Question of the Month – June 2019 Written by: Bob Wilder, MD The Mayo Clinic, Rochester, MN A 15-year-old girl developed an acute viral intestinal illness several months ago with nausea, vomiting and diarrhea. These symptoms resolved in 7 – 10 days, but she has had postprandial right upper quadrant abdominal pain since. She notes that she also hurts with exercise. A pediatric gastroenterologist has seen her and has completed a workup consisting of a normal abdominal ultrasound, an EGD that was normal both visually and by pathology. Disaccharidase levels are normal. Gastric emptying studies were also normal. Fructose breath test was normal. Abdominal radiograph shows “non-obstructive pattern with mild to moderate stool in the colon.” She may have increased pain with bearing down to have a bowel movement, but it returns to baseline thereafter. On exam the gastroenterologist states she has a “positive Carnett’s sign” in the right upper quadrant. What is a Carnett’s sign? A) Carnett’s sign is increased abdominal wall tenderness when the abdominal wall muscles are tensed. B) Carnett’s sign is pain in the right lower abdominal quadrant on palpation of the left side of the abdomen. C) Carnett’s sign refers to pain upon removal of pressure rather than application of pressure to the abdomen. D) Carnett’s sign is pain when the patient is asked to cough whilst tensing the psoas muscle. None Time's up
Question of the Month – May 2019 Submitted by:Michelle S. Kars, MD, FAAPNorth American Partners in Anesthesia A 3 day-old full-term infant weighing 3.7 kg presents for thoracotomy for repair of esophageal atresia. Echocardiogram reveals a small PFO. Currently the infant is on nasal O2 with no pulmonary distress. Laboratory data is significant for INR of 1.4, and platelets of 60,000. On discussion with the surgical and NICU teams, they would like to avoid prolonged intubation after surgery. Which of the following will provide thoracic dermatomal coverage and the longest duration block in order to minimize opioids and expedite extubation following surgery? A) Quadratus Lumborum (QL) block B) Erector Spinae Plane (ESP) block C) Single shot caudal D) Local anesthetic (LA) intercostal infiltration by surgeon None Time's up
Question of the Month – April 2019 This question submitted by Timothy Casias, MDA 15-year-old, 50-kilogram female has history of Complex Regional Pain Syndrome in her right lower extremity for the last 5 years. She presents to the operative room for an open reduction and internal fixation of a displaced distal tibial shaft fracture after falling on ice and hitting her right lower leg on the curb during the winter. She previously is quite disabled from CRPS and spends most of the time in a wheelchair. The decision is to place a popliteal catheter for post-operative pain control. The operation was uneventful, and she has good analgesia with the catheter running 0.2% ropivacaine at 6 ml/hr. Approximately 36 hours after the operation, she has increasing, severe pain. What is your biggest concern for this patient? A. Worsening CRPS B. Failure of regional catheter C. Compartment Syndrome D. Infection None Time's up
Question of the Month – February 2019 The question submitted by Franklin Chiao.A 10-year-old patient with joint hypermobility syndrome presents with acute on chronic pain after a minor orthopedic procedure . She frequently experiences gerd, generalized joint pain, muscle weakness, and disrupted proprioception. She also has a history of anxiety, depression, and fears the onset of pain. Her parents are distressed and concerned. Which of the following would be a good immediate post-operative treatment plan? a) Physical therapy promoting cardiovascular fitness b) Psychological counseling including relaxation techniques c) Intravenous lidocaine infusions for reduction in pain d) Weekly rehabiliation sessions for 6-8 weeks None Time's up
Question of the Month – November 2018 This question submitted by Rani Sunder and Franklin Chiao. A 6-month old boy presents for proximal hypospadias repair. The plan is to perform the surgery under general anesthesia with supplemental regional anesthesia. Which analgesic technique would best manage intraoperative and post-operative pain? A. Penile block B. Pudendal block C. Caudal block D. Spinal None Time's up