Background: Obtaining a central line access is an essential procedure that is necessary in various settings to facilitate the administration of medication. An implantable central line, also known as a portacath, is a subtype with a reservoir installed into a subcutaneous pocket and attached to a catheter.

Case presentation: This is a case of a fractured portacath implanted for the administration of calcium in a two year old female resulting from high syringe pressure.

Discussion: Complications range from immediate injury to vascular and surrounding structures to a delayed manifestation of infection and device malfunction. Catheter fracture in vivo is a very rare complication especially in the paediatric population.

Conclusions:Appropriate size of syringe should be checked with the portacath manufacturer prior to use in order to avoid fracture as a result of high syringe pressure.

Background: Necrotizing fasciitis is a potentially lethal soft tissue infection characterized by rampant necrosis and destruction of subcutaneous tissues. Current estimates of necrotizing soft tissue infections in the United States are 4.3 infections per 100,000 of the population. Although the incidence of necrotizing soft tissue infections has decreased in the last decade, the toxic and lethal nature of the disease process lends utmost importance to accurate diagnosis and immediate management. The purpose of this review article is to report three cases of necrotizing fasciitis and provide literature review in regards to hallmark characteristics, predisposing risk factors and treatment optimization.

Case: The first case depicts a newly diagnosed 43-year-old male HIV patient with necrotizing fasciitis infection characterized by Klebsiella, Serratia and anaerobic bacteria cultures. The second case describes the course of a 71-year-old male diagnosed with necrotizing fasciitis in the setting of a complicated anal fistula characterized by B. fragilis, S. anginosus and Prevotella species. The third and final case describes the course of a 44-year-old female diagnosed with necrotizing fasciitis in the setting of Ludwig’s Angina characterized by Klebsiella and Dubliensis species. Treatment was initiated with extensive wound debridement, multiple washouts and broad antibiotic regimens in all three cases. Additional hyperbaric oxygen therapy was administered in the third case.

Conclusions:These case reports illustrate the range of severity and settings in which necrotizing fasciitis can occur. Significant morbidity and mortality rates are associated with a delay in treatment initiation. Given this, it is of utmost importance to develop and maintain a high clinical acumen for necrotizing soft tissue infections.

L:Guidewires (Kirschner or “K” wires) are often required during minimally invasive spine surgery to facilitate percutaneous pedicle screw placement. The use of guidewires involves a multi-step process that carries the risk of complications and their associated consequences. To date, the reporting of such information has been limited, and the literature has not been thoroughly evaluated. The objective of this study was to conduct a narrative review and assess the burden associated with guidewire use in spine surgeries. Databases searched included PubMed and Embase between the years of 1988 and 2017. In addition to databases, recent data from relevant trade journals were hand-searched. Inclusion criteria were broad to avoid potential exclusion of relevant publications. In total, 31 articles were included. This review found that the risk of complications associated with guidewire use in spine procedures ranged from 0.4% to 14.8%. Complication types included guidewire fracture, cerebrospinal fluid leakage, post-operative ileus, infection, and other spinal hardware failure (e.g., pedicle screw pull-out). Causes of complications typically included breakage and migration of the guidewire (metal fatigue), inexperience with guidewire use, or lack of tactile or visual feedback. Specific surgery types or patient populations may be more susceptible to guidewire-related complications (e.g., L5-S1 level operations). Complications associated with guidewire use may also lead to healthcare resource utilization, including additional operating time, radiation exposure, and re-operations. Solutions to help minimize the risk of such complications and associated consequences are required.

Reports of bilateral Preiser’s disease-avascular necrosis of the scaphoid -- are rare with only 4 cases reported in the English literature. We present the fifth reported case of bilateral Preiser’s disease in the setting of a previously undiagnosed hypercoagulability disorder.

Traumatic tension pneumothoraces can result from blunt or penetrating trauma. We present a case of a 48-year-old man that was diagnosed with traumatic tension pneumothorax following anterior penetrating left hemithorax trauma from a Sylvester Palm frond thorn. Prior reports of traumatic tension pneumothoraces resulting from Sylvester Palm frond thorns were not found in the surveyed literature.

Objective: Current literature debates whether administration of sugammadex translates into a higher operating room (OR) efficiency when compared to neostigmine. This study is a blinded assessment of the effects of sugammadex versus neostigmine on OR efficiency as determined by time of reversal to time of the next case.

Methods: 50 patients undergoing abdominal surgery were randomized and evenly distributed into two groups, one receiving sugammadex (4 mg/kg) and the other, neostigmine (0.06 mg/kg) plus glycopyrrolate (0.004 mg/kg). Muscle paralysis was induced with intravenous rocuronium (0.6 mg/kg). Train of four (TOF) was monitored using acceleromyography every 10 minutes until reversal. Reversal agents were blindly prepared and administered during closing. TOF was then recorded every minute until a T4/T1 ratio ≥ 0.9 was achieved. This was designated as time of complete reversal. Subsequently, post-reversal outcome measures were collected.

Results:Patients receiving sugammadex experienced a significantly shorter reversal time compared to those receiving neostigmine and glycopyrrolate (2.92 ± 1.71 minutes vs. 7.68 ± 5.63 minutes; p =.0002). No other outcome measures were significantly different between groups: time of OR ready for next case was 55.4 min vs. 56.1 min respectively; not significant.

Conclusions:While sugammadex was significantly faster at reversing patient neuromuscular blockade the time from reversal to patient extubation after Sugammadex was prolonged.. This could be due to blinding, as blinded providers are unable to anticipate time of reversal and must compensate by making decisions at safe fixed intervals. This is reflected in that the time gained by administration of sugammadex is approximately equal to the delay experienced across all endpoints collected to the patients’ actual discharge.

Duodenal duplication cysts (DDC) are a rare type of enteric duplication. We describe the clinical presentation and laparoscopic management of a 7-year-old boy with a periampullary DDC.We also discuss the embryologic and imaging features that distinguish DDC from choledococele (CC). Careful consideration of the anatomic relationships between the ampulla, common bile duct, and duplication cyst are essential to avoid intraoperative bile duct injury.