Reexpansion Pulmonary Edema following Tube Thoracostomy in a Pediatric Patient with Anterior Mediastinal Mass.

Reexpansion pulmonary edema (RPE) is an exceedingly rare and potentially fatal complication of a rapidly reexpanded lung following evacuation of air or fluid from the pleural space secondary to conditions such as a mediastinal mass, pleural effusion, or pneumothorax. Clinical presentations can range from mild radiographic changes to acute respiratory failure and hemodynamic instability. The rapidly progressive nature of the disease makes it important for clinicians to appropriately diagnose and manage patients who develop RPE. We present a case of a child with a large malignant pleural effusion who developed severe RPE after tube thoracostomy and ultimately required venoarterial extracorporeal membrane oxygenation (VA-ECMO). The patient was 7-year-old Caucasian male with newly diagnosed ambiguous T cell myeloid leukemia. A chest computerized tomography (CT) demonstrated a large pleural effusion causing tracheal shift and left bronchus compression as well as an anterior mediastinal mass causing compression of the right atria and right ventricle. Tube thoracostomy was performed in the operating room (OR) with deep sedation. The procedure was complicated with hypoxemia, bradycardia, and pulseless cardiac arrest. After return of spontaneous circulation, the child continued to have refractory hypoxemia, profound hypotension, and frothy secretions. Endotracheal intubation was performed with a size 5.0 cuffed endotracheal tube. Chest radiograph demonstrated opacification of the left hemithorax with chest infiltrates. Patient required VA-ECMO for circulatory support. Supportive therapy of RPE was continued and decannulation was done on day three. Tracheal extubation was performed on day five.

Decreased Opioid Consumption in Bone Marrow Harvest Patients Using Quadratus Lumborum Blocks in a Standardized Protocol.

Purpose: Bone marrow harvesting is associated with significant postoperative pain that may have potential negative consequences for the patient and health care system. In the current absence of uniform guidelines, there exists considerable variability amongst providers with respect to perioperative analgesia, especially opioid administration. In this initiative, we explored the potential for preoperative bilateral quadratus lumborum blocks in combination with a standardized perioperative analgesic protocol to manage pain with the goal of reducing perioperative narcotic usage and thereby improving opioid stewardship. Methods: Adults who underwent bone marrow donation from 2018 to 2020 were included in this analysis (n = 32). The pre-implementation group (n = 19) was reviewed retrospectively while the implementation group (n = 13) was evaluated prospectively. Patient demographics, pain scores, and opioid consumption were evaluated. Results: Patient characteristics were equivalent except for anesthesia type with an increased number of patients in the implementation group undergoing spinal anesthesia. The implementation group showed significantly reduced median intraoperative (20.0 mg vs. 0.0 mg; p < 0.001) and total opioid consumption (20.5 mg vs. 0.0 mg; p < 0.001). The number of patients who received any opioids decreased from 84.2% (16/19) before implementation to 23.1% (3/13) after implementation. Conclusion: This change in practice suggests that implementation of a standardized perioperative protocol, including bilateral quadratus lumborum blocks, for bone marrow harvest patients leads to reduced perioperative opioid administration without compromising immediate perioperative pain control.

A Diagnosis of Choriocarcinoma in a Parturient Presenting With Intracranial Hemorrhage.

Choriocarcinoma in a viable pregnancy is uncommon. The diagnosis can easily be missed when there is an explanation for the clinical symptoms that the cancer can mimic. We present the case of a primigravid patient whose choriocarcinoma was initially missed as a result of seemingly obvious explanations for her atypical history and disease manifestation. The patient is a Caucasian female at 30 weeks and 5 days of gestation who presented with persistent headaches and new-onset tonic-clonic seizures found on brain magnetic resonance imaging (MRI) to have a left intracranial hematoma, a 5 mm midline shift, and multiple foci of restricted diffusion. Cerebral angiogram demonstrated arteriovenous malformations (AVMs). The fetus was emergently delivered 1 week into hospitalization for non-reassuring fetal heart tracings in the setting of maternal lethargy secondary to continued AVM hemorrhage. The patient's hospital course was complicated by four episodes of intracranial bleeding and edema requiring neurosurgical intervention. Three weeks after hospitalization she was discharged to a rehabilitation center, shortly after which placental biopsy demonstrated choriocarcinoma. MRI after readmission demonstrated extensive metastatic disease and human chorionic gonadotropin (hCG) levels were greater than 225,000 mIU/mL. Despite two additional neurosurgical procedures and extensive chemotherapy the patient died 3 months after initial presentation. Choriocarcinoma is extremely rare in viable pregnancies, but it should be considered when a parturient presents with intracranial bleeding. A high level of suspicion and serial serum hCG levels may lead to early and potentially life-saving multidrug chemotherapy. With a broader differential, earlier hCG measurement, and earlier treatment, our patient may have survived.