[Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report]. / Sepse aguda pós­operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso.

BACKGROUND: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. OBJECTIVE: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. CASE REPORT: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. CONCLUSIONS: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.

Sclerosing mesenteritis: a comprehensive clinical review.

Sclerosing mesenteritis is a rare disease entity initially described in 1924 with a prevalence reported to be less than 1%. Sclerosing mesenteritis is a comprehensive term used to describe three almost similar clinical entities including mesenteric panniculitis, retractile mesenteritis, and mesenteric lipodystrophy which only differ by their histology. The etiology of sclerosing mesenteritis is uncertain, but the disease has been associated with trauma, autoimmune disease, surgery, and malignancy. The typical presenting symptom is the abdominal pain, but sclerosing mesenteritis has a broad constellation of presenting symptoms which often makes consideration of the diagnosis unlikely. Treatment for this little-understood disease ranges from surgical intervention for patients presenting with obstructive symptoms to immunosuppressive medical therapy for patients presenting with pain. The purpose of this article is to provide an overview of the literature relevant to the diagnosis, etiology, and management of this condition in hopes of making physicians aware of this unique condition.

Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients.

INTRODUCTION: An acquired Tracheoesophageal fistula (TEF) is commonly caused by a malignancy or trauma, with pulmonary infection or aspiration being the presenting symptom. However, in the critical care setting the presentation can be subtle and may present with difficult ventilation. High endotracheal tube cuff pressures can lead to tracheal erosions and thus increasing the chances for developing a TEF. Prolonged intubation in the presence of other risk factors like poor general state of health, episodic hypotension, nasogastric tubes, and repeated intubations can increase the likelihood of developing an acquired TEF. Angioedema of the airway is a rare but potentially devastating complication of angiotensin converting enzyme inhibitors (ACE-I) that could further add insult to the tracheal mucosa, predisposing to an acquired TEF. CASE PRESENTATION: An elderly woman with multiple comorbidities and requiring mechanical ventilation, developed angioedema following intake of ACE inhibitor for hypertension. The ensuing airway edema made weaning off mechanical ventilation difficult. After repeated attempts at extubation, tracheostomy was performed. With the loss of airway after tracheostomy, the possibility of TEF was considered given her multiple risk factors and intra-operative findings of the tracheal mucosa. CONCLUSIONS: While it may be difficult to predict who will actually develop a TEF, it is prudent to identify those at risk and take precautionary measures to prevent one. Emphasis should be placed on daily endotracheal cuff manometric pressure check to prevent ischemic changes of the tracheal mucosa resulting from high cuff pressures. Also, bronchoscopy could be used after extubating susceptible patients to detect an acquired TEF.

Unusual Case of Severe Lactic Acidosis in a Liver Transplant Patient.

Lactic acidosis is a standard indicator for oxygen debt and some other very significant causes. We describe a case of liver transplant patient presenting with vague abdominal pain and lactic acidosis without any liver dysfunction/failure/ischemia/rejection or sepsis. The imaging studies showed vague bowel edema and normal hepatic perfusion. The patient continued to deteriorate with rising lactic acidosis when a repeat CT abdomen eventually showed signs of lymphomatosis peritonei. Biopsy revealed the unusual diagnosis of posttransplant lymphoproliferative disorder. Immediate discontinuation of immunosuppression and initiation of chemotherapy led to clinical improvement. Our intention of presenting this case is to increase awareness of posttransplant lymphoma and propose lactic acidosis as not only an indicator of liver dysfunction or rejection but also an aid for diagnosis of this unusual but fatal and potentially curable condition.

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding.

AIM: To determine whether patients hospitalized with gastrointestinal (GI) blood loss anemia are being checked and treated for iron deficiency. METHODS: Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 µg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females. RESULTS: Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those (91.9%) had anemia during their hospital stay. Ninety-five patients (30.9%) had iron studies performed during hospitalization, and 45 of those (47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50 (17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia (IDA), only 22 (48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes. CONCLUSION: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.

Recovery following desflurane versus sevoflurane anesthesia for outpatient urologic surgery in elderly females.

BACKGROUND: An unresolved question is the time required for the ability to return to complex tasks following anesthesia. OBJECTIVES: This study aims to characterize the severity and duration of cognitive impairment following sevoflurane or desfluane anesthesia after brief surgery using tests of cognitive ability to objectively testing performance. PATIENTS AND METHODS: This study is a double blinded randomized controlled trial. Patients were randomized to receive either a desflurane or sevoflurane-based anesthetic. On the morning of the surgery the subjects performed baseline cognitive task tests (Mini Mental Status exam, Trail Making Test Part A and B, Digit Symbol Coding, Hopkins Verbal Learning Test, Stroop Color and Word Test to determine baseline cognitive function. Cognitive testing was repeated 30 minutes and 1 hour after surgery whereas Modified Telephone Interview for Cognitive Status (TICS-M) and Memory Aging Telephone Screen (MATS) was used on the following day of surgery. RESULTS: Trail Making Test Part B cognitive test showed statistically significant in comparison for pre and post exposure of anesthetics. This difference was seen in the desflurane group. Other cognitive tests did not show differences on exposure to the anesthetic gases. CONCLUSIONS: This study questioned the difference between volatile anesthetic agent's effects on patients completing a battery of neurocognitive tests attempting to answer if one agent has a more profound effect. Our study shows no statistically significant cognitive decline except for those in the Trail Making Part B in the Desflurane group. This conclusion is limited by the inherent limitations of the study, but does reinforce that the systemic inflammatory response from the surgery contributes cognitive impairment.

The effect of training level on opioid utilization efficiency.

STUDY OBJECTIVE: This study focuses on residents' ability to predict opioid administration requirements and if improvement is made as learners progress. Residents request opioid from the pharmacy at the start of the day based on clinical assignment. Unused and wasted opioids are returned at the end of the day. The labor and cost associated with this process are not trivial nor is the risk of excess opioid access. We examined if estimation of daily opioid use by residents increased in accuracy as progression through the program occurred. MATERIALS AND METHODS: We conducted a retrospective analysis in the setting of the operating room examining pharmacy opioid usage. The measurements included the number of vials requested, the number of vials dispensed, and the number of vials returned. Information was stratified in our database by the level of training. The set inclusion criterion was any surgery performed in the operating rooms that required the use of opioids. The exclusion criteria included anesthesia that required a regional block, cardiac surgeries, emergent cases, and obstetric cases. MAIN RESULTS: A total of 104 opioid requests were made that met our criteria. Comparing CA-1 and CA-3 residents and CA-2 and CA-3 residents, a statistically significant difference exists between the number of vials requested and the number returned. Our data show a statistically significant difference in efficiency as residents progress from their CA-1 year to CA-3 year. CONCLUSION: In summary, our findings support the idea that residents are able to better predict opioid requirements for cases as they progress through training. Closely monitoring such patterns can serve a useful educational purpose and allow for identification of misuse. Improvement in cost-effective care and limiting waste while working in a complex integrated health care environment are additional benefits.

Efficacy of hyperbaric oxygen in patients with Crohn's disease: two case reports.

Crohn's disease is an inflammatory disease of the gastrointestinal tract, usually involving the ileum, that can lead to debilitating symptoms of abdominal pain, diarrhea and malabsorption during acute exacerbations. Because there is no known cause of the illness, treatment is based upon symptomatology and may ultimately require bowel resection if response to medical therapy is inadequate. Treatment with hyperbaric oxygen has shown promise in the reduction of inflammation associated with acute exacerbations of Crohn's disease, with alleviation of symptoms and an improvement in quality of life. We present two cases of pediatric patients with exacerbations of Crohn's disease who underwent cycles of hyperbaric oxygen therapy. Each patient was symptomatic and had no improvement despite prolonged medical therapy. Following treatment with hyperbaric oxygen, both patients showed resolution of the inflammatory lesions and improvement in conditions, allowing them to reduce drug therapy. Although the mechanisms by which hyperbaric oxygen reduce inflammation in Crohn's disease is poorly defined, this therapy seems to have offer a safe adjunct in the treatment of refractory exacerbations.

Intraoperative coronary artery vasospasm: a twist in the tale!

The cause of variant angina is localized hyperresponsiveness of the vascular smooth muscle cells caused by non-specific stimuli of vasoconstriction. Autonomic imbalance can be one of the mechanisms of spontaneous vasospasm, and sympathetic or parasympathetic stimulation can induce Coronary Artery Spasm (CAS). Although various reports of CAS events have been described, episodes associated with untwisting or manipulation of a visceral structure remains unique. We report one such case of CAS in association with intraoperative untwisting of a torted ovarian cyst treated with intracoronary nitroglycerine in the catheterization laboratory. Vasospastic or variant angina is a well known clinical condition first described by prinzmetal and colleagues, characterized by CAS in normal and diseased coronary arteries. General anesthesia can be a triggering event. This case demonstrates unique etiology in that spasm was provoked by surgical manipulation of a torted ovarian cyst. CAS has been implicated as a cause of sudden, unexpected circulatory collapse and death during surgery, cardiopulmonary bypass, and other non-cardiac surgical procedures. There are few reports of coronary vasospasm during regional anesthesia and neuroaxial block. Many factors are involved in the occurrences of perioperative CAS including activated sympathetic activity, activated parasympathetic activity, cocaine, alkalosis, hypercalcemia, magnesium deficiency, succinylcholine, vasopressors, essential hypertension, Hyperthyroidism, epidural anesthesia, spinal anesthesia, smoking, lipid metabolic disorder, coronary artery aneurysm, commercial weight loss products. We describe a rare case of CAS during general anesthesia, in a patient with no past history of coronary artery disease, possibly provoked by surgical manipulation ofa torted ovarian cyst, which was diagnosed and treated promptly via cardiac catheterization. Intraoperative coronary artery vasospasm: a twist in the tale!