When the pressure drops: A case of vasoplegia during a structural heart intervention.

A 67-year-old male underwent general anesthesia for left atrial appendage occlusion. During the procedure, the patient developed catecholamine refractory hypotension requiring the administration of several vasopressin boluses to maintain adequate perfusion pressure. At the conclusion of the procedure, mild venous bleeding necessitated the administration of protamine. This led to a further decrease in the patient's blood pressure. Tamponade and continued volume loss were quickly ruled out leading to a diagnosis of vasoplegia syndrome (VS). The patient was appropriately treated with a vasopressin infusion with normalization of blood pressure and no significant morbidity or adverse outcome. With the use of general anesthesia during structural heart interventions on the rapid rise, we discuss the two common causes for vasoplegia along with evidence-based treatments and possible prevention strategies.

Meningitis admitted to a military hospital: a retrospective case series.

Meningitis is a common admission diagnosis. No case series or descriptive studies on meningitis have recently been published. Additionally, no recent data exist on meningitis in the U.S. Military Health System. We reviewed charts of adult patients admitted to Naval Medical Center San Diego between January 2004 and December 2008 with an admission diagnosis of meningitis. Charts were excluded if they did not meet our case definition of meningitis, if missing data, or if meningitis was nosocomial or iatrogenic. We reviewed results of cerebrospinal fluid cultures during this period. We compared rates and characteristics, and outcomes of bacterial and aseptic meningitis. Two hundred twenty-one cases met our criteria. Of these, 208 were aseptic. Cerebrospinal fluid polymerase chain reaction testing was positive for enteroviruses and herpes simplex viruses in 42 (20.2%) and 17 (8.2%) cases, respectively. Of culture/polymerase chain reaction/serologically positive cases, the pathogens were Neisseria meningitidis (3), Streptococcus pneumoniae (3), viridans streptococci (2), Cryptococcus neoformans (2), Coccidioides immitis (2), and Mycobacterium tuberculosis (1). Three patients had poor outcomes: one died from S. pneumoniae and two had long-term neurologic deficits. Meningitis is a common admission diagnosis, but serious virulent pathogens are uncommon and adverse outcomes are rare.

Prevalence of short partial thromboplastin times in a military treatment facility.

BACKGROUND: It was recently noted that a shortened activated partial thromboplastin time (aPTT) is associated with increased venous thromboembolic events. The prevalence of aPTT shortening remains unknown. METHODS: We conducted a retrospective analysis of aPTT results over a 2-month period. These results were not associated with patient clinical information. RESULTS: We obtained 3,376 aPTT samples, which were analyzed in groups: <25.0, 25.0-35.0, and >35.0 seconds (two standard deviations from our laboratory's normal values). Eighty-six samples had aPTT<25 (8.5%), 2,026 samples between 25.0-35.0 (60.0%), and 1,064 samples>35.0 (31.5%). Using chi-square goodness-of-fit, we found a clinically significant greater-than-expected prevalence of low aPTT levels (p<0.001). CONCLUSIONS: Although elevated aPTT samples could be explained by anticoagulation therapy, the reason for our findings of an increased number of low-aPTT studies remains unexplained. Further studies are required to investigate the clinical correlation of low aPTT levels and the incidence of venous thromboembolic events (VTEs) in our population.

Supraventricular tachycardia diagnosed by smartphone ECG.

Diagnosis of paroxysmal supraventricular tachycardia (PSVT) may be difficult due to its episodic nature, which can be brief and self-limited, limiting the ability for clinicians to diagnose the specific rhythm disorder in a timely manner. We present a case of PSVT, which was unable to be diagnosed through typical evaluation with an event monitor despite several years of symptoms. The patient was ultimately diagnosed using the AliveCor Mobile ECG, a smartphone-based ECG device and application, which he purchased himself and captured a typical atrioventricular node re-entrant tachycardia. The patient was then able to email his cardiologist the tracing, which led to an electrophysiology study and successful slow pathway ablation procedure. Smartphone-based technology has the potential to push diagnostic evaluations outside of the healthcare system and empower patients.