Midazolam for the Successful Treatment of Refractory Spinal-Anesthesia-Associated Hypothermia After Cesarean Delivery.

Cesarean deliveries receiving spinal anesthesia with intrathecal morphine are associated with post-operative hypothermia. Lorazepam has been proposed as a reversal agent for treating intrathecal morphine-associated post-cesarean hypothermia. Midazolam is a benzodiazepine familiar to most anesthesia providers and is frequently administered in the perioperative period. We present a post-cesarean delivery spinal anesthesia-associated hypothermia patient successfully treated with intravenous midazolam.

Inferior Vena Cava Leiomyosarcoma With Extension to Right Atrium in a Parturient at 30 Weeks of Gestation: A Case Report.

Primary leiomyosarcomas of the inferior vena cava (IVC) are rare sarcomas, none of which have been described in literature during a third-trimester pregnancy. Here, we describe the complex care of a patient at 30 weeks of gestation who presented to her obstetrician with shortness of breath and lower extremity swelling. She was found to have a 5.0 × 5.0 × 13 cm heterogeneous mass of her IVC, ultimately diagnosed as a leiomyosarcoma. She underwent a cesarean delivery under combined spinal epidural and a subsequent tumor resection and IVC reconstruction requiring multidisciplinary surgical and anesthetic care.

Comparative Effectiveness of Second Vasoactive Agents in Septic Shock Refractory to Norepinephrine.

OBJECTIVE: We aim to identify the appropriate vasoactive agent in patients with septic shock who are refractory to optimal doses of norepinephrine. METHODS: In this retrospective observational cohort study over a 4-year period, patients who received norepinephrine within 24 hours of ICU admission and a second agent within 48 hours were enrolled. RESULTS: Among 2640 patients screened, 234 patients were enrolled, aged 60.8 ± 17.8 years, Acute Physiology and Chronic Health Evaluation IV 98.3 ± 27.5, 81.6% mechanically ventilated, and 65.8% in-hospital mortality. Within 96 hours, 2.8 ± 1.0 vasoactive agents were administered. Fifty, 50, 66, and 68 patients received dobutamine, dopamine, phenylephrine, and vasopressin as the second agent, with crude in-hospital mortality 40.0%, 66.0%, 74.2%, and 76.5%, respectively, P < .001. Survival analysis showed a statistically significant difference in survival time by second vasoactive agent, P < .001. After adjusting for confounding variables, dobutamine showed significant decreased odds ratio (OR) for mortality compared to vasopressin: OR 0.34 (95% confidence interval 0.14-0.84, P = .04). The relative risk of dying was 55.8% lower in patients receiving dobutamine versus vasopressin, P < .01. CONCLUSION: Dobutamine is associated with decreased mortality compared to other second vasoactive agents in septic shock when norepinephrine is not sufficient. A prospective randomized trial examining the outcome impact of the second vasoactive agent is needed.

Integration of Ultrasound in Medical Education at United States Medical Schools: A National Survey of Directors' Experiences.

OBJECTIVES: Despite the rise of ultrasound in medical education (USMED), multiple barriers impede the implementation of such curricula in medical schools. No studies to date have surveyed individuals who are successfully championing USMED programs. This study aimed to investigate the experiences with ultrasound integration as perceived by active USMED directors across the United States. METHODS: In 2014, all allopathic and osteopathic medical schools in the United States were contacted regarding their status with ultrasound education. For schools with required point-of-care ultrasound curricula, we identified the USMED directors in charge of the ultrasound programs and sent them a 27-question survey. The survey included background information about the directors, ultrasound program details, the barriers directors faced toward implementation, and the directors' attitudes toward ultrasound education. RESULTS: One-hundred seventy-three medical schools were contacted, and 48 (27.7%) reported having a formal USMED curriculum. Thirty-six USMED directors responded to the survey. The average number of years of USMED curriculum integration was 2.8 years (SD, 2.9). Mandatory ultrasound curricula had most commonly been implemented into years 1 and 2 of medical school (71.4% and 62.9%, respectively). The most common barriers faced by these directors when implementing their ultrasound programs were the lack of funding for faculty/ equipment (52.9%) and lack of time in current medical curricula (50.0%). CONCLUSIONS: Financial commitments and the full schedules of medical schools are the current prevailing roadblocks to implementation of ultrasound education. Experiences drawn from current USMED directors in this study may be used to help programs starting their own curricula.

Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique.

OBJECTIVES: Sonographic evaluation of neck anatomy before performing percutaneous dilatational tracheostomy (PDT) has been shown to predict PDT success. In this study, we compared the real-time, long-axis, in-plane approach to the traditional bronchoscopically guided landmark technique. METHODS: Data were analyzed from a prospectively maintained PDT database at a university tertiary care medical intensive care unit. A convenience sample of adult patients requiring PDT for prolonged mechanical ventilation dependence was enrolled. Critical care fellows, under direct supervision of an attending intensivist, performed all PDTs. Tracheostomy performance from the sonographically guided and landmark techniques was compared. RESULTS: Twenty-three patients were enrolled: 11 in the sonography group and 12 in the landmark group. Initial midline introducer needle puncture was achieved in 72.7% in the sonography group compared to 8.3% in the landmark group (P< .001). The mean number of introducer needle punctures ± SD was significantly lower in the sonography group compared to the landmark group (1.4 ± 0.7 versus 2.6 ± 0.9; P < .001). The total tracheostomy time was 11.4 ± 4.2 minutes in the sonography group versus 15.3 ± 6.8 minutes in the landmark group (P = .12). Sonography accurately predicted tracheal ring space insertion in 90.9% of patients. Procedural complications did not differ significantly between the groups. CONCLUSIONS: Percutaneous dilatational tracheostomy under real-time sonographic guidance using a long-axis approach may increase the rate of midline punctures and decrease the number of needle punctures when compared to the landmark technique. Sonographic guidance can also help guide accurate and efficient placement of a tracheostomy tube into the desired tracheal ring space.