The Hypoechoic Triangle: A New Sonographic Landmark for Rectus Sheath Block.

Rectus sheath blocks can provide analgesia for upper abdominal midline incisions. These blocks can be placed on patients who are anticoagulated, supine, and under general anesthesia. However, block success rates remain low, presumably because of the difficulty of placing local anesthetic between the correct fascial layers. Here we characterize a hypoechoic triangle with sonography, an anatomic space between adjacent rectus abdominis segments that can be accessed for easier needle tip and catheter placement. This approach could reduce reliance on hydrodissection to correctly identify the potential space and instead improve block efficacy by offering providers a discrete target for local anesthesia.

Four Acid-Base Disturbances in a Critically-Ill Patient Undergoing Emergent Abdominal Surgery.

Lactic acidosis is common in critically-ill surgical patients, but not all perioperative acid-base imbalances are attributable to tissue hypoperfusion. Other causes of acid-base abnormalities can be missed when focused on acute resuscitation of a surgical pathology. This report presents the case of a 60-year-old woman with no past medical history who underwent exploratory laparotomy for umbilical hernia with incarcerated and perforated bowel whose perioperative management was complicated by four acid-base disturbances, including starvation ketosis. This case highlights the importance of early recognition of acid-base imbalances to explain concurrent medical pathology and accurately predict a patient's expected post-operative course.