for assessing the efficacy of ECT.

https://ift.tt/2NISd6o

Heated humidified high-flow nasal oxygen prevents intraoperative body temperature decrease in non-intubated thoracoscopy

Abstract

Purpose

In patients receiving non-intubated video-assisted thoracic surgery (NIVATS), transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has been applied instead of oxygen mask for better oxygenation. However, the THRIVE effects on intraoperative temperature decrease have not been investigated.

Methods

Pre- and postoperative temperatures, measured by an infrared tympanic ear thermometer, taken before sending patients to the operation room and immediately upon their arrival in the postoperative anesthesia unit, were collected from medical records of patients who received NIVATS either with oxygen mask or THRIVE. Intraoperative temperature decrease, calculated by preoperative temperature minus postoperative temperature, was compared between different groups. Multiple linear regression analysis was performed to determine factors associated with intraoperative temperature decrease.

Results

Records of 256 adult patients with forced-air warming were retrospectively analyzed. 172 patients of them received THRIVE and 84 patients received oxygen mask. Preoperative temperatures were comparable between groups (THRIVE: 36.25 ± 0.46 °C; mask: 36.30 ± 0.39 °C, p = 0.43). Postoperative temperatures were significantly higher in patients using THRIVE than those using oxygen masks (36.05 ± 0.59 vs 35.87 ± 0.62 °C, p = 0.025). Significantly less intraoperative temperature decrease was shown in THRIVE group (THRIVE: 0.20 ± 0.69 °C; mask: 0.43 ± 0.69 °C, p = 0.04). According to the multiple linear regression analysis, significant temperature decrease was associated with the advanced age (β_age = 0.01) but not the anesthetic duration. Using THRIVE was correlated with significantly less body temperature decrease (β_TRIVE = − 0.24).

Conclusions

THRIVE effectively prevents intraoperative temperature decrease during NIVATS, especially in old patients.

https://ift.tt/2Py60yt

Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children

BACKGROUND: Because nausea is difficult to evaluate in children, vomiting is used as the objective clinical end point in managing pediatric postoperative nausea and vomiting and postdischarge nausea and vomiting (PDNV). The recently developed pictorial Baxter Retching Faces (BARF) scale has content, construct, and convergent validity in quantifying pediatric nausea intensity. We determined its clinical usefulness in assessing pediatric postoperative nausea and vomiting and PDNV, establishing the lowest age associated with consistently reliable use, the score at which patients identify a need for therapy, and the minimum clinically relevant change in scores, and examined its test–retest reliability. METHODS: We obtained subject ratings of the severity of their nausea using the BARF and visual analog scales in the preoperative, postanesthesia care unit and postdischarge phases. Changes in nausea were rated on a 5-point Likert scale, along with responses to queries of a need for rescue antiemetics at these time points. RESULTS: Children ≥6 years of age had a consistently reliable ability to use the BARF scale (132/132 [100%] vs 59/76 [77.6%] for children ≥6 and 6) in 13 (6.7%). Emesis occurred in 8 (4.1%). Rescue antiemetics were administered to 16 (8.3%), including 2 with severe emesis (≥3 episodes) but in only 2 of 11 (18.2%) with severe nausea without vomiting. PDNV was reported in 39 of the 99 who returned diaries (39.4%), with nausea in 34 (34.3%), severe nausea in 15 (15.2 %), and emesis in 16 (16.2%). CONCLUSIONS: The pictorial BARF scale is easy to use in the clinical setting by children ≥6 years of age, has a minimum clinically relevant difference of 1.47, with scores of 4 or higher associated with a patient-identified need for rescue antiemetics. Assessment of postoperative nausea by the BARF scale has shown that clinically significant nausea occurs frequently in children but is not always treated unless accompanied by vomiting. Accepted for publication September 5, 2018. Funding: This work was supported by internal funding from the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, TX, and Baylor College of Medicine, Houston, TX. The authors declare no conflicts of interest. Clinical trials registration: The trial was registered before patient enrollment at clinicaltrials.gov (NCT 02421952, principal investigator: S.A.B.; date of registration: April 21, 2015). Reprints will not be available from the authors. Address correspondence to Mehernoor F. Watcha, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin St, Suite A 3300, Houston, TX 77030. Address e-mail to mwatcha@gmail.com. © 2018 International Anesthesia Research Society

https://ift.tt/2CKr5Do

Anesthesia in Enhanced Recovery Pathways for Hip and Knee Arthroplasty: Where Is the Evidence?

No abstract available

https://ift.tt/2CM8l6v

Rapid Titration of Intravenous Treprostinil to Treat Severe Pulmonary Arterial Hypertension Postpartum: A Retrospective Observational Case Series Study

BACKGROUND: Pulmonary hypertension during pregnancy carries high mortality rate. The relatively long-acting, specific pulmonary vasodilator treprostinil has been used to improve survival in these parturients. Slow uptitration is performed in most cases, and rapid titration has not been reported in the postpartum period. METHODS: We retrospectively reviewed 17 pregnant patients with severe pulmonary arterial hypertension who were treated with intravenous treprostinil in our institution between 2014 and 2016. Patients' demographic characteristics, etiology, functional status, mode of delivery, anesthetic administration, medical therapy, echocardiographic and hemodynamic measurements, subsequent clinical course, and maternal–fetal outcomes were assessed. The a priori primary outcome is maternal mortality in this study. RESULTS: Rapid titration of intravenous treprostinil was initiated at 1.25 ng/kg/min and increased to effective dose of 10 ng/kg/min by 1.25–2.5 ng/kg/min every 3 hours. In the next 24 hours, we adjusted the dosage to a median maximum dose of 15 ng/kg/min (interquartile range, 15–20 ng/kg/min) over a median uptitration period of 34 hours (interquartile range, 24–41 hours) for 17 parturients with severe pulmonary hypertension. Treprostinil was weaned off by 0.50–1.25 ng/kg/min every 3 hours in 94.3 ± 42.4 hours. Fifteen patients survived to discharge, and only 2 patients died of pulmonary hypertensive crisis (maternal mortality rate, 11.7%). No treprostinil infusion-related postpartum complication was observed. CONCLUSIONS: Our experience suggested that rapid uptitration of intravenous treprostinil combined with oral sildenafil in the postpartum period may be a safe and effective approach for these very sick parturients with severe pulmonary hypertension. Accepted for publication August 23, 2018. Funding: None. 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). T. Wang and J. Lu contributed equally and share first authorship. Reprints will not be available from the authors. Address correspondence to Jiapeng Huang, MD, PhD, Department of Anesthesiology and Perioperative Medicine, University of Louisville, 200 Abraham Flexner Way, Louisville, KY 40202. Address e-mail to jiapenghuang@yahoo.com; and Jinglan Zhang, MD, Department of Surgical Intensive Care Medicine, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing AnZhen Hospital, Capital Medical University, No. 2 AnZhen Rd, Chaoyang District, Beijing 100029, People's Republic of China. Address e-mail to jinglanzhang2006@163.com. © 2018 International Anesthesia Research Society

https://ift.tt/2QSPZUm

In Response

No abstract available

https://ift.tt/2QRf6Xs

Electronic Audit and Feedback With Positive Rewards Improve Anesthesia Provider Compliance With a Barcode-Based Drug Safety System

BACKGROUND: We implemented a previously described barcode-based drug safety system in all of our anesthetizing locations. Providers were instructed to scan the barcode on syringes using our Anesthesia Information Management System before drug administration, but the rate of provider adherence was low. We studied an implementation intervention intended to increase the rate of scanning. METHODS: Using our Anesthesia Information Management System and Smart Anesthesia Manager software, we quantified syringe drug administrations by anesthesia providers with and without barcode scanning. We use an anesthesia team model in which an attending anesthesiologist is paired with a certified registered nurse anesthetist (CRNA) or a resident. Our system identified the pair of providers associated with a particular drug administration, but did not distinguish which providers actually administered the drug. Therefore, the rate of barcode scanning for a particular case was assigned to both providers equally. A baseline rate of scanning was established over a period of 17 months. An audit and feedback intervention was then performed that consisted of monthly performance reports sent by email to individual providers along with coffee gift card awards for top performers. The coffee gift cards were awarded in only the first 2 months of the intervention, while the email performance reports continued on a monthly basis. The coffee card awards were made public. The monthly emails reported the individual provider's rank order of performance relative to other providers, but was otherwise anonymous. The baseline rate of scanning was compared to the rate of scanning after the intervention for a period of 7 months. RESULTS: From November 2014 to March 2017, we accumulated 60,197 cases performed by 88 attending anesthesiologists, 65 CRNAs, and 148 residents. The total number of syringe drug administrations was 653,355. Average scanning performance improved from 8.7% of syringe barcodes scanned during the baseline period from November 2014 to February 2016 to 64.4% scanned during the period September 2016 to March 2017 (P

https://ift.tt/2CgdORS

In Response

No abstract available

https://ift.tt/2Cf0hK9

Attenuation of Unevoked Mechanical and Cold Pain Hypersensitivities Associated With Experimental Neuropathy in Mice by Angiotensin II Type-2 Receptor Antagonism

Recent findings from a phase II clinical trial showed analgesic effects of an angiotensin II type-2 receptor (AT2R) antagonist in postherpetic neuralgia patients. This study aimed to investigate whether AT2R antagonism could provide effective analgesia in voluntary measures of unevoked/ongoing pain-like behaviors in mice with experimental neuropathy. Mice were subjected to spared nerve injury to induce neuropathy and tested in 2 operant behavioral tests to measure ongoing mechanical and cold pain hypersensitivities. Systemic administration of an AT2R antagonist provided effective analgesia in these behavioral measures of mechanical and cold pain in spared nerve injury mice, suggesting its effectiveness in neuropathic pain. Accepted for publication September 6, 2018. Funding: This study was supported by a pilot and feasibility grant from the Washington University Nutrition Obesity Research Center National Institutes of Health grant P30DK056341 (to A.J.S.) and by start-up funds from the Department of Anesthesiology, Washington University Pain Center and Washington University School of Medicine (to D.P.M.). 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 Andrew J. Shepherd, PhD, Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine in St Louis, St Louis, MO 63110. Address e-mail to a.shepherd@wustl.edu; and Durga P. Mohapatra, PhD, Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine in St Louis, St Louis, MO 63110. Address e-mail to d.p.mohapatra@wustl.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2Cg7Yjj

Improving outcomes in ambulatory anesthesia by identifying high risk patients

Purpose of review Currently, outcome data in ambulatory anesthesia are somewhat limited though results are quite good with low reported rates of mortality and major morbidity. As patient comorbidities and surgical invasiveness increase, identifying those patients at higher risk will help to focus quality improvement energy and research where most effective. Better data collection and analysis will refine patient and procedure selection and improve outcomes going forward. Recent findings Complications after ambulatory surgery are associated with age, higher American Society of Anesthesiologists physical status, obstructive sleep apnea, and obesity. Frailty has recently been linked to increased complications in ambulatory surgery as well. Newer ambulatory procedures such as spine and total joint arthroplasty require careful patient selection. Summary Identifying high-risk ambulatory patients can help facilitate development of a strategy to triage these patients, optimize their conditions prior to surgery, and manage their care and disposition postoperatively. Inpatient surgery or admission should be considered for higher risk patients having high invasive surgery. Correspondence to Michael T. Walsh, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +507 284 9700; fax: +507 284 0120; e-mail: walsh.michael1@mayo.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2IXRde2

Hepatic Critical Care

No abstract available

https://ift.tt/2CKNvEa

Prospective, Randomized Comparison of the i-gel and the Self-Pressurized air-Q Intubating Laryngeal Airway in Elderly Anesthetized Patients

BACKGROUND: Age-related changes in upper airway anatomy may affect the overall performance of supraglottic airways significantly. The clinical performance of the i-gel and the self-pressurized air-Q intubating laryngeal airways with noninflatable cuffs for elderly populations remains unknown, unlike in children. Thus, we performed a prospective, randomized comparison of these 2 supraglottic airways in elderly patients undergoing general anesthesia. METHODS: We recruited 100 patients, 65–90 years of age, who were scheduled for elective surgery under general anesthesia with muscle relaxation. The enrolled patients were allocated to the i-gel or self-pressurized air-Q group. We assessed oropharyngeal leak pressure as the primary outcome and fiberoptic view after placement and fixation of the airway and at 10 minutes after the initial assessment. The fiberoptic view was scored using a 5-point scale as follows: vocal cords not visible; vocal cords and anterior epiglottis visible, >50% visual obstruction of epiglottis to vocal cords; vocal cords and anterior epiglottis visible,

https://ift.tt/2CgwfFV

Noncaseating suppurative granulomatous lymphadenitis in adult onset Still’s disease – a diagnostic dilemma in a tuberculosis-endemic region: a case report

Lymphadenopathy is not an uncommon presentation of adult onset Still's disease: it is present in up to two thirds of patients with adult onset Still's disease. The characteristic appearance of lymphadenopathy ...

https://ift.tt/2EiXVgc