An elevation of the intracranial pressure (ICP) secondary to cerebral edema is a major contributor to morbidity and mortality in acute liver failure. In addition, invasive ICP monitoring in this setting is controversial because coagulopathy predisposes patients to hemorrhagic complications. In this case report, we describe the novel use of optic nerve sheath diameter monitoring as a noninvasive modality for checking for acute elevations in ICP in this setting. Because of the merits of rapidly evolving ultrasound technologies, this may serve as a safe method for improving patient care in this setting.

Purpose To study the incidence and risk factors for retinal artery occlusion (RAO) in cardiac surgery. Design Retrospective study using the National Inpatient Sample (NIS). Methods The NIS was searched for cardiac surgery. Retinal artery occlusion was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Postulated risk factors based on literature review were included in multivariate logistic models. Main Outcome Measures Diagnosis of RAO. Results A total of 5 872 833 cardiac operative procedures were estimated in the United States from 1998 to 2013, with 4564 RAO cases (95% confidence interval [95% CI], 4282–4869). Nationally estimated RAO incidence was 7.77/10 000 cardiac operative procedures from 1998 to 2013 (95% CI, 7.29–8.29). Associated with increased RAO were giant cell arteritis (odds ratio [OR], 7.73; CI, 2.78–21.52; P < 0.001), transient cerebral ischemia (OR, 7.67; CI, 5.31–11.07; P < 0.001), carotid artery stenosis (OR, 7.52; CI, 6.22–9.09; P < 0.001), embolic stroke (OR, 4.43; CI, 3.05–6.42; P < 0.001), hypercoagulability (OR, 2.90; CI, 1.56–5.39; P < 0.001), myxoma (OR, 2.43; CI, 1.39–4.26; P = 0.002), diabetes mellitus (DM) with ophthalmic complications (OR, 1.89; CI, 1.10–3.24; P = 0.02), and aortic insufficiency (OR, 1.85; CI, 1.26–2.71; P = 0.002). Perioperative bleeding, aortic and mitral valve surgery, and septal surgery increased the odds of RAO. Negatively associated with RAO were female gender (OR, 0.77; CI, 0.66–0.89; P < 0.001), thrombocytopenia (OR, 0.79; CI, 0.62–1.00; P = 0.049), acute coronary syndrome (OR, 0.72; CI, 0.58–0.89; P = 0.003), atrial fibrillation (OR, 0.82; CI, 0.70–0.95; P = 0.01), congestive heart failure (OR, 0.73; CI, 0.60–0.88; P < 0.001), DM 2 (OR, 0.74; CI, 0.61–0.89; P = 0.001), and smoking (OR, 0.82; CI, 0.70–0.97; P = 0.02). Conclusions Risk factors for RAO in cardiac surgery include giant cell arteritis, carotid stenosis, stroke, hypercoagulable state, and DM with ophthalmic complications; associated with lower risk were female gender, thrombocytopenia, acute coronary syndrome, atrial fibrillation, congestive heart failure, DM 2, and smoking. Surgery in which the heart was opened (e.g., septal repair) versus surgery in which it was not (e.g., CABG) and perioperative bleeding increased the risk of RAO.

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IntroductionThis study evaluated the effect of a surgical opioid-avoidance protocol (SOAP) on postoperative pain scores. The primary goal was to demonstrate that the SOAP was as effective as the pre-existing non-SOAP (without opioid restriction) protocol by measuring postoperative pain in a diverse, opioid-naive patient population undergoing inpatient surgery across multiple surgical services.MethodsThis prospective cohort study was divided into SOAP and non-SOAP groups based on surgery date. The non-SOAP group had no opioid restrictions (n=382), while the SOAP group (n=449) used a rigorous, opioid-avoidance order set with patient and staff education regarding multimodal analgesia. A non-inferiority analysis assessed the SOAP impact on postoperative pain scores.ResultsPostoperative pain scores in the SOAP group compared with the non-SOAP group were non-inferior (95% CI: −0.58, 0.10; non-inferiority margin=−1). The SOAP group consumed fewer postoperative opioids (median=0.67 (IQR=15) vs 8.17 morphine milliequivalents (MMEs) (IQR=40.33); p<0.01) and had fewer discharge prescription opioids (median=0 (IQR=60) vs 86.4 MMEs (IQR=140.4); p<0.01).DiscussionThe SOAP was as effective as the non-SOAP group in postoperative pain scores across a diverse patient population and associated with lower postoperative opioid consumption and discharge prescription opioids.

Intraoperative hypotension may contribute to significant post-operative morbidity and mortality. We present a case of sudden, profound intraoperative hypotension during Harrington rod revision for scoliosis. During resuscitation of the patient, measurement of the central venous oxygen saturation (CVO2) allowed us to narrow our differential diagnosis. We noted a significantly elevated CVO2 and, in the setting of hypotension, diagnosed intraoperative sepsis. After rod removal and stabilization of the patient's hemodynamics, we cancelled the remainder of the case due to the concern of bacteremia and infection of any newly placed hardware. Cultures from the wound later grew methicillin-resistant staphylococcus aureus. This case highlights the value of central venous oxygen saturation in a clinical picture to diagnose the cause of intraoperative hypotension