Rhomboid Intercostal and Subserratus Plane Block: A Cadaveric and Clinical Evaluation

Background and Objectives Fascial plane blocks are rapidly emerging to provide safe, feasible alternatives to epidural analgesia for thoracic and abdominal pain. We define a new option for chest wall and upper abdominal analgesia, termed the rhomboid intercostal and subserratus plane (RISS) block. The RISS tissue plane extends deep to the erector spinae muscle medially and deep to the serratus anterior muscle laterally. We describe a 2-part proof-of-concept study to validate the RISS block, including a cadaveric study to evaluate injectate spread and a retrospective case series to assess dermatomal coverage and analgesic efficacy. Methods For the cadaveric portion of the study, bilateral ultrasound-guided RISS blocks were performed on 6 fresh cadavers with 30 mL of 0.5% methylcellulose with india ink. For the retrospective case series, we present 15 patients who underwent RISS block or RISS catheter insertion for heterogeneous indications including abdominal surgery, rib fractures, chest tube–associated pain, or postoperative incisional chest wall pain. Results In the cadaveric specimens, we identified staining of the lateral branches of the intercostal nerves from T3 to T9 reaching the posterior primary rami deep to the erector spinae muscle medially. In the clinical case series, dermatomal coverage was observed in the anterior hemithorax with visual analog pain scores less than 5 in patients who underwent both single-shot and continuous catheter infusions. Conclusions Our preliminary cadaveric and clinical data suggest that RISS block anesthetizes the lateral cutaneous branches of the thoracic intercostal nerves and can be used in multiple clinical settings for chest wall and upper abdominal analgesia. Accepted for publication March 10, 2018. Address correspondence to: Hesham Elsharkawy, MD, MBA, MSc, Department of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Code E31, Cleveland, OH 44195 (e-mail: elsharh@ccf.org). H.E. has received unrestricted educational funding from PAJUNK (Norcross, GA) and consultant fees from Pacira Pharmaceuticals, Inc. Those companies had no input into any aspect of the present project design or manuscript preparation. The authors declare no conflict of interest. All images are created and used with permission of Cleveland Clinic Center for Medical Art and Photography. 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 Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Dengue fever in a kidney transplant recipient with complicated clinical course: a case report

Dengue fever is the commonest mosquito-borne illness in the tropics and subtropics. Renal transplantation is one of the ever expanding modes of treatment of end-stage renal disease. Hepatitis B is a common inf...

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Successful treatment of out-of-hospital cardiopulmonary arrest due to streptococcal toxic shock syndrome – effectiveness of extracorporeal membrane oxygenation and the rapid antigen group A streptococcus test: a case report

Streptococcal toxic shock syndrome caused by Streptococcus pyogenes, a group A streptococcus, infection is a rare condition that rapidly progresses to multiple organ failure, shock, and death. It is thus importan...

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Tuberculosis treatment failure in AIDS: vengeance with renal and ocular manifestations

Tuberculosis treatment failure is not uncommon in patients with AIDS. Treatment failure is defined as a positive sputum smear or culture at month 5 or later in the course of the treatment. The clinical presentations in these patients show remarkable heterogeneity. In this report, we chronicle the case of a patient with treatment failure presenting as the disseminated disease, specifically ocular and renal tuberculosis. Additionally, we undertake here a brief literature review highlighting the increased resistance to tuberculosis treatment in patients with AIDS, the rarity of ocular tuberculosis and the importance of tailoring drug regimens on an individual basis in these coinfected patients.

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Disseminated tuberculosis masquerading as a neuroendocrine tumour

We describe the case of a 61-year-old man from the Dominican Republic admitted with diarrhoea, fevers and weight loss who was found to have lab studies and imaging (including radiolabeled somatostatin positron emission tomography/CT scan) initially consistent with a metastatic neuroendocrine tumour. However, after weeks of workup and multiple inconclusive biopsies, he was diagnosed with disseminated extrapulmonary tuberculosis. Here we examine the data for neuroendocrine tumour and tuberculosis labs and imaging to delineate where these studies overlap. We also analyse the biases and pitfalls in this case that led to a protracted diagnosis.

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Unilateral renal artery stenosis presenting as acute flaccid paralysis: a rare presentation

Renovascular hypertension is one of the common causes of secondary hypertension. Here we report a case of patient of renal artery stenosis presenting to the emergency department as a case of acute flaccid paralysis. Renal artery stenosis has been associated with hypokalaemia, but rarely reported to be symptomatic. Initial correction of hypokalaemia leads to improvement of weakness and aetiological work up for hypokalaemia with hypertension revealed hypokalaemia due to hyperaldosteronism secondary to unilateral renal artery stenosis. The patient was managed medically with aldosterone antagonist in the anti hypertensive therapy and weakness did not recur despite withdrawal of potassium supplements. On follow-up, the patient was ambulatory with no signs of weakness, controlled blood pressure and normal potassium level.

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Bilateral nasolabial cyst: a rare case

Nasolabial cysts are rare non-odontogenic cysts characterised by their extraosseous appearance and are always located near to ala nasi. They are painless and located beneath the mucosa leading to soft tissue swelling and elevation of nasal ala. Bilateral nasolabial cyst is a rare occurrence. This case report describes the clinical diagnostic features and multimodal imaging appearance of nasolabial cyst with review of literature.

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Severe acute kidney injury due to violent sadomasochistic play

Bondage and discipline, dominance and submission, sadism and masochism (BDSM) refers to a variety of primarily erotic practices. Although safety is crucial for most BDSM practitioners, there are violent forms that may cause serious injury. We present the case of 61-year-old man with no history of chronic kidney disease who developed severe acute anuric kidney injury following violent BDSM play. He had been strapped tightly onto a wooden spanking bench and then received approximately 1000 vigorous hits onto his bare buttocks and thighs. Subsequently, he developed haematuria and became anuric. Laboratory testing revealed strongly elevated serum creatinine levels. Kidney biopsy was unremarkable except mild tubulointerstitial damage. Urinary production increased spontaneously again after 4 days, and serum creatinine normalised over the course of 4 weeks. We believe that a combination of intermittent abdominal compartment syndrome and blunt kidney trauma may have been responsible for this severe acute kidney injury.

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Blood in a Haab Stria

We describe a case of an asymptomatic and spontaneous intracorneal hemorrhage in an adult with congenital glaucoma and blood collected in a Haab stria.
Case Rep Ophthalmol 2018;9:411–415

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Case Series of Inappropriate Concentration of Intraocular Sulfur Hexafluoride

Due to high complexity, vitreoretinal surgery presents a higher number of patient safety incidents compared with other ophthalmic procedures. Intraocular gases are one of the most useful adjuncts to vitrectomy and surprisingly, surgeons commonly admit to having occasional problems with incorrect gas concentration. The aim of this study is to present a consecutive case series of patients with improper concentration of sulfur hexafluoride (SF₆) applied during vitrectomy. Three patients underwent 27-gauge vitrectomy and at the end of surgery inappropriate dilution of 100% SF₆ was administered. It was attributed to a calculation error, change in the gas supplier, or increased partial pressure of SF₆ before dilution. Postoperatively, due to IOP increase, two eyes required intravitreal gas-air exchange. Subsequently, cataract surgery was performed in one eye with concomitant vitrectomy and silicone oil tamponade due to retinal detachment. To prevent such complications, we suggest using intraocular gases with great care, training of ophthalmic personnel, and prompting manufacturers to provide SF₆ in a prepared concentration of 20%.
Case Rep Ophthalmol 2018;9:405–410

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A Case Report of Intravitreal Bevacizumab for Iris Metastasis of Small Cell Lung Carcinoma with Neovascular Glaucoma

A 79-year-old man who had been diagnosed with small cell lung carcinoma (SCLC) complained of right ocular pain and blurred vision. His right intraocular pressure (IOP) was 30 mm Hg, and anterior chamber cells and multiple grayish white iris masses associated with peripheral anterior synechia (PAS) and neovascularization of the right iris were observed. We presumed that the iris masses were iris metastasis of SCLC. Despite therapy with topical eye drops and oral acetazolamide, the IOP was poorly controlled, so we injected intravitreal bevacizumab into his right eye for neovascular glaucoma. Neovascular glaucoma disappeared rapidly, but the IOP did not improve because of total PAS. To our knowledge, there is only one report of the use of intravitreal bevacizumab for SCLC metastasis in that eye and they reported that intravitreal injection resulted in successful short-term regression of presumed iris metastasis and improved control of secondary neovascular glaucoma, and the case had over one-half PAS. The previous report and our results suggest that secondary neovascular glaucoma with iris metastasis may be controlled by early intravitreal bevacizumab injection.
Case Rep Ophthalmol 2018;9:401–404

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