Expectant management of a parturient with serotonin syndrome: A case report.

Serotonin syndrome is a potentially fatal condition caused by central nervous system serotonergic overactivity. The primary principle of managing serotonin syndrome in pregnancy focuses on discontinuation of offending agents and supportive care. In general, delivery should be avoided pending resolution of serotonin syndrome.

Anesthetic Approach to Postpneumonectomy Syndrome.

Postpneumonectomy syndrome is a rare complication in patients who have previously had a pneumonectomy. Over time, the mediastinum may rotate toward the vacant pleural space, which can cause extrinsic airway and esophageal compression. As such, these patients typically present with progressive dyspnea and dysphagia. There is a paucity of reports in the anesthesiology literature regarding the intraoperative anesthetic approach to such rare patients. We present a case of an 18-year-old female found to have postpneumonectomy syndrome requiring thoracotomy with insertion of tissue expanders. Our case report illustrates the complexities involved in the care of these patients with regards to airway management, ventilation concerns, and potential for hemodynamic compromise. This case report underscores the importance of extensive multidisciplinary planning.

Identifying an Oxygenation Index Threshold for Increased Mortality in Acute Respiratory Failure.

BACKGROUND: The objective of this work was to examine current oxygenation index (OI) data and outcomes using electronic medical record data to identify a specific OI value associated with mortality. METHODS: This study was a retrospective electronic medical record data review from the pediatric ICU of Phoenix Children's Hospital, with data mining for variables to calculate OIs on subjects age 1 month to 20 y mechanically ventilated > 24 h, excluding those with known intracardiac shunts or cyanotic heart disease. Age, length of hospital stay, duration of mechanical ventilation, and outcomes were also assessed. The Wilcoxon signed-rank test was used to compare continuous variables, receiver operating characteristic analysis was used in determining discriminant ability, and logistic regression was conducted to determine the odds ratio (OR) for risk of death with increasing OI. RESULTS: OI was calculated on 65 subjects, of whom 6 died (9%). The median maximum OI was 10 for all subjects, 17 for non-survivors, and 8 for survivors (P = .14 via Wilcoxon rank-sum test). ORs indicated a 2.4-fold increase in the odds of death (P = .09, 95% CI 0.9-6.6) for each increasing point in maximum OI. Mean OI OR revealed a 1.9-fold increase in the odds of death (P = .25, 95% CI 0.6-5.9). Receiver operating characteristic analysis indicated a higher discriminate ability for maximum OI (area under the curve = 0.68) than mean OI (area under the curve = 0.58). OI cut-points for mortality were established. Mortality was unchanged until maximum OI > 17, for which mortality nearly tripled at a value of 18% versus 6-7% for range 0-17. CONCLUSIONS: Limitations exist in obtaining serial OI values from current electronic medical records. Serial assessment of OI values may allow creation of alert values for increased mortality risk. Consideration of escalation of therapies for respiratory failure, such as high-frequency ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation may be warranted at lower OIs than historically reported.

Comparative study of wound complications: isolated panniculectomy versus panniculectomy combined with ventral hernia repair.

BACKGROUND: The resection of an abdominal pannus carries the risk of wound-related morbidity in obese patients. Surgeons often perform a panniculectomy (PAN) to gain better access to the abdomen to perform other operations. We evaluated the incidence of wound complications after PAN with and without a concomitant procedure (i.e., ventral hernia repair [VHR]). METHODS: We reviewed the prospective data from all patients who underwent PAN alone and PAN combined with VHR from 2007 to 2011 at a single institution. The demographic data, operative information, and postoperative wound complications and interventions were recorded and analyzed using standard statistical methods. Multivariate logistic regression analysis was performed to control for confounding factors. RESULTS: After excluding the patients who had undergone concomitant procedures involving the gastrointestinal or genitourinary tract, 185 patients were included in the present study (143 patients in the PAN-VHR group and 42 in the PAN group). The average patient age was 55.4 and 47.6 years in the two groups (P = 0.001). The average body mass index was 38.0 and 41.1 kg/m(2) (P = 0.69). Of the 143 patients in the PAN-VHR group, 81.1% were women. In the PAN group, 92.9% were women (P = 0.09). The mean length of follow-up was 6.5 and 3.3 mo in the PAN-VHR and PAN groups, respectively (P = 0.04). In the PAN-VHR group, 96.5% underwent hernia repair with mesh and 29% underwent component separation. Subcutaneous talc was used in 58.6% of the PAN-VHR patients and 38.1% of the PAN patients (P = 0.02). Wound pulse-a-vac irrigation with bacitracin solution was used in 37.1% of PAN-VHR patients and 19.1% of the PAN patients (P = 0.03). The rate of wound complications and interventions for the PAN-VHR and PAN groups were not significantly different statistically (P < 0.05) and included seroma, seroma drainage, wound breakdown or necrosis, cellulitis, wound interventions, including bedside debridement and vac placement, and reoperation. After controlling for age, gender, body mass index, talc use, and pulse-a-vac irrigation use in the multivariate logistic regression analysis, the PAN-VHR group were more likely to develop cellulitis than the PAN-alone group (P = 0.004). The rates of all other wound complications were not significantly different statistically between the two groups after adjusting for confounding factors. CONCLUSIONS: PAN is associated with a significant risk of wound-related complications. The risk of postoperative cellulitis is increased further in patients who undergo concomitant VHR. However, the risk of all other wound complications and the need for interventions was not increased by performing concomitant VHR.