A Case of Severe QTc Prolongation During Targeted Temperature Management - What Can We Learn?

BACKGROUND QTc prolongation during targeted temperature management (TTM) post cardiac arrest is a known effect of hypothermia, but its significance is unclear. Several studies suggest that temporary prolongation during TTM is not prognostic and does not potentiate fatal arrhythmias; however, there are limited cases of patients presenting with QTc intervals >700 milliseconds. CASE REPORT We describe a case in which a 57-year-old woman with diabetes, hypertension, and atrial fibrillation presented with concern for stroke. The hospital course was complicated by cardiac arrest requiring TTM, which was stopped early due to significant QTc prolongation of 746 milliseconds. CONCLUSIONS TTM is beneficial post resuscitation for good neurological outcomes, but it also has known adverse cardiac effects such as QTc prolongation. The significance of QTc prolongation during TTM is unclear as several studies have shown no increased incidence of malignant arrhythmias. One case report in the literature describes the incidence of torsades de pointes due to QTc prolongation during TTM. Further study and guidelines regarding electrocardiogram monitoring are needed to determine the importance of QTc prolongation during TTM.

One Lung Soldier: A Ventilation Conundrum in a Postpneumonectomy Syndrome Complicated by Acute Respiratory Syndrome.

Postpneumonectomy syndrome involves mediastinal shift causing dynamic airway obstruction via compression of the main bronchus and distal trachea. A few case reports describe the development of ARDS in patients with postpneumonectomy syndrome. Reeb et al. (2017) describe the mortality of postpneumonectomy ARDS anywhere from 33% to 88%. One may encounter difficulty in intubation and ventilation as parameters based on ideal body weight may not apply. Prone positioning ventilation and ECMO have been successfully used in isolated cases. We present such a case and highlight challenges in management. A 70-year-old male Vietnam veteran with remote history of right pneumonectomy thirty years prior presented with fever, cough, and dyspnea. Physical exam was significant for T 36.3°C, BP 162/73, heart rate 145 BPM, RR 22 breaths/minute, ht. 1.72 m, and wt. 78 kg, with transmitted right lung sounds and rhonchi on the left. Labs showed WBC 23.92/nL and procalcitonin 0.84 ng/mL. CXR showed left infiltrate and opacification of right hemithorax with right mediastinal shift. EKG showed atrial fibrillation. He was started on broad spectrum antibiotics for pneumonia, but deteriorated, and was intubated for respiratory distress from ARDS. Vasopressors were initiated for shock. Given the history of pneumonectomy, he was initially ventilated with lower tidal volumes (320 mL). However, incremental changes were made to tidal volumes, and ETT was repositioned several times for hypoxia. Epoprostenol and cisatracurium were also initiated. Positional changes would lead to sudden desaturation; hence, prone positioning ventilation was not done. He was not considered for ECMO due to his pneumonectomy status. Unfortunately, his condition worsened progressively and he expired. The guidelines for ARDS are well established. However, postpneumonectomy patients are unique as seen in our patient. It is unclear whether an endobronchial tube advanced into the left bronchus could have helped difficult airway management resulting from suspected postpneumonectomy syndrome as suggested by CXR. Higher tidal volumes were also unsuccessful in alleviating hypoxia and led to persistently elevated plateau pressures and driving pressures as high as 23, which was inconsistent with our goal of lung protective ventilation. Few case reports describe the successful use of prone positioning ventilation or ECMO in postpneumonectomy patients with ARDS. Although not well studied, low tidal volumes supported with ECMO may have been a favorable strategy for our patient.

The identification of risk factors for venous thromboembolism in gastrointestinal oncologic surgery.

BACKGROUND: The aim of this study was to examine the incidence and factors associated with occurrence of venous thromboembolism (VTE) in patients undergoing major gastrointestinal (GI) surgery for malignancy. METHODS: The American College of Surgeon's National Surgical Quality Improvement Program, Participant User File database was queried from 2005 to 2012 to study major GI operations performed for cancer. Predictors of VTE and their relation to survival were studied. RESULTS: In 79,300 patients, the incidence of deep venous thrombosis was 1.7%, and pulmonary embolism was 0.9% during the 30-d postoperative period. The highest rate of VTE occurred after esophagectomy (5.9%) followed by pancreatectomy (3.2%), hepatectomy (3.2%), gastrectomy (2.5%), enterectomy (2.3%), colectomy, and proctectomy (2.0%). On multivariate analysis, disseminated cancer, age ≥ 80 y, body mass index > 35 kg/m(2), functional status, post operative sepsis, pulmonary dysfunction, and longer operative time were associated with occurrence of VTE. Occurrence of VTE was associated with mortality on multivariate analysis (odds ratio 2.4, 95% confidence interval 2.0-3.0, P < 0.001). CONCLUSIONS: Absolute incidence of VTE after major GI surgery is low but is associated with significant mortality and postoperative complications. Disseminated cancer, post operative sepsis, longer operative time, and increased body mass index >35 kg/m(2) further increased the risk of VTE in patients undergoing surgery for malignancy. Surveillance strategies should be implemented for those cancer patients who have multiple risk factors for VTE.