Morton Plant Hospital

High cervical spinal cord injuries (SCIs) can lead to diaphragmatic paralysis, necessitating long-term mechanical ventilation. Diaphragmatic pacemakers (DPs) offer an alternative by stimulating the phrenic nerve to restore diaphragmatic function, thereby improving quality of life and reducing ventilator dependence. However, anesthetic management for DP placement presents unique challenges due to the need to preserve diaphragmatic activity and manage autonomic instability. This case reports a 35-year-old male with complete C4 SCI resulting in quadriplegia and respiratory failure requiring mechanical ventilation. After multiple interventions, including spinal fusion and tracheostomy, he underwent DP placement to reduce ventilator dependency. The patient was successfully transitioned to DP postoperatively and discharged from the hospital on room air via a tracheostomy collar. DP is a valuable intervention for high cervical SCI patients but requires anesthetic strategies that preserve diaphragmatic function and manage common complications such as pneumothorax, autonomic dysreflexia, and ventilator challenges with abdominal insufflation. Avoiding muscle relaxants, continuous diaphragmatic monitoring, and proactive hemodynamic management are essential. The literature highlights rare but serious device-related complications, emphasizing the importance of vigilant intraoperative monitoring and interdisciplinary planning. As DP becomes more accessible, particularly in community hospitals, anesthesiologists must be prepared to navigate its perioperative challenges. This case underscores the importance of tailored anesthetic approaches to support safe and effective DP implantation.

Delayed onset of spinal anesthesia can pose challenges during cesarean section (CS) in patients with a history of chronic opioid use. We present a case of delayed onset of spinal anesthesia in a patient with chronic opioid use undergoing CS, highlighting the clinical implications and management strategies. Delayed onset of spinal anesthesia in chronic opioid users can result from neurophysiological adaptations and pharmacokinetic interactions in the central nervous system. Previous studies have suggested chronic opioid users display a delayed onset and shorter duration of action of neuraxial blockade. This can have great implications in pregnant women who require anesthesia for CS. Delayed onset can lead to misconception of a failed spinal block and conversion to general anesthesia. In reality, additional time may be needed for the block to rise to an adequate level. Additionally, delayed time to incision can lead to poor outcomes for the mother and baby in urgent scenarios. When providing anesthesia for chronic opioid users undergoing CS, it is important to understand the possibility of delayed onset of neuraxial blockade which can impact patient care.

The pneumoperitoneum refers to the presence of free air inside the abdominal cavity. This finding is usually a sequela of a gastrointestinal tract perforation. Still, in rare instances, it can present after cardiac surgery due to the proximity of the peritoneal cavity and pericardium, allowing air to enter the peritoneal cavity. Our patient was a 63-year-old female who initially presented for revision of the mitral valve replacement. A chest X-ray on postoperative day 13 revealed a 6.6 cm lucency under the right diaphragm suggestive of pneumoperitoneum. She was discharged after serial chest X-rays revealed a decrease in the size of the pneumoperitoneum. Twelve days later, our patient was readmitted, as another chest X-ray revealed that the size of the pneumoperitoneum was again increasing. An endoscopy was performed, but it did not reveal any lesions or etiology that would lead to a leak from the gastrointestinal tract. Finally, due to the benign nature of the pneumoperitoneum and the decrease in its size over the following days, we opted for conservative management, and she was discharged again. This case emphasizes the rare occurrence of benign pneumoperitoneum post-mitral valve surgery. While surgery may not always be required for asymptomatic cases, careful vigilance post-cardiac surgery remains crucial to detect potential abdominal complications promptly.

Acute pancreatitis can lead to both local and systemic complications, including pseudocysts, biliary obstruction, duodenal obstruction, sepsis, necrosis, vascular complications, and multiorgan failure. Vascular complications following acute pancreatitis are associated with a high risk of morbidity and mortalitydue to their thrombotic and hemorrhagic effects. When thrombosis is present, it usually involves the splanchnic venous system, but it is rarely seen in the arterial system. Celiac artery thrombosis is rare with only a few cases reported in the literature. In this case, we present a 65-year-old Hispanic female who presented to the emergency department with abdominal pain and nausea, with computed tomography angiography (CTA) of the abdomen revealing acute pancreatitis with thrombosis of the celiac artery, which was managed with anticoagulation.

Most influenza B infections are self-limited, but in some instances, they can cause substantial morbidity and mortality due to complications. Acute fulminant cerebral edema (AFCE) is one of the rare complications. AFCE, a consequence of acute encephalitis, presents as acute onset of alteration in mental status, seizure, and/or headache followed by rapidly progressive encephalopathy, often leading to death. The exact pathophysiology of AFCE is unknown, but many pathomechanisms have been proposed.We present a case of an 18-year-old female in excellent physical condition who presented with respiratory insufficiency after being recently diagnosed with influenza B infection. Three days later, she developed acute encephalopathy, leading to brain death. To our knowledge, this rare case of AFCE developing following influenza B infection is the first reported case outside the pediatric population.

BackgroundSmall reference vessel diameters (RVDs) are a predictor of ischemic events after coronary stenting. Among patients at high bleeding risk (HBR) precluding long-term dual antiplatelet therapy (DAPT), those with small vessel disease (SVD) constitute an especially high-risk subgroup. Here, we evaluated the results of a durable-polymer, coronary zotarolimus-eluting stent (ZES) for the treatment of patients with SVD at HBR with 1-month DAPT.MethodsIn the prospective, multicenter Onyx ONE (One-Month DAPT) Clear study, 1506 patients at HBR treated with a ZES that discontinued DAPT at 30 days were included. The clinical outcomes of patients undergoing treatment of lesions with an RVD of ≤2.5 mm (SVD group, as determined by the angiographic core laboratory) were compared with patients without SVD. The primary end point was the composite of cardiac death or myocardial infarction between 1 and 12 months.ResultsSmall vessel diameter treatment was performed in 489 (32.5%) patients. Patients with SVD were more likely to be women, have undergone a previous percutaneous intervention, and have multivessel coronary artery disease than patients without SVD. There were no significant differences in lesion, device, or procedural success between the groups. The Kaplan-Meier rate estimate of the primary end point was 8.5% and 6.8% in patients with SVD and those without SVD, respectively (P = .425). No significant differences were found in any secondary end point. The Kaplan-Meier rate of stent thrombosis was 0.6% and 0.8% in patients with SVD and those without SVD, respectively (P = .50).ConclusionsAmong patients at HBR treated with a ZES and 1-month DAPT, those with SVD had favorable 12-month ischemic and bleeding outcomes, which were comparable with those of patients with larger caliber vessels.

A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation. The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals. The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.

A 2.5‐year‐old male African hedgehog (Atelerix albiventris) presented with an intraoral, soft tissue mass overlying the left mandible. A computed tomography scan and subsequent fine needle aspirate suggested a malignant spindle cell tumour. The tumour was excised with a partial hemimandibulectomy. Histopathology demonstrated an incompletely excised spindle cell sarcoma. The hedgehog underwent adjuvant therapy consisting of intravenous carboplatin and oral lomustine, followed by palliative radiation therapy once tumour recurrence was noted on follow‐up surveillance. Radiation therapy was initially successful in decreasing tumour size, but the hedgehog re‐presented a month later acutely non‐ambulatory paraparetic with a distal right antebrachial mass. Diagnostics including radiographs and fine needle aspirate were consistent with metastatic neoplasia and humane euthanasia was elected.