Role of Imaging Studies in Evaluating Patients Post Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

A 77-year-old male presented to the ED with a new onset of acute abdominal pain, nausea, and vomiting. He had a previous surgical history of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for an appendiceal tumor. Despite the repeated reassuring abdominal examinations, CT abdomen showed high-grade bowel obstruction and perforation. He was urgently taken to the operating room and underwent resection of 70 cm segment of small ischemic bowel with primary anastomosis. His postoperative course was complicated with atrial fibrillation (AF) requiring cardioversion and medical therapy. Later, he was discharged home under stable conditions. Relying on abdominal signs, an abdominal exam in a patient with a previous history of extensive peritonectomy and post-HIPEC surgery is challenging due to the altered peritoneal anatomy. As a result, the abdominal examination findings can be benign and misleading. This can lead to delayed surgical intervention, thereby increasing morbidity and mortality significantly. Therefore, a detailed evaluation with a low threshold for abdominal imaging studies like abdominal X-rays and CT abdomen series is warranted in this subset of patients

ECMO RESCUE IN A PATIENT WITH THYMOGLOBULIN-INDUCED ARDS AFTER LIVER TRANSPLANTATION

INTRODUCTION: Postoperative care after liver transplantation can be associated with significant cardiopulmonary complications. Thymoglobulin is used for prevention and treatment of acute rejection in organ transplantations. Although there are few case reports describing thymoglobulin induced acute respiratory distress syndrome in immunocompromised patients, there are limited reports to date on the mortality and outcomes for patients who receive extracorporeal membrane oxygenation therapy after liver transplant. DESCRIPTION: We present a case of a 43 year old male with decompensated alcoholic cirrhosis with ascites and hepato-renal syndrome who underwent a liver transplant. Intra-operative course was complicated by vasoplegia and coagulopathy. Post-operatively, patient was on intermittent hemodialysis, on minimal ventilator settings. However, on post-operative day 2 the patient had worsening hypoxia within few hours from receiving a dose of thymoglobulin for immunosuppression. The patient had severe ARDS, with requirement of 100% Fio2 and PEEP of 20. Later in the ICU, patient developed bi-ventricular failure with ejection fraction of 30% with need for veno-arterial extracorporeal membrane oxygenation support. His course was complicated by acute kidney injury requiring slow efficiency dialysis, critical illness induced myopathy and prolonged ICU stay. He required a tracheostomy, prolonged ventilator wean and was eventually discharged home. DISCUSSION: Our patient was diagnosed with thymoglobulin induced ARDS due to acute development of respiratory failure after thymoglobulin administration. Thymoglobulin contains cytotoxic antibodies directed against T-cell markers which can trigger immune mediated acute lung injury. The etiology of thymoglubulin-induced ARDS is not fully understood however it is regarded as a special type of transfusion-related acute lung injury characterized by acute respiratory distress during or within 6 hours after the completion of transfusion. ARDS from thymoglobulin is a rare complication however can be life-threatening. Hence it\u27s prudent that the treating physician is aware of this potential complication which facilitates appropriate management. In our case, management included continuing steroids, utilizing ECMO, renal replacement therapy and ongoing respiratory support

Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies

Introduction: One of the most challenging scenarios an anesthesia provider can face is treating a can\u27t intubate can\u27t ventilate (CICV) patient. The incidence of CICV is estimated to be around one in 10,000 cases. According to the American Society of Anesthesiology Closed Claims Study, adverse respiratory events are the most common type of injury, with difficult intubation and ventilation contributing to the majority of these cases. The objective of this non-interventional quality improvement project was to evaluate the prior training, exposure, and self-reported confidence in handling the CICV scenario among anesthesia providers at Henry Ford Hospital in Detroit, MI. Methods: An online questionnaire was distributed via email to all residents, certified registered nurse anesthetists (CRNAs), and attending anesthesiologists in March 2021. The email contained a link to an online questionnaire via Microsoft Forms (Microsoft Corporation, Redmond, WA). Univariate group comparisons were carried out between the respondents\u27 role (attending, CRNA, or resident), as well as between the number of years that the respondents were in practice (\u3c 5 years, 5-10 years, \u3e 10 years). Results: Out of the total 170 anesthesia providers, 119 participated in the study where 54 (45%) were attendings, 44 (37%) were residents, and 21 (18%) were CRNAs. The majority (75%) did not know the surgical airway kit location, and 87% had not performed the surgical airway procedure before. The vast majority (96.7%) recommended simulation training compared to online training or lecture series, and just over 50% recommended annual training frequency. When looking at the differences in responses based on years of experience as an anesthesia provider, the majority of those with \u3e 10 years in practice knew how to perform the surgical airway technique while respondents with \u3c 5 years did not know how to perform the technique, and 50% of those with five to 10 years experience knew how to perform the surgical airway procedure for a CICV scenario. Conclusion: Although there were many significant differences observed between the various provider roles and years in practice, surprisingly, the responses revealed both a lack of experience and confidence in performing the surgical airway procedure in all provider roles. These findings highlight a need for better emergency airway teaching and training. These findings will be used to guide the design and implementation of improved surgical airway training for residents, CRNAs, and attending anesthesiologists with the goal of better preparedness for handling a CICV scenario

Sequential Organ Failure Assessment (SOFA) Score and Mortality Prediction in Patients With Severe Respiratory Distress Secondary to COVID-19

Background: This study looks at the validity of the sequential organ failure assessment score (SOFA) in detecting mortality in patients with Coronavirus disease of 2019 (COVID-19) pneumonia. Also, it is looking to determine the optimal SOFA score that will discriminate between mortality and survival. Methods: It is a retrospective chart review of the patients admitted to Henry Ford Hospital from March 2020 to December 2020 with COVID-19 pneumonia who developed severe respiratory distress. We collected the following information; patient demographics (age, sex, body mass index), co-morbidities (history of diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, coronary artery disease, or cancer), SOFA scores (the ratio of arterial oxygen tension (PaO(2)) to the fraction of inspired oxygen, Glasgow Coma Scale (GCS) score, mean arterial pressure, serum creatinine level, bilirubin level, and platelet count) as well as inpatient mortality. Results: There were 320 patients; out of these, 111 were intubated. The receiver operating characteristic (ROC) curve for SOFA at the moment of inclusion in the study had an area under the curve of 0.883. The optimal point for discrimination between mortality and survival is SOFA of 5. A SOFA score of less than two is associated with 100% survival, while a score of more than 11 is associated with 100% mortality. Conclusions: SOFA score in COVID-19 patients with severe respiratory distress strongly correlates with the initial SOFA score. It is a valuable tool for predicting mortality in COVID-19 patients

Enterovirus-Induced Severe Rhabdomyolysis and Acute Fulminant Liver Failure in an Immunocompetent Adult Requiring Liver Transplantation: A Case Report

The authors report a case of a young healthy adult with severe rhabdomyolysis and acute fulminant liver failure with multiple organ dysfunction syndromes (MODS), possibly from an enterovirus infection. To the best of our knowledge, this is the first-ever reported case of enterovirus-induced rhabdomyolysis and acute liver failure (ALF) in an immunocompetent adult. It is vital that the treating physician be aware of the association between viral infections, viral myositis, and severe rhabdomyolysis with acute liver failure, which can facilitate the optimal management of such patients. Prompt recognition may provide an opportunity for early interventions, including intravenous immunoglobulin and liver transplantation, if warranted

Thromboelastography and Liver Transplantation: A Target Group

Liver dysfunction results in derangement of hemostasis and thrombosis. Thromboelastography (TEG) has emerged as a tool to guide resuscitative efforts. We aim to identify a target population, and analyze the effects of TEG on product use and blood loss in LT. Adult patients (age \u3e18 years of age) who received LT between 2014 and 2020 were retrospectively reviewed. Those patients who underwent living donor, simultaneous or multi-organ transplants, re-transplants, and recipient \u3c18 years of age, were excluded. A subgroup analysis was done based on INR at transplant. The median, 75th, and 90th percentile of INR at transplant were used as cut-off values and patients were classified into four categories: no coagulopathy, mild, moderate, and severe coagulopathy groups. Four hundred fifty-one patients met criteria and were separated into TEG (n=144) vs non-TEG (n=307) groups. Median blood products used, and blood loss were similar between TEG and non-TEG groups (Table 1). In the subgroup analysis, there was a significant decrease in product use in the TEG group with moderate coagulopathy; Tranexamic acid (TXA) use was significantly higher in the TEG with moderate coagulopathy group (Table 2). In the no, mild and severe coagulopathy groups, there was no difference in product/TXA use or blood loss between the two groups. TEG guided hemostasis and resuscitation in LT resulted in a decrease in product usage, as well as more utilization of TXA, likely by recognition of hyper-fibrinolysis, in patients with moderate coagulopathy (INR between 2.2 and 2.8)