Idiopathic calcinosis cutis of the scrotum: a case report and review of the literature

Abnormal deposition of calcium in the skin or subcutaneous tissue is termed calcinosis cutis. Idiopathic calcinosis cutis of the scrotum is an uncommon entity. The pathogenesis of idiopathic calcinosis cutis o...

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Brain Death in Patients With “Isolated” Brainstem Lesions: A Case Against Controversy

No abstract available

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Comparison of rocuronium requirement in children with continuous infusion versus intermittent bolus: A randomised controlled trial

BACKGROUND Minimising rocuronium administration during paediatric surgery helps to reduce the incidence of residual muscular blockade. OBJECTIVE To determine whether intermittent bolus injection (Bolus group) or continuous infusion (group) requires the lesser amount of rocuronium. DESIGN A prospective, randomised, single-blind controlled trial. SETTING A single university hospital from March to June 2017. PATIENTS Sixty-six children undergoing general anaesthesia. INTERVENTIONS Dose of rocuronium for maintenance of muscle relaxation in either Bolus or continuous infusion group. Train-of-four (TOF) count of two was maintained during surgery. When TOF count reached three, 0.1 mg kg−1 of rocuronium was administered in Bolus group or infused at an increased rate of 0.1 mg kg−1 h−1 in continuous infusion group. MAIN OUTCOME MEASURES Primary outcome was the dose of rocuronium given (μg kg−1 min−1). The recovery time from the TOF count four to TOF 0.7 (RT0.7), and 0.9 (RT0.9) were recorded. All adverse events were recorded up to 30 min after extubation. RESULTS Mean (SD) rocuronium dose in the Bolus group was 6.1 (0.9), [95% confidence interval (95% CI) 5.7 to 6.4] μg kg−1 min−1 and 4.9 (1.0), (95% CI 4.6 to 5.3) μg kg−1 min−1 in the continuous infusion group (P = 0.001). RT0.7 was 24.0 (13.7), 95% CI 19.3 to 28.7) min in the Bolus group, and 25.7 (16.0), (95% CI 20.2 to 31.2) min in the continuous infusion group (P = 0.73). RT0.9 was 30.7 (17.1), (95% CI 24.9 to 36.5) min in the Bolus group, and 30.0 (17.6), (95% CI 24.0 to 36.0) min in the continuous infusion group (P  = 0.91). The incidence of adverse events was not significantly different between two groups. CONCLUSION In children undergoing general anaesthesia, the dose of rocuronium given by continuous administration was less than that with intermittent bolus. TRIAL REGISTRATION ClinicalTrials.gov (identifier: NCT03060707). Correspondence to Hee-Soo Kim, MD, PhD, Department of Anaesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea Tel: +82 2 2072 3659; fax: +82 2 747 5639; e-mail: dami0605@snu.ac.kr © 2018 European Society of Anaesthesiology

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Precise anesthesia in thoracoscopic operations

Purpose of review The current review focuses on precise anesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. Recent findings VATS has become an established and widely used minimally invasive approach with broad implementation on a variety of thoracic operations. In the current environment of enhanced recovery protocols and cost containment, minimally invasive VATS operations suggest adoption of individualized tailored, precise anesthesia. In addition to a perfect lung collapse for surgical interventions with adequate oxygenation during one lung ventilation, anesthesia goals include a rapid, complete recovery with adequate postoperative analgesia leading to early discharge and minimized costs related to postoperative inpatient services. The components and decisions related to precise anesthesia are reviewed and discussed including: letting patients remain awake versus general anesthesia, whether the patient should be intubated or not, operating with or without muscle relaxation, whether to use different separation devises, operating with different local and regional blocks and monitors. Conclusion The determining factors in designing a precise anesthesic for VATS operations involve consensus on patients' tolerance of the associated side effects, the best practice or techniques for surgery and anesthesia, the required postoperative support, and the care team's experience. 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 Ya-Jung Cheng, MD, PhD, Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Jen-Ai Road, Section 1, Taipei 10051, Taiwan. Tel: +88 62 23123456x65517; fax: +88 62 23415736; e-mail: chengyj@ntu.edu.tw Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Orthostatic intolerance following hip arthroplasty: Incidence, risk factors and effect on length of stay a prospective cohort study

BACKGROUND Early postoperative mobilisation is important for enhanced recovery, but can be hindered by orthostatic intolerance, characterised by dizziness, nausea, vomiting, feeling of heat, blurred vision and ultimately syncope. Although the incidence of orthostatic intolerance following total hip arthroplasty has been identified, few studies have yet investigated potential risk factors for developing orthostatic intolerance after hip arthroplasty. OBJECTIVES The aim of this study was to assess the incidence of orthostatic intolerance on the first postoperative day after total hip arthroplasty, potential predisposing risk factors for developing orthostatic intolerance and its effect on length of stay. DESIGN A prospective observational study. SETTING Tertiary hospital, Auckland, New Zealand, May to September 2015. PATIENTS One hundred and seventeen consecutive patients undergoing unilateral total hip arthroplasty. Patients were excluded if they had revision surgery. MAIN OUTCOME MEASURES Incidence of orthostatic intolerance during mobilisation on the first postoperative day. Significant peri-operative risk factors for developing orthostatic intolerance were identified using logistic regression. Length of stay was compared between orthostatic intolerant and orthostatic tolerant patients using the Mann–Whitney U-test. RESULTS On the first postoperative day, 22% of patients failed mobilisation due to orthostatic intolerance. Factors independently associated with orthostatic intolerance were female sex; OR (95% CI), 3.11 (1.01 to 9.57), postoperative use of gabapentin; OR 3.55 (1.24 to 10.15) and high peak pain levels (≥5/10) during mobilisation; OR 4.05 (1.30 to 12.61). Overall, 78% of patients were correctly identified. The model was more accurate at predicting those who would not get orthostatic intolerance (89% correct), compared with those who did have orthostatic intolerance (39% correct). Length of stay was longer in patients with orthostatic intolerance (P = 0.019). CONCLUSION Orthostatic intolerance is common after total hip arthroplasty. Optimising pain control prior to mobilisation and limiting gabapentin use may modify the risk of developing postoperative orthostatic intolerance. Although personalised recovery pathways appear attractive, at present, the ability to predict at-risk individuals is still limited. 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 Dr David A. Rice, Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand E-mail: david.rice@aut.ac.nz 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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Use of tracheal ultrasound combined with clinical parameters to select left double-lumen tube size: A prospective observational study

BACKGROUND Left double-lumen tubes (LDLTs) are used in thoracic surgery to allow one-lung ventilation. Their size is usually chosen on the basis of clinical parameters (height, sex). Double-lumen endobronchial tubes are frequently undersized/oversized, risking tube displacement or tracheal trauma. A correlation between ultrasound tracheal diameter and left main bronchus dimension has been demonstrated. OBJECTIVES We hypothesised that the insertion of undersized/oversized double-lumen tubes is frequent when the size is selected using standard criteria, and that the use of ultrasound to estimate tracheal diameter may help to reduce the frequency of insertion of oversized tubes. DESIGN Two-step prospective observational study. SETTING The operating room of a French University hospital from January 2016 to February 2017. PATIENTS We enrolled 102 and 50 consecutive patients undergoing elective thoracic surgery in Steps 1 and 2 (males 63.7 and 60.0%, age 63 (13) and 63 (11) years, height 170 (13) and 169 (9) cm, respectively). INTERVENTION In Step 1, the size of the LDLT inserted was selected on the basis of clinical parameters. Ultrasound data about tracheal diameter were collected to determine cut-off points associating height and tracheal diameter. Cut-off values for ultrasound tracheal diameter were applied retrospectively to test their capability to reduce the insertion rate of oversized tube. In Step 2, the LDLT size was chosen according to the determined combined cut-off values. MAIN OUTCOME MEASURE LDLT size was considered adequate if the bronchial cuff volume required for isolation of the lung (i.e. no difference between inspiratory and expiratory lung volumes) was 0.5 to 2.5 ml of air; undersized and oversized tubes required more than 2.5 ml and less than 0.5 ml, respectively. RESULTS In Step 1, LDLT size was appropriate/undersized/oversized in 40 (39.2%)/23 (22.6%)/39 (38.6%) of patients. Cut-off values derived from ultrasound measurements would have reduced the use of oversized tubes by 20.6% (P 

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Monitoring haemodynamic response to fluid-challenge in ICU: Comparison of pressure recording analytical method and oesophageal Doppler

BACKGROUND The ability of the pressure recording analytical method (PRAM) in tracking change in cardiac output (ΔCO) after a fluid challenge in ICU needs to be evaluated with the most contemporary comparison methods recommended by experts. OBJECTIVE Our objective was to report the trending ability of PRAM in tracking ΔCO after a fluid challenge in ICU and to compare this with oesophageal Doppler monitoring (ODM). DESIGN Prospective, observational study. SETTING Hôpital Lariboisière and Hôpital Européen George Pompidou, Paris, France, from April 2016 to December 2017. PATIENTS Critically ill patients admitted to ICU with monitoring of CO monitored by ODM and invasive arterial pressure. INTERVENTION ΔCO after fluid challenge was simultaneously registered with ODM and PRAM connected to the arterial line. MAIN OUTCOME MEASURE Polar statistics (mean angular bias, radial limits of agreement and polar concordance rate) and clinical concordance evaluation (error grid and clinical concordance rate). Predictors of bias were determined. RESULTS Sixty-eight fluid challenge were administered in 49 patients. At the time of fluid challenge, almost all were mechanically ventilated (99%), with 85% receiving norepinephrine. Admission diagnosis was septic shock in 70% of patients. Patients had a Sequential Organ Failure Assessment score of 10 [7 to 12] and a median Simplified Acute Physiology Score II of 61 [49 to 69]. Relative ΔCO bias was 7.8 (6.3°) with radial limits of agreement of ±41.7°, polar concordance rate 80% and clinical concordance rate 74%. ΔCO bias was associated with baseline bias (P = 0.007). Baseline bias was associated with radial location of the arterial line (P = 0.03). CONCLUSION When compared with ODM, PRAM has insufficient performance to track ΔCO induced by fluid challenge in ICU patients. Baseline bias is an independent predictor of trending bias. TRIAL REGISTRATION IRB 00010254-2016-033. Correspondence to Romain Barthélémy, MD, Department of Anaesthesia, Burn, and Critical Care, Saint-Louis Lariboisière University Hospital, AP-HP, 2 Rue Ambroise Paré, 75475 Paris Cedex 10, France E-mail: romain.barthelemy@aphp.fr 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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Anticoagulation Management and Heparin Resistance During Cardiopulmonary Bypass: A Survey of Society of Cardiovascular Anesthesiologists Members

We surveyed Society of Cardiovascular Anesthesiologists members regarding anticoagulation practices for cardiopulmonary bypass and attitudes on heparin resistance. Of 550 respondents (18.5% response rate), 74.9% (95% CI, 71.3%–78.5%) used empiric weight-based dosing of heparin, and 70.7% (95% CI, 66.9%–74.5%) targeted an activated clotting time of either 400 or 480 seconds to initiate cardiopulmonary bypass. Of note, 17.1% (95% CI, 13.9%–20.2%) of respondents reported activated clotting time targets lower than those recommended by recent 2018 Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology guidelines or failed to monitor heparin effects at all. When heparin resistance was encountered, 54.2% of respondents (95% CI, 50.0%–58.4%) administered antithrombin concentrates as a first-line therapy. 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. Accepted for publication November 13, 2018. Funding: This work was supported by Grifols, S.A., in the form of a research grant. The sponsor had no involvement in either data analysis or manuscript preparation. Conflicts of Interest: See Disclosures at the end of the article. 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 Roman M. Sniecinski, MD, MSc, Department of Anesthesiology, Emory University Hospital, 1364 Clifton Rd, NE, Atlanta, GA 30322. Address e-mail to rsnieci@emory.edu. © 2018 International Anesthesia Research Society

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Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application

When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists—the Pedi Crisis 2.0 application—as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology. Accepted for publication October 8, 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). †† The members of the secondary authors "The Pedi Crisis Application Working Group" are listed in the Appendix. Reprints will not be available from the authors. The REDCap electronic data capture tools are supported by a National Institutes of Health Clinical and Translational Science Award UL1TR000430 and hosted by the University of Chicago, Chicago, IL. Address correspondence to Anna Clebone, MD, Department of Anesthesiology and Critical Care Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637. Address e-mail to aclebone@gmail.com. © 2018 International Anesthesia Research Society

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Design and Evaluation of a Wireless Electrocardiogram Monitor in an Operating Room: A Pilot Study

BACKGROUND: Wired electrocardiogram monitors are an important component of current perioperative monitoring. Wireless monitoring units could help reduce the number of cables attached to patients and thus improve anesthesia ergonomics and patient management. However, there is concern that electromagnetic interference generated by electrosurgical units may prevent effective wireless signals in the operating room. To evaluate the extent of this problem, we developed a Bluetooth electrocardiogram prototype monitor and compared its electrocardiogram traces to those captured with a standard wired electrocardiogram monitor in our operating room. METHODS: Bluetooth electrocardiogram and standard electrocardiogram traces captured from 10 patients undergoing surgical procedures that required use of an electrosurgical unit were compared by analysis of the durations of the P wave, QRS complex, and T wave and the position of the ST segment from the isoelectric line. The impact of the electrosurgical units on the Bluetooth electrocardiogram and S-electrocardiogram recordings was also assessed. RESULTS: There were no clinically relevant differences in P wave, QRS complex, or T-wave durations (0.006, 0.004, and 0.017 seconds, respectively) between Bluetooth electrocardiogram and standard electrocardiogram or in the position of the ST segment from the isoelectric line (0.02 mV). Mean differences were near zero, and Bland–Altman limits of agreement for individual differences were narrow (−0.035 to 0.047, −0.03 to 0.038, and −0.112 to 0.078 seconds for P wave, QRS complex, and T-wave durations, respectively, and −0.13 to 0.17 mV for ST segment position). Electrosurgical units use electrically disrupted Bluetooth electrocardiogram and standard electrocardiogram signals, but there was no electromagnetic interference effect on the Bluetooth electrocardiogram signals. CONCLUSIONS: Wireless electrocardiogram using Bluetooth can be reliably used in the operating room. The electrosurgical unit induces electric rather than electromagnetic artifacts, thus affecting wired and wireless electrocardiogram in a similar fashion. Accepted for publication November 1, 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). Reprints will not be available from the authors. Address correspondence to Philippe Ariès, MD, Department of Anesthesia and Intensive Care, Military Teaching Hospital "Clermont Tonnerre," Brest 29200, France. Address e-mail to philippe.aries@chu-brest.fr. © 2018 International Anesthesia Research Society

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Cardiac Emergencies in Children: A Practical Approach to Diagnosis and Management

No abstract available

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Narcolepsy, Anesthesia, and Sedation: A Survey of the Perioperative Experience of Patients With Narcolepsy

BACKGROUND: Patients with narcolepsy may be at increased perioperative risk due to the interactions among anesthesia, narcolepsy, and narcolepsy medications. This study sought to determine the perioperative experience of narcoleptic patients undergoing anesthesia or sedation, the frequency of perioperative counseling, and self-reported surgical complications. METHODS: A 22-question survey was developed by expert consensus and distributed by the Narcolepsy Network. Recruitment was via the Narcolepsy Network's list-serve and a Facebook link to the survey. One thousand and twenty respondents reported a diagnosis of narcolepsy and 1 or more procedures under anesthesia or sedation. Descriptive, comparative statistics and logistic regression were utilized. RESULTS: Respondents were mostly women (79.5%) and Caucasian (84.9%), with a mean age of 45 ± 16 years. Most respondents did not receive counseling regarding the possibility of increased sleepiness (70%), cataplexy (90%), or drowsy driving (59%) postanesthesia. More than half of respondents reported adverse events (medication withdrawal symptoms, inadequate pain relief, increased cataplexy). Subjects with cataplexy more frequently reported surgical complications (70% vs 31%; P = .03) and medication withdrawal symptoms (stimulant medications: odds ratio, 3.0 [95% CI, 1.9, 3.06]; P > .001 and antidepressant medications: odds ratio, 6.5 [95% CI, 2.1–19.5]; P = .001). Of the total sample, 18% indicated surgical complications. Undergoing 5 or more separate surgeries or procedures was associated with a 2-fold increase in self-reported complications (odds ratio, 2.2 [95% CI, 1.3–3.4]; P = .001), difficulty waking (odds ratio, 2.1 [95% CI, 1.45–3.06]; P = .001), and inadequate pain relief (odds ratio, 1.77 [95% CI, 1.01–3.13]; P

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Acute esophageal necrosis: a case series and its management

Abstract

'Black Esophagus' or acute esophageal syndrome (AEN) is extremely rare entity characterized by patchy or diffuse circumferential necrosis of esophagus. To date, there is minimal number of cases described with this phenomenon. The main objective of this case series is to discuss the diagnosis of extremely rare condition seen in two patients within 1 year and its effective management by adopting conservative measures in a tertiary hospital. The objective of our case series is to discuss the diagnosis of an extremely rare condition seen in two patients within a short span of 6 months and its effective management by adopting conservative measures in a tertiary care hospital. An overall conservative approach, serial endoscopic monitoring and effective follow-up resulted in zero mortality with successful outcomes.

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Primary repair of re-entry intimal tear in a patient with limited extension of acute type A aortic dissection

Abstract

Principles of type A aortic dissection surgery emphasize the importance of operative survival and long-term outcome. Various surgical strategies have emerged aiming for improved freedom of reoperation but they can be technically demanding or associated with higher operative risks. We report a type A aortic dissection case with extension of the dissection to the proximal descending aorta where a re-entry intimal tear was identified. Instead of extensive aortic arch repair, we managed the tear with a primary suture closure technique. In conjunction with a hemiarch repair of the proximal aorta, this approach enabled a prompt and complete resolution of the false lumen at minimal cost of circulatory arrest time.

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Retroperitoneal hematoma from lumbar artery as an unusual complication after rectal perforation with massive retroperitoneal emphysema

Abstract

The patient was a 54-year-old woman diagnosed with adult Still's disease, undergoing high-dose steroid and immunosuppressant therapy for 5 years, who was admitted to our hospital with abdominal pain. Computed tomography (CT) revealed pneumoperitoneum around the rectum and a large quantity of retroperitonal emphysema around the inferior vena cava, aorta and left kidney. An emergency laparotomy was performed. Intraoperative observation revealed a perforation on the mesenteric side of the rectum due to diverticulum, and Hartmann's operation was performed. Deep tenderness and anemia were observed 4 days postoperatively. CT revealed extravasation in the left retroperitoneal space and a retroperitoneal hematoma, and emergency embolization of lumbar arteries was performed. Retroperitoneal bleeding associated with peritonitis after surgery is very rare. We surmised that higher-dose immunosuppressive therapy and gastrointestinal perforation with emphysema in the retroperitoneum induced lumbar artery bleeding. Clinicians should consider these factors as a potential cause of retroperitoneal hematoma.

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Traumatic small bowel perforation in a case of a perineal hernia

Abstract

Perineal hernias following pelvic surgery are rare. Traumatic small bowel perforation in a patient with a perineal hernia is yet to be described. This case report describes a 69-year-old female who following an abdominoperineal resection for cancer developed a perineal hernia and unfortunately sustained perineal trauma. She presented with peritonitis and findings on laparotomy were that of two points of perforation to terminal ileal loop adherent to perineal defect. Resection and a side-to-side anastomosis performed. Repair of the hernia using mesh was considered but not performed due to risk of mesh infection. Perineal hernias have become more common since the advent of laparoscopic pelvic surgery. Although various methods have been described to repair these hernias, there is lack of robust evidence supporting one repair technique over others.

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