A Case of Gerbode Ventricular Septal Defect Endocarditis.

•A Gerbode VSD is a communication between the left ventricle and right atrium.•Etiologies include trauma, infective endocarditis, and iatrogenic causes.•Echocardiographic evaluation for this defect requires a careful interrogation.

A Novel Process Audit for Standardized Perioperative Handoff Protocols.

A perioperative handoff protocol provides a standardized delivery of communication during a handoff that occurs from the operating room to the postanestheisa care unit or ICU. The protocol's success is dependent, in part, on its continued proper use over time. A novel process audit was developed to help ensure that a perioperative handoff protocol is used accurately and appropriately over time. The Audit Observation Form is used for the Audit Phase of the process audit, while the Audit Averages Form is used for the Data Analysis Phase. Employing minimal resources and using quantitative methods, the process audit provides the necessary means to evaluate the proper execution of any perioperative handoff protocol.

Upper Extremity Peripheral Intravenous Line Infiltration With Concomitant Loss of Pulses Treated With Lipoaspiration: A Case Report.

Peripheral intravenous cannulation in children is associated with occasional morbidity. We present a case where a large volume of blood, administered through a small peripheral cannula in the antecubital fossa, was found to have extravasated into the soft tissues, causing catastrophic vascular compromise. The expedient removal of the extravasate using a lipoaspiration cannula restored perfusion immediately to the affected limb and negated the need for surgical fasciotomies.

CONTINUOUS NON-INVASIVE ARTERIAL PRESSURE DEVICE AS AN ADJUNCT TO RECOGNIZE FLUCTUATING BLOOD PRESSURES DURING ELECTIVE CESAREAN SECTION UNDER SUBARACHNOID BLOCKADE (SAB).

BACKGROUND: Measuring non-invasive blood pressure (NIBP) in less than one minute intervals (STAT NIBP measurements) is not always feasible. Therefore, large number of undetectable hypotension episodes can only be recognized with continuous beat to beat monitoring of blood pressure, for example, by continuous non-invasive arterial pressure monitor (CNAP). OBJECTIVE: The purpose of the current study was to investigate whether CNAP correlates well with conventional intermittent oscillometric NIBP during elective cesarean sections under subarachnoid blockade (SAB) and whether CNAP based patient management results in improved immediate maternal vasopressor requirements and improved immediate fetal/neonatal outcomes compared with NIBP based patient management. MATERIALS AND METHODS: The CNAP finger cuff together with the CNAP arm cuff were placed on the same arm which also had the peripheral intravenous access.. On the contralateral arm the conventional NIBP arm cuff was placed. Study Group: The patients were managed by the anesthesia provider based on the CNAP monitor readings. Control Group: The patients were managed by the anesthesia provider based on the NIBP monitor readings. Results: The CNAP-based treatment (study) group had a statistically significant lower use of oxytocin and lower estimated blood loss than the NIBP-based treatment (control) group. The differences in incidences of vasopressors use and peri-operative nausea vomiting between study group and control group did not reach statistical significance. CNAP readings were more likely to be in systolic hypotensive phases (80mmHg) as compared to NIBP readings. CONCLUSION: Continuous non-invasive arterial pressure (CNAP) device may ONLY act as an adjunct to recognize fluctuating blood pressures during elective cesarean section under subarachnoid blockade (SAB).

RESIDENT IMPLEMENTATION OF THE 2007 ACC/AHA GUIDELINES ON PREOPERATIVE CARDIAC EVALUATION IN NON-CARDIAC SURGERY PATIENTS: IS CLINICAL EXPERIENCE ENOUGH?

BACKGROUND: Preoperative evaluation of surgical patients is important, as perioperative complications are associated with increased mortality. Specialties including anesthesiology, internal medicine, cardiology, and surgery are involved in the evaluation and management of these patients. This institutional study investigated the residents' knowledge of the 2007 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on perioperative evaluation of patients undergoing non-cardiac surgery. METHODS: This pilot study used a web-based survey questionnaire to assess resident's knowledge of the 2007 ACC/AHA guidelines through individual steps and corresponding branch point(s) in twelve clinical scenarios. Additionally, residents were asked if they were aware of, or if they had received lectures on ACC/AHA guidelines. Staff anesthesiologists with training in cardiac and intensive care medicine validated the scenarios. RESULTS: A total of 104 resident participants were surveyed including 35 anesthesiology residents, 41 internal medicine residents, 20 surgery residents, and 8 cardiology fellows. Awareness of the 2007 ACC/AHA guidelines by specialty was: anesthesiology (85%), internal medicine (97.6%), cardiology (100%), and surgery (70%). Only 54.3% of anesthesiology, 31.7% of internal medicine, 100% of cardiology, and 10% of surgery residents stated they received lectures. The overall mean score achieved on the eleven scenarios was 50.4% for anesthesiology, 47.0% for internal medicine, 55.7% for cardiology, and 42.3% for surgery. CONCLUSIONS: Although the majority of residents were aware of the 2007 ACC/AHA guidelines, fewer received lectures and regardless of specialty, implementation of these guidelines was poor. There exists significant room for improvement in the understanding of preoperative assessment of non-cardiac surgery patients.

RENAL PROTECTION IN THE CARDIAC SURGERY PATIENT: PERI-OPERATIVE SODIUM BICARBONATE INFUSION (POSBI) OR NOT?

BACKGROUND: Acute renal failure following cardiac surgery is not uncommon and carries a high level of morbidity and mortality. The aim of our study was to determine whether perioperative sodium bicarbonate infusion (POSBI) would decrease acute kidney injury in cardiac surgery patients and improve post-operative outcomes. METHODS: A retrospective analysis of 318 cardiac surgery patients from 2008-2011 was performed. Clinical parameters were compared in patients receiving POSBI versus sodium chloride. Serum creatinine levels were measured in the first five post-operative days. The primary outcome measured was the number of patients developing post-operative renal injury. Secondary outcomes included three-month mortality, intensive care unit and hospital length of stay. RESULTS: Patients given POSBI showed no significant differences compared to the normal saline cohort in regards to increases in serum creatinine [< 25% rise in Cr: 93% vs 94%; > 25% rise in Cr: 6% vs 6%; > 50% rise in Cr: 1% vs 1%; > 100% rise in Cr: 1% vs 0%, all with p-value > 0.99]. There were fewer patients with AKIN stage 1 renal failure receiving POSBI [8% vs 28%, p = 0.02] however there was no difference between POSBI and sodium chloride cohorts in AKIN stages 2 and 3 renal failure. Mortality, duration of hospitalization and ICU stay were not statistically significant. CONCLUSIONS: POSBI resulted in fewer patients developing AKIN stage 1 renal failure. Despite this, there appears to be little benefit in the prevention of acute kidney injury after 48 hours or mortality reduction in cardiac surgery patients.

Unusual case of contralateral Horner's syndrome following stellate-ganglion block: a case report and review of the literature.

Stellate-ganglion block (SGB) is a commonly performed procedure for the treatment of numerous conditions, including upper-extremity complex regional pain syndromes and arterial insufficiency. The appropriate response to SGB includes ipsilateral Horner's syndrome and temperature elevation of affected extremity. Contralateral and bilateral Horner's syndrome following SGB are rarely seen, with only six prior cases reported. We describe a case of a 47-year-old female with right-hand pain secondary to Raynaud's phenomenon who underwent SGB with subsequent contralateral Horner's syndrome and review the literature of this rare phenomenon.

Esophageal perforation following cervical spine surgery: A review with considerations in airway management.

Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgery for the treatment of spondylosis, radiculopathy, myelopathy, and trauma to the cervical spine. Esophageal perforation is a rare yet serious complication following ACDF with an incidence of 0.02 to 1.52%. We describe a case of a 24-year-old man who underwent ACDF and corpectomy following a motor vehicle accident who subsequently developed delayed onset esophageal perforation requiring surgical intervention. We believe that the detailed review of the surgical management of esophageal perforation following cervical spine surgery will provide a deeper understanding for the Intensivist in regards to postoperative airway management in these types of patients. Careful extubation over a soft flexible exchange catheter should take place to help reduce the risk of perforation in the event reintubation is required.

Neurosurgical rotations or clerkships in US medical schools.

OBJECT: Medical student exposure to neurosurgery is limited. To improve the educational interactions between neurosurgeons and medical students as well as neurosurgical medical student rotations or clerkships (NSCs) we must first understand the current status. METHODS: Two questionnaires were sent, one to every neurosurgery course coordinator or director at each US neurosurgery residency program (99 questionnaires) and one to the associated parent medical school dean's office (91 questionnaires), to assess the current status of NSCs and the involvement of neurosurgeons at their respective institutions. RESULTS: We received responses from 86 (87%) of 99 neurosurgery course coordinators or directors and 64 (70%) of 91 medical school deans' offices. Most NSCs do not have didactic lectures (53 [62%] of 86 NSCs), provide their medical students with a syllabus or educational handouts (53 [62%] of 86), or have a recommended/required textbook (77 [90%] of 86). The most common method of evaluating students in NSCs is a subjective performance evaluation. Of 64 medical school deans, 38 (59%) felt that neurosurgery should not be a required rotation. Neurosurgical rotations or clerkships are primarily offered to students in their 4th year of medical school, which may be too late for appropriate timing of residency applications. Only 21 (33%) of 64 NSCs offer neurosurgery rotations to 3rd-year students. CONCLUSIONS: There is significant room for improvement in the neurosurgeon-to-medical student interactions in both the NSCs and during the didactic years of medical school.

Spontaneous involution of Rathke cleft cysts: is it rare or just underreported?

Rathke cleft cysts (RCCs) are benign cystic lesions of the sella that arise from the remnants of Rathke pouch. Although most are asymptomatic, symptoms can result from mass effect and commonly include headache, endocrinopathy, or visual field disturbance. Although asymptomatic patients undergo conservative treatment, patients with symptoms are typically treated surgically. The authors report 9 patients with symptomatic cystic sellar lesions and imaging characteristics consistent with an RCC; in all cases there was spontaneous involution of the lesions, and in 5 of 7 patients presenting with headache the symptom resolved. Spontaneous involution of an RCC may be more common than the paucity of prior reports would suggest, especially because the natural history of both symptomatic and asymptomatic RCCs is poorly understood. The potential for spontaneous involution, together with the clinical course of the patients reported here, supports a conservative approach for patients with symptomatic RCCs presenting solely with headache.

A supratentorial, hemorrhagic, intraparenchymal epidermoid cyst.

Epidermoid cysts are slow growing benign tumors that represent < 1-2% of all intracranial tumors and rarely present as supratentorial, intraparenchymal masses. We present the first report of a supratentorial, hemorrhagic, intraparenchymal epidermoid cyst with its presentation, our operative approach, post-operative course, radiographic features, and a literature review.

Postlaminoplasty kyphotic deformity in the thoracic spine: case report and review of the literature.

In the pediatric population, a strong correlation between multilevel laminectomy and postlaminectomy spinal deformities, predominantly kyphosis, has been demonstrated. This has been observed mainly in the cervical and thoracic spine. Therefore, laminoplasty was proposed as an alternative to laminectomy with a reduced incidence of spinal deformity and need for stabilization and fusion. Moreover, to the best of our knowledge, postlaminoplasty kyphosis of the thoracic spine has not been previously described in the literature. We report the case of a pediatric patient who rapidly developed severe thoracic kyphosis 3 months after resection of a symptomatic extradural spinal arachnoid cyst and multilevel en bloc thoracic laminoplasty, and review the relevant literature.