Perioperative outcomes and the effects of anesthesia in congenital central hypoventilation patients.

PURPOSE: Patients with congenital central hypoventilation syndrome (CCHS) have autonomic dysfunction and lack ventilatory responses to hypoxemia and hypercarbia and thus are prone to adverse events during general anesthesia. The objective of this study was to describe the perioperative outcomes of patients with CCHS who were undergoing diaphragm pacer (DP) implantation surgeries under general anesthesia. METHODS: A retrospective cohort study was conducted on patients with CCHS who underwent DP implantation surgeries at CHLA between January 2000 and May 2016. Charts were reviewed for demographics, PHOX2B genotype, ventilatory support, comorbidities, anesthesia administered, and perioperative courses. RESULTS: Of 19 patients with CCHS (58% female) mean age at surgeries was 8.6 ± 5.8 years. Seventeen patients were ventilator-dependent during sleep only; two were ventilator dependent 24 h per day. Mean surgery duration was 3.1 ± 0.5 h. Seventeen patients were extubated to PPV via tracheostomy in the OR. Two patients were extubated to NPPV on postoperative day (POD) 1. Mean transition time to home ventilator or NPPV was 3.0 ± 2.2 days, and mean hospital stay was 5.0 ± 2.1 days. One patient premedicated without ventilatory support developed hypoxemia and hypoventilation. Ten patients (52%) had intraoperative events such as bradycardia, hypotension, significant hypoxemia, and bronchospasm. Fifteen patients had postoperative events. Hypoxemia, pneumonia, and atelectasis accounted for most of perioperative complications. One patient experienced seizure on POD 2 due to hypercarbia. CONCLUSION: Patients with CCHS are vulnerable to the cardiorespiratory effects of sedative and anesthetic agents. Therefore, they require vigilant monitoring and optimal ventilatory support in the perioperative period.

Perioperative respiratory adverse events in children undergoing triple endoscopy.

OBJECTIVES: Children with aerodigestive disorders often have many of the reported risk factors for development of perioperative respiratory adverse events. This study sought to evaluate the incidence of such events in this group of patients undergoing general anesthesia for "triple endoscopy" (flexible bronchoscopy with bronchoalveolar lavage, rigid laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) and to identify any patient-specific or procedure-specific risk factors associated with higher incidence of perioperative respiratory adverse events. METHODS: We performed a retrospective chart review of children 18 years or younger who underwent triple endoscopy as part of an aerodigestive evaluation. Data collected from medical records included: preoperative polysomnography, symptoms of acute respiratory illness, medical comorbidities, demographics, postoperative hospital or intensive care unit admission, and all respiratory events and interventions in the perioperative period. Patient-specific and procedure-specific factors were investigated via univariate analysis for any correlations with perioperative respiratory adverse events. RESULTS: Of the 122 patients undergoing triple endoscopy, 69 (57%) experienced a perioperative respiratory adverse event. We found no difference in the incidence of perioperative respiratory adverse events among children with documented lung disease compared with those with no lung disease (OR: 0.89, p = .8 95% CI: 0.43, 1.8), and no significant difference between those children who had a respiratory illness at the time of surgery, 1-2 weeks prior, 3-4 weeks prior, and those with no preceding respiratory illness. A higher percentage of males had a perioperative respiratory adverse event, compared with females (OR: 2.7, p = .01 95% CI: 1.3, 5.09). CONCLUSION: Patients undergoing triple endoscopy for evaluation of aerodigestive disorders at our institution experienced perioperative respiratory adverse events at a rate of 57%.

Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: a case series.

PURPOSE: The saphenous nerve, a branch of the femoral nerve, is a pure sensory nerve that supplies the anteromedial aspect of the lower leg from the knee to the foot. There is limited evidence of the effectiveness of ultrasound-guided techniques to block the saphenous nerve. We therefore undertook a retrospective case series to investigate the efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block. METHODS: During a four-month period, all patients receiving a subsartorial saphenous nerve block for lower extremity surgery at our institution had their medical records reviewed. Patient demographics and data were recorded, including block characteristics, intraoperative anesthetic management, pre-block, post-block, and postoperative pain scores, as well as postoperative analgesic dosing. Preoperative block success was defined by minimal intraoperative analgesic administration and a pain score of 0 in the postanesthesia care unit not requiring analgesic supplementation. Postoperative block success was defined by reduction of pain score to 0 without need for additional analgesic dosing. RESULTS: Thirty-nine consecutive patients were identified as receiving an ultrasound-guided subsartorial saphenous nerve block. Overall, this ultrasound-guided technique was found to have a 77% success rate. CONCLUSION: This case series shows that an ultrasound-guided subsartorial approach to saphenous nerve blockade is a moderately effective means to anesthetize the anteromedial lower extremity. The success rate is based on stringent criteria with an endpoint of postoperative analgesia. A randomized prospective study would provide a more definitive answer regarding the efficacy of this technique for surgical anesthesia.

The role of fluorescence in situ hybridization assay for surveillance of non-muscle invasive bladder cancer.

OBJECTIVE: To compare the sensitivity and specificity of UroVysion fluorescence in situ hybridization assay (FISH) with cystoscopy and urine cytology in the surveillance of patients with documented non-muscle invasive bladder cancer (CIS, pTa and pT1). METHODS: This retrospective study was done on a consecutive series of patients undergoing surveillance for non-muscle invasive bladder cancer. The results of FISH were analyzed with concurrent cystoscopy and urine cytology. RESULTS: In all, 94 follow up visits from 59 patients were evaluated. The mean follow up was 52 months. FISH detected 30/48 recurrences of bladder cancer, as compared to 20/48 for cytology and 47/48 on cystoscopy. Hence, the sensitivity of FISH was 63% compared to 42% for cytology (p value 0.03) and 98% for cystoscopy (p value 0.0001). However, cytology was significantly more specific (89%) than FISH (65%) or cystoscopy (41%). FISH was significantly more sensitive in diagnosing Grade 3 tumors (p = 0.0005) than Grades 1 and 2 tumors, when compared with cytology. There was no significant difference in the sensitivity and specificity between FISH and cytology for Grade 1 and 2 tumors. Sensitivity of urine cytology was similar for Grade 3 versus Grades 1 and 2 tumors (p = 0.56). FISH was able to detect all three CIS recurrences whereas cytology was positive in two and atypical in one sample. CONCLUSIONS: FISH has a significantly higher sensitivity than cytology in diagnosing patients with Grade 3 bladder tumors. The low specificity of FISH seen in our study and based on the currently available evidence, the test does not satisfy the criteria for replacing cystoscopy or cytology for surveillance of patients with non-muscle invasive bladder cancer.

Utilization of Intraoperative Real-time Three-Dimensional Transoesophageal Echocardiography to Objectively Assess Improvement in Synchronization and Regional Wall Motion after Coronary Reperfusion.

It is well known that myocardial ischemia leads to Regional Wall Motion Abnormalities (RWMAs) and reversible depression of Left Ventricular (LV) systolic function. Transoesophageal Echocardiography (TEE) is an established tool for early diagnosis of new RWMAs. However, evaluation of RWMAs by echocardiography is largely qualitative and relies on visual assessment of wall segments. Evaluation of LV systolic function and Ejection Fraction (EF) is more reproducible and accurate with Real-Time 3D Echocardiography (RT3DE) as compared with two-dimensional and M-mode techniques. Primary advantages for RT3DE are fast and largely automated volumetric analysis of LV function and LV volumes, without geometric assumptions and risk of underestimating volumes in foreshortened views. This case illustrates the use of intraoperative RT3DE during coronary artery bypass surgery to objectively assess: LV systolic function with LV volumes and RWMAs and improvement in cardiac synchronization following coronary reperfusion.

Chondroid syringoma of the external ear canal presenting as a cyst.

Chondroid syringoma of the external ear canal is a rare, usually firm or polypoid tumor, representing the cutaneous counterpart of pleomorphic adenoma of salivary glands. We report a very rare case of chondroid syringoma in a 40-year-old man who presented with a fluid-containing cyst in the external ear canal. Clinical and radiological examinations showed involvement of the whole external canal to the annulus. The cystic lesion was totally excised along with the overlying skin. The postoperative course was uneventful.

Amelanotic melanoma presenting with cervical lymphadenopathy.

We present a rare case of an amelanotic melanoma of unknown primary presenting with cervical lymphadenopathy. A 20-year-old man presented with large left sided neck lump, associated dysphagia and weight loss. Examination revealed a hard mass in the left posterior triangle of neck and sacral sensory loss. Fine needle aspiration cytology of the mass suggested a poorly differentiated carcinoma. Computed tomography showed a left sided, 8×13 cm cervical mass with liver, lung and bony metastases. Histological examination of the lymph nodal mass confirmed the diagnosis of a metastatic amelanotic melanoma. The patient was treated with glucocorticoids, radiation therapy for the sacral bony deposit, and chemotherapy. Despite an initial reduction of his target lesions, his condition subsequently deteriorated and he died 4 months after diagnosis.