Recognition and Management of Subcutaneous Emphysema as a Complication of Robotic-Assisted Laparoscopic Surgery: A Case Report.

This case report discusses an unlikely occurrence of massive subcutaneous emphysema in an elective robotic-assisted laparoscopic total hysterectomy in a 45-year-old, ASA class 1 woman. The patient's perioperative course was otherwise uncomplicated, with the subcutaneous emphysema developing at surgical closure. The patient presented with substantial crepitus spanning from her face to her lower extremities and hypercarbia with end-tidal carbon dioxide readings persistent between 60 and 70 mm Hg. This case did not result in clinically significant airway obstruction because of provider vigilance. However, undiagnosed subcutaneous emphysema without a secured airway may lead to respiratory distress, respiratory depression, airway obstruction, tracheal deviation, and tension pneumothorax.

Pediatric Emergence Delirium: A Case Study.

The pathophysiology of emergence delirium (ED) remains a mystery. Using a case study approach, ED is discussed from a clinical perspective. The case is a 4-year-old male who had myringotomy tube placement while anesthetized with sevoflurane. The negative outcome for this child is presented. The epidemiology of the phenomena is reviewed and definitions are examined. Several methods to assess ED are presented, accompanied by a discussion of the development of assessment tools. Research findings are included that address the possible causes of ED including preoperative anxiety, rapid awakening, pain, and a predisposition for this phenomenon in certain children. Various interventions, both pharmacologic and nonpharmacologic are considered. The impact of anesthesia on pediatric brain development is discussed and finally some possible solutions are hypothesized.

Perioperative Delirium Protocol for the Older Patient.

PURPOSE: Delirium is an acute change in cognition and attention. It may affect any age group. It is most common in older patients and is associated with a significant increase in mortality. The purpose of this project was to implement an assessment protocol to identify patients at risk for postoperative delirium. DESIGN: A case study approach was used. METHODS: The Confusion Assessment Method (CAM) tool for screening and diagnostic purposes was used to train surgeons, anesthesia providers, and nurses. A standardized delirium assessment and management protocol was developed and implemented. FINDINGS: The CAM and geriatric preoperative assessment was used with the patient discussed in the case study. The patient did not experience postoperative delirium and was discharged from perioperative services on the same day. CONCLUSION: Evidence informs us that early recognition and multifaceted interventions can prevent postoperative delirium in the elderly.