1/27. An unreported risk in the use of home nasal continuous positive airway pressure and home nasal ventilation in children: mid-face hypoplasia.We report the case of a 15-year-old boy with obstructive sleep apnea and obesity who was treated since the age of 5 with nasal continuous positive airway pressure. Due to the long-term use of a nasal mask, the child developed a mid-face hypoplasia. Chronic use of a nasal mask for home ventilation in children should always be associated with regular evaluations of maxillomandibular growth.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/27. proteinuria and focal segmental glomerulosclerosis in severely obese adolescents.OBJECTIVE: To describe the clinical and laboratory features of obesity associated proteinuria and focal segmental glomerulosclerosis. STUDY DESIGN: The patients were seen over a 12-year period at two large children's hospitals. Renal biopsies, performed for the diagnosis of unexplained heavy proteinuria and prepared for light, immunofluorescent, and electron microscopy, were read independently by two pediatric pathologists. blood pressure, body mass index, serum levels of creatinine, albumin, and cholesterol, and 24-hour urinary protein were measured. RESULTS: Seven African American adolescents were identified with obesity-associated proteinuria, which was characterized by severe obesity (120 /- 30 kg), markedly elevated body mass index (46 /- 11), mild hypertension (134/74 /- 10/18 mm Hg), slightly low to normal serum albumin levels (3.6 /- 0.2 g/dL), moderately elevated serum cholesterol levels (196 /- 60 mg/dL), and elevated 24-hour protein excretion (3.1 /- 1.3 g/dL). Calculated creatinine clearance was normal in 6 patients and decreased in one. Typical renal histologic features included glomerular hypertrophy, focal segmental glomerulosclerosis, increased mesangial matrix and cellularity, relative preservation of foot process morphology, and absence of evidence of inflammatory or immune-mediated pathogenesis. One patient showed a dramatic reduction in proteinuria in response to weight reduction. Three patients who were given angiotensin-converting enzyme inhibitors had reduced urinary protein losses from 2.9 g to 0.7 g per day. One patient developed end-stage renal disease. CONCLUSION: Obese adolescents should be monitored for proteinuria, which has distinct clinical and pathologic features and may be associated with significant renal sequelae. Such proteinuria may respond to weight reduction and/or treatment with angiotensin-converting enzyme inhibitors.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
3/27. Combined spinal-epidural anesthesia for cesarean section in a patient with peripartum dilated cardiomyopathy.PURPOSE: To report a case of peripartum dilated cardiomyopathy associated with morbid obesity and possible difficult airway presenting for elective cesarean section, which was successfully managed with combined spinal-epidural anesthesia. CLINICAL FEATURES: A morbidly obese parturient with a potentially difficult airway, suffering from idiopathic peripartum cardiomyopathy (ejection fraction 20%), was scheduled for an elective cesarean section. A combined spinal epidural anesthesia was performed and 6 mg of bupivacaine were injected into the subarachnoid space. This was supplemented after 60 min with 25 mg of bupivacaine injected epidurally. The patient's hemodynamic status was monitored with direct intra-arterial blood pressure and central venous pressure measurements. The patient's perioperative course was uneventful. CONCLUSION: In patients suffering from peripartum cardiomyopathy, undergoing cesarean section, combined spinal-epidural anesthesia may be an acceptable anesthetic alternative.- - - - - - - - - - ranking = 0.4keywords = pressure (Clic here for more details about this article) |
4/27. lower extremity compartment syndrome following a laparoscopic Roux-en-Y gastric bypass.BACKGROUND: bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. CASE REPORT: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy, which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4-month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. CONCLUSION: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
5/27. A technique developed by a morbidly obese patient to eat more despite an adjustable gastric band.A woman who had undergone gastric banding is described. In her non-compliance, she developed a subxiphoid pressure maneuver to empty her stomach and permit further intake.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
6/27. Pressure-induced rhabdomyolysis after bariatric surgery.Rhabdomyolisis most commonly occurs after muscle injury, alcohol ingestion, drug intake and exhaustive exercise. Prolonged muscle compression at the time of surgery may produce this complication. obesity has been reported as a risk factor for pressure-induced rhabdomyolysis, but no reports associated with bariatric surgery could be found in the literature. We report 3 superobese patients who developed rhabdomyolysis after bariatric surgery. This complication was attributed to direct and prolonged pressure of the bed against the dorsal and gluteal muscles.- - - - - - - - - - ranking = 0.4keywords = pressure (Clic here for more details about this article) |
7/27. rhabdomyolysis of gluteal muscles leading to renal failure: a potentially fatal complication of surgery in the morbidly obese.BACKGROUND: rhabdomyolysis is a well-known cause of renal failure and is most commonly caused by ischemia/reperfusion or crush injury. We describe a new cause of this syndrome in a series of 6 patients who underwent necrosis of the gluteal muscles after bariatric surgery, 3 of whom eventually died of renal failure. methods: Potential etiologic factors were studied by comparing these patients with a consecutive series of 100 patients undergoing primary uncomplicated bariatric surgery during a 1-year period. Demographics, preoperative BMI, co-morbidities, duration of operation, and postoperative creatinine phosphokinase (CPK) levels. RESULTS: All patients presented with an area of buttock skin breakdown initially diagnosed as a simple decubitus ulcer. All had extensive myonecrosis of the medial gluteal muscles requiring extensive debridement. 5 of the 6 patients were male, with median BMI 67 compared with a median BMI 55 in the control group (P=0.0022). The patients were on the operating-room table for a median of 5.7 hours compared with 4.0 in the control group (P=0.01). 3 of the 6 developed renal failure requiring dialysis, which was fatal in all. One other patient developed a transient elevation of BUN and creatinine which did not require dialysis. Since recognition of this pattern, we now routinely perform serial CPK measurements. Median CPK rise in uncomplicated patients was to 1,200 mg/dl (SD 450-9,000), while CPK in affected patients ranged from 26,000 to 29,000 IU/l. We now routinely add additional buttock padding in very obese patients and institute aggressive hydration and mannitol diuresis if CPK rises above 5,000. No cases have occurred in the past 18 months in 220 patients. CONCLUSIONS: This is an important and potentially fatal complication of bariatric surgery. Very obese male patients with prolonged surgery are at risk of gluteal muscle necrosis with consequent renal failure, which we hypothesize is due to pressure by the operating-table leading to rhabdomyolysis and the creation of a compartment syndrome. Prevention may be aided by attention to intraoperative padding and positioning, and by limiting the duration of the operation.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
8/27. Correction of AV-nodal block in a 27-year-old man with severe obstructive sleep apnea--a case report.A 27-year-old morbidly obese man diagnosed with severe obstructive sleep apnea (OSA) and experiencing significant ventricular asystoles at times exceeding 8 seconds, during polysomnography. The bradyarrhythmias were successfully corrected with the application of a nasal continuous positive airway pressure (CPAP) mask. Follow-up 24-hour ambulatory Holter monitoring without the aid of a nasal CPAP mask and repeat polysomnography with a CPAP mask after several weeks of continuous CPAP therapy during sleep revealed no evidence of ventricular asystole, despite no change in the patient's body mass index. We discuss several mechanisms explaining the findings in this particular patient.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
9/27. Intra-operative pneumothorax complicating laparoscopic Roux-en-Y gastric bypass.BACKGROUND: Intra-operative pneumothorax (PTX) is an infrequent complication of laparoscopic surgery. Most cases are attributed to CO(2) diffusion across congenital diaphragmatic defects and resolve spontaneously. We report a case of PTX during a laparoscopic Roux-en-Y gastric bypass (LRYGBP). When applied to this specific patient population, the current literature recommendations for the management of intra-operative PTX are questioned. MATERIAL AND methods: A retrospective chart review of 400 consecutive LRYGBP procedures performed over a 30-month period revealed 1 case of PTX (0.025%). RESULTS: A bulging left diaphragm, hypotension, bradycardia, decreased pO(2), and elevated EtCO(2) and airway pressures, were noted early in the case. She initially responded to conservative management but required multiple subsequent hospital admissions for pulmonary complications. CONCLUSIONS: pneumoperitoneum-induced PTX during laparoscopic bariatric surgery is a rare complication. Its treatment must be based on the potential underlying cause, with consideration of these patients' often delicate pulmonary status. In stable patients, where the PTX is attributed to diaphragmatic or hiatal dissection, expectant treatment is appropriate. In all other situations, however, we believe that tube thoracostomy is indicated. An algorithm for treatment of PTX in laparoscopic bariatric surgery is proposed. It follows the dictum of maintaining extreme vigilance and a low threshold for aggressive intervention in this group of patients.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
10/27. Very low-dose spinal anesthesia for cesarean section in a morbidly obese preeclamptic patient and its potential implications.To our knowledge, based on a literature search, this is the first case report of successful cesarean section requiring a very low total dose of 5 mg hyperbaric spinal bupivacaine without any spinal or intravenous supplements in a morbidly obese (BMI=66 kg/m(2)) preeclamptic parturient. This parturient appeared to be more sensitive than the average to spinal anesthesia for cesarean section. Titrating the neuraxial drugs to effect with a combined spinal-epidural or epidural technique instead of a single-shot spinal may be useful in cases such as this. This report does not suggest the routine use of low-dose spinal anesthesia without supplements, but illustrates the wide variability in dosage and sensitivity to spinal anesthetics, and suggests that further research is needed in this area, particularly in morbidly obese parturients. Furthermore, it emphasizes the importance of vigilance and frequent blood pressure and respiration monitoring even in cases of low-dose spinal analgesia, such as that used in the combined spinal-epidural technique for labor analgesia.- - - - - - - - - - ranking = 0.2keywords = pressure (Clic here for more details about this article) |
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