Comparison of pulmonary complications in patients undergoing transcatheter aortic valve implantation versus open aortic valve replacement.

OBJECTIVE: The purpose of this study was to investigate and compare the differences in postoperative pulmonary complications in patients undergoing aortic valve replacement by open repair (OAVR) versus those undergoing transcatheter aortic valve implantation by the transapical approach (TAVI-A) or transfemoral approach (TAVI-F). DESIGN: A retrospective review of data from aortic valve replacement patients. SETTING: A private, non-profit hospital. PARTICIPANTS: Thirty patients with severe aortic stenosis requiring surgical replacement. INTERVENTIONS: Data collected from TAVI-F, TAVI-A, and OAVR patient charts. MATERIALS AND METHODS: Patients were divided into 3 groups: 10 patients undergoing OAVR, 10 patients undergoing TAVI-F, and 10 patients undergoing TAVI-A. Pulmonary complications and length of stay were recorded and analyzed. The TAVI-F group had the lowest number of total pulmonary complications per patient (1.0±0.667) compared to the OAVR group (1.8±0.789, p = 0.04) and TAVI-A group (2.0±1.054, p = 0.02). The most frequent complication was atelectasis. TAVI-F patients spent the least amount of time on the ventilator (TAVI-F median 2.6, IQR 4.8 h, TAVI-A median 4.9, IQR 7.6 h, and OAVR median 6.6, IQR 17.3 h, p = 0.02) and were discharged in half the time of the other groups (TAVI-F median 3.2, IQR 1.3 days, TAVI-A median 5.6, IQR 3.5 days, OAVR median 6.1, IQR 4.6 days, p = 0.008). CONCLUSIONS: Due to the high incidence of multiple comorbidities and increased age, it is important to take into consideration the risk of pulmonary complications when choosing the surgical and anesthetic approach to TAVI in this high-risk group of patients.

Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients.

OBJECTIVE: The primary objective of this retrospective chart review is to describe 1 year's experience of an academic emergency department (ED) in treating a wide spectrum of headache classifications with intramuscular injections of 0.5% bupivacaine bilateral to the spinous process of the lower cervical vertebrae. BACKGROUND: Headache is a common reason that patients present to an ED. While there are a number of effective therapeutic interventions available for the management of headache pain, there clearly remains a need for other treatment options. The intramuscular injection of 1.5 mL of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae has been used to treat headache pain in our facility since July 2002. The clinical setting for the study was an academic ED with an annual volume of over 75,000 patients. METHODS: We performed a retrospective review of over 2805 ED patients with the discharge diagnosis of headache and over 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004. All adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of their headache were gleaned from these 2 larger databases and were included in this retrospective chart review. A systematic review of the medical records was accomplished for these patients. RESULTS: Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 417 patients. Complete headache relief occurred in 271 (65.1%) and partial headache relief in 85 patients (20.4%). No significant relief was reported in 57 patients (13.7%) and headache worsening was described in 4 patients (1%). Overall a therapeutic response was reported in 356 of 417 patients (85.4%). Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes. Associated signs and symptoms such as nausea, vomiting, photophobia, phonophobia, and allodynia were also commonly relieved. CONCLUSION: Our observations suggest that the intramuscular injection of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical spinous process appears to be an effective therapeutic intervention for the treatment of headache pain in the outpatient setting.

Patient follow-up after negative lower extremity bedside ultrasound for deep venous thrombosis in the ED.

OBJECTIVES: To evaluate the rate of patient compliance with follow-up ultrasound (US) examinations 5 to 7 days after emergency physician EP performed US exams to rule out lower extremity deep venous thrombosis (DVT) in the ED. METHODS: This was a prospective observational study at a level I ED with a residency program, US training program, and an annual census of 75000. Hospital-based emergency US credentialing is available and derived from American College of Emergency Physicians guidelines. Five US-credentialed emergency physicians participated in the study. All patients who received negative lower extremity DVT US exams were eligible. All higher risk patients were given verbal and written instructions and provided with prescriptions to have a follow-up US examination 5 to 7 days after their examination in the ED. Those classified as "low risk" based on Wells criteria were excluded. After 3 months, patients were contacted via telephone and asked questions regarding their follow-up US examinations, reasons for not following up, continued symptoms, and thromboembolic events. Statistical methods included descriptive statistics. RESULTS: One hundred fifty-nine patients were eligible for enrollment during the 10-month study period. Eighty-five patients (54%) fell into the higher risk category of these; 54 (64%) were contacted successfully. Fifteen (28%) of the patients contacted had obtained a follow-up US exam. Of the 39 who did not follow-up, 29% were told by their physician that a follow-up US was unnecessary, 21% forgot to follow-up, 8% did not follow-up for financial reasons, 16% felt better, 5% could not arrange a study, 21% were unsure. One patient died from sepsis before a follow-up scan. Two patients were diagnosed with DVT, one at 7 days follow-up and the other 9 months later (this particular patient had their 7-day scan cancelled by their primary care physician). CONCLUSION: Patients who were instructed to obtain follow-up lower extremity US examinations to rule out propagation of unseen, distal DVTs did so at a very low rate in our study. One of the largest impediments in our study population was a patients' primary care physician who may not understand the need for a follow-up US examination.

Diagnosis of periorbital gas on ocular ultrasound after facial trauma.

Ocular trauma can occur from isolated facial trauma or in major blunt trauma such as motor vehicle accidents or falls. Despite the etiology of the injury, a thorough evaluation is important but may often be difficult if severe swelling is present. Recently, emergency ultrasound has seen the use of ocular ultrasound to evaluate visual changes and trauma. Literature suggests that unsuspected and difficult to diagnose pathology may be easily detected on ultrasound of the orbit. We present 3 cases of isolated facial trauma in which routine evaluation with ocular ultrasound led to the discovery of periorbital air with one patient having air insufflating the upper lid of the affected side.