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Neurogenic stunned myocardium (NSM) is syndrome of myocardial dysfunction following an acute neurological insult. We report a case of NSM that occurred intraoperatively in a pediatric patient undergoing endoscopic fenestration and shunt revision. Accidental outflow occlusion of irrigation fluid and ventricular distension resulted in an acute increase in heart rate and arterial blood pressure. Subsequently, the patient developed stunned myocardium with global myocardial hypokinesia and pulmonary edema. She was promptly treated intraoperatively then admitted to the pediatric intensive care unit with resolution of her symptoms within 12 h. She was later discharged to home on the fourth postoperative day. In the current endoscopic era, this report highlights the possibility of intraoperative NSM and neurogenic pulmonary edema in the pediatric population. Early detection and treatment with a team approach help to achieve optimal control of this life-threatening condition and improve the outcome.

Regional topography and climate variation yield differences in ecosystem attributes that make spatially scaled estimates of forest productivity challenging. Foliar nitrogen is a primary indicator of forest ecosystem productivity and is used in regional estimates of terrestrial productivity, but this characteristic has not been well described in the Central Appalachian region. Here we describe foliar and soil N variation among species and elevations at two spatial scales in the Central Appalachian region: (1) across the Elklick watershed in the Fernow Experimental Forest and (2) across the state of West Virginia. We found higher foliar N concentrations at both scales than those previously reported for other temperate forest regions. Canopy and soil nitrogen concentrations were also much greater in the Fernow than generally observed across West Virginia. Soil N concentrations in the Fernow were two times greater than those observed across West Virginia.Species-related differences were observed at both spatial scales, but were not always consistent. Canopy N ranges are generally consistent across elevations throughout the state of West Virginia, but should be scaled according to species-related elevation effects for studies that estimate productivity differences in response to harvest or changing species composition. The incongruence of foliar and soil N concentrations at the Fernow Experimental Forest are not explained by elevation or species composition, but are likely a consequence of greater historical N and H + deposition relative to the surrounding West Virginia region.

Importance: Operative laryngoscopy is a commonly performed ambulatory procedure in patients with significant co-morbidity. Optimal anesthetics for surgical exposure with rapid return to baseline after the procedure enhances postoperative patient safety. Objective To determine whether sugammadex hastens recovery in patients undergoing operative laryngoscopy under general anesthesia with rocuronium-induced paralysis. Design Prospective clinical intervention randomized single-blinded, single-center study in an academic tertiary care center. Approved by the institutional review board and registered with ClinicalTrials.gov Settings Single center tertiary care academic institution. Participants 18 years or older, American Society of Anesthesiology physical status I–III with ability to give written informed consent undergoing operative laryngoscopy. Intervention Participants were randomized into two groups. Both groups received inhaled anesthetic: sevoflurane, remifentanil, and rocuronium at 0.6–1.2 mg/kg for intubation and anti-nausea prophylaxis. Group 1 received reversal with neostigmine (0.04 mg/kg) and glycopyrrolate (0.01 mg/kg). Group 2 received reversal with sugammadex (4 mg/kg). Vital signs were maintained at 20% of baseline in both groups. Post anesthesia care unit nurses were blinded to the reversal agent and were the evaluators of the discharge criteria and times. Primary end point was time to extubation after the procedures and secondary end points were: Subjective interpretation of surgical conditions by the surgeon, hemodynamic, respiratory parameters, anesthetics, and opioids used, operative time, and duration to achieve discharge readiness. Results A total of eighty-four participants, who were similar in age, sex, and weight in both groups. The primary end point and secondary end points were similar except time to meet discharge criteria in the two groups. 65% in the sugammadex versus 35% in the neostigmine group met Aldrete criteria of 18 or higher on arrival at the post anesthesia care unit. Conclusions Optimizing the anesthetic regimen, along with stable intraoperative hemodynamics and reversal with sugammadex improves discharge readiness in patients undergoing operative laryngoscopy.