Potential Life-threatening Complications Research Articles

Clinical findings and outcomes of 153 dogs surgically treated for intestinal intussusceptions.

To describe perioperative characteristics and outcomes of dogs surgically treated for intestinal intussusception. Multi-institutional, retrospective study. One hundred fifty-three client-owned dogs with intestinal intussusception. Dogs were included when they had undergone surgical treatment of a confirmed intestinal intussusception. Medical records were reviewed for demographics and clinical data, including surgical complications (graded 1-4). Follow-up was obtained via telephone interview with owners and referring veterinarians. Dogs had a median age of 10 months (range, 2-156), and the most common location for intussusception was ileocolic (66/153 [43%]). Most cases had no identifiable cause (104/155 [67%]). Intestinal resection and anastomosis (IRA) was performed in 129 of 153 (84%) dogs; enteroplication was performed in 28 of 153 (18%) dogs, including 13 with and 15 without IRA. Intraoperative complications occurred in 10 of 153 (7%) dogs, all involving intestinal damage during attempted manual reduction. The median duration of follow-up after discharge was 334 days (interquartile range, 15-990; range, 1-3302). Postoperative complications occurred in 53 of 153 (35%) dogs, including 22 of 153 (14%) with severe (grade 3 or 4) events. Diarrhea, regurgitation, and septic peritonitis were the most common postoperative complications; intussusception recurred in four of 153 (3%) dogs, all within 72 hours postoperatively. Fourteen-day postoperative mortality rate was 6%. Surgical treatment of intestinal intussusception was curative in most dogs, even when an underlying cause was not identified. Surgical complications were common, including a 14% risk of life-threatening short-term complications. Surgical treatment of intestinal intussusception offers an excellent prognosis, but the potential life-threatening complications should be considered.

Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: A joint ESA/ESICM guideline.

: Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure with risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) have developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula (HFNC), noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately postextubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery.

Anaerobic Necrotizing Pneumonia: Another Potential Life-threatening Complication of Vaping?

An adolescent girl with a history of frequent electronic cigarette use of nicotine was hospitalized with severe necrotizing pneumonia. Blood cultures obtained before the administration of empirical broad-spectrum intravenous antibiotics had positive results for the growth of Fusobacterium necrophorum The pathogen is an uncommon but well-known cause of anaerobic pneumonia with unique features that are collectively referred to as Lemierre syndrome or postanginal sepsis. The syndrome begins as a pharyngeal infection. Untreated, the infection progresses to involve the ipsilateral internal jugular vein, resulting in septic thrombophlebitis with direct spread from the neck to the lungs causing multifocal necrotizing pneumonia. The teenager we present in this report had neither a preceding pharyngeal infection nor Doppler ultrasonographic evidence for the presence of deep neck vein thrombi, leading us to explore alternative mechanisms for her pneumonia. We propose the possibility that her behavior of frequent vaping led to sufficient pharyngeal irritation such that F necrophorum colonizing her oropharynx was inhaled directly into her lungs during electronic cigarette use. Preexisting, but not yet recognized, vaping-related lung injury may have also contributed to her risk of developing the infection. The patient was hospitalized for 10 days. At follow-up one month later, she still became short of breath with minimal exertion.

Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: a joint ESA/ESICM guideline.

Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure at risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula, noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that: in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately post-extubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery. Electronic supplementary materialThe online version of this article (10.1007/s00134-020-05948-0) contains supplementary material, which is available to authorized users.

COMPARISON OF ULTRASOUND GUIDED, ULTRASOUND ASSISTED AND “BLIND” PERICARDIOCENTESIS

A pericardiocentesis is a procedure associated with potential life-threatening complications, such as liver and lung perforation. A “blind” pericardiocentesis is performed by orientation according to certain anatomic landmarks only. As a safer option, ultrasound can be employed to guide the

Single running suture technique is associated with low rate of bronchial complications after lung transplantation

BackgroundLung transplantation has evolved to a routinely performed surgical procedure in patients with end-stage pulmonary disease. Bronchial healing problems are rare but represent a potential life-threatening complication. Herein, we aimed to define the incidence, classification, and treatment of bronchial complications after lung transplantation. Material and MethodsAll patients receiving lung transplantation between January 1999 and December 2017 were included in this retrospective study. All bronchial anastomoses were performed in a standardized technique using a single, polydioxanone running suture. The rate of anastomotic complications requiring an intervention, type of complication according the 2018 International Society for Heart and Lung Transplantation classification, and the clinical management were retrospectively analyzed. ResultsA total of 2941 anastomoses were performed in 1555 patients. The overall incidence of relevant anastomotic complications was 1.56%, 0.68% for left anastomoses, and 2.44% for right anastomoses. In 6 patients, a surgical revision or retransplantation was performed, whereas endoscopic treatment alone was sufficient in 39 patients. One patient underwent right-sided retransplantation 6 months after the first lung transplantation after failed endoscopic treatment attempts. International Society for Heart and Lung Transplantation grade “S Lc Ec” was the most common type of anastomotic complication. The overall incidence decreased within the study period from 2.4% in the era 1999 to 2003 to 0.8% in the era 2014 to 2017. We found no significant difference in overall survival of patients with and without anastomotic complications (P = .995; hazard ratio, 0.99; 95% confidence interval, 0.63-1.58). ConclusionsThe single running suture technique is associated with a very low rate of true anastomotic complications. Close follow-up and early endoscopic treatment of patients with anastomotic complications result in excellent long-term outcomes.

An international registry of patients with plasminogen deficiency (HISTORY).

Plasminogen deficiency is an ultra-rare multisystem disorder characterized by the development of fibrin-rich pseudomembranes on mucous membranes. Ligneous conjunctivitis, which can result in vision impairment or loss, is the most frequent symptom reported. Affected systems may also include the respiratory tract, oropharynx, female reproductive tract, gingiva, middle ear, renal collecting system, skin and central nervous system. Untreated, plasminogen deficiency may result in significant reduction in quality of life and morbidity with potential life-threatening complications. Non-specific therapies are inadequate and plasminogen concentrates are not commercially available. The current understanding of plasminogen deficiency and management of disease symptoms and its progression are based on case reports/series and two small clinical trials. To date there has never been a comprehensive, international study to examine the natural history or optimal therapeutic intervention; knowledge gaps include identification of contributing factors and triggers of disease manifestations, inability to predict disease course, and insufficient real-world data for use of therapeutics. We have created an international, observational study (HISTORY) in a large cohort of persons with plasminogen deficiency and first-degree family members to address these gaps and to advance knowledge and care. HISTORY will build upon the established relationship between the Indiana Hemophilia and Thrombosis Center and the Fondazione Angelo Bianchi Bonomi, IRCCS Ca’ Granda Ospedale Maggiore Policlinico - University of Milan and will utilize a modified version of the Prospective Rare Bleeding Disorders Database (PRO-RBDD). A biorepository containing samples from subjects with plasminogen deficiency will be established. This article describes the rationale behind the study and efforts towards its goals.

496 A fatal case of MitraClip thrombosis

Abstract Case An 80 year old man presented with persistent dyspnea two months following placement of three MitraClip devices for severe degenerative mitral regurgitation (MR). On exam, he had an apical holosystolic murmur. A transesophageal echocardiogram revealed displacement of one of the MitraClip devices (Figure 1A, red arrow showing the displaced MitraClip) and moderate-severe MR (Figure 1B). He underwent implantation of a fourth MitraClip with reduction of his MR to mild-moderate (Figure 1C, 1D; yellow arrow showing the new MitraClip). Shortly after, he experienced severe melena and hematochezia and became lethargic and hypotensive. He was transferred to the Cardiac Intensive Care Unit, was intubated and aggressively supported. Extensive work-up revealed diffuse gastric body ischemia and ulceration. A transthoracic echocardiogram showed his most recent MitraClip being well seated with mild-moderate MR. He developed refractory multi-organ failure and expired eight days following the procedure. Autopsy revealed thrombi attached to the initially placed MitraClip’s (Figure 1E, 1F) and thromboemboli to the small bowel, spleen and brain. Discussion MitraClip is the predominant non-surgical alternative for percutaneous mitral valve repair in inoperable patients with symptomatic MR, either primary or secondary. Despite its growing use, there remains a paucity of data on its safety and the potential life-threatening complications, especially when more than one device are placed. Current recommendations include dual antiplatelet therapy with aspirin and clopidogrel. In patients already on anticoagulation, continuation of it is recommended. Very few cases of MitraClip thrombosis have been reported so far. Acute development of spontaneous echo contrast (SEC) and early thrombus was described in a patient with severe, primary MR receiving 2 MitraClip"s. Both SEC and the early thrombus resolved once the second device was removed. In another case, intraprocedural thrombus formation was described on the right side of the interatrial septum close to the MitraClip guide catheter. The underlying pathophysiologic mechanism and the predisposing factors to acute and subacute thrombosis associated with MitraClip are unclear. One plausible explanation could be the acute dramatic hemodynamic alterations related to the reduction in MR and new mild mitral stenosis. In addition, the MitraClip itself may act as a prothrombotic nidus. Potential risk factors include: advanced age and multiple comorbidities predisposing to proinflammation and prothrombosis. The use of MitraClip is only expected to increase in the future. Large scale clinical trials are needed to further define the safety of the device and delineate the optimal antiplatelet and/or antithrombotic regimen. Abstract 496 Figure. Pre and post TEE and autopsy findings.

The feasibility and safety of sharp recanalization for superior vena cava occlusion in hemodialysis patients: A retrospective cohort study.

Hemodialysis catheter-related superior vena cava (SVC) occlusions can cause considerable morbidity for patients and be challenging to treat if refractory to conventional guide wire transversal. This pilot study assessed the feasibility and safety of sharp recanalization of SVC occlusion in hemodialysis patients. This study retrospectively enrolled hemodialysis patients treated in West China Hospital diagnosed with SVC occlusion who failed traditional guide wire transversal from January 2014 to November 2017. In brief, a guide wire from the femoral approach was advanced to the lower end of the obstructive lesion to act as a target, while the stiff end of hydrophilic wire was advanced though a jugular approach. Under fluoroscopic guidance in biplane imaging, the occlusive SVC lesion was penetrated with the stiff wire that was snared and pulled through. Graded dilation of the SVC and subsequent tunneled-cuffed catheter implantation were performed. Demographic information and clinical outcomes were recorded and evaluated. Sixteen patients with a mean age of 62 ± 13 years (13 females and 3 males) who received SVC sharp recanalization were included in this study. The sharp recanalization procedure was successfully performed in 14 patients (87.5%). Two patients were complicated with SVC laceration and hemopericardium but remained asymptomatic and required no surgical repair. One patient suffered ventricular fibrillation during procedure. Despite the return of spontaneous circulation, the patient unfortunately died of gastrointestinal tract bleeding after 3 days in ICU. Follow-up suggested the 6-month catheter patency to be 92.85% and 12-month catheter patency to be 58.33%. No long-term procedure-related complications were recorded. Sharp recanalization might be a feasible strategy in managing SVC occlusion in hemodialysis patients. The potential life-threatening complications (cardiac arrhythmia and SVC laceration) necessitate strict eligibility screening, skillful operation, and avoidance of over-dilation of SVC.

Hyperkalemia and blood pressure regulation

Hypertension is common in the general population. Management of hypertensive patients at risk of hyperkalemia is challenging due to potential life-threatening complications such as cardiac arrest. Chronic hyperkalemia is often associated with impaired renal ability to excrete excessive potassium ions (K+). This may refer to chronic kidney disease or certain pharmacological interventions, including broadly used renin-angiotensin-aldosterone system and calcineurin inhibitors. Understanding the intrinsic mechanisms permitting kidney adaptations to hyperkalemia is critical for choosing therapeutic strategies. Valuable insights were obtained from the analysis of familial hyperkalemic hypertension (FHHt) syndrome, which became a classic model for coincidence of high blood pressure and hyperkalemia. FHHt can be caused by mutations in several genes, all of them resulting in excessive activity of with-no-lysine kinases (WNKs) in the distal nephron of the kidney. WNKs have been increasingly recognized as key signalling enzymes in the regulation of renal sodium ions (Na+) and K+ handling, enabling adaptive responses to systemic shifts of potassium homoeostasis consequent to variations in dietary potassium intake or disease. The WNK signalling pathway recruits a complex protein network mediating catalytic and non-catalytic effects of distinct WNK isoforms on relevant Na+- or K+-transporting proteins. In this review article, we summarize recent progress in understanding WNK signalling. An update of available models for renal adaptation to hyperkalemic conditions is presented. Consequences for blood pressure regulation are discussed. Pharmacological targeting of WNKs or their substrates offers promising options to manage hypertension while preventing hyperkalemia.

Management Strategies and Satisfaction Levels in Patients with Sickle Cell Disease: Interim Results from the International Sickle Cell World Assessment Survey (SWAY)

Management Strategies and Satisfaction Levels in Patients with Sickle Cell Disease: Interim Results from the International Sickle Cell World Assessment Survey (SWAY)

Veno-Occlusive Disease (VOD) after Hematopoietic Stem Cell Transplant (HSCR): Always a Catastrophic Illness?

Introduction Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS), a potential life-threatening complication of conditioning regimens performed for HSCT, is due to an endothelial cell activation/damage and a prothrombotic-hyper-fibrinolytic condition. The clinical diagnosis and grading of VOD/SOS are based on the Seattle, Baltimore and EBMT criteria. Aims The aim of our work was to establish the incidence of VOD/SOS in our patient series, the time of clinical diagnosis, the best treatment options in relation to disease severity, the effectiveness of defibrotide treatment for severe/very severe forms, and the incidence of multi-organ failure (MOF). Methods Patients In the period January 2016-June 2019, 146 allogeneic HSCT were performed at our Institution. Patients' median age was 57 years (range 25-72) and 52% of them were males. The primary disease was AML in 82 (56.1%), MDS in 33 (22.6%), ALL in 16 (10.9%), MM in 5 (3.4%), primary or secondary Myelofibrosis in 10 (6.8%). Performance status was good (Karnofsky score ≥90) in 80% of HSCT. At HSCT, 31 patients (21.2%) had either had a previous hepatic disease or increased levels of alanine transaminases (ALT) and 36 (24.6%) had altered pulmonary functional tests. Thirty-five HSCTs were from HLA identical siblings, 55 from MUD and 35 from haplo-identical family donors. Conditioning regimen were either myeloablative or RIC depending on patients' age and co-morbidities. Stem cell source was BM in 36 (24.6%) patients, peripheral hematopoietic stem cells in 109 (74.6%) and cord blood in one. Standard acute GVHD prophyaxis consisted of Cylosporine A (CsA) and short methotrexate or CsA and micofenolate mofetyl in haplo-transplants. Definition, grading and treatment of VOD Diagnosis and grading of VOD/SOS were based on the Seattle, Baltimore and EBMT criteria. Renal dysfunction was defined as serum creatinine ≥3x baseline value, creatinine clearance or glomerular filtration rate declined to ≤40% of baseline or dialysis dependence due to VOD/SOS. Pulmonary dysfunction was defined as oxygen saturation ≤90% on room air, requirement for supplemental oxygen to maintain oxygen saturation ≥90%, or ventilator dependence not due to infection. Abdomen echo-tomography was performed in all patients to evaluate the presence of ascites. Patients having a pre-transplant liver disease or increased ALT levels received ursodeoxycholic acid (UDCA) as pharmacological prophylaxis Results In our series VOD/SOS occurred in 22/146 patients (15.0%) according to Seattle criteriaand in 13 (8.9%) according to Baltimore criteriaand the recent EBMT scale. Median time to VOD/SOS development was 7 days post-HSCT (range 0-18). Based on the proposed EBMT scale for grading, 9 patients were classified as mild VOD/SOS, one as moderate, 11 as severe and one as very severe. VOD/SOS target organs were the liver in 6 patients, the liver and the lung in 6 and the lung in one. Defibrotide treatment (6.25/kg/day for 21 days) was promptly started in 12 patients including the case with the moderate form of VOD/SOS and delayed by 23 days in one patient. VOD/SOS progression occurred in 7 patients: one evolved from a mild to a severe form and 6 from a severe to a very severe form. Defibrotide treatment induced a response in 10 patients: 8 achieved a complete response and 2 a partial response. However, these last two patients died of a thrombotic microangiopathy syndrome three and four months post-transplant. The remaining 3 patients, including the case with a delayed defibrotide start, experienced a multi-organ failure (MOF) that had been preceded by a liver (one case) and a lung VOD/SOS (two cases). Interestingly, the patient with a liver VOD/SOS had showed a severe liver dysfunction on pre-transplant work-up and the remaining two with a lung VOD/SOS a severe lung dysfunction on pre-transplant work-up. Conclusions In our series the incidence of VOD/SOS is similar to that reported by the literature; two organs involvement predicts a high risk of MOF evolution; UDCA is the therapy of choice for mild VOD/SOS; defibrotide, especially if promptly started, is very effective in inducing VOD/SOS resolution. Disclosures No relevant conflicts of interest to declare.

The Effect of Pharmacological Thromboprophylaxis, Tourniquet and Drainage on Hemorrhagic Complications in the Early Stage after Knee Arthroplasty: Preliminary Results

Background — venous thromboembolic complications (VTC) are potential life-threatening complications following knee arthroplasty (KA). An optimal thromboprophylaxis strategy should reduce the risk of developing VTC without increasing the risk of hemorrhagic complications. The purpose of the study is to evaluate the effect of the drugs (acetylsalicylic acid, dabigatran etexilate and rivaroxaban) for the pharmacological thromboprophylaxis and the features of the surgical procedure (use of the tourniquet and drainage) on hemorrhagic complications in early periods after knee arthroplasty. Materials and Methods. 335 patients (65 men and 270 women), without additional risk factors for the development of thromboembolic complications, were included into the study. Those patients were admitted for planned primary / revision knee arthroplasty and corresponded to inclusion / non-inclusion criteria. Patients were randomized into three clinical groups, depending on the drug used thromboprophylaxis. During the inpatient treatment period, all patients recorded the development of symptomatic VTCs and the development of hemorrhagic complications. According to the clinical indications, the number of knee joint punctures was taken into account: patella balloting, restricted flexion and a smooth joint contour. Results. Symptomatic VTCs were not observed during the study period. The volume of intraoperative blood loss did not depend on the drugs used for thromboprophylaxis, and was determined only by the surgical technique (ρs= -0.615, p = 0.0001). The use of the tourniquet during the procedure significantly reduced intraoperative blood loss (p = 0.023). No relation between surgical technique and anemia on the 5th day (ρs = 0.11, p = 0.05), as well as between surgical technique and total blood loss (ρs = 0.12, p = 0.01) was established; weak reliable correlation between the use of the tourniquet and hidden blood loss (ρs = -0.22, p = 0.01) was reported. A negative average significant correlation was observed (ρs = -0.42, p = 0.01) for the volume of total blood loss and hemoglobin level on the 5th day after the surgery. The number of postoperative punctures was comparable in the study groups. Conclusion. Sample of present size is not sufficient to make conclusions about the equal efficacy of using acetylsalicylic acid, dabigatran and rivaroxaban for thromboprophylaxis after knee arthroplasty in patients without additional risk factors for thrombosis. Data on the significant correlation of the surgical technique with the volume of intraoperative and latent blood loss, as well as total blood loss and hemoglobin level on the 5th day after the operation allow to suggest a possible effect of the drug for thromboprophylaxis on blood loss stargin from 2nd day after the procedure.

The successful use of extra-corporeal membrane oxygenation as rescue therapy for unilateral pulmonary edema following minimally invasive mitral valve surgery.

Unilateral right pulmonary edema has been reported as a potential life-threatening complication after minimally invasive mitral valve surgery. Nearly 2% of these cases in the immediate postoperative period have been reported to require extra-corporeal membrane oxygenation support as a rescue therapy for severe hypoxia. The exact pathophysiology of this condition remains unclear, but has been assumed to be related to ischemia-reperfusion injury and re-expansion pulmonary edema. We present in this report the successful use of extra-corporeal membrane oxygenation to manage two cases of severe hypoxia and multiorgan dysfunction secondary to unilateral right pulmonary edema.

SYSTEMIC AIR EMBOLISM AFTER PERCUTANEOUS CT-GUIDED LUNG BIOPSY

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Computed-tomography (CT) guided transthoracic needle biopsy (TTNB) is widely performed to establish a histological diagnosis of peripheral lung tumors. Systemic air embolism is described as a rare complication. CASE PRESENTATION: In a 70-year-old man with systemic arterial hypertension and benign prostatic hypertrophy a peripheral pulmonary consolidation in the left upper lobe and multiple brain nodules were detected after an acute episode of epilepsy. As a primary lung tumor was suspected, he underwent a total body positron emission tomography-CT scan, showing pathological glucose uptake in the left lung lesion (Figure 1) and metastatic involvement of mediastinal lymph nodes, adrenal glands and vertebral bodies. His coagulation profile, hemoglobin and platelets levels were normal, so a bronchoscopy with transbronchial lung biopsy under fluoroscopy was set. The histological analysis showed bronchial inflammatory cells, so the patient underwent a CT-guided TTNB. Under local anesthesia, two bioptic samples were collected using the 18-gauge outer coaxial needle by an expert interventional radiologist (Figure 2A). During the procedure the onset of air embolism in both heart ventricles, main pulmonary artery and ascending aorta was immediately detected on CT scans (Figure 2B). A layer of ipsilateral pneumothorax (maximum thickness 12 mm) together with chest wall subcutaneous emphysema were present. The patient complained about general malaise with signs of hypotension and desaturation. No electrocardiographic alterations were recorded. After he was administered 100% oxygen through a mask and hydrated, his clinical conditions rapidly improved. Two hours later a chest and brain CT scans were repeated. While cardiac, aortic and pulmonary artery air embolisms were solved, the pneumothorax layer increased (20 mm) (Figure 3). No ischemic lesions were detected in brain CT scans. The patient was maintained on close monitoring and after four days the pneumothorax was no longer radiologically detectable. An invasive lung adenocarcinoma was diagnosed and the patient was referred to the Oncology Department. DISCUSSION: Systemic air embolism is described in 0.02-0.07% of TTNB (1). Direct exposure of pulmonary vein to air through the needle, bronchovenus fistula formation and air penetration from the pulmonary arterial circulation to the pulmonary vein are all possible pathogenic mechanisms (2). Possible prevention strategies include avoiding coughing and straining during the procedure and ventilation with positive pressure (3). No specific treatment has established yet other than supplying 100% oxygen and hyperbaric chamber. The patient has to be strictly monitored because potential life-threatening complications may rise and the repetition of a chest-brain CT scan may be urgently needed (3). CONCLUSIONS: Even if uncommon, systemic air embolism after TTBN must be always considered and rapidly handled. Reference #1: Sinner WN. Complications of percutaneous transthoracic needle aspiration biopsy. Acta Radiol. 1976;17:813-28 Reference #2: Mokhlesi B, Ansaarie I et al. Coronary artery air embolism complicating CT.guided transthoracic needle biopsy of the lung. Chest. 2002;121:993-996 Reference #3: Hare SS, Gupta ATC et al. Systemic arterial air embolism after percutaneous lung biopsy. Clin Radiol. 2011;66:589-596. DISCLOSURES: No relevant relationships by Paolo Ceruti, source=Web Response No relevant relationships by SARA ALESSANDRA LONNI, source=Web Response

Acute kidney injury following left ventricular assist device implantation: Contemporary insights and future perspectives

Currently, an increasing number of patients with end-stage heart failure are being treated with left ventricular assist device (LVAD) therapy as bridge-to-transplantation, bridge-to-candidacy, or destination therapy (DT). Potential life-threatening complications may occur, specifically in the early post-operative phase, which positions LVAD implantation as a high-risk surgical procedure. Acute kidney injury (AKI) is a frequently observed complication after LVAD implantation and is associated with high morbidity and mortality. The rapidly growing number of LVAD implantations necessitates better approaches of identifying high-risk patients, optimizing peri-operative management, and preventing severe complications such as AKI. This holds especially true for those patients receiving an LVAD as DT, who are typically older (with higher burden of comorbidities) with impaired renal function and at increased post-operative risk. Herein we outline the definition, diagnosis, frequency, pathophysiology, and risk factors for AKI in patients with an LVAD. We also review possible strategies to prevent and manage AKI in this patient population.

CT and MRI imaging and interpretation of hepatic arterioportal shunts.

Hepatic arterioportal shunts (HAPS) occur due to organic or functional fistulization of blood flow between arterial hepatic vasculature and venous portal systems. It is a type of hemodynamic abnormality of the liver being observed increasingly with the use of temporal imaging modalities. HAPS occur due to other underlying hepatic abnormalities including the presence of an underlying tumor or malignancy. When a HAPS is present, the appearance of these abnormalities on imaging studies suggests an underlying abnormality, must be considered atypical even if asymptomatic, and warrants careful evaluation. Over time, and as a function of degree of fistulae, symptoms and potential life-threatening complications may arise from the HAPS. These systemic complications may include the development of portal hypertension, splenomegaly, as well as accelerated metastasis in patients with malignant tumors. This manuscript reviews common underlying conditions associated with HAPS and their radiologic interpretation.

Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study.

In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7-10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date. The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications. A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7-20.5, p = 0.005) and deep-extraaxial-benign ("skull base") tumors (OR 3.6, 95% CI 1.3-9.7, p = 0.011) were found to be independent predictors of thromboembolic complications. In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.

Refeeding syndrome relevance for critically ill patients

Abstract Refeeding Syndrome (RFS) is a potential life-threatening complication of the nutritional therapy in the replenishment phase after period of starvation. This not very known syndrome may be a life-threatening metabolic condition due to rapid, inadequate nutritional support in malnourished catabolic patients. The intake of food and therefore the switch from a catabolic to an anabolic metabolism is most considered etiological mechanism. The main biochemical feature of RFS is hypophosphatemia and low levels of potassium and magnesium. Lack of vitamins, especially vitamin B1 or thiamine is often present and involves severe clinical complications.

Innovations in Quality Improvement of Intravascular Catheter-Related Bloodstream Infections

Significant reductions in catheter-related bloodstream infections (CRBSI) have occurred in the United States. Reductions in CRBSIs are attributed to the widespread implementation of the practice-based measures and innovations in the diagnosis, treatment, and prevention of CRBSI. Diagnosis of CRBSI historically required removal of the central venous catheter (CVC) for catheter tip culture. Removing the CVC for CRBSI diagnosis predisposes many patients to potential life-threatening complications. Advances in diagnostic techniques such as culturing catheter hubs, catheter entry site cultures, applying differential time to positivity, molecular diagnostics, biomarkers, and innovative approaches like biosensors on the CVC lumen may provide an alternative to CVC removal. Removal of the CVC is common for the treatment of CRBSI; however, antimicrobial lock therapy is increasingly used as a CVC salvage method. Implementation of newer technology such as antimicrobial coated catheters, chlorhexidine-impregnated dressings, and antiseptic port protectors are crucial for the prevention of CRBSIs. Increasing evidence also support newer sutureless CVC securement devices prevent CRBSIs. CRBSI remains a significant clinical problem despite advances made in the diagnosis, management, and prevention. Molecular techniques are increasingly being used for pathogen identification in CRBSI, but the optimal diagnostic test remains debatable. Increasing experience is being gained with antimicrobial lock therapy for CRBSI treatment with catheter salvage. Use and adherence to practice-based measures and technological innovations has significantly reduced CRBSIs. Continued efforts are required to develop a cost-effective and targeted approach for CRBSI prevention.