Nexplanonectomy-the surgical removal of an embolized implanted contraceptive device: a case report and review of the literature.

BACKGROUND: Nexplanon implants are a common hormonal contraceptive modality. Though rare, these devices can embolize into the injured wall of the basilic vein, through the right heart, and finally wedge itself into a pulmonary artery. With adherence to the arterial wall over time, it becomes less amenable to endovascular retrieval. Patients may present with symptoms mimicking a pulmonary embolism, or without any symptoms at all. In asymptomatic cases, endovascular retrieval and/or surgery is required when patients wish to begin having children prior to biological inactivity. The current literature showed as little as nine case reports detailing lung tissue removal in the aim of reversing a patient's implanted contraceptive device. CASE PRESENTATION: A 22-year-old asymptomatic active-duty Caucasian female presented for elective outpatient Nexplanon removal. The suspicion of possible implant migration arose when it was discovered to be non-palpable in her left arm. After plain film x-rays failed to localize the implant, a chest x-ray and follow-up Computed Tomography (CT) scan revealed that the Nexplanon had migrated to a distal branch of the left pulmonary artery. Due to the patient's strong desires to begin having children, the decision was made for removal. Initial endovascular retrieval failed due to Nexplanon encapsulation within the arterial wall. Ultimately, the patient underwent a left video-assisted thoracoscopic surgery (VATS) for exploration and left lower lobe basilar S7-9 segmentectomy, which successfully removed the Nexplanon. CONCLUSIONS: Implanted contraceptive devices can rarely result in migration to the pulmonary vasculature. These radiopaque devices are detectable on imaging studies if patients and clinicians are unable to palpate them. An endovascular approach should be considered first to spare lung tissue and avoid chest-wall incisions, but can be complicated by encapsulation and adherence to adjacent tissue. A VATS procedure with single-lung ventilation via a double-lumen endotracheal tube allows surgeons to safely operate on an immobilized lung while anesthesiologists facilitate single-lung ventilation. This patient's case details the uncommon phenomenon of Nexplanon migration, and the exceedingly rare treatment resolution of lung resection to remove an embolized device.

Intraoperative Acute Cardiac Tamponade as a Result of Intracardiac Perforation Requiring Emergency Continuous Pericardiocentesis and Open Sternotomy: A Case Report and Literature Review of a Rare but Fatal Complication.

Intraoperative acute cardiac tamponade associated with iatrogenic intracardiac perforation from percutaneous interventional cardiac procedures is a rare but potentially catastrophic complication. We report a case of intraoperative acute hemopericardium caused by a left atrial (LA) perforation resulting in cardiac tamponade in a patient undergoing a baffling procedure for the correction of two anomalous pulmonary veins draining into her superior vena cava (SVC) that required continuous pericardiocentesis with autologous blood transfusion via the femoral vein and an emergency intraoperative transfer from the interventional cardiology cath lab to the cardiac operating room for an open sternotomy and primary repair. An 86-year-old female with known right-ventricular (RV) failure with preserved ejection fraction (left ventricular ejection fraction (LVEF): 50-55% on transesophageal echocardiography (TEE) one week prior) and atrial fibrillation was admitted for her third heat failure exacerbation in two months despite being adherent to her aggressive diuresis medication regimen. Upon her readmission and due to her symptomatic and seemingly refractory heart failure, the patient underwent a cardiac computer tomography (CT) with 3D reconstruction that showed previously undiagnosed partial anomalous pulmonary venous return (PAPVR) of two of her four pulmonary veins aberrantly draining into the SVC. This anatomic pathology was deemed to be the likely etiology of her repeated episodes of recurring heart failure exacerbations, shortness of breath, peripheral edema, and fatigue. The patient was counseled and consented to a percutaneous baffle of the two anomalous veins to redirect more of the returning pulmonary venous blood away from the SVC and to the LA. While under general endotracheal anesthesia (GETA) with a TEE in place during the procedure, the patient suddenly developed acute hypotension, tachycardia, and a reduction in expired carbon dioxide (EtCO2) was noted quickly followed by evidence of a rapidly accumulating hemopericardium on TEE. Cardiothoracic surgery was urgently consulted to the interventional cardiology cath lab while the patient underwent an emergency pericardiocentesis that momentarily alleviated her hemodynamic instability, cardiac tamponade physiology, and deteriorating overall clinical picture. While performing continuous pericardiocentesis with autologous return of the aspirated blood via femoral venous access the patient was urgently transported to the cardiac operating room and prepped for emergency sternotomy for primary repair of the LA. Following primary repair via sternotomy, multiple drains were placed and the thoracic cavity was closed with wires. The patient was immediately transported to the surgical intensive care unit (SICU) intubated, mechanically ventilated, and sedated. During this time, the patient progressively required additional vasoactive and inotropic agents to support her mean arterial pressure (MAP), and following a multidisciplinary discussion with the patient's family regarding her goals of care, the decision was made to withdraw further resuscitation efforts and the patient expired four hours later.

Intraoperative Management of Tracheal Cautery Injury in a Post-Bypass Cardiac Surgery Patient.

We present the case of a tracheal injury that occurred during a Maze procedure performed via sternotomy that was not initially detected by ventilator air leak, but rather by the visual presence of gas bubbles escaping the trachea during chest irrigation. Careful investigation and machine check did reveal a subsequent air leak that would have otherwise been overlooked. Furthermore, the use of intraoperative bronchoscopy was essential in guiding and confirming surgical repair. This case underscores the need for ongoing vigilance and suggests the utility of chest irrigation with Valsalva maneuvers after procedures performed in the vicinity of the trachea to exclude injury.

Intracardiac Heterotopic Liver Presenting as a Right Atrial Myxoma: A Case Report.

Intracardiac heterotopic liver is a very rare entity. The most unique aspect of this entity is the increased carcinogenic potential of the tissue. This condition must be considered when assessing an intracardiac mass along with more common differential diagnoses such as neoplasms, thrombi, and vegetations. In this report, we present a case of a patient who presented to cardiac surgery for elective excision of a right atrial mass that was determined to be an accessory liver lobe. We discuss the diagnostic challenges, clinical management, and surgical and anesthetic implications of this rare finding.

Fatal transfusion-associated graft-versus-host disease with concomitant immune hemolysis in a group A combat trauma patient resuscitated with group O fresh whole blood.

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare but well-established fatal complication of blood transfusion. It can occur in immunocompetent patients when they receive transfusions from human leukocyte antigen-haploidentical donors who have lymphocytes with antigens that are not recognized as foreign by the host, but that recognize the host's tissues as foreign. It is generally viewed as a T-cell-mediated process. Graft-induced immune hemolysis or passenger lymphocyte syndrome is a well-described complication of marrow or solid organ transplantation in which immune competent donor B cells produce alloantibodies to recipient red blood cell (RBC) antigens and cause hemolysis of the recipient's RBCs. It is generally considered as a separate process from GVHD, although it could be considered a type of GVHD. Despite the theoretical possibility of both a B-cell and T-cell component to TA-GVHD, detection of a humoral antibody in cases of acute TA-GVHD has not been described. We describe the clinical course and laboratory evaluation of a group A combat trauma patient who was acutely resuscitated with group O fresh whole blood and RBCs and group AB fresh-frozen plasma who experienced the onset of the clinical symptoms of TA-GVHD as well as the onset of hemolysis due to donor-derived anti-A in his plasma 11 days after transfusion.

Critical care medicine at Walter Reed Army Medical Center in support of the global war on terrorism.

BACKGROUND: The military medical experience during wartime is unique and distinct from civilian medical practice. Historically, the military has produced innovations resulting in both civilian and military medical care advances, and our current conflict is no different. In this article, we provide a description of the medical and surgical intensive care units at Walter Reed, their history, and approach to new issues encountered in the care of Operation Iraqi Freedom and Operation Enduring Freedom soldiers. Additionally, descriptive statistics regarding the number of Operation Iraqi Freedom and Operation Enduring Freedom soldiers admitted to the critical care service, basic demographics, general category of injury, and discussion of intensive care unit issues unique to this patient population, such as Acinetobacter and traumatic brain injury, are presented. DISCUSSION: We intend to provide a general description of our Operation Iraqi Freedom/Operation Enduring Freedom trauma population cared for by the critical care service at Walter Reed Army Medical Center, as well as a discussion of our approach to caring for some of their unique issues, to detail experiences that could translate into improvements for civilian trauma centers.

Improved anesthesia support of the forward surgical team: a proposed combination of drawover anesthesia and the life support for trauma and transport.

The Ohmeda Portable Anesthesia Complete is the apparatus available for delivery of general anesthesia in the forward surgical teams in the U.S. Army. The Life Support for Trauma and Transport is being field tested for use as a single patient critical care transport bed. An effective circuit was created which linked the currently fielded draw-over anesthesia machine with the patient ventilator (Impact 754 Eagle) mounted in the Life Support for Trauma and Transport, with bench testing indicating that the anesthesia levels were accurate and that it was a useful system for field resuscitation and surgery. Others should be able to utilize this information for the benefit of their patients in field environments, especially forward surgical teams and others working in austere health care locations.