In Response.

Abstract

We thank Dr Veyckemans1 for the thoughtful commentary, and we likewise have been encouraged overall by the responses to our articles on the perioperative cardiac arrest from the anesthesia and critical care community. We continue to learn from our peers that there is a desire to expand the differential diagnoses presented in these papers. These are often related to the perioperative care of the adult but sometimes related to pediatric and obstetrical care. Because we view learning as a team endeavor, we welcome additional responses and input from the anesthesia and critical care community. Additionally, for content areas pertaining to obstetrical cardiac arrest and pediatric anesthesia critical events, we refer our colleagues to the excellent studies by Jeejeebhoy et al,2 Lipman et al,3 and Clebone et al.4 Concerning the specifics of the letter to the editor, Dr Veyckemans1 notes several rare events that we have experienced clinically—ones that we will certainly include in the differential diagnosis lists in future updates. However, we do have several comments in reply. Concerning the management of pneumothorax, the cited reference is concerning a case series of 7 patients, only 1 of whom experienced hypotension. While these cases may have involved pneumothorax from peritoneal insufflation (most of which were diagnosed with auscultation), in the setting of hemodynamic instability or cardiac arrest in which tension pneumothorax is suspected, we still advocate needle decompression as a lifesaving maneuver as noted in our manuscript. Additionally, we would suggest that the conclusion reached by Dr Veyckemans1 concerning the avoidance of dexamethasone for postoperative nausea and vomiting prophylaxis in pediatric cancer patients is likely too strong for the referenced article, which comes from a case report. While hyperkalemia from tumor lysis is known to occur in some patients with cancer, many chemotherapy regimens include high-dose steroids as part of chemotherapy induction and maintenance, and therefore we would recommend knowing the potential for hyperkalemia from tumor lysis in this patient population, but not universally avoiding steroids as 1 part of a treatment regimen for postoperative nausea and vomiting. Finally, we agree with Dr Veyckemans1 concerning the fact that patient position is of less importance during venous air embolism than is focusing on breaking up airlock or bubbles in the right ventricle that are restricting blood flow. Matthew D. McEvoy, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee[email protected] Karl-Christian Thies, MD, FRCA, FERC, DEAADepartment of Anaesthesia and Pre-hospitalEmergency MedicineBirmingham Children’s HospitalBirmingham, United Kingdom Sharon Einav, MDDepartment of AnesthesiologyShaare Zedek Medical Center and Hebrew University Faculty of MedicineJerusalem, Israel Kurt Ruetzler, MDDepartments of General Anesthesiology and Outcomes ResearchCleveland ClinicCleveland, Ohio Vivek K. Moitra, MD, FCCMDepartment of AnesthesiologyColumbia University, College of Physicians and SurgeonsNew York, New York Mark E. Nunnally, MD, FCCMDepartment of Anesthesiology, Medicine,Surgery & NeurologyNew York UniversityNew York, New York Arna Banerjee, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee Guy Weinberg, MDDepartment of AnesthesiologyThe University of Illinois at ChicagoChicago, Illinois Andrea Gabrielli, MD, FCCMDepartment of AnesthesiologyUniversity of PennsylvaniaPhiladelphia, Pennsylvania Gerald A. Maccioli, MD, FCCMSheridan HealthcareMiami, Florida Gregory Dobson, MDDepartment of AnesthesiaDalhousie UniversityHalifax, Nova Scotia, United Kingdom Michael F. O’Connor, MD, FCCMDepartment of Critical Care MedicineUniversity of ChicagoChicago, Illinois