Undiagnosed Lambert-Eaton Myasthenic Syndrome in the Era of Sugammadex: A Case Report.

OBJECTIVE: In this case report, we discuss the rare manifestation of prolonged neuromuscular blockade in a patient with history of small cell lung cancer and undiagnosed Lambert-Eaton myasthenic syndrome (LEMS) who had previously received succinylcholine for general anesthesia without incident but subsequently exhibited prolonged neuromuscular blockade during a laparoscopic procedure. We aimed to emphasize the importance of reversal agent safety and precision as well as vigilant perioperative and postoperative care. METHODS: We used the patient's electronic medical record, direct patient care experiences, and comprehensive literature review for this case report. RESULTS: Sugammadex was administered with mild improvement. Suspecting undiagnosed LEMS, neostigmine was administered, yielding satisfactory muscle strength and successful extubation. In retrospect, the patient reported history of weakness when lifting weights that improved upon exertion. CONCLUSIONS: Sugammadex is an efficient and effective agent for reversal of neuromuscular blockade. However, proper monitoring of the depth and recovery of blockade is imperative to when using sugammadex with optimal safety and precision in all patients. Perioperative care teams must remain vigilant with a high index of suspicion for neuromuscular junction pathology to properly plan perioperative care for patients at risk, especially those with small cell lung cancer who may have undiagnosed LEMS.

Telehealth as an effective method of follow-up for pediatric post tonsillectomy patients.

PURPOSE: To determine if pediatric patients can be safely and effectively managed postoperatively with nurse led telehealth communication. METHODS: This is a retrospective case series conducted at a tertiary academic medical center pediatric otolaryngology practice. Retrospective chart review was conducted on patients <18 years old who underwent tonsillectomy from January 2017 to December 2019. Patients were managed postoperatively with a telehealth communication on postoperative day (POD) 3-5 and again at 4-6 weeks. Patient demographics, satisfaction with follow-up, number of office visits, and postoperative complications were recorded. RESULTS: 829 tonsillectomy patients were identified. Average patient age was 5.7 years (range 10 months-16 years). Successful contact was made with the patient's caregiver on POD 3-5 for 511 patients. 322 patients successfully completed 4-6 weeks telehealth follow-up. 292 patients (91 %) reported improvement in pre-operative symptoms at 4-6 weeks. Overall, 98 % of patients who completed telehealth follow-up were satisfied with this method and did not desire an additional office appointment. 62 patients (21 %) participated in an office follow-up in 2017, 54 patients in 2018 (19 %), and 36 patients (14 %) in 2019. Only 61 of these visits were routinely scheduled postoperative tonsillectomy office visits. 53 patients (6 %) had a postoperative tonsillectomy bleed and 31 patients (4 %) required return to the operating room for cauterization. CONCLUSION: Telehealth is successful in reducing the number of post-tonsillectomy office visits for pediatric patients without a subsequent increase in complications. Reduction in office visits can lead to cost reduction and increased availability of pediatric otolaryngology appointments.