Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report

Introduction: Hydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment. Case Report: We report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation. Conclusion: The presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

No Implementation Without Representation: Real-Time Pharmacist Intervention Optimizes Rapid Diagnostic Tests for Bacteremia at a Small Community Hospital

Background: Rapid diagnostic tests (RDTs) for bacteremia allow for early antimicrobial therapy modification based on organism and resistance gene identification. Studies suggest patient outcomes are optimized when infectious disease (ID)-trained antimicrobial stewardship personnel intervene on RDT results. However, data are limited regarding RDT implementation at small community hospitals, which often lack access to on-site ID clinicians. Methods: This study evaluated the impact of RDTs with and without real-time pharmacist intervention (RTPI) at a small community hospital with local pharmacist training and asynchronous support from a remote ID Telehealth pharmacist. Time to targeted therapy (TTT) in patients with bacteremia was compared retrospectively across 3 different time periods: a control without RDT, RDT-only, and RDT with RTPI. Results: Median TTT was significantly faster in both the RDT with RTPI and RDT-only groups compared with the control group (2 vs 25 vs 51 hours respectively; P < .001). TTT was numerically faster for RDT with RTPI compared with RDT-only but did not reach statistical significance ( P = .078). Median time to any de-escalation was significantly shorter for RDT with RTPI compared with both RDT-only (14 vs 33 hours; P = .012) and the control group (14 vs 45 hours; P < .001). Median length of stay was also significantly shorter in both RDT groups compared with the control group (4.0 vs 4.1 vs 5.5 hours; P = .013). Conclusion: This study supports RDT use for bacteremia in a small community hospital with ID Telehealth support, suggesting additional benefit with RTPI.

Repurposing a Small Community Hospital Surgical Residency Program in an Epicenter of the COVID-19 Pandemic

Background COVID-19 put a stop to the operative experience of surgical residents, leaving reassignment of the team, to the frontlines. Each program has adapted uniquely; we discuss how our surgical education changed in our hospital. Study Design A retrospective review of changes in general surgery cases, bedside procedures, and utilization of residents before and during the pandemic. Procedures were retrieved from electronic medical records. Operating room (OR) cases 1 month before and 5 weeks after the executive order were collected. Triple lumen catheter (TLC), temporary hemodialysis catheter (HDC), and pneumothorax catheter (PC) insertions by surgical residents were recorded for 5 weeks. Results Before the pandemic, an average of 27.9 cases were done in the OR, with an average of 10.1 general surgery cases. From March 23 to April 30, 2020, the average number of cases decreased to 5.1, and general surgery cases decreased to 2.2. Elective, urgent, and emergent cases represented 83%, 14.6%, and 2.4% prior to the order and 66.7%, 15.1%, and 18.2%, respectively, after the order. Bedside procedures over 5 weeks totaled to 153, 93 TLCs, 39 HDCs, and 21 PCs. Conclusion Repurposing the surgical department for the concerns of the pandemic has involved all surgical staff. We worked with other departments to allocate our team to areas of need and re-evaluated daily. The strengths of our team to deliver care and perform many bedside procedures allowed us to meet the demands posed by this disease while remaining as a cohesive unit.

Duodenal perforation in the pediatric population: two rare cases at a small community hospital

Duodenal ulcer perforation is very uncommon in the pediatric population; hence, it is usually not considered in the differential diagnosis of acute abdomen in this age group. In our small community hospital, we had two rare cases of perforated peptic ulcer in the pediatric population within a short span of time. A 14-year-old male and a 13-year-old female child presented to the emergency room with acute abdominal pain. No other symptoms were reported and neither had any history of peptic ulcer disease. Abdominal CT showed pneumoperitoneum consistent with perforated hollow viscus. Subsequent exploratory laparotomy indicated perforated duodenal ulcer in both children. These cases illustrate that perforated peptic ulcers should be considered in children presenting with acute abdomen.

Higher naloxone dosing may be required for opioid overdose

Purpose Carfentanil is a synthetic opioid with an estimated potency that is 10,000 times more than that of morphine and 100 times more than that of fentanyl. Although there is a paucity of evidence, when considering the potency of carfentanil, it is reasonable to speculate that larger doses of naloxone may be required to resuscitate patients after carfentanil ingestion. This case report discusses the use of high-dose naloxone in 2 patients with suspected carfentanil overdose presenting to a small community hospital. Summary Two patients with suspected carfentanil overdose presented to a 30-bed emergency department at a community hospital in New Hampshire. Cyanosis and respiratory distress were noted in both instances, and airway intervention was ultimately deemed necessary. Patient 1 required a total of 12 mg of naloxone to be successfully resuscitated, while patient 2 required a total of 10 mg for resuscitation. Both patients were successfully resuscitated with high doses of naloxone. The use of high-dose naloxone prevented the need for intubation in these patients. Conclusion While more robust studies should be considered, emergency personnel should be comfortable using higher-than-standard doses of naloxone in appropriate cases.

Development and implementation of a regional anesthetic service by general anesthesiologists for total joint arthroplasty patients in a small community hospital in the United States

Background & Objective: Regional anesthesia (RA) blocks are most commonly performed in large academic hospitals and has been shown to reduce postoperative pain. The lack of RA blocks in rural hospitals leaves a large subset of the population without availability of this service. In North Carolina, there is an increased need for these services in small community hospitals. This study examined RA nerve block success rates for total knee, hip, and shoulder arthroplasty procedures. We hypothesized that through proper mentorship, general anesthesiologists could provide safe and efficacious RA blocks at a small, community hospital.Methodology: An Institutional Review Board (IRB) approved retrospective study was performed at Lexington Medical Center (LMC), in Lexington, North Carolina part of Wake Forest Baptist Health. We analyzed 307 patients who underwent total joint arthroplasty (195 knee, 69 hip and 43 shoulder replacements) at LMC. Demographics, type of blocks, block success, and intraoperative analgesics used were also recorded. VAS was used to assess postoperative pain.Results: We found an overall success rate of 96.3% for all joints; 95.2%-femoral or 98.9%-adductor canal, 90.4%-lumbar plexus, 100%-interscalene block for knee, hip and shoulder arthroplasties respectively. 283/307 (92.2%) patients reported a verbal pain score between 0-2 in the PACU. There was a significantly higher mean fentanyl dose/h in patients that did not receive a lumbar plexus block for hip procedures.Conclusion: The results of our study support that general anesthesiologists can provide rural communities with quality, specialized regional anesthesia care safely, and at an equivalent level to that of anesthesiologists specialized in RA blocks at large academic institutions.Citation: VanEenenaam DP, Johnson KN, Harris HM, Choi JA, Bullock MW, Forest DJ, Bryan YF. Development and implementation of a regional anesthetic service by general anesthesiologists for total joint arthroplasty patients in a small community hospital in the United States. Anaesth pain & intensive care 2019;23(3):250-255