Post-traumatic bilateral vesicocutaneous fistula of thighs treated with buccal mucosa graft urethroplasty and cyanoacrylate glue instillation: a novel treatment for management of a complicated fistula

Post-traumatic vesicocutaneous fistula (VCF) is a rare variant of urinary fistulas. These fistulas may externally communicate to abdomen, perineum, buttocks, scrotum or very rarely thigh. These fistulas usually develop at a variable time duration after trauma and are usually preceded with thigh swelling or abscess formation followed by spontaneous rupture. We, hereby, report a case of VCF of bilateral thighs with associated penobulbar urethral stricture after road traffic accident which was managed with dual modality of buccal mucosa graft urethroplasty surgery and cyanoacrylate glue injection in the fistulous tracts. To the best of our knowledge, this is first report of bilateral VCFs communicating externally to thighs. In literature, very few cases of VCFs of thigh are reported and are rarely managed with adhesive glue application.

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Cushings reflex secondary to neck haematoma following thyroidectomy

Neck haematoma following thyroid surgery can present with respiratory distress which is generally attributed to airway obstruction. We recently had a 63-year-old female patient who underwent total thyroidectomy for toxic nodular goitre. However, within 4 hours of surgery, she developed sudden respiratory distress which was managed by prompt evacuation of the neck haematoma. Just before the haematoma evacuation, the patient had hypertension and bradycardia along with the distress. The arterial blood gas analysis sampled at that time was normal. Intraoperatively, the tracheal framework was found rigid and non-pliable. Considering the various clinical–biochemical findings observed, we think that the cause of the respiratory distress in the index case was transiently elevated intracranial pressure, secondary to bilateral internal jugular veins' compression. We hypothesise that in many patients with immediate postoperative neck haematoma, the Cushing's reflex would at least contribute partly, if not solely to the respiratory distress.

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Three differently timed presentations of dermatomyositis associated with advanced ovarian cancer

Each of the three patients reported in this article presented with dermatomyositis at various stages of their advanced ovarian cancer. Dermatomyositis was the presenting feature and preceded the diagnosis of ovarian cancer by several months in one patient. In another patient, dermatomyositis occurred just prior to the scheduled third cycle of palliative chemotherapy after surgical debulking for stage 4 disease. The third patient presented with pathognomonic diagnostic features of dermatomyositis after ovarian cancer recurrence. Diagnosis was delayed in at least two of these patients; however, once appropriately diagnosed, each patient responded well to immunomodulatory treatment. In one patient, initiation of oral prednisolone seemed to correlate with a steady improvement in her proximal myopathy. A pulsed methylprednisolone approach was used in another patient with conversion to a tapering dose of oral prednisolone to good effect. In the patient in whom the most severe myopathy affecting bulbar muscle groups was demonstrated, an infusion of 5 days of intravenous immunoglobulin produced an eventual improvement in her steroid-refractory myopathy.

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Macrophage Activation Syndrome, Glomerulonephritis, Pericarditis, and Retinal Vasculitis as Initial Presentation of Systemic Lupus Erythematosus

Macrophage activation syndrome (MAS) is a rare manifestation of systemic lupus erythematosus (SLE) with potentially life-threatening consequences. To the best of our knowledge, this is the first case reported in literature for a constellation of MAS, glomerulonephritis, pericarditis, and retinal vasculitis as initial presentation of SLE. Despite extensive multisystem involvement of his disease, the patient responded well to initial steroid treatment, with mycophenolate mofetil successfully added as a steroid-sparing agent. Our case highlights the importance of multispecialty collaboration in the diagnosis and management of SLE with multisystem involvement.

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Bronchial Blocker Use in the Difficult Airway Patient Requiring Lung Isolation: Clarification as to What Blockers Are Actually Available

No abstract available

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Intraoperative Considerations for Transgender Patients

No abstract available

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In Response

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In Response

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Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children: A Retrospective Review of a Single-Institution Experience

With few published reports on erector spinae plane block use in children, limited guidance on perioperative local anesthetic dosing exists. We present a series of 22 patients who received erector spinae plane catheters with programmed intermittent bolus for various surgeries. Median loading dose of 0.4 mL/kg (interquartile range [IQR], 0.1 mL/kg) ropivacaine 0.5%, intraoperative bolus of 0.3 mL/kg/h (IQR, 0.1 mL/kg) ropivacaine 0.2%, and a postoperative programmed intermittent bolus regimen of maximum 0.6 mg/kg/h resulted in highest pain scores on postoperative day 1 with a median score of 1.7 of 10 (IQR, 1.8) and highest morphine equivalents consumed on postoperative day 2 with a median score of 0.16 mg/kg up to 120 hours after surgery. Accepted for publication August 22, 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 Ban C. H. Tsui, MD, FRCPC, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, 300 Pasteur Dr, 3rd Floor, Room H3584, MC 5640, Stanford, CA 94305. Address e-mail to bantsui@stanford.edu. © 2018 International Anesthesia Research Society

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Acute Stroke Management in the First 24 Hours: A Practical Guide for Clinicians

No abstract available

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Obstetric Anesthesiology in the United States: Current and Future Demand for Fellowship-Trained Subspecialists

No abstract available

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Lack of Bias Evaluation and Inadequate Study Selection May Produce Misleading Results

No abstract available

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Should We Always Continue β-Blocking Agents Preoperatively?

No abstract available

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Is Tube Thermosoftening Helpful for Videolaryngoscope-Guided Nasotracheal Intubation?: A Randomized Controlled Trial

BACKGROUND: Thermosoftening of the endotracheal tube (ETT) and telescoping the ETT into a rubber catheter have been suggested as a method for reducing epistaxis during nasotracheal intubation (NTI). However, thermosoftening technique is known to make it difficult to navigate the ETT into trachea without the use of Magill forceps during NTI. The cuff inflation technique has been suggested as an effective alternative to the use of Magill forceps to improve the oropharyngeal navigation of the ETT, irrespective of their stiffness, during direct laryngoscope-guided NTI. We evaluated whether thermosoftening of the ETT telescoped into rubber catheters has an additional benefit in reducing nasal injury. Simultaneously, we also evaluated whether thermosoftening of the ETT worsened orotracheal navigability during cuff inflation-supplemented videolaryngoscope-guided NTI. METHODS: One hundred forty patients were randomly assigned to 1 of the 2 groups depending on whether the ETT was softened by warming or not. The primary outcome was the incidence of epistaxis during NTI. The secondary outcome was nasotracheal navigability of the ETT, assessed by navigation grade and time required for insertion of ETT in each phase (from nose to oropharynx, from oropharynx to glottic inlet aided by cuff inflation if needed, and from glottic inlet to trachea). RESULTS: The ETTs were successfully inserted through the selected nostril of all 140 patients. In the thermosoftening group, the incidence and severity of epistaxis was significantly lower (7% vs 51%; difference of 44.2%; 95% confidence interval, 29.9%–56.2%; P .99 and P = .054, respectively) and from the glottic inlet to the trachea (P > .99 and P = .750, respectively) between the 2 groups. In both groups, all ETTs could be navigated into the trachea without the use of Magill forceps. CONCLUSIONS: Supplemented with cuff inflation during videolaryngoscope-guided NTI, thermosoftening of the ETT telescoped into rubber catheters has a substantial benefit because it significantly reduces the incidence of epistaxis without worsening the oropharyngeal navigability of the ETT. Accepted for publication August 17, 2018. Funding: None. The authors declare no conflicts of interest. This study was approved by the Institutional Ethics Committee (institutional review board [IRB] approval number 2017-03-020, IRB contact information: Institutional Review Board, Hallym University Kangnam Sacred Heart Hospital, B1, 12, Siheung-daero 187-gil, Yeongdeungpo-gu, Seoul 07441, Republic of Korea. E-mail: dandelionc@hallym.or.kr. Reprints will not be available from the authors. Address correspondence to Joo Hyun Jun, MD, PhD, Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea. Address e-mail to ilpleut@naver.com. © 2018 International Anesthesia Research Society

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Multimodal General Anesthesia: Theory and Practice

Balanced general anesthesia, the most common management strategy used in anesthesia care, entails the administration of different drugs together to create the anesthetic state. Anesthesiologists developed this approach to avoid sole reliance on ether for general anesthesia maintenance. Balanced general anesthesia uses less of each drug than if the drug were administered alone, thereby increasing the likelihood of its desired effects and reducing the likelihood of its side effects. To manage nociception intraoperatively and pain postoperatively, the current practice of balanced general anesthesia relies almost exclusively on opioids. While opioids are the most effective antinociceptive agents, they have undesirable side effects. Moreover, overreliance on opioids has contributed to the opioid epidemic in the United States. Spurred by concern of opioid overuse, balanced general anesthesia strategies are now using more agents to create the anesthetic state. Under these approaches, called "multimodal general anesthesia," the additional drugs may include agents with specific central nervous system targets such as dexmedetomidine and ones with less specific targets, such as magnesium. It is postulated that use of more agents at smaller doses further maximizes desired effects while minimizing side effects. Although this approach appears to maximize the benefit-to-side effect ratio, no rational strategy has been provided for choosing the drug combinations. Nociception induced by surgery is the primary reason for placing a patient in a state of general anesthesia. Hence, any rational strategy should focus on nociception control intraoperatively and pain control postoperatively. In this Special Article, we review the anatomy and physiology of the nociceptive and arousal circuits, and the mechanisms through which commonly used anesthetics and anesthetic adjuncts act in these systems. We propose a rational strategy for multimodal general anesthesia predicated on choosing a combination of agents that act at different targets in the nociceptive system to control nociception intraoperatively and pain postoperatively. Because these agents also decrease arousal, the doses of hypnotics and/or inhaled ethers needed to control unconsciousness are reduced. Effective use of this strategy requires simultaneous monitoring of antinociception and level of unconsciousness. We illustrate the application of this strategy by summarizing anesthetic management for 4 representative surgeries. 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 June 11, 2018. Funding: This work was supported by the National Institutes of Health (Bethesda, MD): R01 GM104948 (to E.N.B.) and P01GM118269 (to E.N.B.); and by the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA. Conflicts of Interest: See Disclosures at the end of the article. A glossary of terms is available in the Appendix. Reprints will not be available from the authors. Address correspondence to Emery N. Brown, MD, PhD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Grey-Jackson 444, Boston, MA 02114. Address e-mail to enb@neurostat.mit.edu. © 2018 International Anesthesia Research Society

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Performance of Air Seal of Flexible Reinforced Laryngeal Mask Airway in Thyroid Surgery Compared With Endotracheal Tube: A Randomized Controlled Trial

BACKGROUND: Flexible reinforced laryngeal mask airway (FLMA®) has gained popularity in thyroid surgery, but air leak and displacement are still concerns. METHODS: In this randomized, single-blinded, noninferiority, controlled trial, we randomized patients scheduled for elective radical thyroidectomy to an endotracheal tube (ETT) group or a FLMA group. The primary outcomes were ventilation leak volume, peak airway pressure, and partial pressure of end-tidal carbon dioxide (PetCO2). Data for primary outcomes were collected after insertion of ETT/FLMA, at incision, and at 10-minute intervals during surgery. Ten milliliters, 5 cm H2O, and 10 mm Hg were used as the noninferiority deltas for ventilation leak volume, peak airway pressure, and PetCO2, respectively. We assessed noninferiority of FLMA to ETT on the primary outcomes over time using the results of a linear mixed-effects model. The position of FLMA mask was evaluated before and after surgery, and the airway complications were recorded. RESULTS: A total of 132 patients were included: 65 in ETT group and 67 in FLMA group. Differences (FLMA group minus ETT group) of ventilation leak volume, peak airway pressure, and PetCO2 from the mixed-effects models were 2.09 mL (98.3% confidence interval [CI], –6.46 to 10.64), −0.60 cm H2O (98.3% CI, –2.15 to 0.96), and 1.02 mm Hg (98.3% CI, 0.04–1.99), respectively. Score of fiber-optic position of FLMA was significantly higher after surgery than before. There was no severe shift, loss of the mask seal, regurgitation, or aspiration in the FLMA group. One patient in the FLMA group experienced brief and easily controlled laryngospasm. CONCLUSIONS: In thyroid surgery, FLMA is noninferior to ETT in the peak airway pressure and PetCO2 although mild to moderate mask shift could occur during surgical manipulation. There is no evidence for a higher complication rate when FLMA is used. Accepted for publication July 27, 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). Clinical Trial Number: ChiCTR-IOR-15006602. LMA Flexible and LMA Classic are registered trademarks of Teleflex Incorporated or its affiliates. Reprints will not be available from the authors. Address correspondence to Jie Yi, MD, Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China. Address e-mail to easyue@163.com. © 2018 International Anesthesia Research Society

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