Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure.

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

Forearm Bier block: a new regional anesthetic technique for upper extremity surgery.

PURPOSE: This study aimed to introduce the technique and results of a forearm Bier block for upper extremity surgery. INTRODUCTION: Various techniques of anesthesia are used for hand surgery. Intravenous regional anesthesia, the Bier block, is an effective anesthetic technique. However, there exist several disadvantages and potential complications. We present our technique and results using the forearm Bier block. MATERIALS AND METHOD: A retrospective review was performed studying our experience using forearm Bier block from May to December of 2010. The technique involves exsanguination of the forearm and inflation of a pneumatic tourniquet placed distal to the elbow joint. Twenty-five milliliter of 0.5% lidocaine is injected intravenously. One hundred five patients underwent hand surgery using this technique. There were 53 females and 52 males with a median age of 56 years. In total, 121 procedures were performed. Patients were interviewed by telephone 24 hours postoperatively. RESULTS: All patients received adequate anesthesia from the block. There were no intraoperative and no postoperative complications. There were no mechanical or tourniquet problems. Average tourniquet time was 10.1 minutes. Total operating time was less than 30 minutes. DISCUSSION: Forearm Bier block presents several advantages over standard upper arm technique. Conventional Bier block involves a double tourniquet and a significant amount of lidocaine, which has potential cardiac and neurologic toxicity. Consequently, minimum tourniquet inflation time is 30 minutes. The dosage of lidocaine needed to provide analgesia using the forearm Bier block is significantly reduced, thereby minimizing the potential for these complications. This lower dose allows for shorter tourniquet time rather than the standard 30 minutes. This shorter tourniquet time in itself presents several advantages. Tourniquet pain and risk of ischemic problems are minimized, and efficiency is increased. This efficiency has practical and financial implications such as decreased total operating and recovery room times, decreased cost of medicines, and decreased operating time for the surgeon. Lastly, this technique might also be used for lower extremity surgeries. CONCLUSIONS: Forearm Bier block is a safe and efficient method for upper extremity surgery. It significantly reduces the risk of complications and increases the efficiency of the surgeon and surgery facility.

Immediate microsurgical breast reconstruction and simultaneous sentinel lymph node dissection: issues with node positivity and recipient vessel selection.

Sentinel lymph node dissection (SLND) during mastectomy has been increasing given the decreased risk of lymphedema. Simultaneous reconstruction with a microsurgical breast reconstruction is often performed, but with node positivity a completion axillary lymph node dissection (ALND) must be performed subsequently. This study examines the potential risks especially in relation to microsurgical reconstruction. All patients undergoing microsurgical breast reconstruction at an academic institution from 2004 to 2010 were evaluated in a prospective database. Patients with immediate reconstruction and SLND were identified. Management of positive lymph node status was ascertained through extensive chart review. There were 610 reconstructions performed, 170 delayed and 440 immediate. From the immediate reconstructions, 110 patients (25%) had SLND and of these patients, 16 (14.55%) had a positive SLND. All 16 patients had internal mammary recipient vessels for free tissue transfer. Seven patients had intraoperative completion ALND, while nine patients had staged completion ALND at a later date. There were no adverse affects from completion ALND. Simultaneous mastectomy, SLND, and microsurgical reconstruction can be performed safely. The internal mammary vessels are preferred recipient vessels as node positive patients may require subsequent completion ALND. If a thoracodorsal anastomosis is performed, a potential risk exists for vessel injury and flap loss with completion ALND.

Characteristics of 1616 Consecutive Dog Bite Injuries at a Single Institution.

Dog bite injuries remain a common form of pediatric trauma. This single-institution study of 1616 consecutive dog bite injuries over 4 years revealed a much higher prevalence of dog bites as compared with other similar centers. Though inpatient admission was rare (9.8%), 58% of all patients required laceration repair, primarily in the emergency department. Infants were more than 4 times as likely to be bitten by the family dog and more than 6 times as likely to be bitten in the head/neck region. Children ≤5 years old were 62% more likely to require repair; and 5.5% of all patients required an operation. Pit bull bites were implicated in half of all surgeries performed and over 2.5 times as likely to bite in multiple anatomic locations as compared to other breeds. The relatively high regional prevalence and younger age of injured patients as compared with other centers is a topic of further study but should draw attention to interventions that can minimize child risk.