'A pain in the buttock': A case report of gluteal compartment syndrome after robotic partial nephrectomy.

Acute compartment syndrome is a surgical emergency that, if unrecognised, leads to tissue and muscle ischaemia, necrosis, multi-organ failure and even death. Gluteal compartment syndrome is a rare type of compartment syndrome that typically occurs as a sequela of trauma, and its presentation may be difficult to recognise. We describe a case of a patient who developed gluteal compartment syndrome following a prolonged renal surgery in lateral decubitus position. Our case report aims to raise clinicians' awareness to consideration of this rare syndrome in patients presenting with lower extremity or back pain after prolonged surgery.

A proposed algorithm for combining transcranial Doppler ultrasound monitoring with cerebral and somatic oximetry: a case report.

PURPOSE: Transcranial Doppler (TCD) ultrasound is a non-invasive monitor of cerebral blood velocity that can be used intraoperatively. The purpose of this report is to describe how different patterns seen on TCD can help identify the cause of cerebral desaturation when near-infrared spectroscopy (NIRS) oximetry is used concomitantly. CLINICAL FEATURES: A 69-yr-old male patient undergoing coronary revascularisation and aortic valve replacement developed perioperative complications that were detected using a combination of transtemporal TCD of the middle cerebral artery along with cerebral and somatic NIRS. Initial brain desaturation was secondary to hypocapnia during which TCD-derived blood velocity and somatic NIRS values remained unchanged. After the procedure, a second episode of brain desaturation occurred secondary to a technical issue with the aortic valve prosthesis requiring a return to cardiopulmonary bypass (CPB); there were no high-intensity transient signals (HITS) on TCD. Brain desaturation occurred a third time following the second attempt to separate from CPB at which time TCD detected a significant amount of HITS suggesting air emboli that were associated with acute right ventricular dysfunction; there was also a reduction in somatic NIRS. CONCLUSIONS: Combining TCD with cerebral NIRS allows for the rapid identification of three different mechanisms of brain desaturation. An algorithm is proposed to help identify the origin of NIRS cerebral desaturation. Prospective clinical trials are needed to investigate potential benefits of multimodal brain monitoring and its impact on short and/or long-term clinical outcomes.

RéSUMé: OBJECTIF: L'échographie par Doppler transcrânien (DTC) est un moniteur non invasif de la vélocité sanguine cérébrale qui peut être utilisé en période peropératoire. L'objectif de ce compte rendu est de décrire comment différents tracés observés sur le DTC peuvent aider l'anesthésiologiste à identifier la cause de la désaturation cérébrale lorsque l'oxymétrie par spectroscopie proche infrarouge (SPIR) est utilisée de manière concomitante. ÉLéMENTS CLINIQUES: Un homme de 69 ans subissant une revascularisation coronarienne et un remplacement de valve aortique a présenté des complications périopératoires détectées grâce à la combinaison d'un DTC trans-temporal de l'artère cérébrale moyenne et d'une SPIR cérébrale et somatique. La désaturation cérébrale initiale était secondaire à une hypocapnie, pendant laquelle la vélocité sanguine dérivée du DTC et les valeurs de SPIR somatique sont demeurées inchangées. Après l'intervention, un deuxième épisode de désaturation cérébrale est survenu suite à un problème technique avec la prothèse de valve aortique, nécessitant un retour sous circulation extracorporelle (CEC); il n'y avait pas de signaux transitoires de haute intensité (HITS) sur le DTC. Il y a eu un troisième épisode de désaturation cérébrale suite à la deuxième tentative de sevrage de la CEC; à ce moment-là, le DTC a détecté une quantité significative de HITS, suggérant des embolies gazeuses associées à une insuffisance ventriculaire droite aiguë; une réduction de la SPIR somatique a également été observée. CONCLUSION: La combinaison du DTC à la SPIR cérébrale a permis d'identifier trois différents mécanismes de désaturation cérébrale. Un algorithme est proposé pour aider le clinicien à déterminer l'origine de la désaturation cérébrale sur la SPIR. Des études cliniques prospectives sont nécessaires afin d'explorer les avantages potentiels d'un monitorage cérébral multimodal et son impact sur les devenirs cliniques à court et à long terme.

Whole body ultrasound in the operating room and intensive care unit.

Whole body ultrasound can be used to improve the speed and accuracy of evaluation of an increasing number of organ systems in the critically ill. Cardiac and abdominal ultrasound can be used to identify the mechanisms and etiology of hemodynamic instability. In hypoxemia or hypercarbia, lung ultrasound can rapidly identify the etiology of the condition with an accuracy that is equivalent to that of computed tomography. For encephalopathy, ocular ultrasound and transcranial Doppler can identify elevated intracranial pressure and midline shift. Renal and bladder ultrasound can identify the mechanisms and etiology of renal failure. Ultrasound can also improve the accuracy and safety of percutaneous procedures and should be currently used routinely for central vein catheterization and percutaneous tracheostomy.

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study.

OBJECTIVE: Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines. METHODS: A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care. RESULTS: A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training. DISCUSSION: Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training. IMPLICATION: IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.

Organ growth in chicken embryos during hypoxia: implications on organ "sparing" and "catch-up growth".

The primary aim of this study was to establish whether or not embryonic hypoxia selectively affects the growth of specific organs. Chicken embryos were incubated either in normoxia (Nx) or in hypoxia (15% O2 from embryonic day E5, Hx). The length of the beak and third toe (as indexes of skeletal growth) and the weights of internal organs (eyes, brain, heart, lungs, liver, kidneys, stomach, and intestines) were collected at E14, E17, E19, and E20. Hypoxia reduced embryonic body weight (BW). At any given age, the specific weight (organ weight/BW) of some organs in Hx was higher, and that of others was lower, than in Nx. However, almost all differences disappeared when organ weights were compared as function of BW, rather than at fixed chronological ages. The important exception was the chorioallantoic membrane (CAM), the mass of which in Hx developed out of proportion. In a third group of embryos, hypoxic until E14 and normoxic thereafter, there was no post-hypoxic catch-up growth, differently from what known to occur postnatally. A possible interpretation is that catch-up growth does not depend on the age of the embryo but on its BW. In conclusion, at least in the chicken embryo and for the level of hypoxia tested, hypoxia has no selective effects on the growth of specific organs, except for the CAM. Qualitative differences in the weight response to hypoxia among organs observed at any given age can be explained largely by the effects of the blunted growth on the growth trajectory of the individual organs.

Hypoxic incubation blunts the development of thermogenesis in chicken embryos and hatchlings.

We asked to what extent sustained hypoxia during embryonic growth might interfere with the normal development of thermogenesis. White Leghorn chicken eggs were incubated at 38 degrees C either in normoxia (Nx, 21% O2) or in hypoxia [Hx, 15% O2, from embryonic day 5 (E5) until hatching]. The Hx embryos had lower body weight (W) throughout incubation, and hatching was delayed by about 10 h. For both groups, all measurements were conducted in normoxia. At embryonic day E11, the static temperature-oxygen consumption (ambient T-Vo2) curve was typically ectothermic (Q10 = 1.92-1.94) and similar between Nx and Hx. Toward the end of incubation (E20), the Q10 averaged 1.41 +/- 0.06 in Nx and 1.79 +/- 0.08 in Hx (P < 0.005), indicating that the onset of the thermogenic response in Hx lagged behind Nx. In the 1-day-old hatchlings (H1), body weight did not significantly differ between Nx and Hx. At H1, the T-Vo2 curves were endothermic-type, and more so in the older (>8 h old) than in the newly hatched (<8 h old) chicks, whether examined statically or dynamically as a function of time. In either case, the thermogenic responses of Hx were lower than those of Nx. In a 43-31 degrees C thermocline, the preferred T of the Hx hatchlings was around 37.3 degrees C, and similar to Nx, suggesting a similar setpoint for thermoregulation. We conclude that hypoxic incubation blunted the development of thermogenesis. This could be interpreted as an example of epigenetic regulation, in which an environmental perturbation during early development alters the phenotypic expression of a regulatory system.