Characteristics and Treatment of Patients Diagnosed With Paradoxical Adipose Hyperplasia After Cryolipolysis: A Case Series and Scoping Review.

BACKGROUND: Paradoxical adipose hyperplasia (PAH), a rare side effect of CoolSculpting (cryolipolysis), is characterized by fatty enlargement of the treatment area occurring months after the procedure. OBJECTIVES: The purpose of this study was to report a retrospective case series of patients diagnosed with PAH at the authors' institution, increase the collective understanding of this complication and subsequent management, and raise the question of who should ethically perform cryolipolysis. METHODS: All participants diagnosed with PAH by a plastic surgeon at a large academic medical center were identified. Demographic information, medical history, procedure details, time to PAH diagnosis, and corrective surgical intervention details were collected. Mean duration of time from cryolipolysis treatment to diagnosis of PAH was calculated, along with other descriptive statistics. A scoping review of all PAH literature published in PubMed, Embase, and Web of Science was also conducted. RESULTS: Four patients diagnosed with PAH after cryolipolysis were identified for inclusion in this study. The calculated incidence of PAH at our center was 0.67%. All patients requested therapy for PAH and subsequently underwent either liposuction, abdominoplasty, or both. The mean duration of in-person follow-up time after final surgical treatment of PAH was 13.8 + 19.8 months (range, 2.8-43.5). Fortunately, no patients showed signs of PAH recurrence, and 3 out of 4 patients did not show signs of residual deformity. CONCLUSIONS: Findings from this patient cohort and scoping review provide evidence that although revisions may be required, conventional body contouring methods, not in the armamentarium of non-plastic surgeon practitioners, effectively alleviated PAH.

Anesthetic Management of Children With Propionic Acidemia Undergoing Esophagogastroduodenoscopy.

Propionic acidemia is a rare genetic disorder of metabolism that predisposes patients to metabolic acidosis, lethargy, neurologic dysfunction, developmental delays, and cardiomyopathy. Perioperative anesthetic management is guided toward mitigating the effects of preoperative fasting times, maintaining normovolemia, and preventing cardiovascular complications secondary to underlying cardiomyopathy. Commonly used anesthetic agents may have undesirable side effects in these patients. Propofol, the lactate in Lactated Ringer's, and neuromuscular blocking agents that undergo ester hydrolysis are poorly metabolized and can lead to metabolic acidosis. Opioids, such as fentanyl and morphine, should be used judiciously in patients with coexisting developmental delays to avoid oversedation and delayed time to resuming oral intake postanesthesia. In addition, inhaled anesthetics have direct myocardial depressive effects and can compromise cardiac function in the setting of pre-existing cardiomyopathy. The perioperative period represents a critical time in this population and appropriate planning is crucial to prevent perioperative morbidity. We present a case of an eight-year-old child undergoing esophagogastroduodenoscopy under general anesthesia and describe the anesthetic concerns we addressed to provide a safe perioperative course.

Endotracheal Intubation Using Alfentanil in a Pediatric Patient with a Mitochondrial Myopathy and Gastroparesis.

Children with mitochondrial disorders represent a subset of patients who require unique anesthetic considerations. Routinely administered medications for general anesthesia, such as propofol, have been shown to increase the risk of developing metabolic acidosis. In addition, both depolarizing and nondepolarizing neuromuscular blockers are contraindicated due to the risk of hyperkalemic cardiac arrest and worsening of preexisting muscle weakness, respectively. These limitations pose challenges while choosing appropriate medications for induction of general anesthesia, especially when the risk of aspiration is high. We present a novel case of using inhaled sevoflurane and intravenous alfentanil to facilitate intubation in a 4-year-old girl with a complex 1 mitochondrial disorder suffering from severe gastroparesis and esophageal dysmotility.

Emergency Sugammadex Reversal in an 850-G Premature Infant: A Case Report.

Sugammadex is a novel reversal agent for the neuromuscular blocking agents rocuronium and vecuronium; it has been shown to rapidly and completely reverse neuromuscular blockade for rocuronium and vecuronium, even when the blockade is profound. We present the case of a 2-week-old, 850-g infant born at 25 weeks' gestation, who presented to the operating room for exploratory laparotomy and repair of ileal atresia. Anesthesia was induced and neuromuscular blockade with 1.2 mg/kg of rocuronium was administered. The neonate experienced rapid oxyhemoglobin desaturation and progressively became very difficult to mask ventilate. Direct laryngoscopy failed to result in successful intubation of the trachea and ventilation became impossible. To reverse the effects of rocuronium, 16 mg/kg of sugammadex was administered. Immediately after, the infant resumed spontaneous ventilation and was able to maintain adequate oxyhemoglobin saturation between 90% and 95% with supplemental oxygen. To our knowledge, this is the first report of successful reversal of neuromuscular blockade, with sugammadex, in an emergent situation after failure to intubate/ventilate an extremely low birth weight infant.

Ketamine infusion reduces narcotic requirements following gastric bypass surgery: a randomized controlled trial.

BACKGROUND: As the obesity epidemic worsens, anesthesiologists should expect to see more obese patients presenting for surgical procedures. Opioids cause respiratory depression, which has caused complications in patients with obstructive sleep apnea. Opioids can also cause nausea, prolonging the time that patients spend in the postanesthesia care unit. Ketamine is a potential analgesic alternative that may have advantages to narcotics in the bariatric population. OBJECTIVES: To determine whether an intraoperative ketamine infusion would reduce postoperative narcotic use in patients during the first 48 hours after laparoscopic gastric bypass. SETTING: Major academic medical center. METHODS: There were 54 participating patients. The intervention group (n = 27) was randomized to receive 100 µg of fentanyl with anesthesia induction, then a 20-mg bolus of ketamine, followed by a 5 µg/kg/min intraoperative ketamine infusion starting after anesthesia induction and ending after wound closure commenced. The control group (narcotic only, n = 27) also received 100 µg of fentanyl at anesthesia induction and intraoperative boluses of fentanyl at the discretion of the anesthesia team, with .3 mg of hydromorphone administered approximately 45 minutes before the completion of surgery. RESULTS: At 24 hours, the mean morphine-equivalent units (MEUs) were 12.7 (standard deviation [SD], 9.9; 95% confidence interval [CI], 8.8-16.6) for the ketamine group (n = 28) and 16.5 (SD, 9.8; 95% CI, 12.6-20.4) for the control group (n = 28). At 48 hours, the MEUs were 16.7 (SD, 12.0; 95% CI, 11.9-21.4) for the ketamine group and 22.7 (SD, 14.9; 95% CI, 16.8-28.6) for the control group. Cumulative MEUs for 24 hours (P = .039) and 48 hours (P = .058) postoperatively were lower in the ketamine group compared with the narcotic-only (control) group, although the difference at 48 hours did not reach statistical significance. Compared with the narcotic-only group, the ketamine group used 26% fewer MEUs after 24 hours and 31% fewer MEUs after 48 hours. This difference can mostly be attributed to group differences during the first 6 hours after surgery. CONCLUSIONS: Ketamine successfully reduced the amount of opioids required to control bariatric patients' pain at 24 hours postoperatively, but not over the 48-hour postoperative period.

Aortopexy Complicated by ST Segment Elevations in a Four-Month-Old Infant.

A four-month-old female infant presented for a thoracoscopic aortopexy for severe tracheomalacia. The case proceeded uneventfully until a specimen bag was introduced into the chest to remove the thymus. The child developed significant ST segment elevations in all 12 leads on electrocardiogram. An emergent intraoperative echocardiogram was performed but did not reveal any findings to account for the diffuse ST segment elevations. The ST segment elevations remained elevated for 48 hours following the procedure with no apparent hemodynamic instability or structural damage to the heart. Troponin levels returned to normal a few days later, and the child was discharged home without sequelae. The incidence of ST segment elevations in children without congenital heart disease is rare but can potentially lead to significant morbidity and mortality. This case report seeks to highlight the importance of swift recognition of ST changes in the pediatric population, discuss possible causes, and describe appropriate workup.

Thromboelastography-targeted management of severe coagulopathy and off-label use of four-factor prothrombin complex concentrate in an infant with massive bleeding.

: A 4-month-old girl initially presented to the pediatric ICU at 9 days old with multiorgan failure and cerebellar hemorrhage secondary to disseminated enteroviral infection and was eventually listed for liver transplant. Due to severe coagulopathy, she developed a hemothorax after line placement. Despite operative exploration and multiple recombinant factor VIIa doses, massive bleeding continued. The bleeding was finally controlled with thromboelastography-targeted platelet and cryoprecipitate transfusion in addition to four-factor prothrombin complex concentrate administration. This management strategy was invaluable in controlling bleeding from an iatrogenic cause.

Complete Tracheal Transection in a 3-Year-Old After Blunt Neck Trauma: a Case Report.

Pediatric laryngotracheal injuries from blunt force trauma are rare but can lead to significant morbidity and mortality. In pediatric patients with severe laryngotracheal disruption, extracorporeal membrane oxygenation has been used to improve oxygenation and ventilation until definitive repair can be performed. We describe the case of a 3-year-old girl with blunt neck trauma secondary to an all-terrain vehicle accident in which her neck was clotheslined against a fence, leading to a complete tracheal transection at the C7-T1 level. Emergent extracorporeal membrane oxygenation cannulation was initiated. We discuss the evaluation and management of tracheal injuries and the requisite multidisciplinary team approach. Pediatric patients with laryngotracheal trauma require definitive airway management, which should be performed by skilled personnel.