Andrew J. Otey

Intentional ingestions of foreign objects among prisoners: A review.

The intentional ingestion of foreign objects (IIFO) is described more commonly in prison populations than in the general population, with an estimated annual incidence of 1 in 1900 inmates in our state correctional facilities. Incidents often involve ingestion of small metal objects (e.g., paperclips, razor blades) or other commonly available items like pens or eating utensils. Despite ingestion of relatively sharp objects, most episodes can be clinically managed with either observation or endoscopy. Surgery should be reserved for those with signs or symptoms of gastrointestinal perforation or obstruction. For those with a history of IIFO, efforts should focus on prevention of recurrence as subsequent episodes are associated with higher morbidity, significant healthcare and security costs. The pattern of IIFO is often repetitive, with escalation both in frequency of ingestions and in number of items ingested. Little is known about successful prevention strategies, but efforts to monitor patients and provide psychiatric care are potential best-practice strategies. This article aims to provide state-of-the art review on the topic, followed by a set of basic recommendations.

Refractory Hypotension after Liver Allograft Reperfusion: A Case of Dynamic Left Ventricular Outflow Tract Obstruction

Hypotension after reperfusion is a common occurrence during liver transplantation following the systemic release of cold, hyperkalemic, and acidic contents of the liver allograft. Moreover, the release of vasoactive metabolites such as inflammatory cytokines and free radicals from the liver and mesentery, compounded by the hepatic uptake of blood, may also cause a decrement in systemic perfusion pressures. Thus, the postreperfusion syndrome (PRS) can materialize if hypotension and fibrinolysis occur concomitantly within 5 min of reperfusion. Treatment of the PRS may require the administration of inotropes, vasopressors, and intravenous fluids to maintain hemodynamic stability. However, the occurrence of the PRS and its treatment with inotropes and calcium chloride may lead to dynamic left ventricular outflow tract obstruction (DLVOTO) precipitating refractory hypotension. Expedient diagnosis of DLVOTO with transesophageal echocardiography is extremely vital in order to avoid potential cardiovascular collapse during this critical period.

Perioperative Cognitive Protection—Cognitive Exercise and Cognitive Reserve (The Neurobics Trial): A Single-blind Randomized Trial

PURPOSE The Neurobics Trial is a single-blind, parallel-group, randomized, controlled trial. The main study objective is to compare effectiveness of preoperative cognitive exercise versus no intervention for lowering the incidence of postoperative delirium. Enrollment began March 2015 and is ongoing. METHODS Eligible participants include patients older than 60 years of age scheduled for nonemergent, noncardiac, nonneurological surgery at our institution. Patients provide consent and are screened at our Outpatient Preoperative Assessment Clinic to rule out preexisting cognitive dysfunction, significant mental health disorders, and history of surgery requiring general anesthesia in the preceding 6 months. Participants meeting criteria are randomized to complete 1 hour daily of electronic tablet-based cognitive exercise for 10 days before surgery or no preoperative intervention. Compliance with the effective dose of 10 total hours of preoperative exercise is verified on return of the patient for surgery with time logs created by the software application and by patient self-reporting. After surgery, patients are evaluated for delirium in the postanesthesia recovery area, and then twice daily for the remainder of their hospitalization. Additionally, postoperative quality of recovery is assessed daily, along with pain scores and opiate use. More comprehensive cognitive assessments are completed just before discharge for baseline comparison, and quality of recovery is assessed via telephone interview 7, 30, and 90 days post-surgery. The primary outcome is the incidence of delirium during the postoperative hospitalization period. Randomization is computer generated, with allocation concealment in opaque envelopes. All postoperative assessments are completed by blinded study personnel. FINDINGS The study is actively recruiting with 19 patients having provided consent to date, and a total of 264 patients is required for study completion; therefore, no data analysis is currently under way (www.clinicaltrials.gov; NCT02230605). IMPLICATIONS To our knowledge, the Neurobics Trial is the first randomized, controlled study to investigate the effectiveness of a significant preoperative cognitive exercise regimen for the prevention of delirium after noncardiac, nonneurological surgery in elderly patients.

CASE 9—2015 Anesthetic Management of a Patient With Esophago-Pericardial Fistula Complicating Atrial Fibrillation Radiofrequency Ablation

AF is tailored toward rhythm and heart rate control using anti- arrhythmic medications and anticoagulation therapy to prevent embolic stroke. However, antiarrhythmic therapy fails in a significant number of patients. Drug-refractory AF currently is managed with catheter ablation (CA) procedures, which are associated with a complication rate of about 5% and a mortality rate of approximately 0.001%. 3-11 CA procedures, such as cryoablation and radiofrequency ablation (RFA), can be associated with the following early periprocedure complications: bleeding from cardiovascular injury, cardiac tamponade, pericarditis, pulmonary vein (PV) thrombosis, and embolic stroke. Late CA-related complications include esophago-pericardial fistula (EPF), left atrial-esophageal fistula (LAEF), stroke, PV stenosis, and death. 3,4,7,9-13 The mechanism of LAEF and EPF formation is not clear. However, direct thermal injury and ischemia to the esophagus have been described as inciting complications after RFA and cryoablation procedures. These complications typically occur during posterior ablation of the left atrium (LA) and the PVs. Post-thermal injury esophageal inflammation, necrosis, and/or adhesion to the heart

Association between intentional ingestion of foreign objects and psychiatric disease among prisoners: A retrospective study

Introduction: Intentional ingestion of foreign objects (IIFO) is prevalent among U.S. prisoners. IIFOs often require surgical or endoscopic interventions, extended hospital stays, and may result in significant morbidity or even mortality. Although psychiatric illness is prevalent among prisoners engaging in IIFO, this association remains poorly defined. The aim of this study is to describe the psychiatric illness profile among prisoners diagnosed with IIFO. We hypothesized that repeated episodes of IIFO are associated with an escalating pattern of documented psychiatric illness. Methods: After approvals were obtained from our Institutional Review Board and the Ohio Department of Rehabilitation and Correction, a retrospective study was conducted of prisoners presenting to our facility with IIFO between 2004 and 2011. All historical and concurrent psychiatric diagnoses were abstracted from the medical record and classified into Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition based categories. In addition, medical history, alcohol/drug use, and prior episodes of IIFO were recorded. Statistical analyses included Chi-square and Kruskal–Wallis tests for categorical and continuous data, respectively. Results: We analyzed 136 IIFO episodes involving 27 patients. Repeat IIFO episodes were associated with an increasing number of psychiatric diagnoses. Patients with their fifth or later IIFO had a larger number of psychiatric diagnoses and the number of objects ingested as compared to patients presenting with a first episode (P < 0.01). Similarly, patients who went on to present with additional episodes of IIFO during the study had more psychiatric diagnoses identified throughout their visits (P < 0.01). The proportion of patients with mood and anxiety disorders (including post-traumatic stress) was progressively greater among prisoners with recurrent episodes of IIFO (P < 0.05). Other psychiatric disorders were not significantly associated with IIFO escalation. Conclusions: We observed a significant association between IIFO recurrences and increases in both the quantity of ingested items and the number of documented psychiatric diagnoses. Of note, psychiatric diagnoses of malingering or secondary gain were not identified in the current patient sample. Consideration of early psychiatric evaluation and intervention in the setting of IIFO, especially recurrent IIFO, is strongly encouraged. The following core competencies are addressed in this article: Medical knowledge, Patient care, Systems-based practice.

Elevated Transaortic Valvular Gradients After Combined Aortic Valve and Mitral Valve Replacement An Intraoperative Dilemma

High transaortic valvular gradients, after combined aortic valve and mitral valve replacement, require prompt intraoperative diagnosis and appropriate management. The presence of high transaortic valvular gradients after cardiopulmonary bypass, in this setting, can be secondary to the following conditions: prosthesis dysfunction, left ventricular outflow tract obstruction, supravalvular obstruction, prosthesis–patient mismatch, hyperkinetic left ventricle from administration of inotropes, left ventricular intracavitary gradients, pressure recovery phenomenon, and increased transvalvular blood flow resulting from hyperdynamic circulation or anemia. Transesophageal echocardiography is an extremely useful tool for timely diagnosis and treatment of this complication. We describe a case of a critically ill patient with endocarditis and acute lung injury, who presented for combined aortic valve and mitral valve replacement. Transesophageal echocardiographic assessment, post–cardiopulmonary bypass, revealed high transaortic valvular gradients due to encroachment of the mitral prosthesis strut on the left ventricular outflow tract, which was compounded by a small, hypertrophied, and hyperkinetic left ventricle. Discontinuation of inotropic support, administration of fluids, phenylephrine, and esmolol led to resolution of the high gradients and prevented further surgery.

BMI as a predictor for potential difficult tracheal intubation in males

Introduction Difficult tracheal intubation is a common source of mortality and morbidity in surgical and critical care settings. The incidence reported of difficult tracheal intubation is 0.1%–13% and reaches 14% in the obese population. The objective of our retrospective study was to investigate and compare the utility of body mass index (BMI) as indicator of difficult tracheal intubation in males and females. Material and methods We performed a retrospective chart review of patients who underwent abdominal surgeries with American Society of Anesthesiologists I to V under general anesthesia requiring endotracheal intubation. The following information was obtained from medical records for analysis: gender, age, height, weight, BMI, length of patient stay in the Post Anesthesia Care Unit, past medical history of sleep apnea, Mallampati score, and the American Society of Anesthesiologists classification assigned by the anesthesia care provider performing the endotracheal intubation. Results Of 4303 adult patients, 1970 (45.8%) men and 2333 (54.2%) women were enrolled in the study. Within this group, a total of 1673 (38.9%) patients were morbidly obese. The average age of the study group was 51.4 ± 15.8 and the average BMI was 29.7 ± 8.2 kg/m2. The overall incidence of the encountered difficult intubations was 5.23% or 225 subjects. Thus, our results indicate that BMI is a reliable predictor of difficult tracheal intubation predominantly in the male population; another strong predictor, with a positive linear correlation, being the Mallampati score. Conclusion In conclusion, our data shows that BMI is a reliable indicator of potential difficult tracheal intubation only in male surgical patients.

Republication: Examination of financial charges associated with intentional foreign body ingestions by prisoners: A pattern of escalation

Introduction: Intentional ingestions of foreign objects (IIFO) continue to be prevalent among prisoners. Our previous research examined determinants of hospital admission, endoscopy, and surgery among prisoners who ingest foreign objects. However, little is known about the financial impact of these events on healthcare facilities that service the prisoner population. This study aims to fill this gap by examining hospital charges attributable to 435 prisoner episodes of IIFO. Methods: A retrospective review of all prisoners who presented to our medical center with the complaint of IIFO was conducted. Both Institutional Review Board and Bureau of Prisons approvals were obtained before data collection. All prisoners ages 18–75 were included between the dates of January 2004 and December 2011. Episodes were divided into three categories: (a) Unverified IIFO wherein ingested object was claimed by the patient but never identified; (b) verified IIFO wherein ingested object was clearly identified; (c) secondary events due to direct complications of previous IIFO episode (s). The temporal occurrence of IIFO was organized by increasing the number of episodes and grouped accordingly. Detailed list of hospital charges was obtained for every IIFO episode including: (a) emergency services, (b) procedures, (c) laboratory, (d) surgical supplies, (e) allied health services, (f) radiology studies, (g) anesthesiology charges, (h) pharmacy, and (h) intensive care costs. Descriptive statistics were used to analyze basic data. Kruskal–Wallis test was used to examine differences among nonnormally distributed variables and sub-groups. Statistical significance set at alpha = 0.05. Results: A total of 435 IIFO episodes occurred during the study period in a population of 125 patients (mean age 33.8 ± 11.7 years, median age 34 [range 19–75] years, 92.8% male). Hospital charges associated with these episodes totaled

Severe Mitral Regurgitation After Left Ventricular Pseudoaneurysm Repair

6,209,557. There were 94 unverified IIFOs, 332 verified IIFOs, and 9 secondary events. Verified IIFOs were associated with significantly greater median charges (

Comment on: Alternate description of waveform: Pulsus bisferiens

5,860) than unverified IIFOs (