Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Quadratus Lumborum Blocks for Pediatric Bone Marrow Harvesting: A Case Report.

Bone marrow harvesting is a means to obtain stem cells to treat certain hematologic conditions in related or unrelated individuals. The most cited complication after bone marrow harvesting is surgical site pain. We developed a protocol incorporating regional anesthesia to improve pain control and reduce opioid use. A retrospective chart review was performed on three pediatric patients who underwent bone marrow harvesting for a sibling recipient and were managed via a standardized regional pain protocol. Each patient was treated with bilateral quadratus lumborum blocks in the operating room, prior to incision. Anesthesia records were reviewed for opioid administration intraoperatively and postoperatively. Two of three patients underwent successful QL blocks as evidenced by pain scores of 0/10 and lack of opioid administration in the post-anesthesia care unit. One patient was found to have a failed block and exhibited pain in the immediate and post-discharge time frame. Following this outpatient procedure, all patients were discharged home to the care of their parents, and no patients required admission due to pain. By utilizing the framework of a successful regional anesthesia model adapted from our adult bone marrow donor patients, we were able to employ a minimal opioid anesthetic and reunite patients with their families efficiently. We continue to use quadratus lumborum blocks in our pediatric patients to facilitate perioperative analgesia.

Relationship Between Palliative Care Consults and Outcomes of Pediatric Surgical Patients During Terminal Admissions.

Background: Pediatric patients often undergo surgery during terminal admissions. However, the involvement and timing of palliative care consults in caring for these patients has not been readily described. Objective: To describe the presence and timing of palliative care consults for pediatric patients who undergo surgical procedures during terminal admissions. Design: Retrospective cohort study using data from the electronic health record. Setting and Participants: Pediatric patients who underwent at least one surgical procedure during a terminal admission at an urban, quaternary hospital in the United States from January 1, 2016 to December 31, 2021. Main Outcomes and Measures: Patients' medical, surgical, and admission-level characteristics were abstracted. Associations were evaluated between these characteristics and the occurrence and timing of a palliative care consult relative to surgery and death. Results: Of 134 patients, 84% received a palliative care consult during their terminal admission. Approximately 36% of consults occurred before surgery, and 12% were within one day of death. Children without a palliative care consult were more likely than children with a consult to die during surgery (19.1% vs. 2.7%, p = 0.02), have surgery within 24 hours of death (52.4% vs. 15.9%, p < 0.001), and undergo a full resuscitation attempt (47.6% vs. 12.4%, p = 0.002). Receipt of a palliative care consultation did not differ by patient sex, reported race and ethnicity, language, insurance, or income level. Conclusions and Relevance: Palliative care consults support high-quality end-of-life care for children and impact perioperative outcomes, including intensity of surgical care and resuscitation in the final hours of life.

Decreased Opioid Consumption in Bone Marrow Harvest Patients Using Quadratus Lumborum Blocks in a Standardized Protocol.

Purpose: Bone marrow harvesting is associated with significant postoperative pain that may have potential negative consequences for the patient and health care system. In the current absence of uniform guidelines, there exists considerable variability amongst providers with respect to perioperative analgesia, especially opioid administration. In this initiative, we explored the potential for preoperative bilateral quadratus lumborum blocks in combination with a standardized perioperative analgesic protocol to manage pain with the goal of reducing perioperative narcotic usage and thereby improving opioid stewardship. Methods: Adults who underwent bone marrow donation from 2018 to 2020 were included in this analysis (n = 32). The pre-implementation group (n = 19) was reviewed retrospectively while the implementation group (n = 13) was evaluated prospectively. Patient demographics, pain scores, and opioid consumption were evaluated. Results: Patient characteristics were equivalent except for anesthesia type with an increased number of patients in the implementation group undergoing spinal anesthesia. The implementation group showed significantly reduced median intraoperative (20.0 mg vs. 0.0 mg; p < 0.001) and total opioid consumption (20.5 mg vs. 0.0 mg; p < 0.001). The number of patients who received any opioids decreased from 84.2% (16/19) before implementation to 23.1% (3/13) after implementation. Conclusion: This change in practice suggests that implementation of a standardized perioperative protocol, including bilateral quadratus lumborum blocks, for bone marrow harvest patients leads to reduced perioperative opioid administration without compromising immediate perioperative pain control.

Serum correlation, demographic differentiation, and seasonality of blubber testosterone in common bottlenose dolphins, Tursiops truncatus, in Sarasota Bay, FL.

Blubber and serum testosterone levels were compared among 55 individual common bottlenose dolphins, Tursiops truncatus, in Sarasota Bay, FL during 2011-2019. A significant positive relationship between the matrices was found in male testosterone concentrations in 29 paired samples (r2 = 0.932). Mature males (n = 17) had 300 times greater mean testosterone concentration in serum than immature males (n = 17). A comparison of blubber samples, including 12 females, 24 immature males, and 19 mature males, revealed significant differences in mean blubber testosterone values among all three demographics. Immature males had greater than 6 times the average blubber testosterone concentration of females and mature males had almost 100 times that of immature males. Estimated testis volume was highly correlated with blubber testosterone concentration and mature males had 60 times greater average testis volume than immature males. We observed seasonal variation in blubber testosterone in mature males, consistent with known reproductive patterns. These data suggest males can be distinguished from females and designated as mature or immature via blubber testosterone concentrations, an observation that validates dart biopsy sampling as a means of obtaining demographic data.

Initial validation of blubber cortisol and progesterone as indicators of stress response and maturity in an otariid; the California sea lion (Zalophus californianus).

Chronic stress can have detrimental effects on an individual's health and reproductive success. The use of cortisol quantification as an indicator of stress in free-ranging cetaceans and phocids is increasing but no studies have applied this technique on blubber in otariids. We measured cortisol concentrations in blubber samples obtained from California sea lions, Zalophus californianus, stranded in San Diego County and those incidentally killed in the California drift gillnet fishery. We also measured progesterone concentrations to assess female reproductive status and, in males, as a potential secondary measure of adrenal steroid production. Blubber cortisol and progesterone values were compared across demographic groups (sex and maturity), season, and proportion blubber lipid extracted. Stranded animals (247.3±70.767SEng/gblubber) had significantly higher cortisol concentrations compared to fishery bycaught (8.1±2.108SEng/gblubber) animals. These findings are likely driven by inherent differences in the cause of death and associated nutritional state coupled with the mean duration of expiration for these two groups of animals (i.e., the duration from an animal's initial perception of the threat-to-self until death). The duration of transition from healthy state to death in stranded animals is on the order of many hours to weeks while in fishery bycaught animals, this transition occurs much more rapidly (i.e., seconds to tens of minutes). The presumed longer duration of the mortality event in stranded animals gives sufficient time for elevated cortisol to diffuse into the blubber. No significant differences between demographic groups, or season were found. However, blubber cortisol declined inversely with proportion blubber lipid extracted, suggesting utility in assessing long-term nutritional status. Blubber progesterone was significantly higher in mature females than immature females (153.8±54.546SEng/gblubber and 9.7±3.60SEng/gblubber respectively), containing on average 15 times more progesterone, irrespective of pregnancy state. Additionally, a significant relationship between mean cortisol and progesterone was found in males with >35% blubber lipid (p<0.0001). This study is an initial step in validating blubber cortisol and progesterone concentrations as a potential marker of stress response and reproductive state, respectively, in otariids. Especially when paired with dart biopsying, this approach could represent a relatively rapid way to assess baseline stress, nutritional status and reproductive states in otariids while minimizing the effects of sampling.

Hemolytic uremic syndrome with simultaneous Shiga toxin producing Escherichia coli and complement abnormalities.

BACKGROUND: Hemolytic uremic syndrome is a common cause of acute kidney injury in children. In children, hemolytic uremic syndrome is most commonly associated with gastrointestinal infections caused by Shiga toxin-producing Escherichia coli or other enteric organisms. Although less common, atypical hemolytic uremic syndrome is triggered by multiple factors and portends a significantly worse prognosis with a high rate of recurrence. CASE PRESENTATION: Here we discuss the case of a 10 year old Caucasian male presenting with thrombocytopenia, anemia, and acute kidney injury. CONCLUSIONS: This case highlights the clinical challenges in diagnosing and managing patients with hemolytic uremic syndrome. Because of similarity in symptoms, differentiating Shiga toxin-producing Escherichia coli associated hemolytic uremic syndrome and atypical hemolytic uremic syndrome can be challenging. However, because of the increased morbidity and mortality of atypical hemolytic uremic syndrome, early detection and initiation of therapy are critical. Providers must have a heightened suspicion in order to initiate supportive care or disease directed therapy in the case of atypical hemolytic uremic syndrome.