A & A case reports
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An 82-year-old man required aortic valve replacement because of aortic stenosis. A transapical approach was chosen to reduce surgical mortality. Initially, echocardiography and fluoroscopy confirmed correct valve positioning. ⋯ Cardiac output was restored once the valve was replaced. The patient fully recovered. This case report highlights the importance of periprocedural transesophageal echocardiography, which instantly detected the malpositioned valve and guided emergency management of this severe complication.
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We report the perioperative management of a patient with melanoma. Surgical intervention was withheld at multiple institutions because of the presence of metastases; the patient was undergoing experimental immunotherapy and had responded everywhere except in the liver. ⋯ She died of late complications. This case highlights physiologic and ethical considerations.
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Case Reports
Transesophageal Echocardiography Assisting in the Diagnosis of Intraabdominal Hemorrhage During Cardiac Arrest.
Transesophageal echocardiography (TEE) has been frequently used to identify potential etiologies of intraoperative cardiac arrest for noncardiac surgical patients. However, rescue TEE to assist in the diagnosis of intraabdominal hemorrhage has never been reported. We present a patient who developed cardiac arrest on emergence after an elective abdominal surgery. ⋯ It also demonstrated a 3.3- by 13.2-cm circular perihepatic fluid collection on transgastric views raising concern for major intraabdominal hemorrhage as the cause for the cardiac arrest. This prompted surgical reexploration, which confirmed the diagnosis. We suggest that transgastric views to identify intraabdominal fluid collections should be considered during a rescue TEE if intraabdominal hemorrhage is suspected.
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Case Reports
Diffuse Limb Discoloration with Indigotindisulfonate (Indigo Carmine®) and the Associated Implications.
Anesthesiologists often administer medications through an IV catheter that is distal to a noninvasive blood pressure (NIBP) cuff. We report 2 cases where indigotindisulfonate (Indigo Carmine) was administered through an IV catheter distal to an NIBP cuff. NIBP cuff inflation after indigotindisulfonate administration resulted in diffuse limb discoloration distal to the NIBP cuff although the IV catheter remained completely within the intact vein. These cases suggest that administration of medications that have the same physical characteristics as indigotindisulfonate under the same conditions (i.e., proximal venous occlusion) could also result in an interstitial distribution of these drugs.
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We examined hospitals that exclusively used the billing modifier QZ in anesthesia claims for a 5% sample of Medicare beneficiaries in 2013. We used a national Medicare provider file to identify physician anesthesiologists and nurse anesthetists affiliated with these hospitals. ⋯ Our results illustrate the challenges of using modifier QZ to describe anesthesia practice arrangements in hospitals. The modifier QZ does not seem to be a valid surrogate for no anesthesiologist being involved in the care provided.