Focal Neurologic Deficit After Epidural Catheter Removal Leads to Meningioma Diagnosis.

We present an unusual case of a 60-year-old female who developed subtle, new-onset left upper and lower extremity weakness on day five of perioperative thoracic epidural placement. The onset of a focal neurological deficit after epidural placement usually raises suspicion for the presence of an epidural hematoma, abscess, or traumatic cord lesion. However, in this patient, brain imaging revealed a large, previously undiagnosed intracranial mass. Classically, the risk of mass-related intracranial pressure shifts leading to neurological changes is associated with spinal techniques, including diagnostic lumbar puncture, combined spinal-epidural catheter analgesia, and unintended dural puncture during epidural placement. However, based on this case and our summary of case reports in the literature, we determined that symptom onset associated with an intracranial mass may also arise after apparently uncomplicated epidural placement. Symptom onset in our case series ranged from six hours to ten days and was highly variable depending on tumor location, with reported signs and symptoms including headache, vision changes, focal deficits, or alterations of consciousness. Further studies are required to establish definitive causation between the epidural technique and changes in cerebrospinal fluid pressures leading to symptom onset. Though rare, this is a time-sensitive diagnosis that must be considered for any patient with unexplained neurological findings after neuraxial anesthesia.

Post-operative Non-sustained Ventricular Tachycardia in a COVID-19 Positive Patient After Ketamine and Dexmedetomidine Infusion.

We present a case of an elderly, 75-year-old gentleman with COVID-19 infection and a permanent pacemaker in place, presenting for elective procedure, under monitored anesthesia care with dexmedetomidine. In the postoperative period, while still in the Post Anesthesia Care Unit (PACU), the patient became unresponsive and was found to have episodes of arrhythmia. The patient was managed in the PACU by the anesthesia team. To date, our report is the only one addressing cardiac complications in elderly patients with preexisting cardiac comorbidity, in the immediate perioperative period.

Perioperative Hypothermia after Transurethral Surgeries: Is it Necessary to Heat the Irrigation Fluids?

OBJECTIVE: To investigate the role of heated irrigation fluids in the risk of hypothermia and related complications in patients undergoing transurethral procedures. METHODS: The medical records of all patients who underwent transurethral procedures between 2000 and 2016 at the VA Hospital were reviewed. Irrigation fluids have been heated to 42°C since 2013, as per the institutional policy (Group II). Prior to this date, room temperature solutions were used (Group I). The perioperative body temperature, use of warming devices, procedure length, and anaesthesia type were extracted from records and compared for both groups. In addition, demographic and anthropometric data, preoperative comorbidities, laboratory data, admission information and postoperative complications were obtained from the quality improvement database. RESULTS: There were 1,363 patients in Group I and 269 patients in Group II. Perioperative temperature was decreased by 0.10°C in Group I compared to a temperature gain of 0.32°C in Group II (p<0.001). Three hundred and forty-eight (21%) patients undergoing transurethral procedures developed hypothermia <36°C. There was no difference in the incidence of postoperative mortality or complications between the normothermic and hypothermic patients. CONCLUSION: The replacement of room temperature solutions with warmed solutions for irrigation during transurethral procedures reduced the risk of temperature loss and hypothermia following these procedures. Available heating strategies effectively prevented the perioperative heat loss; however, such strategies did not affect the incidence of postoperative complications.

AN ANALYSIS OF OPERATING PHYSICIAN AND PATIENT RADIATION EXPOSURE DURING RADIAL CORONARY ANGIOPLASTIES.

The objective of this study was to evaluate radiation exposure levels in conjunction with operator dose implemented, patient vascular characteristics, and other technical angiographic parameters. In total, 756 radial coronary angioplasties were evaluated in a major metropolitan general hospital in Tabriz, Iran. The classification of coronary lesions was based on the ACC/AHA system. One interventional cardiologist performed all of the procedures using a single angiography unit. The mean kerma-area product and mean cumulative dose for all cases was 5081 µGy m2 and 814.44 mGy, respectively. Average times of 26.16 and 9.1 min were recorded for the overall procedure and fluoroscopy, respectively. A strong correlation was demonstrated between types of lesions, number of stents and vessels treated in relation to physician radiation exposure. It was determined that operator radiation exposure levels for percutaneous coronary interventions lesions (complex) were higher than that of simple and moderate lesions. In addition, operator radiation exposure levels increased with the treatment of more coronary vessels and implementation of additional stents.

Vertebrobasilar Artery Stroke as the Heralding Sign of Systemic Lupus Erythematosus.

Cerebral ischemia because of vertebrobasilar insufficiency (VBI) rarely presents as an initial sign within the systemic lupus erythematosus (SLE) population, and there are very few case reports supporting this manifestation. This report details 3 different patients with SLE who experienced VBI as an initial manifestation. Patient 1 was a 24-year-old female who developed a bilateral pontine lesion as a consequence of basilar artery stenosis. Patient 2 was a 34-year-old male with an acute ischemic lesion on the right side of his cerebellum and pons because of significant stenosis in the distal segment of the right vertebral artery. Patient 3 was a 37-year-old female, previously diagnosed with multiple sclerosis, with multiple lesions in her cerebellum and pons bilaterally. Further investigations within this case revealed severe stenosis of the left vertebral artery. The diagnosis of SLE was based on clinical presentations such as myalgia, skin rashes, ulcers, and fatigue along with relevant laboratory findings including positive anti ds-DNA antibody and depressed levels of complement C3 and C4 proteins. In young patients with multifocal ischemic lesions or infarcts in the posterior cerebral circulation system, physicians should investigate for less common etiologies such as SLE.

Antioxidant reserve of the lungs and ventilator-associated pneumonia: A clinical trial of high dose selenium in critically ill patients.

PURPOSE: To evaluate the effect of supplemental selenium administration on the incidence of ventilator-associated pneumonia (VAP) in critically ill patients. METHODS: Ninety-nine mechanically ventilated patients were randomized to receive either selenium or isotonic saline infusion for 10days. The primary endpoint was serum glutathione peroxidase-3 (GPX-3) activity and secondary endpoints were development of VAP or death, ICU stay and vasopressor requirement. Serum concentrations of selenium and GPX-3 were measured on Day-1, Day-4 and Day-10. Chi Square and log-rank analyses were used for statistical analyses and odds ratios were calculated. RESULTS: Serum selenium and GPX-3 activity levels increased steadily in the treatment group within 10days (P<0.025), while they remained unchanged in the placebo group. The incidence of VAP was 19.4/1000days of mechanical ventilation in the placebo group while it was 15.8/1000 ventilated days in the treatment group (P=0.250). The risk of VAP or death was similar between the treatments and placebo groups. CONCLUSION: Despite increasing the antioxidant activity, selenium supplementation did not affect the incidence of VAP in critically ill patients. The risk of developing VAP or death within 30days of ICU admission remained the same in the treatment and the controls.

Which one is a better predictor of ICU mortality in septic patients? Comparison between serial serum lactate concentrations and its removal rate.

PURPOSE: To predict 28-day mortality with serum lactate and oxygenation profile in sepsis. METHODS: 82 patients were admitted to the ICU with sepsis. Comorbid disease, hemodynamic and oxygenation parameters were recorded. Serum lactate was measured at T0, T6, T12 and T24 hours of admission. Arterial and venous oxygen saturation levels were also measured. Regression and ROC analyses were used to predict death within 28days. RESULTS: Out of 82 patients, 32 died within 28days of ICU admission. Non-survivors differed from survivors in having higher serum lactate concentrations on admission (0.6mmol/L; P=0.033), requiring more norepinephrine (14µg/min; P<0.001), higher frequency of acute kidney injury, prolonged mechanical ventilation (5-days; P<0.001) and ICU stay (1-day; P=0.029). Saturation of oxygen in arterial (a), central venous blood (cv) and (a-cv) were similar between the survivors and non-survivors. T24 level of lactate was the best predictor of 28-day mortality with 78% sensitivity and 90% specificity (AUC=0.912±0.033). CONCLUSION: Serial measurements of serum lactate with special emphasis on its concentration at 24hour after admission remains the most predictive of short-term mortality in the ICU. Other predictors of mortality are relatively inferior and must be used collectively in context to better predict the clinical outcome of sepsis.