Glucagon-Like Peptide-1 Receptor Agonists During Electroconvulsive Therapy: Case Report With Evolving Concerns and Management Considerations.

ABSTRACT: Glucagon-like peptide-1 receptor agonists are an emerging class of medications transforming the management of diabetes mellitus and obesity, two highly prevalent and chronic medical conditions associated with significant morbidity and posing serious public health concerns. Although generally well tolerated and relatively safe to use, case reports of patients taking these medications while undergoing elective procedures with general anesthesia describe a potential heightened risk of regurgitation and pulmonary aspiration of gastric contents, deriving from the delayed gastric emptying effect of these agents. Based on increased recognition of this risk, the American Society of Anesthesiologists convened a task force to review available data, resulting in the promulgation of a new procedural management guideline for patients on these drugs and undergoing elective procedures with general anesthesia. However, this guideline pertains mostly to procedures and situations that are distinct from electroconvulsive therapy (ECT). This case report describes the experience of a patient on semaglutide, a glucagon-like peptide-1 receptor agonist for obesity, undergoing ECT, provides a general overview of this novel drug class, identifies issues specific to ECT management, and suggests potential adaptations to patient care over different phases of ECT practice.

Postoperative Trapped Lung After Orthotopic Liver Transplantation is a Predictor of Increased Mortality.

Pleural effusions are a common complication of orthotopic liver transplantation (OLT), and chronic post-OLT pleural effusions have been associated with worse outcomes. Furthermore, "trapped lung" (TL), defined as a restrictive fibrous visceral pleural peel preventing lung re-expansion, may have prognostic significance. We performed a retrospective analysis of adult OLT recipients over a 9-year period at UCLA Medical Center. Post-OLT patients with persistent pleural effusions, defined by the presence of pleural fluid requiring drainage one to 12 months after OLT, were included for analysis. Outcomes for patients with and without TL were compared using univariate and multivariate analysis. Of the 1722 patients who underwent OLT, 117 (7%) patients met our criteria for persistent postoperative pleural effusion, and the incidence of TL was 21.4% (25/117). Compared to patients without TL, those with TL required more surgical pleural procedures (OR 59.8, 95%CI 19.7-181.4, p < 0.001), spent more days in the hospital (IRR 1.56, 95%CI 1.09-2.23, p = 0.015), and had a higher risk of mortality (HR 2.47, 95%CI 1.59-3.82, p < 0.001) following transplant. In sum, we found that post-OLT TL was associated with higher morbidity, mortality, and healthcare utilization. Future prospective investigation is warranted to further clarify the risk factors for developing postoperative pleural effusions and TL.

The Evaluation Point-of-Care Ultrasound in the Post-Anesthesia Unit-A Multicenter Prospective Observational Study.

INTRODUCTION: Point-of-care ultrasound (POCUS) is the most rapidly growing imaging modality for acute care. Despite increased use, there is still wide variability and less evidence regarding its clinical utility for the perioperative setting compared to other acute care settings. This study sought to demonstrate the impact of POCUS examinations for acute hypoxia and hypotension occurring in the post-anesthesia care unit (PACU) versus traditional bedside examinations. METHODS: This study was designed as a multi-center prospective observational study. Adult patients who experienced a reduced mean arterial blood pressure (MAP < 60mmHG) and/or a reduced oxygen saturation (SpO2 < 88%) in the PACU from 7AM to 4PM were targeted. POCUS was available or not for patient assessment based on PACU team training. All providers who performed POCUS exams received standardized training on cardiac and pulmonary POCUS. All POCUS exam findings were recorded on a standardized form and the number of suspected mechanisms to trigger the acute event were captured before and after the POCUS exam. PACU length of stay (minutes) across groups was the primary outcome. Results: In total, 128 patients were included in the study, with 92 patients receiving a POCUS exam. Comparison of PACU time between the POCUS group (median = 96.5 min) and no-POCUS groups (median = 120.5 min) demonstrated a reduction for the POCUS group, p = 0.019. Hospital length of stay and 30-day hospital readmission did not show a significant difference between groups. Finally, there was a reduction in the number of suspected diagnoses from before to after the POCUS examination for both pulmonary and cardiac exams, p-values < 0.001. CONCLUSIONS: Implementation of POCUS for assessment of acute hypotension and hypoxia in the PACU setting is associated with a reduced PACU length of stay and a reduction in suspected number of diagnoses.

Liver Transplantation in a Patient With Antiphospholipid Syndrome: A Case Report.

Antiphospholipid syndrome (APS) is an acquired thrombophilic disorder characterized by autoantibodies to cell membrane phospholipids. While altered coagulation can complicate end-stage liver disease, there are few reports describing the perioperative management for liver transplantation in recipients with a preexisting hypercoagulable disorder, such as APS. We present a patient with a history of APS, Budd-Chiari syndrome with cirrhosis, hepatopulmonary syndrome, and heparin-induced thrombocytopenia who underwent liver transplantation complicated by hepatic artery thrombosis. Management included postoperative anticoagulation with a factor Xa inhibitor and, after repeat transplantation, transition to long-term anticoagulation therapy with eventual recovery.

Misconnections in the Critically Ill: Injection of High-Dose Gadolinium into an External Ventricular Drain.

We report an unfortunate case of accidental administration of intrathecal gadolinium through an external ventricular drain in a postcraniotomy patient during magnetic resonance imaging of the brain. The incident occurred after the venous contrast line was connected mistakenly to the ventricular drainage catheter. The patient subsequently developed confusion, aphasia, and right facial droop with new computed tomography evidence of diffuse cerebral edema and stroke. Review of the magnetic resonance image revealed the inappropriate presence of subarachnoid gadolinium. Despite all interventions, the patient developed irreversible neurologic disability. We address the clinical sequelae, management strategies, and factors contributing to the catheter misconnection that led to this event.