Effect of large volume paracentesis performed just prior to transjugular intrahepatic portosystemic shunt on the anesthetic management during the procedure.

BACKGROUND AND AIMS: Patients often undergo paracentesis prior to a transjugular intrahepatic portosystemic shunt (TIPS) procedure to improve respiratory mechanics. However, the effect of large volume paracentesis (LVP) on intraoperative hemodynamics and anesthetic management when it is performed immediately before the TIPS procedure is not well documented. MATERIAL AND METHODS: This is a retrospective study in patients undergoing the TIPS procedure between 2004 and 2017. Patients were divided into two groups based on the volume of preoperative paracentesis, namely, small volume paracentesis (SVP), defined as paracentesis volume less than 5 L and LVP, defined as paracentesis volume of at least 5 L. Patients' demographics and perioperative information were collected through chart review. The Wilcoxon signed-rank test, student's t-test, and Fisher's exact test were used when appropriate. Uni- and multivariate linear regression analyses were used to determine the predictive value of paracentesis volume in relation to intraoperative hemodynamics and management of hypotension. RESULTS: Of 49 patients, 19 (39%) received LVP and the remainder received SVP. Baseline demographics were comparable between groups as were intraoperative hypotension and volume of infused crystalloid and colloid. However, vasopressor use (P = 0.02) and packed red blood cell transfusion (P = 0.01) were significantly higher in the large volume group. Paracentesis volume was an independent predictor of the phenylephrine dose (P = 0.0004), and of crystalloid (P = 0.05) and colloid (P = 0.009) volume administered after adjusting for age, sex, body mass index, alcohol use, hemoglobin, and model for end-stage liver disease score. CONCLUSION: The anesthetic management of patients who undergo LVP just prior to a TIPS procedure may require larger doses of vasopressors and colloids to prevent intraoperative hemodynamic instability during the TIPS placement but may be as well tolerated as SVP.

Egg-and-Banana Sign: A Novel Diagnostic CT Marker for Pulmonary Hypertension.

OBJECTIVE: The purpose of this study was to retrospectively determine whether the egg-and-banana sign, defined as the visualization of the main pulmonary artery (PA) at the level of the aortic arch, is a sensitive and specific diagnostic marker for pulmonary hypertension. MATERIALS AND METHODS: A total of 186 patients who, between January 2014 and July 2017, received right heart catheterizations and underwent CT studies that included the aortic arch within 140 days of catheterization were evaluated in this retrospective study. Of these patients, 127 had pulmonary hypertension (PH), and 59 who did not have PH served as control subjects. Two blinded radiologists reviewed each study for the egg-and-banana sign. The diameters of the main PA and ascending aorta were also measured. Contingency tables, ROC curves, and a t test were used for statistical analysis. RESULTS: The egg-and-banana sign was associated with a higher mean PA pressure, a higher ratio of the diameter of the PA to the diameter of the ascending aorta (Ao) (hereafter referred to as the "PA-to-Ao ratio"), and a larger PA diameter (p < 0.006). It had a specificity of 85% and a positive predictive value of 85%. When the egg-and-banana sign was used in combination with a main PA diameter larger than 29 mm and a PA-to-Ao ratio greater than 1, its specificity increased to 91% and 93%, respectively. When considered as individual markers, the PA diameter had a high sensitivity (80%; AUC value, 0.74) and the PA-to-Ao ratio had a high specificity (81%; AUC value, 0.73) for PH. Moderate correlations were noted between PA pressure and PA diameter (r = 0.37) and between PA pressure and PA-to-Ao ratio (r = 0.43). CONCLUSION: The egg-and-banana sign has a high specificity and PPV for PH. Specificity increased when the sign was used in combination with other classic CT markers.

A diagnostic challenge: An incidental lung nodule in a 48-year-old nonsmoker.

A 43-year-old female with a medical history of renal stones, hypertension, diabetes mellitus Type 2, and depression presented to her urologist with bilateral flank pain. She complained of worsening exertional dyspnea over the last several months with recent weight gain. She also endorsed night sweats and intermittent, scant hemoptysis over the past year. She denied fever, chills, nausea, vomiting, diarrhea, constipation, hematuria, or excessive joint or muscle pain. Physical examination was unremarkable. Computed tomography scan of abdomen and pelvis demonstrated bilateral nonobstructing renal stones and a 1.8 cm × 1.7 cm nodular opacity in the right lower lobe of the lung, not present on previous scan 1 year prior. Surgical wedge resection was performed and subsequent pathologic examination demonstrated a 1.2 cm × 0.6 cm × 0.5 cm soft, gelatinous well-demarcated mass in the right lower lobe wedge specimen without gross evidence of necrosis or hemorrhage confirming colloid adenocarcinoma of the lung.

Ectopic thyroid: The great mimicker.

Ectopic thyroid tissue is very rare, but its prevalence increases in those with thyroid pathology. It typically occurs due to aberrant development of the thyroid gland during its migration to the pretracheal region. In this report, there are two cases of mediastinal ectopic thyroid tissue discussed, which were initially considered to be malignancies. The hospital course, diagnostic workup, including the use of computed tomography and positron emission tomography scans, and the characteristic features of the tissue are examined here. Due to the imaging characteristics, it is important to consider ectopic thyroid tissue as a differential diagnosis for mediastinal masses as encountered in these cases. Asymptomatic ectopic thyroid tissue is usually treated medically; however, patients in both of our cases opted for surgical resection of the masses even after confirmation of the origin of the tissues.

Primary spontaneous pneumothorax in conjunction with Marfan syndrome.

A 25-year-old man with a history of Marfan syndrome, asthma and smoking presented with worsening dyspnoea and right-sided chest pain worsened with deep breathing after a fall 2 days prior. Diagnostic imaging revealed a spontaneous right-sided pneumothorax due to ruptured subpleural bullae in the apex of the right lung. Smaller subpleural bullae were also noted in the apex of the left lung. A chest tube was placed to reduce the right pneumothorax successfully.

Fibrinolytic administration via EKOS catheter used in pulmonary embolism.

A 69-year old bed-bound woman presented with chest pain and diaphoresis. Diagnostic imaging led to the diagnosis of bilateral extensive pulmonary emboli extending into all segmental branches. Tissue plasminogen activator (tPA) was administered via 2 separate EKOS catheters. Repeat evaluation after 33 hours revealed improvement of right ventricular size and function. EKOS catheters are useful for administration of fibrinolytics in pulmonary embolism.

Persistent Lobar Atelectasis in a Patient With Chronic Hoarseness.

A 61-year-old woman presented for outpatient evaluation of a 1-week history of fever and upper respiratory symptoms. She denied tobacco use, weight loss, hemoptysis, chronic cough, or recent travel and was in otherwise good health. Her medical history was insignificant except for her chronic hoarseness from a prior laryngeal disease. She denied any worsening hoarseness or any other vocal changes. She did report a positive family history of squamous cell lung cancer in her father.