Anesthesia and pain medicine最新文献

Background: Cerebrospinal fluid (CSF) leakage may cause intracranial hypotension and postural headache. Secondary intracranial hypotension may result from an iatrogenic dural puncture or traumatic injury associated with pain procedures.

Case: A 45-year-old male developed a headache 26 days after spinal pain procedure. Headache was characterized as postural, worsening with standing or sitting and improving while lying down. The pain did not resolve despite the administration of oral and intravenous analgesics. A spinal magnetic resonance imaging revealed epidural venous congestion and a suspicious CSF leak around the left L4/5 level. The patient received an epidural blood patch (EBP), the headache improved dramatically, and the patient was discharged.

Conclusions: Delayed postural headaches may not be directly related to pain management. Nevertheless, intracranial hypotension related to pain management should be suspected even in this case. If confirmed, quickly applying an EBP is an effective treatment option.

Spinal anesthesia (SA) is gaining recognition as a safe and efficacious regional alternative to general anesthesia for elective lumbar surgery. However, unfamiliarity with management issues related to its use has limited the adoption of awake spine surgery, despite its benefits. Few centers in the United States routinely offer SA for elective lumbar surgery, and a comprehensive workflow to standardize SA for lumbar surgery is lacking. In this article, we examine recent literature on the use of SA in lumbar surgery, review the experience of our institution with SA in lumbar surgery, and provide a cohesive outline to streamline the implementation of SA from the perspective of the anesthesiologist. We review the critical features of SA in contemporary lumbar surgery, including selection of patients, methods of SA, intraoperative sedation, and management of several important technical considerations. We aimed to flatten the learning curve to improve the availability and accessibility of the technique for eligible patients.

Background: Internal jugular veins are the most frequently accessed site for central venous catheterization in patient management, whereas complications involving vertebral veins are a rare occurrence.

Case: A 73-year-old male suspected to have a urothelial carcinoma was scheduled for elective left nephroureterectomy. During central venous catheterization using the anatomic landmark technique to target the internal jugular vein, a guidewire is inadvertently inserted into the suspected vertebral vein. Following the correction of the catheterization, a radiologist reviewed the preoperative enhanced computed tomography and confirmed that the initially punctured vessel was the vertebral vein. On the third day after surgery, the central venous catheter was removed, and the patient did not exhibit any complications, such as bleeding, swelling, and neurological symptoms.

Conclusions: The use of ultrasonography during central venous catheterization is recommended to evaluate the anatomy of the puncture site and prevent misinsertion of the catheter, which can lead to several complications.

Background: Acute-on-chronic liver failure (ACLF) is a life-threatening disease that requires urgent liver transplantation (LT). Accurate identification of high-risk patients is essential for predicting post-LT survival. The chronic liver failure consortium ACLF score is a widely accepted risk-stratification score that includes total white blood cell (WBC) counts as a component. This study aimed to evaluate the predictive value of total and differential WBC counts for short-term mortality following LT in patients with ACLF.

Methods: A total of 685 patients with ACLF who underwent LT between January 2008 and February 2019 were analyzed. Total and differential WBC counts were examined as a function of the model for end-stage liver disease for sodium (MELD-Na) score. The association between total and differential WBC counts and 90-day post-LT mortality was assessed using multivariable Cox proportional hazards regression analysis.

Results: The total WBC counts and neutrophil ratio were higher in patients with ACLF than in those without ACLF. The neutrophil ratio was significantly associated with 90-day post-LT mortality after adjustment (hazard ratio [HR], 1.04; P = 0.001), whereas total WBC counts were not significantly associated with 90-day post-LT mortality in either univariate or multivariate Cox analyses. The neutrophil ratio demonstrated a relatively linear trend with an increasing MELD-Na score and HR for 90-day post-LT mortality, whereas the total WBC counts exhibited a plateaued pattern.

Conclusions: Neutrophilia, rather than total WBC counts, is a better prognostic indicator for short-term post-LT mortality in patients with ACLF.

Background: Endobronchial ultrasound (EBUS) is widely used to diagnose lung cancer. Monitored anesthesia care (MAC) can enhance patient comfort and procedural conditions during EBUS. EBUS under MAC is usually safe but can lead to various complications.

Case: A 34-year-old male who had increased sputum for two months showed an enlarged paratracheal lymph node and planned for lymph node biopsy by EBUS. During EBUS under MAC, an unexpected oxygen saturation decline required intervention. After intubation, copious frothy fluid was suctioned from the bronchi, and oxygenation was recovered. A narrowed trachea and the EBUS bronchoscope might have resulted in upper airway obstruction, and suction performed under these conditions might have caused pulmonary edema. The patient received non-invasive ventilation and high-flow nasal cannula and recovered without complications.

Conclusions: When there is an expected risk of upper airway obstruction during EBUS, careful preoperative evaluation and preparation are essential to prevent negative pressure pulmonary edema.