Postoperative Diaphragmatic Liver Herniation Diagnosed by Point-of-Care Ultrasound.

Point-of-care ultrasound (PoCUS) is a sensitive and specific tool in early identification of malignant pathologies in unstable patients leading to improved outcomes. Postoperative diaphragmatic rupture is rare, can be life-threatening, and is difficult to diagnose. This report describes a 62-year-old women undergoing thoracoscopic right hemidiaphragm plication with acute postoperative hemodynamic instability. Bedside PoCUS identified hepatic herniation into the thorax causing cardiac compression and lateral displacement, which lead to expedited imaging and surgical reexploration.

Unexpected Shocks From a Subcutaneous Implantable Cardioverter-Defibrillator Despite Attempted Reprogramming and Magnet Use: A Case Report.

We present the case of a patient with a subcutaneous implantable cardioverter-defibrillator (S-ICD) in situ. Device interrogation and reprogramming were unsuccessful due to a software mismatch between the device and programmer. The device manufacturer recommended magnet application to suspend antitachycardia therapy. Despite using this strategy, the S-ICD discharged multiple times. The S-ICD has unique perioperative considerations for the anesthesiologist. This case provides an example of the complexity of electrophysiologic devices in current use and the necessity of the anesthesia provider to stay up to date with evolving device management strategies.

Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study.

BACKGROUND: Pediatric adenotonsillectomy (A&T) is associated with prolonged pain and functional limitation. Celecoxib is an effective analgesic in adult surgery patients; however, its analgesic efficacy on pain and functional recovery in pediatric A&T patients is unknown. METHODS: During 2009-2012, children (age 2-18 yr) scheduled for elective A&T were enrolled in a single-centre double-blind randomized controlled trial. Study participants received either oral placebo or celecoxib 6 mg·kg(-1) preoperatively, followed by 3 mg·kg(-1) twice daily for five doses. The primary outcome was the mean "worst 24-hr pain" scores during postoperative days (PODs) 0-2 on a 100-mm visual analogue scale (VAS). Secondary outcomes for PODs 0-7 included co-analgesic consumption, adverse events, and functional recovery. The impact of the CYP2C9*3 allele - associated with reduced celecoxib hepatic metabolism - on recovery was considered. RESULTS: Of the 282 children enrolled, 195 (celecoxib = 101, placebo = 94) were included in the primary outcome analysis. While on treatment, children receiving celecoxib experienced a modest reduction in the average pain experienced over PODs 0-2 (7 mm on a VAS; 95% confidence interval [CI]: 0.3 to 14; P = 0.04) and a "clinically significant" reduction (≥ 10 mm on a VAS; P ≤ 0.01) on PODs 0 and 1. During PODs 0-2, the mean acetaminophen consumption was lower in the celecoxib group vs the placebo group (78 mg·kg(-1); 95% CI: 68 to 89 vs 97 mg·kg(-1); 95% CI: 85 to 109, respectively; P = 0.03). No differences in adverse events, functional recovery, or satisfaction were observed by POD 7. The CYP2C9*3 allele was associated with less pain and improved functional recovery. CONCLUSIONS: A three-day course of oral celecoxib reduces early pain and co-analgesic consumption; however, an increase in dose, dose frequency, and duration of dose may be required for sustained pain relief in the pediatric setting. The CYP2C9*3 allele may influence recovery. This trial was registered at: ClinicalTrials.gov: NCT00849966.