Early Detection, Prevention, and Management of Acute Limb Ischemia in Adults Supported With Venoarterial Extracorporeal Membrane Oxygenation.

Acute limb ischemia caused by peripheral venoarterial extracorporeal membrane oxygenation (ECMO) cannulation is associated with increased mortality. Early detection of limb hypoperfusion may lead to timely intervention and prevent irreversible muscle damage. Methods to determine the adequacy of tissue oxygenation in cannulated extremities include bedside physical examination, trending serum biochemical markers, and somatic near-infrared spectroscopy. To prevent ECMO-related limb ischemia events, interventions include the addition of distal antegrade perfusion catheters to the arterial ECMO canula, minimizing arterial cannula diameter, placing arterial and venous cannulae on opposite extremities, and adding a side-arm graft to the cannulated artery. If the limb develops early signs of ischemia, preventative measures such as distal perfusion catheter insertion or changing the location of the arterial cannula should be performed. Acute compartment syndrome requires emergency fasciotomy or amputation if the limb is unsalvageable. Opportunities for future research include improving monitoring technology and standardizing the use of the distal perfusion catheter.

Variations in Epidural Steroid Injection Practice Patterns by Pain Medicine Physicians in the United States.

BACKGROUND: Epidural steroid injections (ESI) are one of the most commonly performed pain procedures; however, there has been variation in techniques and approaches amongst pain physicians in the United States. The formation of a multidisciplinary working group was made with considerations to help guide ESI practice. OBJECTIVE: Pain medicine physicians in the United States were surveyed in order to provide an update on current practices for both transforaminal and interlaminar ESI. STUDY DESIGN AND SETTING: This was a cross-sectional survey of pain medicine physicians in the United States. METHODS: This study was approved by the institutional review board of our institution. Based on the American Society of Interventional Pain Physicians membership database, an email list was generated, and a web-based survey was sent to interventional pain physicians at academic centers, private practices, government hospitals, and community settings across the United States. Cervical, lumbar, and caudal ESI sections were divided into questions regarding preferences for fluoroscopic views, injectates, and techniques. RESULTS: A total of 261 responses were analyzed. All but one used fluoroscopy for lumbar ESI. There were variations in methods to detect intravascular uptake, choice of injectate, and the use of particulate steroids for lumbar transforaminal epidural steroid injection (TFESI). LIMITATIONS: The response rate is a limitation, and thus the results may not be representative of all pain medicine physicians in the United States. CONCLUSIONS: Since the 2015 multidisciplinary pain workgroup recommendations were made for ESI, there appears to be a trend towards following these guidelines compared to prior surveys looking at ESI practices. However, our survey shows there continues to be variations in ESI practice that deviates from these guidelines.

Urothelial Superior Vena Cava Syndrome with Limited Response to Radiation Therapy.

Radiation therapy (RT) is the standard of care for cases of superior vena cava (SVC) syndrome secondary to metastatic adenopathy. Histologies vary in radiosensitivity and response time, making alternative therapies such as chemotherapy and/or intravenous stenting preferable alternative options for certain diagnoses. Metastatic urothelial carcinoma is a particularly rare cause of SVC syndrome with only 3 cases reported in the literature. Consequently, optimal management remains challenging, particularly in cases of high tumor burden. Here we present a case of highly advanced metastatic urothelial cancer with SVC syndrome and tracheal compression. The patient started urgent RT but expired midway through her treatment course due to systemic progression of disease, requiring SVC and tracheal stenting. The authors review the literature including discussion of the few other known cases of SVC syndrome due to urothelial carcinoma and a review of this histology's response to RT. This experience suggests, that in cases of SVC syndrome with widespread advanced disease, stenting and chemotherapy with or without RT may be the most important initial treatment plan, depending on goals of care.