Newsletter #31
Hey there! I hope you’re all doing well. A warm welcome to our newcomers! This past week, I encountered a case that was too intriguing not to share. Below, I’ve detailed the presentation and initial investigations. I’ll leave the definitive diagnosis and management for next week’s edition—see if you can crack the case before then!
1. Patient History
A 30-year-old female was brought to the Emergency Department (ED) by paramedics after being found unconscious outside a store. No collateral information was available (identity and medical history unknown), and there were no visible signs of trauma or external injury.
2. Clinical Presentation
Upon arrival, the patient was in a deep coma with a Glasgow Coma Scale (GCS) of 6/15. However, the clinical team noted a striking set of paradoxical symptoms:
- CNS Depression: The patient was completely unresponsive to verbal commands.
- No Focal Signs: A neurological exam revealed no signs of CNS localization (no lateralizing signs or focal deficits), suggesting a global rather than a structural brain insult.
- Hyperexcitability: Despite the coma, she exhibited intense, generalized myoclonic jerks triggered by any physical contact or loud noises in the room with bilateral Babinski sign.
- Respiratory Status: RR 18, SpO2 90% on room air. Lungs were clear on auscultation with no signs of hypersecretion.
- Autonomic/Vitals: Temperature was 36.5°C, pupils were miotic, BP was 95/60 mmHg, and HR was 62 bpm.
- Other: Notably, there were no signs of tongue biting or urinary incontinence, making a typical post-ictal state less likely.
3. Diagnostic Findings
Initial lab work was surprisingly unremarkable, adding to the mystery:
- Labs: CBC, electrolytes (Na+, K+, Cl-), blood glucose, urea, creatinine, and hemostasis were all within normal limits.
- Toxicology: Standard screens for opioids, benzodiazepines, and alcohol were negative.
- Imaging: A CT scan of the head showed no acute intracranial pathology.
The Challenge:
Our team considered several possibilities, but it took a specific clinical 'clue' (and some vital history from the family! :) ) to provide the definitive answer.
What’s your top differential? Comment below or wait until next week for the conclusion!
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Anesthesiology:
Systematic reviews & meta-analyses:
1- General:
- Validation status of definitive airway management simulators: a systematic review, BJA, 12 March 2026, Link
2- Airway & Mechanical Ventilation:
- High-Flow Nasal Oxygen and the Risk of Gastric Insufflation: A Systematic Review and Meta-Analysis Supplemented by Narrative Synthesis, A&A, 5 March 2026, Link
Clinical trials:
1- General:
- Comparing Black Coffee to Coffee With Creamer in Gastric Emptying Time: A Nonrandomized Control Trial, A&A Practice, March 2026, Link
- Postoperative Urinary Retention After Reversal of Neuromuscular Block by Neostigmine versus Sugammadex in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Trial, A&A, 6 March 2026, Link
2- Airway & Mechanical Ventilation:
- The effect of high-flow nasal cannula oxygen therapy on preventing hypoxemia during deep sedation extubation after laparoscopic surgery: a prospective randomized controlled trial, BMC Anesthesiology, 11 March 2026, Link
3- Cardiovascular & Hemodynamics:
- Sivelestat and Incidence of Acute Respiratory Distress Syndrome After Cardiovascular Surgery: A Randomized Clinical Trial, JAMA Open, 11 March 2026, Link
4- Thoracic:
- Intravenous lidocaine reduces systemic inflammation but not myocardial injury following thoracic surgery for lung cancer: a randomized controlled trial, BMC Anesthesiology, 7 March 2026, Link
5- Neuro:
- Multisensory virtual reality reduces postoperative delirium in elderly patients undergoing laparoscopic gastrointestinal surgery: A single-centre randomised controlled trial, EJA, 12 March 2026, Link
6- Obstetrics & Gynecology:
- Transthoracic echocardiographic evaluation of maternal cardiac output: colloid preload versus crystalloid coload during cesarean delivery under spinal anesthesia: randomized clinical trial, BMC Anesthesiology, 12 March 2026, Link
7- Pediatric:
- The efficacy of gabapentin in reducing perioperative opioid requirements in pediatric open-heart surgery: a randomized double-blinded controlled study, Journal of Cardiothoracic and Vascular Anesthesia, 6 March 2026, Link
8- Orthopedic:
- Effects of perioperative probiotic supplementation on postoperative gastrointestinal recovery in elderly hip fracture patients: a randomized controlled trial, BMC Anesthesiology, 6 March 2026, Link
9- Regional Anesthesia & Pain Management:
- Analgesic efficacy of liposomal bupivacaine adductor canal block combined with periarticular infiltration after total knee arthroplasty: a prospective, double-blind, randomized controlled trial, BMC Anesthesiology, 12 March 2026, Link
- Effect of preoperative ultrasound-guided stellate ganglion block on pain thresholds and postoperative nausea and vomiting in gynecological laparoscopy: a randomised clinical trial, BMC Anesthesiology, 11 March 2026, Link
- Analgesic efficacy of blocking nerve to vastus lateralis muscle versus lateral femoral cutaneous nerve after knee surgeries: a randomized trial, BMC Anesthesiology, 7 March 2026, Link
- Efficacy and safety of liposomal bupivacaine versus bupivacaine for retrolaminar block for postoperative analgesia in patients undergoing posterior lumbar interbody fusion: a randomized controlled trial, BMC Anesthesiology, 7 March 2026, Link
- Comparison of erector spinae plane block and rhomboid intercostal block for postoperative pain management in patients undergoing unilateral breast surgery, BMC Anesthesiology, 6 March 2026, Link
