Saudi Journal of Anaesthesia最新文献

Regional anesthesia has become an integral component of postoperative analgesia and multimodal analgesia during surgery, providing opioid sparing effects and maintaining a beneficial adverse effect profile. Although neuraxial techniques were initially the primary techniques used for intraoperative and postoperative anesthesia and analgesia, many of these techniques have been replaced by selective nerve blockade. This has been facilitated by the widespread use of ultrasound-guided over conventional landmark techniques. Fascia iliaca compartment blockade (FICB) is performed by depositing a local anesthetic agent underneath the FI fascial sheath which lies on top of the iliopsoas muscle. With the landmark technique, the FICB is more commonly applied using an approach below the inguinal ligament. Advancements in the use of ultrasound have led to development of a potentially superior suprainguinal fascia iliaca (SIFI) block for hip and thigh surgery. An improved cephalad distribution of the local anesthetic solution within the fascia iliaca compartment and comparable analgesic efficacy compared to the more invasive lumbar plexus block has resulted in increased use of the SIFI block in both adults and pediatric-aged patients. The SIFI block aims to target the femoral nerve (FN), lateral femoral cutaneous nerve (LFCN), and obturator nerve (ON), thus providing analgesic coverage for hip, femur, and thigh surgery. Although the FN and LFCN are reported to be consistently blocked by the suprainguinal approach, blockade of the ON may be less reliable and requires a higher volume of the local anesthetic agent, proving this technique to be a volume-dependent block. A lower volume of local anesthetic solution may be associated with block failure, especially in the area supplied by the ON and less frequently in the distribution of the LFCN. Thus, local anesthetic concentration must be adjusted in smaller children and infants to maintain effective volume while not exceeding local anesthetic dosing limitations. The current manuscript reviews the innervation of the lower extremity including the anatomy of the fascia iliaca compartment, outlines different approaches for the fascia iliaca block, and reviews the current practice of SIFI blockade in adults and children.

Trans-Nasal Trans-Sphenoidal (TNTS) route has become the preferred conduit for operating on a surgically amenable pathology of pituitary gland. The procedure necessitates close monitoring of perioperative hemodynamic stability, especially in patients with impaired heart function. Patients with coronary artery disease (CAD) and compromized cardiac function with very low ejection fraction increase the risk of perioperative major adverse cardiac events (MACE). In this case, a 54-year-old obese female, a known case of CAD post-PTCA with left ventricular systolic dysfunction with apical hypokinesia, complete left bundle branch block with an ejection fraction of 30% with hypertension and diabetes in the last 5 years under medication posted for TNTS excision. A combination of regional and general anesthesia was adopted to curb the sympathetic stimulus, blunt the surgical stress response and pressor response at various stimulating time points, and minimize sympathetic stimulation in the perioperative period. Minimal fluctuation in heart rate and blood pressure during the surgery was observed, which was supposedly attributed to sphenopalatine ganglion (SPG) block and lignocaine. This case underscores the importance of implementation of USG-guided bilateral SPG block and lignocaine infusion and represents a novel approach in perioperative anesthetic management, particularly for cardiac patients undergoing TNTS surgery with low ejection fraction.

Vasoplegia, characterized by low systemic vascular resistance despite normal to high cardiac output, can result from various conditions, including cardiac surgery, and progress to vasoplegic shock if untreated. This case study involves a male in his 70s with multiple risk factors, including a left ventricular ejection fraction of 35%, who developed vasoplegia after taking lisinopril on the day of his elective coronary artery bypass graft (CABG) surgery. Despite initial management with vasopressors, the patient's condition necessitated postponing the CABG. The patient was stabilized in the ICU with a combination of vasopressin, epinephrine, norepinephrine, and hydrocortisone, and his vasoplegia was successfully treated with hydroxocobalamin, leading to significant clinical improvement. The patient later underwent a successful CABG without preoperative ACE inhibitor use. This case underscores the potential of hydroxocobalamin as an effective treatment for vasoplegia, particularly following ACE inhibitor use in cardiac surgery patients.

Interscalene and supraclavicular brachial plexus nerve blocks are routinely used for upper extremity surgeries, although they carry the risk of phrenic nerve involvement, which can lead to diaphragmatic paralysis. The costoclavicular block is a newer block that may mitigate the risk of this complication while providing similar coverage. Our case involves a patient who presented with a displaced distal radius fracture. He received a preoperative single-shot costoclavicular nerve block before undergoing a distal radius open reduction and internal fixation. The patient did not require any opioids or other pain medications intraoperatively or postoperatively in the post-anesthesia care unit. This case supports the utility of using a costoclavicular nerve block for upper extremity surgeries.

Supraglottic carcinoma presents significant challenges in airway management during general anesthesia. We report a case of a 26-year-old female with extensive supraglottic growth undergoing a biopsy. Awake fiber-optic intubation was performed due to the risk of airway obstruction and difficulty with direct laryngoscopy. Upper airway anesthesia was achieved with nebulized lignocaine and the spray-as-you-go technique. Successful intubation was followed by an uneventful surgical procedure and a smooth recovery. This case highlights the efficacy and safety of awake fiber-optic intubation in managing difficult airways in patients with supraglottic tumors, minimizing complications and enhancing patient outcomes.