Continuing Education

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done. Eight hours later, the patient became hypotensive and hypoxemic and emergent CT revealed a gastric perforation. The patient was transferred to the intensive care unit and ultimately required endotracheal intubation with mechanical ventilation. The commentary discusses the complications associated with nasogastric tube insertion, assessing and treating acute agitation secondary to delirium, and the importance of clear communication during shift changes and handoffs.

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone. The patient subsequently developed severe metabolic encephalopathy due to overdose of both gabapentin and opiates and failure to reduce medication doses in the setting of ESRD. The commentary discusses pain management and the signs of gabapentin toxicity in patients with renal dysfunction, as well the implications of clinical decision support-related alert fatigue and approaches to reduce adverse events arising from drug-disease interactions.

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest. In the second case, the patient underwent an uncomplicated elective thyroid lobectomy but developed increased neck pain and swelling the next day. A large hematoma was identified, and the patient was taken emergently to the operating room for evacuation. The commentary discusses risk factors for postoperative cervical hematomas, the importance of prompt identification and evaluation of cervical hematomas in the early postoperative period, and approaches for managing postoperative cervical hematomas.

This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic testing. The patient was admitted to the hospital with gastrointestinal symptoms and diagnosed with cholecystitis and gangrenous gallbladder. Two months after his admission for cholecystitis, he was readmitted for severe vomiting and hypotension. An upper gastrointestinal endoscopy with biopsy unexpectedly showed that his duodenum was heavily infiltrated with a parasitic helminth (worm) called Strongyloides stercoralis. He was treated with the anti-parasitic drug ivermectin and eventually improved enough to be discharged from the hospital. The commentary summarizes factors contributing to the missed diagnosis of strongyloidiasis, potential consequences of a failure to diagnose this infection, and approaches to identify patients who should be tested for Strongyloides infection.

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns. While preparing the patient for discharge, the nurse paged the fellow requesting discharge orders. The fellow assumed that the attending physician had reviewed the CXR and submitted the discharge orders as requested. Thirty minutes after the patient was discharged the radiologist called the care team to alert them to the finding of pneumothorax on the post-procedure CXR. The commentary summarizes complications associated with bronchoscopy and strategies to improve perioperative safety.

A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally. The operative note mentioned no visible injury upon entry into the abdominal cavity, but there were extensive adhesions in the pelvis. Nine hours after discharge, the patient presented to another hospital due to increasing pain, nausea, and fever. The patient underwent a laparotomy and the surgical team found fecal contamination upon entry into the peritoneal cavity; the surgeons concluded that the most plausible explanation was a trocar injury. The commentary discusses the risk of vascular and bowel injury during peritoneal access for laparoscopy and the importance of patient history and abdominal anatomy when considering approaches to abdominal entry.

A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions  and hospital safety practices that can limit the risk of latex exposure.

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed. A second gastroenterologist suggested a diagnosis of intestinal ischemia to the patient, her primary gastroenterologist, her PCP, and endocrinologist but the other physicians did not follow up on the possibility of mesenteric ischemia. On another ED visit, the second gastroenterologist consulted a surgeon, and a mesenteric angiogram was performed, confirming a diagnosis of mesenteric ischemia with gangrenous intestines. The patient underwent near-total intestinal resection, developed post-operative infections requiring additional operations, experienced cachexia despite parenteral nutrition, and died of sepsis 3 months later.  The commentary discusses the importance of early diagnosis of mesenteric ischemia and how to prevent diagnostic errors that can impede early identification and treatment.

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits. The stroke team did not order emergent CT angiography and perfusion imaging but recommended routine magnetic resonance imaging with angiography (MRI/MRA) for further evaluation, which showed extensive cerebral infarction in the distribution of an occluded left middle cerebral artery (MCA). Due to the delayed diagnosis of left MCA stroke, it was too late to perform any neurovascular intervention. The commentary highlights the importance of timely use of stroke alert protocols, challenges with CT angiography in early acute ischemic stroke, and the importance of communication and collaboration between ED and neurology teams.

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.  An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line.  The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome.  Signs of compartment syndrome eventually resolved without any surgical intervention.  The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.