Pub Date : 2023-01-01DOI: 10.13107/jaccr.2023.v09.i03.223
Amruta M Kulkarni, Vijay L Shetty, Gurneet Singh Sawhney
Introduction: Language function is complex, involving association between Broca’s motor speech area, Wernicke’s sensory speech area and various interconnected cortical and sub-cortical regions. For lesions in eloquent areas, awake craniotomy with intra-operative neurological monitoring of motor and language function, aids in maximal safe resection of lesion with minimal neurological deficit. Case presentation: We present a case of 40-year-old patient with left frontal lobe lesion involving motor and speech area who underwent awake craniotomy under scalp block and titrated sedation. Though resection was in safe zone as marked both by neuro-navigation and direct electrical stimulation, patient developed aphasia intra-operatively. The aphasia resolved post-operatively with speech therapy over two weeks. Resection in Supplementary motor area (SMA) in the dominant hemisphere may be the likely cause of aphasia in this patient, resulting in reversible SMA syndrome. Conclusion: SMA syndrome must be considered as differential diagnosis of deficit during awake craniotomy when resection is in SMA. Keywords: Aphasia, Supplementary motor area, Awake craniotomy, Eloquent areas
{"title":"Intra-Operative Supplementary Motor Area Aphosia During Awake Craniotomy a Case Report","authors":"Amruta M Kulkarni, Vijay L Shetty, Gurneet Singh Sawhney","doi":"10.13107/jaccr.2023.v09.i03.223","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.223","url":null,"abstract":"Introduction: Language function is complex, involving association between Broca’s motor speech area, Wernicke’s sensory speech area and various interconnected cortical and sub-cortical regions. For lesions in eloquent areas, awake craniotomy with intra-operative neurological monitoring of motor and language function, aids in maximal safe resection of lesion with minimal neurological deficit. Case presentation: We present a case of 40-year-old patient with left frontal lobe lesion involving motor and speech area who underwent awake craniotomy under scalp block and titrated sedation. Though resection was in safe zone as marked both by neuro-navigation and direct electrical stimulation, patient developed aphasia intra-operatively. The aphasia resolved post-operatively with speech therapy over two weeks. Resection in Supplementary motor area (SMA) in the dominant hemisphere may be the likely cause of aphasia in this patient, resulting in reversible SMA syndrome. Conclusion: SMA syndrome must be considered as differential diagnosis of deficit during awake craniotomy when resection is in SMA. Keywords: Aphasia, Supplementary motor area, Awake craniotomy, Eloquent areas","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"46 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371601","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01DOI: 10.13107/jaccr.2023.v09.i03.226
Mohamad Ibrahim Ayoub, Cesar Padilla, Justo Gonzalez, Husien Taleb, Elie Geara, Adeeb Oweidat
We describe a case of preeclampsia where lung ultrasonography facilitated the diagnosis of pulmonary edema while also showing real-time resolution of B-lines after diuresis. The diagnostic accuracy of B-line clearance using lung ultrasonography across diverse patient populations (heart failure, renal failure) holds promise for use in the obstetric patient population. To our knowledge this is the first report which shows real-time resolution of B-lines using lung ultrasonography in a pregnant patient with preeclampsia associated pulmonary edema. Given the established validity of this tool, we believe lung ultrasonography holds promise in the management of critically ill obstetric patients. Keywords: Preeclampsia, TTE (transthoracic echocardiography), POCUS (point-of-care ultrasonography), FRC (functional residual capacity), B-lines, A-lines
{"title":"Sonographic Resolution of B-Lines after Diuresis in a Pregnant Patient with Preeclampsia Associated Pulmonary Edema","authors":"Mohamad Ibrahim Ayoub, Cesar Padilla, Justo Gonzalez, Husien Taleb, Elie Geara, Adeeb Oweidat","doi":"10.13107/jaccr.2023.v09.i03.226","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.226","url":null,"abstract":"We describe a case of preeclampsia where lung ultrasonography facilitated the diagnosis of pulmonary edema while also showing real-time resolution of B-lines after diuresis. The diagnostic accuracy of B-line clearance using lung ultrasonography across diverse patient populations (heart failure, renal failure) holds promise for use in the obstetric patient population. To our knowledge this is the first report which shows real-time resolution of B-lines using lung ultrasonography in a pregnant patient with preeclampsia associated pulmonary edema. Given the established validity of this tool, we believe lung ultrasonography holds promise in the management of critically ill obstetric patients. Keywords: Preeclampsia, TTE (transthoracic echocardiography), POCUS (point-of-care ultrasonography), FRC (functional residual capacity), B-lines, A-lines","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Transurethral resection of bladder tumors (TURBT) is the first-line method and mainstay for endoscopic diagnosis, staging, and treatment of urinary bladder tumours. Hypotonic fluid absorption, electrolyte imbalance from irrigation, haemorrhage, and obturator jerk episodes are just a few of the procedure’s intrinsic risks. Cardiovascular issues were more likely to arise in elderly patients undergoing this surgery. A high risk of pulmonary oedema, arrhythmia, and bleeding problems exists in individuals with coronary artery disease (CAD), dilated cardiomyopathy (DCMP), multiple comorbidities, and anticoagulant medication. Case Presentation: Here, we provide a challenging situation of A 74-year-old man was scheduled to have TURBT (Transurethral Resection of Bladder Tissue) for a bladder mass with hematuria and many comorbidities, including Hypertension (HTN), Chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), post percutaneous transluminal coronary angioplasty (PTCA), cerebrovascular accident (CVA), dilated cardiomyopathy (DCMP), ejection fraction (EF) 25%, and Severe MR necessitating obturator nerve block (ONB), spinal anaesthesia (SA), and epidural anaesthesia (EA) for perioperative and postoperative anaesthetic as well as analgesia, which was effectively handled without any difficulties. Conclusion: Elderly patient with ischemic cardiomyopathy are at higher risk of major cardiovascular events perioperatively. Low dose spinal anaesthesia combined with epidural anaesthesia provides better hemodynamic stability, prevents myocardial depression, provide perioperative analgesia and early ambulation. Keywords: Obturator nerve block, Spinal anaesthesia, General anaesthesia practice, Transurethral Resection of Bladder Tissue (TURBT), Cerebrovascular accident (CVA), Chronic obstructive pulmonary disease (COPD)
{"title":"Low Dose Combined Spinal-Epidural (CSE) Anaesthesia with Blocks for Management of A High-Risk Geriatric Patient with Dilated Cardiomyopathy Posted for TURBT","authors":"Vivek Sharma, Hiteshi Aggarwal, Vivek Prakash, Pallavi Ahluwalia","doi":"10.13107/jaccr.2023.v09.i03.221","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.221","url":null,"abstract":"Introduction: Transurethral resection of bladder tumors (TURBT) is the first-line method and mainstay for endoscopic diagnosis, staging, and treatment of urinary bladder tumours. Hypotonic fluid absorption, electrolyte imbalance from irrigation, haemorrhage, and obturator jerk episodes are just a few of the procedure’s intrinsic risks. Cardiovascular issues were more likely to arise in elderly patients undergoing this surgery. A high risk of pulmonary oedema, arrhythmia, and bleeding problems exists in individuals with coronary artery disease (CAD), dilated cardiomyopathy (DCMP), multiple comorbidities, and anticoagulant medication. Case Presentation: Here, we provide a challenging situation of A 74-year-old man was scheduled to have TURBT (Transurethral Resection of Bladder Tissue) for a bladder mass with hematuria and many comorbidities, including Hypertension (HTN), Chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), post percutaneous transluminal coronary angioplasty (PTCA), cerebrovascular accident (CVA), dilated cardiomyopathy (DCMP), ejection fraction (EF) 25%, and Severe MR necessitating obturator nerve block (ONB), spinal anaesthesia (SA), and epidural anaesthesia (EA) for perioperative and postoperative anaesthetic as well as analgesia, which was effectively handled without any difficulties. Conclusion: Elderly patient with ischemic cardiomyopathy are at higher risk of major cardiovascular events perioperatively. Low dose spinal anaesthesia combined with epidural anaesthesia provides better hemodynamic stability, prevents myocardial depression, provide perioperative analgesia and early ambulation. Keywords: Obturator nerve block, Spinal anaesthesia, General anaesthesia practice, Transurethral Resection of Bladder Tissue (TURBT), Cerebrovascular accident (CVA), Chronic obstructive pulmonary disease (COPD)","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371780","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01DOI: 10.13107/jaccr.2023.v09.i03.224
Husien Taleb, Stefan Trela, Mohammad I Ayoub
Erector spinae plane block (ESPB) is a novel fascial plane block that has been first described in 2016. ESPB has been considered as an alternative for brachial plexus blocks in the shoulder and upper back surgeries as the erector spinae muscle extends to the cervical level. We present a case of a 34-year-old, 6-foot, 145 kg female patient with a BMI of 43.5, for which we successfully inserted dual-level ESPB catheters combined with single shot interscalene for an upper extremity forequarter amputation. Keywords: Erector spinae plane block, Interscalene block, Morbidly obese, Forequarter amputation
{"title":"Perioperative Analgesia for Forequarter Amputation in a Morbidly Obese Patient: Dual ESP Block Catheters Plus Interscalene Block","authors":"Husien Taleb, Stefan Trela, Mohammad I Ayoub","doi":"10.13107/jaccr.2023.v09.i03.224","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.224","url":null,"abstract":"Erector spinae plane block (ESPB) is a novel fascial plane block that has been first described in 2016. ESPB has been considered as an alternative for brachial plexus blocks in the shoulder and upper back surgeries as the erector spinae muscle extends to the cervical level. We present a case of a 34-year-old, 6-foot, 145 kg female patient with a BMI of 43.5, for which we successfully inserted dual-level ESPB catheters combined with single shot interscalene for an upper extremity forequarter amputation. Keywords: Erector spinae plane block, Interscalene block, Morbidly obese, Forequarter amputation","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"69 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01DOI: 10.13107/jaccr.2023.v09.i03.225
Vaibhavi Baxi, Ravisha Parikh
Introduction: Sudden brady-arrhythmias during anaesthesia can be life threatening. Bradycardia and asystole have been reported during Maxillofacial surgeries due to tri-gemino-cardiac reflex. We report a case of a rare complication of asystole following dissection and handling of deep lobe of parotid gland during total parotidectomy under general anaesthesia. Case Presentation: A 70-year-old, 82 kgs, normotensive female scheduled for total left parotidectomy for tumor excision with nerve monitoring under general anaesthesia developed severe bradyarrhythmia soon progressing to asystole; 85 mins into surgery during dissection of deep lobe of parotid possibly due to tri-gemino-cardiac reflex. Conclusion: We present this case of asystole during parotidectomy to demonstrate the significance and possible severity of the reflex bradycardic response during surgical handling of deep lobe of parotid gland. Keywords: Cardiac arrest, Parotidectomy, Resuscitation, General anaesthesia, Nerve monitoring.
{"title":"A Case of Cardiac Arrest During Parotidectomy Surgery","authors":"Vaibhavi Baxi, Ravisha Parikh","doi":"10.13107/jaccr.2023.v09.i03.225","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.225","url":null,"abstract":"Introduction: Sudden brady-arrhythmias during anaesthesia can be life threatening. Bradycardia and asystole have been reported during Maxillofacial surgeries due to tri-gemino-cardiac reflex. We report a case of a rare complication of asystole following dissection and handling of deep lobe of parotid gland during total parotidectomy under general anaesthesia. Case Presentation: A 70-year-old, 82 kgs, normotensive female scheduled for total left parotidectomy for tumor excision with nerve monitoring under general anaesthesia developed severe bradyarrhythmia soon progressing to asystole; 85 mins into surgery during dissection of deep lobe of parotid possibly due to tri-gemino-cardiac reflex. Conclusion: We present this case of asystole during parotidectomy to demonstrate the significance and possible severity of the reflex bradycardic response during surgical handling of deep lobe of parotid gland. Keywords: Cardiac arrest, Parotidectomy, Resuscitation, General anaesthesia, Nerve monitoring.","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371610","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction Long Covid has been recognized as a distinct entity with thrombotic sequelae [1]. Persistent systemic vascular inflammation caused by thrombosis drives the complications associated with long COVID. The risks of arterial and venous thrombosis after COVID-19 extend well beyond the hospitalization period. Early prophylactic anticoagulation has been shown to reduce the incidence of post-covid thrombotic sequelae [2]. Some evidence suggests the use of a higher than prophylactic dose for primary venous thromboembolism prophylaxis, especially in patients with a history of venous thromboembolism (VTE) [1]. We present a case of long Covid who developed recurrent thrombosis despite being on a therapeutic dose of anticoagulation. Case Presentation A 55-year-old male was brought to our Emergency Department with complaints of diffuse abdominal pain and black-coloured stools for three days. Contrast-enhanced CT abdomen (CECT) showed distal superior mesenteric artery (SMA) thrombosis and splenic infarct (Figure 1). He was treated for mild Covid-19 infection three months back. History also revealed he was hospitalized two months ago with a diagnosis of non-ST segment elevated myocardial infarction (NSTEMI) and acute ischemic stroke (Figure 2), which was managed with antiplatelets, statins and anticoagulants. He was discharged on oral anticoagulants (Tab Rivaroxaban 15 mg twice daily) for three months and was on regular follow-up. There was no history of smoking or hypertension. Protein C, Protien S, homocysteine levels were normal. After the diagnosis of SMA thrombosis, his anti-coagulation was increased to Tab Rivaroxaban 20 mg twice daily. No further thrombotic episodes have been noted as of date. Discussion This case suggests that unexplained repeat thrombotic events at multiple sites may have been a consequence of Covid-19 infection. Covid-19 patients experience both arterial and venous thromboembolism [3]. Most commonly, the former presents as myocardial infarction and ischemic stroke, whereas the latter as deep venous thrombosis and pulmonary embolism. Mechanisms include changes in lung structure secondary to chronic hypoxia, persistent immune dysfunction, and endothelial damage [1]. Risks of thrombotic events after mild Covid-19 are less clear, with the need and intensity of prophylactic anti-coagulation in this subset of patients being a matter of future research [4]. Shabaka et al. have shown that patients with a history of Covid-19 infection and previous thromboembolic events were at higher risk of developing a repeat thrombotic event [5]. Physicians need to be vigilant about the thrombotic events in patients with long Covid, even in patients receiving therapeutic anti-coagulation. Such patients require more frequent monitoring for signs of thrombotic events, risk factor management, and adherence to preventive therapies [3].
{"title":"Post COVID Thrombotic Sequelae: Once Bitten, Twice Shy!","authors":"Cherian Roy, Rohit Kumar Patnaik, Samir Samal, Shakti Bedanta Mishra, Nupur Karan","doi":"10.13107/jaccr.2023.v09.i03.227","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.227","url":null,"abstract":"Introduction Long Covid has been recognized as a distinct entity with thrombotic sequelae [1]. Persistent systemic vascular inflammation caused by thrombosis drives the complications associated with long COVID. The risks of arterial and venous thrombosis after COVID-19 extend well beyond the hospitalization period. Early prophylactic anticoagulation has been shown to reduce the incidence of post-covid thrombotic sequelae [2]. Some evidence suggests the use of a higher than prophylactic dose for primary venous thromboembolism prophylaxis, especially in patients with a history of venous thromboembolism (VTE) [1]. We present a case of long Covid who developed recurrent thrombosis despite being on a therapeutic dose of anticoagulation. Case Presentation A 55-year-old male was brought to our Emergency Department with complaints of diffuse abdominal pain and black-coloured stools for three days. Contrast-enhanced CT abdomen (CECT) showed distal superior mesenteric artery (SMA) thrombosis and splenic infarct (Figure 1). He was treated for mild Covid-19 infection three months back. History also revealed he was hospitalized two months ago with a diagnosis of non-ST segment elevated myocardial infarction (NSTEMI) and acute ischemic stroke (Figure 2), which was managed with antiplatelets, statins and anticoagulants. He was discharged on oral anticoagulants (Tab Rivaroxaban 15 mg twice daily) for three months and was on regular follow-up. There was no history of smoking or hypertension. Protein C, Protien S, homocysteine levels were normal. After the diagnosis of SMA thrombosis, his anti-coagulation was increased to Tab Rivaroxaban 20 mg twice daily. No further thrombotic episodes have been noted as of date. Discussion This case suggests that unexplained repeat thrombotic events at multiple sites may have been a consequence of Covid-19 infection. Covid-19 patients experience both arterial and venous thromboembolism [3]. Most commonly, the former presents as myocardial infarction and ischemic stroke, whereas the latter as deep venous thrombosis and pulmonary embolism. Mechanisms include changes in lung structure secondary to chronic hypoxia, persistent immune dysfunction, and endothelial damage [1]. Risks of thrombotic events after mild Covid-19 are less clear, with the need and intensity of prophylactic anti-coagulation in this subset of patients being a matter of future research [4]. Shabaka et al. have shown that patients with a history of Covid-19 infection and previous thromboembolic events were at higher risk of developing a repeat thrombotic event [5]. Physicians need to be vigilant about the thrombotic events in patients with long Covid, even in patients receiving therapeutic anti-coagulation. Such patients require more frequent monitoring for signs of thrombotic events, risk factor management, and adherence to preventive therapies [3].","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"20 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371606","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01DOI: 10.13107/jaccr.2023.v09.i03.222
Geetanjali Singhal, S P Sharma, Satyabrata Mohanty
In surgery for foot drop, regional anaesthesia, with selective sensory block and preserved motor function, can be of immense benefit to the surgeon. It allows patient to move foot on command, thus helping in identifying functional tendons, and determine the efficacy of transplanted tendon intraoperatively. We describe a simple and effective technique to achieve this, using hypobaric local anaesthetic drug for spinal anaesthesia and keeping the patient prone in jack-knife position for 15 minutes This allows only sensory posterior nerve roots to be blocked, sparing the motor anterior nerve-roots. Keywords: Levobupivacaine, Baricity, Anaesthetic local, Density, Motor sparing block, Tendon transfer, Spinal anaesthesia
{"title":"Posterior Spinal Hemi- Anaesthesia for Tendon Transfer in Patient with Foot Drop- Case Report","authors":"Geetanjali Singhal, S P Sharma, Satyabrata Mohanty","doi":"10.13107/jaccr.2023.v09.i03.222","DOIUrl":"https://doi.org/10.13107/jaccr.2023.v09.i03.222","url":null,"abstract":"In surgery for foot drop, regional anaesthesia, with selective sensory block and preserved motor function, can be of immense benefit to the surgeon. It allows patient to move foot on command, thus helping in identifying functional tendons, and determine the efficacy of transplanted tendon intraoperatively. We describe a simple and effective technique to achieve this, using hypobaric local anaesthetic drug for spinal anaesthesia and keeping the patient prone in jack-knife position for 15 minutes This allows only sensory posterior nerve roots to be blocked, sparing the motor anterior nerve-roots. Keywords: Levobupivacaine, Baricity, Anaesthetic local, Density, Motor sparing block, Tendon transfer, Spinal anaesthesia","PeriodicalId":484438,"journal":{"name":"Journal of anaesthesia and critical care case reports","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136371781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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