A 47-year-old female undergoes bilateral mastectomy with immediate reconstruction with free TRAM flap. She is admitted to the ICU for flap monitoring. When you evaluate her, she is complaining of shortness of breath and is intermittently unresponsive.
How do you proceed?
Correct Answer: B
The incidence of pneumothorax after breast reconstruction is extremely rare (0.55%). However, it should be considered in any patient who presents with respiratory complaints in the perioperative period. Other nonthoracic procedures that carry a risk for inadvertent pneumothorax include open nephrectomy, and robotic or laparoscopic surgery regardless of the indication.
A 77-year-old female presents with acute worsening of abdominal pain. She describes nausea and vomiting along with some diarrhea after a recent trip to Florida, but states that these symptoms were improving when she suddenly developed severe acute abdominal pain. She denies similar abdominal complaints in the past and reports no prior abdominal surgeries. Past medical history is significant for atrial fibrillation of which she takes rivaroxaban, although she does report she may missed a few doses earlier in the week.
What would be the test of choice to confirm the diagnosis?
Correct Answer: C
Acute mesenteric ischemia (AMI) is characterized into arterial or venous occlusion. There is also a form of AMI that is associated with vasocontriction or low-flow states termed NOMI. Arterial occlusion by emboli used to be the most common cause of AMI, but with the widespread use of anticoagulants the cause of AMI is more evenly split between embolic and thrombotic sources. Although echocardiogram as well CT of the chest may prove essential in identifying the source of embolic phenomenon, the initial chest of choice to confirm the diagnosis is a CT angiography of the abdomen and pelvis as this test is relatively quick and readily available. The diagnostic gold standard remains conventional angiography, but this study is more often utilized after the diagnosis of AMI has been established and catheter-based interventions appear warranted.
Which of the following is NOT considered a risk factor for nonocclusive mesenteric ischemia (NOMI)?
Correct Answer: A
All the above are considered risks for NOMI except for infrarenal ABF. ABF bypass is associated with ischemic colitis as the inferior mesenteric artery is typically sacrificed. NOMI results in local malperfusion due to splanchnic vasospasm. This can be the result of vasoconstrictive medications, shock, cardiac arrest with ROSC, or ACS as can been seen after aggressive resuscitation (ie burn injury resuscitation). Cardiopulmonary bypass, extracorporeal membrane oxygenation, and hemodialysis are associated with NOMI and should be considered in patients with a concerning clinical picture. Many patients with NOMI are critically ill, which makes examination findings difficult to follow. The classic “pain out of proportion” is nearly impossible to appreciate thereby making a high clinical suspicion important for early identification and management. Symptoms can be nonspecific, which can include but not limited to abdominal distension, new or worsening feeding intolerance, or unexplained metabolic acidosis. Mesenteric ischemia is an emergency, and there should be no delays in obtaining a diagnosis.
A 79-year-old female with a past medical history of COPD is admitted to the ICU for community-acquired pneumonia. She develops fever, and blood-tinged diarrhea. She remains KUB reveals air-fluid levels within the small bowel. A CT demonstrates fatstranding involving the colon and colonic wall thickening.
The BEST method to confirm the diagnosis and begin treatment is:
Correct Answer: D
Risk factors for ischemic colitis are older age (>65 years), constipation, vasculitis, sickle cell disease, and COPD. Infrarenal aortic aneurysms and aortic surgery are also common causes of left-sided ischemic colitis. Often, this can be managed expectantly, but colonoscopy can confirm the diagnosis. However, it can be difficult to determine partial-thickness from full-thickness ischemia by endoscopy alone. Hypotension and worsening metabolic acidosis require emergent surgical consultation, but the majority of ischemic colitis can be managed medically. Medical management includes adequate resuscitation, nasogastric decompression, avoidance of hypotension, serial abdominal examinations, and IV antibiotics. Barium and contrast enemas should be avoided as there is a risk for perforation. Symptoms that do not improve within 24 to 48 hours should prompt a reevaluation either with endoscopy, CT, or both.
Which scenario is MOST consistent with abdominal compartment syndrome (ACS)?
ACS is defined by intra-abdominal hypertension in conjunction with organ dysfunction. An elevated IAP by indirect measurement with bladder pressure is insufficient to prompt management especially surgical decompression. Usually, a constellation of symptoms occur, which include respiratory insufficiency and notably reduced pulmonary compliance, hypotension from reduced venous return, and decreased urine output. In addition, increased intracranial pressure is observed with ACS, and this can be observed in patients with ICP monitors in place. In general, an intra-abominal pressure of >25 mm Hg warrants surgical compression, but the overall clinical picture should correspond with ACS to maximize benefits of an open abdomen and reduce morbidity. It is important to note that even with an open abdomen, ACS can occur, and it is important to remain vigilant when the constellation of symptoms exist.
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