Post-Operative Delirium Masking Acute Angle Closure Glaucoma.

Introduction: Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA). Case presentation: A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline. Conclusion: AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.

Point of care ultrasound: a clinical decision support tool for COVID-19.

The COVID-19 global pandemic has overwhelmed health services with large numbers of patients presenting to hospital, requiring immediate triage and diagnosis. Complications include acute respiratory distress syndrome, myocarditis, septic shock, and multiple organ failure. Point of care ultrasound is recommended for critical care triage and monitoring in COVID-19 by specialist critical care societies, however current guidance has mainly been published in webinar format, not a comprehensive review. Important limitations of point of care ultrasound include inter-rater variability and subjectivity in interpretation of imaging findings, as well as infection control concerns. A practical approach to clinical integration of point of care ultrasound findings in COVID-19 patients is presented to enhance consistency in critical care decision making, and relevant infection control guidelines and operator precautions are discussed, based on a narrative review of the literature.

Comparing organ donation decisions for next-of-kin versus the self: results of a national survey.

OBJECTIVES: Intensive care audits point to family refusal as a major barrier to organ donation. In this study, we sought to understand refusal by accounting for the decision-maker's mindset. This focused on: (1) how decisions compare when made on behalf of a relative (vs the self); and (2) confidence in decisions made for family members. DESIGN: Cross-sectional survey in Singapore. SETTING: Participants were recruited from community settings via door-to-door sampling and community eateries. PARTICIPANTS: 973 adults who qualified as organ donors in Singapore. RESULTS: Although 68.1% of participants were willing to donate their own organs, only 51.8% were willing to donate a relative's organs. Using machine learning, we found that consistency was predicted by: (1) religion, and (2) fears about organ donation. Conversely, participants who were willing to donate their own organs but not their relative's were less driven by these factors, and may instead have resorted to heuristics in decision-making. Finally, we observed how individuals were overconfident in their decision-making abilities: although 78% had never discussed organ donation with their relatives, the large majority expressed high confidence that they would respect their relatives' wishes on death. CONCLUSIONS: These findings underscore the distinct psychological processes involved when donation decisions are made for family members. Amidst a global shortage of organ donors, addressing the decision-maker's mindset (eg, overconfidence, the use of heuristics) may be key to actualizing potential donors identified in intensive care units.

Anaesthetic management of a patient with Fontan physiology for electrophysiology study and catheter ablation.

The success of the Fontan procedure for congenital single ventricle anatomy has resulted in adult patients with Fontan physiology requiring anaesthesia for cardiac and non-cardiac procedures. We present the perioperative management of a patient with Fontan physiology who underwent electrophysiological study with radiofrequency ablation for atrial tachycardia under general anaesthesia. Good communication between the multidisciplinary teams, a detailed understanding of the patient's complex cardiac anatomy and physiology, as well as the ability to recognise and manage perioperative complications all play a vital role for a successful outcome.

Effect of remifentanil on the recovery profile after head and neck surgeries: A prospective study.

BACKGROUND AND AIMS: Development of opioid tolerance in the perioperative period due to remifentanil remains controversial. We evaluated occurrence of opioid tolerance and other adverse effects due to remifentanil in patients undergoing head and neck surgery. MATERIAL AND METHODS: We recruited adult participants with ASA status I to III who received general anesthesia for approximately 2 h for elective head and neck procedures. Remifentanil infusion was used in one group and intermittent boluses of morphine or fentanyl were administered in another group. Postoperative pain was treated with intermittent boluses of morphine and fentanyl in post-anaesthesia care unit (PACU) to achieve a numerical rating scale score of 3. Opioid requirement was assessed as an indicator of opioid tolerance. Patients were also evaluated for time to discharge from PACU. RESULTS: We studied 222 adults aged between 21 and 80 years. One hundred and eleven patients received a combination of remifentanil infusion and morphine boluses, and another 111 patients received only fentanyl and/or morphine boluses intraoperatively. Fifty-one patients in the remifentanil group and 25 in the fentanyl/morphine group required opioids in the PACU. Opioid requirement were significantly more (mean ± SD, 44.98 ± 59.7 Vs 20.23 ± 46.66 mcg.kg-1; P = 0.001) and required longer time to discharge from PACU in the remifentanil group compared to the fentanyl/morphine group (Mean ± SD, 88.6 ± 39.5 min Vs 73.1 ± 38.4 min; P < 0.001). No difference in the incidence of adverse effects in two groups was noted. CONCLUSION: At clinically relevant doses, intraoperative remifentanil infusion appears to increase opioid consumption in the immediate postoperative period. This can result in delayed discharge from PACU for patients undergoing elective head and neck procedures.

Massive Hemoptysis Through Endotracheal Tube During Emergency Cesarean Delivery: A Case Report and Literature Review.

Severe pulmonary hemorrhage occurred through the endotracheal tube during an emergency cesarean delivery. Intubation trauma was excluded with fiberoptic bronchoscopy. Episodes of hemoptysis continued for 48 hours. The patient was subsequently diagnosed with diffuse alveolar hemorrhage because of systemic lupus erythematosus. The diagnostic workup, successful management, and literature review are presented.

Investigating analgesic and psychological factors associated with risk of postpartum depression development: a case-control study.

AIM: The aim of this study was to investigate the role of peripartum analgesic and psychological factors that may be related to postpartum depression (PPD). METHODS: This case-control study was conducted in pregnant females who delivered at KK Women's and Children's Hospital from November 2010 to October 2013 and had postpartum psychological assessment. Demographic, medical, and postpartum psychological status assessments, intrapartum data including method of induction of labor, mode of labor analgesia, duration of first and second stages of labor, mode of delivery, and pain intensity on hospital admission and after delivery were collected. PPD was assessed using the Edinburgh Postnatal Depression Scale and clinical assessment by the psychiatrist. RESULTS: There were 62 cases of PPD and 417 controls after childbirth within 4-8 weeks. The odds of PPD was significantly lower (33 of 329 [10.0%]) in females who received epidural analgesia for labor compared with those who chose nonepidural analgesia (29 of 150 [19.3%]) ([odds ratio] 0.47 (0.27-0.8), P=0.0078). The multivariate analysis showed that absence of labor epidural analgesia, increasing age, family history of depression, history of depression, and previous history of PPD were independent risk factors for development of PPD. CONCLUSION: The absence of labor epidural analgesia remained as an independent risk factor for development of PPD when adjusted for psychiatric predictors of PPD such as history of depression or PPD and family history of depression.

Acute unilateral submandibular gland swelling associated with the laryngeal mask airway.

We describe a rare complication of acute unilateral submandibular gland swelling following the use of laryngeal mask airway (LMA) in two patients with otherwise uneventful perioperative airway management. This is likely to be a consequence of the pressure exerted by the airway cuff on the tissues within the submandibular triangle. As this complication is rarely reported, its true incidence may in fact be higher, suggesting a need for greater attention on LMA cuff pressures and degree of cuff inflation. We discuss the presenting clinical features, pathophysiology and utilisation of ultrasonographic confirmation of sialadenopathy, and review the current anaesthetic literature to raise awareness of this unusual and under-reported complication of LMA. This complication can be mitigated by incorporating routine manometric checks and limiting intracuff pressures to < 60 cmH2O, potentially avoiding LMA insertions in patients with sialolithiasis and avoiding the use of nitrous oxide.