Point-of-Care Ultrasound Aids in the Management of Patient Taking Semaglutide Before Surgery: A Case Report.

Semaglutide, a glucagon-like peptide-1 (GLP-1) analog, has various effects on the gastrointestinal tract. In patients undergoing anesthesia delayed gastric emptying time can have sequelae if not identified preoperatively. Modalities include thorough history regarding the last dose administration of a GLP-1 analog and ultrasound of gastric contents before induction of anesthesia. We present a case in which gastric ultrasound identified a patient at increased risk for aspiration on induction and allowed for appropriate alterations in the anesthetic plan.

Patient selection in ambulatory surgery.

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Maintaining One-Lung Ventilation With an Endobronchial Blocker Through a Damaged Left-Sided Double-Lumen Tube: A Case Report.

One-lung ventilation (OLV) can be accomplished utilizing a double-lumen tube (DLT) and an endobronchial blocker (EBB) or intentionally placing a standard endotracheal tube (ETT) into a mainstem bronchus. However, secondary options must be available should the primary method fail. We present a case where an EBB and a fiberoptic bronchoscope (FOB) were successfully passed through a left-sided DLT to reestablish right-lung isolation after the DLT bronchial cuff was surgically damaged. We advocate competency in placing both DLTs and EBBs, as well as having EBBs readily accessible as a secondary isolation method during OLV.

Intraoperative Management of Tracheal Cautery Injury in a Post-Bypass Cardiac Surgery Patient.

We present the case of a tracheal injury that occurred during a Maze procedure performed via sternotomy that was not initially detected by ventilator air leak, but rather by the visual presence of gas bubbles escaping the trachea during chest irrigation. Careful investigation and machine check did reveal a subsequent air leak that would have otherwise been overlooked. Furthermore, the use of intraoperative bronchoscopy was essential in guiding and confirming surgical repair. This case underscores the need for ongoing vigilance and suggests the utility of chest irrigation with Valsalva maneuvers after procedures performed in the vicinity of the trachea to exclude injury.

Not Your Average Mediastinal Mass: A Case of a Large Mediastinal Teratoma in a Patient With a History of Polio Disease.

Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease.

Postoperative Thyroid Storm After Evacuation of a Complete Hydatidiform Mole: A Case Report.

Gestational trophoblastic disease can lead to excess thyroid hormone release and rarely, thyroid storm. We present a case of complete molar pregnancy with hyperthyroidism that was not identified or treated before surgical evacuation of uterine contents. Untreated hyperthyroidism preoperatively led to unanticipated thyroid storm immediately after emergence from anesthesia. It is important for anesthesia providers to recognize the link between gestational trophoblastic disease and thyrotoxicosis, and appreciate the severe consequences than can occur if left untreated. Anesthesia providers should strongly consider preoperative consultation and treatment. Being prepared to treat intraoperative symptoms and thyroid storm is paramount.

Waddell (Nonorganic) Signs and Their Association With Interventional Treatment Outcomes for Low Back Pain.

BACKGROUND: The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions. METHODS: We prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP. Categories of Waddell signs included nonanatomic tenderness, pain during sham stimulation, discrepancy in physical examination, overreaction, and regional disturbances divulging from neuroanatomy. The primary outcome was change in patient-reported "average" numerical rating scale for pain intensity (average NRS-PI), modeled as a function of the number of Waddell signs using simple linear regression. Secondary outcomes included a binary indicator of treatment response. We conducted secondary and sensitivity analyses to account for potential confounders. RESULTS: We enrolled 318 patients: 152 in the ESI cohort, 102 in the facet cohort, and 64 in the SIJ cohort, having sufficient data for primary analysis on 308 patients. Among these, 62% (n = 192) had no Waddell signs, 18% (n = 54) had 1 sign, 11% (n = 33) had 2, 5% (n = 16) had 3, 2% (n = 7) had 4, and about 2% (n = 6) had all 5 signs. The mean change in average NRS-PI in each of these 6 groups was -1.6 ± 2.6, -1.1 ± 2.7, -1.5 ± 2.5, -1.6 ± 2.6, -1 ± 1.5, and 0.7 ± 2.1, respectively, and their corresponding treatment failure rates were 54% (102 of 192), 67% (36 of 54), 70% (23 of 33), 75% (12 of 16), 71% (5 of 7), and 83% (5 of 6). In the primary analysis, an increasing number of Waddell signs were not associated with a significant decrease in average NRS-PI (coefficient [Coef] = 0.19; 95% confidence interval [CI], -0.43 to 0.05; P = .12). A higher number of Waddell signs were associated with treatment failure, with a 1.35 increased odds of treatment failure per cumulative number of signs (P = .008). CONCLUSIONS: Whereas this study found no consistent relationship between Waddell signs and decreased mean pain scores, a significant relationship between the number of Waddell signs and treatment failure was observed.

Activity-independent neural influences on cat soleus motor unit phenotypes.

The physiological and phenotypic properties of motor units in the cat soleus muscle were studied after 4 months of inactivity induced by spinal cord isolation (SI). The soleus of some SI cats were stimulated for 30 min/day during an isometric (SI-I), shortening (SI-S), or lengthening (SI-L) phase of a simulated step cycle. Mean maximum tetanic tensions were approximately 15, 26, 32, and 51% of the control in the SI, SI-S, SI-L, and SI-I groups. Mean time-to-peak tension was approximately 50% shorter than the control in all SI groups. One motor unit was glycogen-depleted in each muscle via repetitive stimulation. Eighteen physiologically slow and 9 fast motor units from the spinal cord-isolated groups consisted of fibers that contained only slow myosin heavy chain (MHC) and sarco(endo)plasmic reticulum calcium-adenotriphosphatase (SERCA) isoforms. Two motor units (physiologically fast) consisted primarily of fibers that contained both fast and slow MHC and SERCA. These data reflect a dissociation between isometric speed-related properties and MHC and SERCA isoforms following inactivity. The predominance of fibers containing both fast and slow MHC and SERCA isoforms in 2 motor units demonstrates a strong motoneuronal influence on the muscle-fiber phenotype even when the motoneurons are silent.

Influences of electromechanical events in defining skeletal muscle properties.

Inactivity of the cat soleus muscle was induced via spinal cord isolation (SI), and the cats were maintained for 4 months. The soleus was electrically stimulated while lengthening (SI-L) or shortening (SI-S) during a simulated step cycle or during isometric (SI-I) contractions. For the SI, SI-S, SI-L, and SI-I groups, the soleus weights were 33, 55, 55, and 64% of the control, respectively, and the maximum tetanic tensions were 15, 30, 36, and 44% of the control, respectively. The specific tension was lower in all SI groups than in the control. Absolute forces at stimulation frequencies of 5-200 Hz were smaller in all SI groups than in the control. The SI-I group tended to have higher values for all force-related parameters than the other SI groups. Fatigue resistance was similar among all groups. The isometric twitch time-to-peak tension was shorter, and the frequency of the stimulation-tension response was shifted to the right in all SI groups with respect to the control. Maximum shortening velocities were 70, 59, and 73% faster for the SI, SI-S, and SI-L groups and similar to the control for the SI-I group. Inactivity resulted in an increased percentage of faster myosin heavy chains (MHCs) that was blunted in the SI-I and SI-L groups but not in the SI-S group. Pure type I MHC fibers atrophied by 80, 59, 58, and 47% in the SI, SI-S, SI-L, and SI-I groups. The data from the SI group quantify the contribution of activity-independent factors in maintaining the mechanical and phenotypic properties of the cat soleus. Relative to a fast-fatigable muscle, these results suggest that only 25% of the slowness (type I MHC) and none of the resistance to fatigue of the soleus muscle are dependent on activity-related factors. Short, daily bouts of electromechanical activation ameliorated several of these adaptations, with the isometric contractions being the most effective countermeasure. The clinical implications of these findings for rehabilitation strategies are discussed.