Rectal perforation following paclitaxel and carboplatin chemotherapy for advanced ovarian cancer: a case report and review of the literature

Paclitaxel is a chemotherapy drug commonly used in the management of ovarian cancer. Colonic perforation is an extremely rare complication of paclitaxel administration with few case reports in the medical lite...

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A quadricuspid aortic valve in an asymptomatic 40-year-old man: a case report

Integrated transthoracic and transesophageal echocardiography enables identification and characterization of a quadricuspid aortic valve anomaly.

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What are the odds? Prostate metastases to ureter and peritoneum

In patients with prostate cancer, metastases mostly develop in bone, lung, liver, pleura and adrenal glands. Prostate carcinoma metastases to the ureter are very rare, and the peritoneum is an even rarer site of prostate metastases. We present two cases of ureteral metastases of prostate cancer, of which one patient also developed malignant ascites and peritoneal metastases. An overview of the literature on these metastatic sites is also provided. Both patients presented with hydronephrosis and a ureteral mass. Biopsies of the masses were taken, which showed the presence of prostate carcinoma metastases. The first patient was treated with chemotherapy but was diagnosed with progressive disease and died 3 years later. The second patient was diagnosed with pathology-confirmed peritoneal metastases 8 months later. He died 2 years after presentation with hydronephrosis.

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Acute biliary pancreatitis masking haemobilia due to a false aneurysm of the right hepatic artery after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a commonly performed surgical procedure. The postoperative course is often uncomplicated; however, complications like infection, biliary leakage, and bleeding and bile duct injury can occur. Here we report on a patient with common bile duct obstruction and haemobilia due to a false aneurysm of the right hepatic artery after laparoscopic cholecystectomy, masked by biliary pancreatitis, complicated by an infarction of the liver after embolisation. The aetiology of upper gastrointestinal bleeding greatly varies. This case is an uncommon case of gastrointestinal bleeding due to a false aneurysm of the right hepatic artery, which was successfully treated.

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Rapid and life-threatening heart failure induced by pazopanib

A 70-year-old man with history of stage IV renal cell carcinoma, chronic atrial fibrillation on warfarin, coronary artery disease status post-percutaneous coronary intervention resulting in an ischaemic cardiomyopathy with left ventricular ejection fraction of 40%–45%, presented with shortness of breath 10 days after starting pazopanib. Within the first week of starting pazopanib, the patient developed fatigue and progressive dyspnoea on exertion. His symptoms quickly worsened and he had compromised mental status. He was transferred to the intensive care unit (ICU) and intubated due to continued respiratory distress. He was found to be in cardiogenic shock and was started on inotropic support with dobutamine and norepinephrine. With maximum support, the patient was slowly weaned off vasopressors and was successfully extubated on ICU day 9. His hospital stay lasted 29 days with management of multiple medical complications, and he was eventually discharged to a rehabilitation facility.

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Hypertension and severe hypokalaemia associated with ectopic ACTH production

Ectopic adrenocorticotropic hormone (ACTH) secretion represents 5%–10% of cases of Cushing's syndrome (CS), and approximately 50%–60% of these arise from neuroendocrine lung tumours, including small-cell lung cancer (SCLC). We report a 42-year-old man admitted with hypertension, metabolic alkalosis and severe hypokalaemia. On physical examination, centripetal obesity with 'moon face' and 'buffalo's hump' were identified, and wheezing on left lung was heard. A markedly elevated serum cortisol, ACTH and urine free cortisol production supported the diagnosis of CS. Chest CT showed a left hilar mass with metastasis to the liver, adrenal glands and lymph nodes. Bronchoscopy identified bronchial infiltration by SCLC. Treatment with metyrapone and chemotherapy was started. Despite initial improvement, progressive clinical deterioration occurred, culminating in death 1 year after diagnosis. Ectopic ACTH secretion is uncommon but should be suspected in patients with severe hypokalaemia, hypertension and metabolic alkalosis, especially in the context of lung cancer.

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How did a prosthetic femoral head migrate to the mesorectum?

Description 

This 64-year-old man underwent a total hip replacement for osteoarthritis via a posterior approach. Day 1 postoperatively, he felt his hip click while turning into a chair. X-ray revealed an anterior hip dislocation with the prosthetic femoral head disengaged and migrated into the pelvis. CT demonstrated the ceramic head was retroperitoneal, anterior to the right iliac bone within the iliopsoas muscle interval (figure 1). His case was discussed with hip revision and trauma specialists with a provisional plan to revise the hip replacement and remove the femoral head. The patient, however, did not wish invasive, intra-abdominal surgery and requested a limited approach for implant retrieval. Revision hip surgery was performed with anteversion of the acetabular component adjusted; retrieval of the femoral head was not possible through this approach. A further attempt via a minimally invasive, retroperitoneal approach along the inner table of pelvic wall was...

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Silicone oil mimicking pathology on CT imaging

An 81-year-old man was taken to Accident & Emergency after a fall. CT brain imaging demonstrated a well-defined, homogenous, hyperdense mass in the posterior segment of the left eye. Reported as vitreous haemorrhage, an urgent ophthalmological assessment was instigated.

Detailed history revealed previous vitreoretinal procedures for multiple retinal detachments. Ophthalmological examination confirmed presence of silicone oil in this eye.

The appearance of silicone oil in the eye has become an increasingly prevalent finding given its continued use in complex vitreoretinal procedures since 1962. Clinicians regularly interpreting orbital, facial and brain imaging need to be aware of these imaging appearances to prevent diagnostic confusion.

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Bilateral cataracts as the presenting feature of type 1 diabetes in an 11-year-old girl

Paediatric cataracts can present a diagnostic dilemma to ophthalmologists. Next-generation DNA sequencing (NGS) has been promoted as a tool to expedite the diagnosis of an underlying cause in such cases.¹ The authors present an unusual case of bilateral cataracts in an 11-year-old girl as the first presenting feature of new type 1 diabetes mellitus. Prompt diagnosis and subsequent management of this potentially life-threatening condition were achieved through careful history taking and targeted biochemical testing. The authors feel this case highlights the significance of simple measures such as thorough history taking in the assessment of paediatric cataracts. It is important that these skills are not lost through the availability of clinical tools such as NGS.

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Use of an onlay corneal lamellar graft for brittle cornea syndrome

Brittle cornea syndrome (BCS1 OMIM #229200, BCS2 #614170) is a rare autosomal recessive condition characterised by diffuse thinning and fragility of the cornea. Affected individuals are at risk of globe rupture and blindness after relatively minor eye trauma. We describe a 9-year-old girl with BCS1, already blind in one eye following trauma, who had a 14 mm diameter corneoscleral onlay graft to her contralateral eye to reduce gross irregular corneal astigmatism and potentially to reduce further risk from accidental injury. Although there was a significant initial improvement in the unaided visual acuity, there was subsequent visual loss from secondary glaucoma. In addition, despite the onlay graft, an acute corneal hydrops developed approximately 2 years following surgery, suggesting that in BCS1, corneal tissue degeneration or resorption continues despite external support. Finally, because secondary glaucoma is not a feature of BCS1, we speculate that the onlay graft may have reduced aqueous outflow by compression of the thinned sclera.

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Coeliac artery dissection as a rare manifestation of Behcets disease

Behcet's disease is a multisystemic vasculitis. Arterial involvement in the form of acute dissection is rare. A 42-year-old Lebanese man with Behcet's disease presented with severe abdominal pain. On exam, blood pressure was 162/104 mm Hg, and he exhibited epigastric tenderness. CT angiogram demonstrated an acute dissection of the coeliac artery trunk, common hepatic artery and proper hepatic arteries, with asymmetric thickening of the proximal left subclavian artery and circumferential thickening of the abdominal infrarenal aorta suggestive of vasculitis. Treatment included intravenous clevidipine, nitroprusside and methylprednisolone, which transitioned to oral metoprolol, amlodipine and prednisone. He responded well. Arterial dissections have been described with Behcet's. We report a coeliac artery aneurysm in association with a flare of Behcet's disease. Arterial wall inflammation combined with the sheering forces of hypertension likely predisposes to arterial dissection.

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Oesophageal-pleural fistulation identified through repeated malpositioning of nasogastric tubes

Two previously fit and healthy males with acute onset dyspnoea and respiratory failure required invasive ventilation for respiratory failure. Insertion and correct positioning of nasogastric tubes (NGT) proved to be difficult repeatedly in both cases over the course of a number of days. Repeated imaging found NGT tips sited in varied, atypical positions including extension into the hemithoraces. Delineation of repeated malpositioned NGTs identified oesophageal perforations in the case of both patients, one with fistulation into the right pleura and the other into the left pleura. Both patients developed an empyema ipsilateral to the side of fistulation. Both patients died, with subsequent postmortems concluding one patient to have experienced a spontaneous out-of-hospital oesophageal perforation, and the second patient's perforation developing as a consequence of a distal oesophageal squamous cell carcinoma. These two cases highlight the importance of questioning the possibility of underlying oesophageal pathology promptly if repeated NGT insertions are unsuccessful or imaging reveals unusual transit paths of NGTs.

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Adult-onset Stills disease with haemorrhagic pericarditis and tamponade preceded by acute Lyme disease

A 61-year-old Caucasian man presented with a fever of unknown origin, a transient erythematous rash on his right upper extremity and chest pressure after being treated for erythema migrans (Lyme disease). Echocardiogram demonstrated a large pericardial effusion with tamponade. He underwent pericardiostomy with tube placement. Workup for infectious and malignant etiologies was negative. Histology of the pericardium showed acute on chronic fibrinous haemorrhagic pericarditis. The patient met criteria for adult-onset Still's disease. Symptoms resolved following treatment with methylprednisolone and anakinra. We believe this is the first case of adult-onset Still's disease precipitated by acute Lyme disease.

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Wandering spleen caused by subcapsular haemorrhage

Description  

A 51-year-old woman 8 years post- human leukocyte antigen (HLA)-matched allogeneic haematopoietic cell transplant presented to her gynaecologist with abdominal pain and a new, large abdominopelvic mass that had gradually grown over a few weeks. She reported severe vomiting followed by days of debilitating abdominal pain during a self-limited gastroenteritis 4 weeks earlier. Her medical history was notable for follicular lymphoma with associated splenomegaly. While she achieved complete remission after haematopoietic cell transplant, she continued to have thrombocytopaenia. She had no history of abdominal surgery and had one vaginal birth. At presentation, she complained of mild abdominal pain and fullness in her lower abdomen and denied other systemic or gastrointestinal symptoms. Her physical examination was notable only for a firm, non-tender abdominopelvic mass spanning most of her lower abdomen. Her labs were significant for thrombocytopaenia (132 k/uL) and mildly low white blood cell count (WBC 2.79 K/uL) and a normal...

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Nitrofurantoin: friend or foe?

Nitrofurantoin remains the gold standard treatment of uncomplicated cystitis as well as prophylactic treatment of recurrent urinary tract infections. Drug-induced hepatotoxicity presents in acute (3 in 1 000 000) and chronic (1 in 1500) forms. We present a patient with acute liver failure after 5 days of treatment. A 69-year-old man admitted for chronic obstructive pulmonary disease exacerbation 5 days into treatment for cystitis with nitrofurantoin. On admission he was noted to be jaundiced with elevated liver enzymes and normal international normalised ratio. Investigation for infectious, autoimmune and cholestatic causes of hepatotoxicity was negative. The patient improved after discontinuation of the drug and 10 days of methylprednisolone. There are scant data on acute liver failure in the setting of short-term nitrofurantoin administration. The mechanism of toxicity remains unclear, but is hypothesised to be an autoimmune process in which steroids may play a role in treatment. Diagnosis is one of exclusion as the only definitive method of diagnosis is rechallenge.

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Cerebral air embolism from a Central Venous Catheter: A timely reminder of the importance of rapid diagnosis

Cerebral air embolism (CAE) is a rare, avoidable and potentially fatal iatrogenic complication. Here, we report a case of CAE associated with a central venous catheter in the internal jugular vein that resulted in neurological deficits and generalised epileptic seizures. A 64-year-old man admitted for fasciotomy for compartment syndrome developed CAE with left-sided neurological deficits. The suspected origin was retrograde air flow from the right internal jugular venous catheter. The air spontaneously resorbed without the need for specific therapy, and he made a good recovery. CAE is an infrequent iatrogenic complication that requires prompt diagnosis to avoid significant morbidity and mortality. This case serves as a timely reminder that adverse outcome such as stroke, seizures or death can be avoided by a high index of suspicion and prompt diagnosis. Hyperbaric oxygen is the prime therapeutic measure, but high-quality evidence on its clinical value is lacking.

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Tension haemothorax from a bleeding branch of the renal artery following isolated penetrating thoracic trauma: a rare presentation

A 27-year-old man presented to a major trauma centre with two posterolateral thoracic stab injuries over the right scapula and thoracoabdominal junction. He was tachycardic and hypotensive with a chest X-ray revealing a large right-sided tension haemothorax, requiring insertion of two intercostal chest drains. A subsequent CT scan demonstrated a grade 4 right kidney laceration with active back bleeding from a renal artery branch, through a right diaphragmatic defect, into the pleural cavity. Embolisation of the feeding renal vessel controlled the bleeding and avoided the need for a nephrectomy. The patient required subsequent video-assisted thoracoscopic evacuation of the haemothorax and diaphragmatic repair, confirming that there was no associated lung or major vessel injury. A ureteric stent was ultimately inserted to manage a persistent urinary leak. This case highlights a rare cause for a common traumatic presentation and the need for a multidisciplinary approach in effective management of complex, multiorgan trauma.

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Small bowel adenocarcinoma in a patient with Lynch syndrome

A 49-year-old male patient, morbidly obese, with a background of Lynch syndrome and subtotal colectomy for colon cancer in 2007, presented with severe abdominal pain in December 2015. Since then, the patient presented multiple times to the emergency department with severe diffuse abdominal pain. After extensive examination, no clear cause for the pain was identified and it was thought to be secondary to adhesions, incisional hernias and psychological. Examinations via radiological imaging were challenging due to body habitus and claustrophobia. In September 2017, the patient was admitted from outpatient clinic with severe abdominal pain, weight loss and anaemia. A CT scan of abdomen and pelvis demonstrated a dilated jejunal loop with a possible tumour. Surgery confirmed a small bowel tumour and, nearly 2 years after the initial presentation, the patient was diagnosed with adenocarcinoma of the jejenum. The patient underwent surgical excision and his symptoms subsided.

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Burkitts neurolymphomatosis of the trigeminal nerve

Description 

A 48-year-old woman presented with 8 months of right-sided burning facial pain and 4 weeks of unsteadiness. She had reduced right facial sensation and corneal reflex. She had no pyramidal or cerebellar signs. Examination of the other cranial nerves was unremarkable. She had reduced sensation in all modalities along the left side of her body.

MRI showed a right-sided enhancing cerebellopontine angle lesion indenting the mid-pons contiguous with a thickened trigeminal nerve extending towards Meckel's cave (figure 1A) with subtle enhancement of the vermis and posterior pons. There was also oedema of the pons (figure 1B). Whole-body CT and PET were unremarkable.

Figure 1

MRI brain. (A) T1-weighted post-gadolinium. (B) T2-weighted image.

A benign pathology such as trigeminal schwannoma or meningioma of the cerebellopontine angle was considered. Therefore, subtotal resection was performed to decompress the pons for symptomatic relief.

...

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Keratinising squamous metaplasia of the bladder

Keratinising squamous metaplasia of the bladder is a very rare entity that carries a risk of progression to malignancy. We present a case of a 62-year-old man found to have the condition and discuss the management dilemma with a review of the literature.

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Infarcted accessory spleen masquerading as a mesenteric cyst

An accessory spleen is a rare entity which is usually asymptomatic. When symptomatic, it presents as an acute abdomen, with either torsion, rupture or haemorrhage. We present the case of a 20-year-old man who presented with chronic lower abdominal pain since 3 months and a lump in the left lower quadrant. On clinical examination and investigations, the lump was diagnosed as a mesenteric cyst, and an uncomplicated laparoscopic excision was performed. The postoperative histopathological examination reported it as an infarcted accessory spleen.

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Eight-year follow-up of resurfacing hemiarthroplasty for advanced glenohumeral osteoarthritis following total acromionectomy

Total acromionectomy is now a largely historical procedure due to a number of biomechanical sequelae caused by defunctioning of the deltoid, although its overall effect on joint kinematics is uncertain. This presents a challenge when considering arthroplasty for subsequent glenohumeral arthritis. We report on successful management of such a case, treated with resurfacing hemiarthroplasty 57 years following acromionectomy. The patient continues to enjoy excellent functional outcome of the shoulder at 8 years after arthroplasty.

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Emergence delirium in children is related to epileptiform discharges during anaesthesia induction: An observational study

BACKGROUND Epileptiform discharges frequently occur in children during induction of anaesthesia. However, studies analysing the impact of epileptiform discharges on postoperative emergence delirium in children are still scarce. The aim of this study is to correlate the incidence of epileptiform activity during anaesthesia induction with the occurrence of emergence delirium during stay in the recovery room. OBJECTIVES Prospective, observational cohort study in children 0.5 to 8 years old undergoing planned surgery. Bifrontal electroencephalogram electrodes were placed before induction of anaesthesia. Visual electroencephalogram analysis was performed from start of anaesthetic agent administration until intubation with regard to epileptiform patterns: rhythmic polyspikes; periodic epileptiform discharges; delta with spikes; and suppression with spikes. Emergence delirium was assessed during stay in the recovery room using the Pediatric Assessment of Emergence Delirium Score. DESIGN Prospective, observational cohort study. SETTING University hospital – Germany/Berlin. Children were included between September 2015 and February 2017. PATIENTS A total of 62 Children, aged 0.5 to 8 years old undergoing planned surgery were included. MAIN OUTCOME MEASURES Primary outcome was emergence delirium. Secondary outcomes, peri-operative Electroencephalography (EEG) data analysis. The presented study analysed an association between emergence delirium and the occurrence of epileptiform discharges during anaesthesia induction. RESULTS A total of 43.5% of the children developed emergence delirium and 56.5% did not. Epileptiform discharges were observed more often in children developing emergence delirium (63%) compared with children not developing emergence delirium (43%). But only the occurrence of interictal spike events – such as rhythmic polyspikes; periodic epileptiform discharges and delta with spikes – were significantly related to emergence delirium (emergence delirium-group 48% vs. nonemergence delirium-group 14%, OR = 5.6 [95% CI: 1.7 to 18.7]; P = 0.004). CONCLUSION Emergence delirium in children is significantly related to interictal spike events occurring during induction of anaesthesia. CLINICAL TRIAL NCT02481999. Correspondence to Susanne Koch, Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany Tel: +49 30 450 651 078; fax: +49 30 450551019; e-mail: susanne.koch@charite.de 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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Low-dose ketamine infusion reduces postoperative hydromorphone requirements in opioid-tolerant patients following spinal fusion: A randomised controlled trial

BACKGROUND The current opioid epidemic highlights the urgent need for effective adjuvant therapies to complement postoperative opioid analgesia. Intra-operative ketamine infusion has been shown to reduce postoperative opioid consumption and improve pain control in opioid-tolerant patients after spinal fusion surgery. Its efficacy for opioid-naïve patients, however, remains controversial. OBJECTIVE We hypothesised that low-dose ketamine infusion after major spinal surgery reduces opioid requirements in opioid-tolerant patients, but not in opioid-naïve patients. DESIGN Randomised placebo-controlled prospective study. SETTING Single-centre, tertiary care hospital, November 2012 until November 2014. PATIENTS A total of 129 patients were classified as either opioid-tolerant (daily use of opioid medications during 2 weeks preceding the surgery) or opioid-naïve group, then randomised to receive either ketamine or placebo; there were thus four groups of patients. All patients received intravenous hydromorphone patient-controlled analgesia postoperatively. INTERVENTION Patients in the ketamine groups received a ketamine infusion (bolus 0.2 mg kg−1 over 30 min followed by 0.12 mg kg−1 h−1 for 24 h). Patients in the placebo groups received 0.9% saline. MAIN OUTCOME MEASURES The primary outcome was opioid consumption during the first 24 h postoperatively. The secondary outcome was numerical pain scores during the first 24 h and central nervous system side effects. RESULTS Postoperative hydromorphone consumption was significantly reduced in the opioid-tolerant ketamine group, compared with the opioid-tolerant placebo group [0.007 (95% CI 0.006 to 0.008) versus 0.011 (95% CI 0.010 to 0.011) mg kg−1 h−1, Bonferroni corrected P 

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Frailty Phenotypes and Relations With Surgical Outcomes: A Latent Class Analysis

BACKGROUND: Frailty is an important concept in the care of older adults although controversy remains regarding its defining features and clinical utility. Both the Fried phenotype and the Rockwood deficit accumulation approaches cast frailty as a "burden" without exploring the relative salience of its cardinal markers and their relevance to the patient. New multifactorial perspectives require a reliable assessment of frailty that can validly predict postoperative health outcomes. METHODS: In a retrospective study of 2828 unselected surgical patients, we used item response theory to examine the ability of 32 heterogeneous markers capturing limitations in physical, functional, emotional, and social activity domains to indicate severity of frailty as a latent continuum. Eighteen markers efficiently indicated frailty severity and were then subject to latent class analysis to derive discrete phenotypes. Next, we validated the obtained frailty phenotypes against patient-reported 30-day postoperative outcomes using multivariable logistic regression. Models were adjusted for demographics, comorbidity, type and duration of surgery, and cigarette and alcohol consumption. RESULTS: The 18 markers provided psychometric evidence of a single reliable continuum of frailty severity. Latent class analyses produced 3 distinct subtypes, based on patients' endorsement probabilities of the frailty indicators: not frail (49.7%), moderately frail (33.5%), and severely frail (16.7%). Unlike the moderate class, severely frail endorsed emotional health problems in addition to physical burdens and functional limitations. Models adjusting for age, sex, type of anesthesia, and intraoperative factors indicated that severely frail (odds ratio, 1.89; 95% confidence interval, 1.42–2.50) and moderately frail patients (odds ratio, 1.31; 95% confidence interval, 1.03–1.67) both had higher odds of experiencing postoperative complications compared to not frail patients. In a 3-way comparison, a higher proportion of severely frail patients (10.7%) reported poorer quality of life after surgery compared to moderately frail (9.2%) and not frail (8.3%) patients (P

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Midazolam Premedication Facilitates Mask Ventilation During Induction of General Anesthesia: A Randomized Clinical Trial

BACKGROUND: During induction of general anesthesia, proper mask ventilation is crucial for supplying sufficient oxygen to unconscious patients. Midazolam has a relaxing effect on airway muscles. We hypothesized that sedative premedication with midazolam would facilitate mask ventilation during anesthetic induction. METHODS: Patients undergoing elective surgery under general anesthesia were randomized into 2 groups. The midazolam group received midazolam premedication at the reception area, 3 minutes before transfer to the operating room. Patients in the control group were treated with normal saline as a placebo. The primary outcome was difficulty of mask ventilation during induction, as evaluated using the Warters scales. RESULTS: A total of 97 patients completed the analysis: 49 in the control group and 48 in the midazolam group. The patients in the midazolam group showed a significantly lower mask ventilation difficulty score on the Warters scale than that of the control group (mean [standard deviation], 0.92 [1.13] vs 0.19 [0.57]; estimated difference [95% confidence interval], 0.73 [0.37−1.09]; P

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Comparison of Intermittent Intravenous Boluses of Phenylephrine and Norepinephrine to Prevent and Treat Spinal-Induced Hypotension in Cesarean Deliveries: Randomized Controlled Trial

BACKGROUND: Phenylephrine (PE) is currently the vasopressor of choice to prevent and treat spinal-induced hypotension at cesarean delivery (CD). However, its use is often associated with reflex bradycardia. Norepinephrine (NE) has been put forward as an alternative vasopressor during CD due to its ability to treat hypotension while maintaining heart rate (HR). Recent studies have focused on the role of NE used as an infusion with favorable results compared to PE. No studies have compared equipotent bolus doses of PE and NE at CD. We hypothesized that when used in equipotent doses as an intermittent bolus regimen to prevent and treat spinal-induced hypotension, NE would result in a reduction in the incidence of bradycardia compared to PE. METHODS: This was a double-blind, randomized clinical trial of women undergoing elective CD under spinal anesthesia. Women were randomized to receive either PE 100 µg or NE 6 µg when the systolic blood pressure (SBP) was below baseline. In addition to the randomized treatment, ephedrine was given intravenously to both groups if the SBP was below baseline and the HR 120% of baseline), tachycardia (HR >120% of baseline), ≥2 episodes of bradycardia, nausea, vomiting, umbilical artery and vein blood gases, and Apgar scores. RESULTS: One hundred twelve patients were randomized. The incidence of bradycardia was lower in the NE group compared to the PE group (10.9% vs 37.5%; P

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Factors Associated With Recovery Room Intravenous Opiate Requirement After Pediatric Outpatient Operations

BACKGROUND: Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures. METHODS: After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4–17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves. RESULTS: Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55–0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67–0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82–0.87]). CONCLUSIONS: Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness. Accepted for publication July 3, 2018. Funding: National Institute of General Medical Sciences grant number K23 GM104354 supported O.O.N.'s work. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Olubukola O. Nafiu, MD, FRCA, MS, Department of Anesthesiology, Section of Pediatric Anesthesiology, University of Michigan Health System, 1500 E Medical Centre Dr, Room UH 1H247, Ann Arbor, MI 48109. Address e-mail to onafiu@med.umich.edu. © 2018 International Anesthesia Research Society

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The GCs-SGK1-ATP Signaling Pathway in Spinal Astrocytes Underlied Presurgical Anxiety-Induced Postsurgical Hyperalgesia

BACKGROUND: Patients undergoing surgery often feel anxious. Accumulating evidence indicated that presurgical anxiety was related to the more severe postsurgical pain. An animal model was established that exposed Sprague-Dawley rats to a single-prolonged stress (SPS) procedure to induce presurgical anxiety-like behaviors. The experiment revealed that presurgical anxiety not only aggravated but also prolonged postsurgical pain. However, the underlying mechanisms were unknown. METHODS: The rats in group C + Cort, group I + Cort, group A + Cort, and group AI + Cort were injected with corticosterone. The rats in group C + RU486, group I + RU486, group A + RU486, and group AI + RU486 were injected with mifepristone (RU486). The rats in group C + GSK650394 and group AI + GSK650394 were injected with GSK650394. The rats in group C + FC1 and group AI + FC1 were injected with fluorocitrate (FC) 30 minutes before SPS, 30 minutes before incision, and on postoperative days 1, 2, 3, 4, and 5. The rats in group C + FC2 and group AI + FC2 were injected with FC on postoperative days 7, 8, 9, 10, 11, 12, and 13. The paw withdrawal mechanical threshold was assessed 24 hours before SPS and from postoperative days 1 to 28. The level of corticosterone was determined by enzyme-linked immunosorbent assay. The expression of serum/glucocorticoid regulated kinase 1 (SGK1), interleukin-1β, and tumor necrosis factor-α was visualized by Western blot. The concentrations of adenosine triphosphate (ATP) were measured by ATP assay kit. RESULTS: This study showed SPS elevated plasma glucocorticoids and ATP release from astrocytes, which meant the mechanical pain hypersensitivity in presurgical anxiety-induced postsurgical hyperalgesia was dependent on GCs-SGK1-ATP signaling pathway. SGK1 protein level in astrocytes was increased in response to the glucocorticoid stimuli and enhanced the extracellular release of ATP. Furthermore, spinal astrocytes played a key role in the maintenance. Targeting spinal astrocytes in maintenance phase prevented the pathological progression. CONCLUSIONS: These data suggested an important signaling pathway that affected the pain sensitivity after operation caused by presurgical anxiety. Accepted for publication June 12, 2018. Funding: Supported by National Natural Science Foundation of China 81471129, 81171048, and a grant from the Department of Health of Jiangsu Province of China XK201140. 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). Z. Zhang and H. Wu contributed equally to this work. Reprints will not be available from the authors. Address correspondence to ZhengLiang Ma, PhD, Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China. Address e-mail to mazhengliang1964@163.com. © 2018 International Anesthesia Research Society

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Comparative Regimens of Lipid Rescue From Bupivacaine-Induced Asystole in a Rat Model

BACKGROUND: It is currently unknown whether bupivacaine-induced asystole is better resuscitated with lipid emulsion (LE) administered peripherally or centrally, and whether different LE regimens administered peripherally demonstrated similar effects. In this study, we compared the effects of various regimens of lipid administration in a rat model of bupivacaine-induced asystole. METHODS: Forty-five adult male Sprague-Dawley rats were subjected to bupivacaine-induced asystole and randomly divided into 3 lipid regimens groups: (1) 20% LE was administered continuously via the internal jugular vein (CV-infusion group); (2) 20% LE was administered continuously via the tail vein (PV-infusion group); and (3) 20% LE was administered as divided boluses via the tail vein (PV-bolus group). The maximum dose of LE did not exceed 10 mL·kg−1. External chest compressions were administered until the return of spontaneous circulation (ROSC) or the end of a 40-minute resuscitation period. RESULTS: The survival rate, rate of ROSC, systolic blood pressure, heart rate, heart rate–blood pressure product, and coronary perfusion pressure during 2–40 minutes in the CV-infusion and PV-bolus groups were significantly higher than those in the PV-infusion group (P

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Postoperative Corneal Injuries: Incidence and Risk Factors

BACKGROUND: Previous studies of postoperative corneal injury rates relied on provider-initiated incident reports, which may underestimate the true incidence. Postoperative administration of proparacaine eye drops is used almost exclusively to diagnose corneal injury; therefore, identifying instances of administration may provide a better estimate of corneal injuries. We compared proparacaine administration versus provider-initiated reports to determine rates of corneal injury. In addition, potential associations between clinical variables and injury were assessed with a matched case–control study. METHODS: The health records of 132,511 sequential adult postanesthesia recovery room admissions (January 1, 2011 to June 30, 2017) were reviewed to identify postoperative proparacaine administration and incident reports of corneal injury. Patients with corneal injury were matched with control patients at a 1:2 ratio to assess factors associated with injury. RESULTS: Proparacaine drops were administered to 442 patients (425 patients received proparacaine for diagnosis and 17 patients received proparacaine for unrelated reasons). Incident reports identified 320 injuries, and the aggregate corneal injury count was 436 (incidence, 3.3 injuries [95% confidence interval {CI}, 3.0–3.6] per 1000 cases of general anesthesia). Proparacaine administration had a greater case ascertainment percentage than incident reporting (97.5% vs 73.4%; P

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Informed Consent in Pediatric Anesthesia: A Narrative Review

Informed consent for pediatric anesthesia challenges practitioners to navigate complex ethical, medical, and legal ambiguities. A patient's status as a minor does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced evaluation of age and development to involve the patient to an appropriate extent. Given the complexities involved with pediatric informed consent in anesthesia practice and research, it is important to understand the experience of key stakeholders involved. For this review, we searched Medline, the Cochrane database, PROSPERO, and Clinicaltrials.gov for studies involving pediatric anesthesia informed consent. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data were extracted from included studies: title, authors, date of publication, study type, intervention, data collection method, participant type (ie, parent, pediatric patient, anesthesia provider), number of participants, pediatric patient age range, and primary outcome measures. Twenty-two articles were included for final review: studies of informed consent in pediatric anesthesia span many aspects of informed consent. Parental understanding has been studied most often (7/22 studies), followed by parental preferences (5/22 studies) and provider-related outcomes (5/22 studies) such as time spent interacting with patients, subjective reporting on amount of training related to informed consent, and provider satisfaction with the informed consent process. Outcomes pertaining to pediatric patients themselves constitute the smallest number of studies, including child anxiety (1/22), child understanding (1/22), and child refusal (1/22). Among the parties involved, parents have been most frequently identified as the subjects of these studies (2719/3805 subjects across all included studies, or 71% of all subjects). Pediatric patients are the least frequently involved subjects of studies that investigate informed consent in pediatric anesthesia (493/3805, or 13% of all subjects). Anesthesia providers and investigators have been study subjects (593/3805, or 16% of all subjects) for a range of topics including time spent interacting with patient, nature of informed consent conversation in relation to trainee status, satisfaction with informed consent process, and priorities for informed consent content. The aim of the present narrative review is to summarize the work that has been done on informed consent for pediatric anesthesia. Accepted for publication July 3, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Max M. Feinstein, MA, Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH, 44106. Address e-mail to mmf76@case.edu. © 2018 International Anesthesia Research Society

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Questions Raised by “Profound Intraoperative Hypotension Associated With Transfusion via the Belmont Fluid Management System”

No abstract available

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Feasibility of a Perioperative Text Messaging Smoking Cessation Program for Surgical Patients

Although surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1–3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message–based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted. Accepted for publication July 3, 2018. Funding: This study was funded internally by Mayo Clinic. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Margaret B. Nolan, MD, Department of Anesthesiology, Mayo Clinic, 200 1st St SW, Joseph Bldg 4–184, Rochester, MN 55906. Address e-mail to Nolan.margaret@mayo.edu. © 2018 International Anesthesia Research Society

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Smoothing Effect in Vital Sign Recordings: Fact or Fiction? A Retrospective Cohort Analysis of Manual and Continuous Vital Sign Measurements to Assess Data Smoothing in Postoperative Care

BACKGROUND: Data smoothing of vital signs has been reported in the anesthesia literature, suggesting that clinical staff are biased toward measurements of normal physiology. However, these findings may be partially explained by clinicians interpolating spurious values from noisy signals and by the undersampling of physiological changes by infrequent manual observations. We explored the phenomenon of data smoothing using a method robust to these effects in a large postoperative dataset including respiratory rate, heart rate, and oxygen saturation (SpO2). We also assessed whether the presence of the vital sign taker creates an arousal effect. METHODS: Study data came from a UK upper gastrointestinal postoperative ward (May 2009 to December 2013). We compared manually recorded vital sign data with contemporaneous continuous data recorded from monitoring equipment. We proposed that data smoothing increases differences between vital sign sources as vital sign abnormality increases. The primary assessment method was a mixed-effects model relating continuous-manual differences to vital sign values, adjusting for repeated measurements. We tested the regression slope significance and predicted the continuous-manual difference at clinically important vital sign values. We calculated limits of agreement (LoA) between vital sign sources using the Bland–Altman method, adjusting for repeated measures. Similarly, we assessed whether the vital sign taker affected vital signs, comparing continuous data before and during manual recording. RESULTS: From 407 study patients, 271 had contemporaneous continuous and manual recordings, allowing 3740 respiratory rate, 3844 heart rate, and 3896 SpO2 paired measurements for analysis. For the model relating continuous-manual differences to continuous-manual average vital sign values, the regression slope (95% confidence interval) was 0.04 (−0.01 to 0.10; P = .11) for respiratory rate, 0.04 (−0.01 to 0.09; P = .11) for heart rate, and 0.10 (0.07–0.14; P

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Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery

Enhanced recovery after surgery protocols for bariatric surgery are increasingly being implemented, and reports suggest that they may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after bariatric surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, opioid minimization and multimodal analgesia, protective ventilation strategy, fluid minimization), and postoperative (multimodal analgesia with opioid minimization) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for enhanced recovery after surgery for bariatric surgery. There is evidence in the literature, and from society guidelines, to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for bariatric surgery. Accepted for publication July 2, 2018. Funding: This project was funded under contract number HHSP233201500020I from the Agency for Healthcare Research and Quality and US Department of Health and Human Services. Conflicts of Interest: See Disclosures at the end of the article. The opinions expressed in this document are those of the authors and do not reflect the official position of Agency for Healthcare Research and Quality or the US Department of Health and Human Services. Reprints will not be available from the authors. Address correspondence to Christopher L. Wu, MD, Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. Address e-mail to wuch@hss.edu. © 2018 International Anesthesia Research Society

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