A&A practice最新文献

Carotid sinus hypersensitivity (CSH) is commonly associated with elderly patients and underlying cardiovascular conditions. We present a rare case of cardiac arrest in a young, healthy female, occurring immediately after a jaw thrust maneuver during mask ventilation, due to carotid sinus compression and subsequent vagal stimulation. This case highlights the need to consider CSH as a cause of sudden intraoperative cardiac arrest, even in young patients without risk factors.

The quadroiliac plane block (QIPB) is a novel posterior fascial plane technique targeting the quadratus lumborum fascia at the iliac crest. We describe a 68-year-old, 88-kg woman with breast cancer-related lymphedema who underwent total hip arthroplasty under general anesthesia and declined neuraxial anesthesia. A continuous QIPB was performed postoperatively using an epidural catheter inserted into the posterior thoracolumbar fascial plane. After an initial 40 mL of 0.25% bupivacaine, infusion continued at 10 mg/h. Sensory spread progressed from L2-L4 to L1-L5 within 1 hour. Pain scores remained ≤2 without opioids, and no complications occurred.

Functional neurological disorder is a rare, nonorganic condition that may occur postoperatively, with variable symptomatology including sensory or motor impairments inconsistent with known medical disorders. We report the case of an elderly woman who developed postoperative unresponsiveness, immobility, and mutism with awareness lasting several hours after general anesthesia at a freestanding ambulatory surgery center. The patient was transferred to an emergency department, where an extensive neurological evaluation was unremarkable, and she spontaneously returned to baseline hours later. This acute and challenging presentation of postoperative functional neurological disorder illustrates that the condition may closely mimic organic emergencies, preventing same-day discharge.

The Fontan procedure requires anesthetics, allowing rapid awakening for early extubation and less circulatory depression owing to passive pulmonary blood flow hemodynamics. Remimazolam, a short-acting benzodiazepine, may be a suitable anesthetic choice; however, its use in this procedure is unreported. We present a 2-year-old boy with a single-right ventricle and pulmonary valve stenosis who underwent the Fontan procedure under anesthesia with remimazolam (3-8 mg kg-1 h-1) and fentanyl (21.8 μg/kg). Hemodynamics remained stable under electroencephalographic monitoring, and the patient was extubated in the operating room without any complications. Therefore, remimazolam may be a feasible sedative option during the Fontan procedure.

Vocal cord paralysis (VCP) is an uncommon but clinically significant complication of prolonged or repeated intubation in critically ill patients. Bilateral cases may cause acute stridor and airway compromise, whereas unilateral cases present with hoarseness or aspiration, often delaying recognition and increasing morbidity. We report 4 intensive care unit (ICU) patients with postintubation VCP diagnosed by fiberoptic laryngoscopy. Presentations ranged from bilateral injury resulting in stridor to unilateral dysfunction, with management strategies including observation, tracheostomy, and posterior cordotomy. This series underscores the diagnostic challenges, anatomical vulnerability of the recurrent laryngeal nerve, and need for early multidisciplinary evaluation to optimize outcomes and prevent long-term impairment.

Percutaneous hepatic perfusion (PHP) is an effective treatment for isolated liver metastases from uveal melanoma. Intraoperative anesthetic management is challenging due to extreme hemodynamic fluctuations associated with the venovenous bypass circuit, hemofiltration system, and hepatic artery chemotherapy delivery. Patients often require maximal doses of multiple vasopressors to maintain adequate perfusion. The mechanism of intraoperative hypotension is hypothesized to be due to catecholamine filtration, though literature supporting this mechanism is limited. The following report describes the successful use of angiotensin II for hypotension management during a PHP procedure, supporting the potential for an alternative mechanism for this profound vasoplegia.

The opioid crisis has been a factor that has significantly impacted pain management practices, leading to cautious opioid prescribing among physicians. This study explores how anesthesiology trainees navigate pain treatment decisions, focusing on how patient characteristics influence opioid prescribing behaviors. We found that trainees initially relied on "red flags" to assess a patient's propensity to abuse opioids. However, trainees' judgements were also shaped over the course of the clinical encounter on an individual basis. The study found no clear racial differences in prescribing decisions but highlighted the complex interplay between medical indications, patient behaviors, and socioeconomic factors in the trainees' assessments.

We report the case of a 77-year-old, American Society of Anesthesiologists (ASA) physical status IV man who developed profound and sustained electrocerebral silence (ECS) during a hemicolectomy. This critical electroencephalogram (EEG)-detected event, occurring in the absence of hypotension, prompted the immediate discontinuation of all anesthetic agents. The procedure, converted to an open laparotomy, was completed without hypnotic or analgesic support, guided solely by the persistent neurophysiological suppression. The patient emerged hours later, developing postoperative delirium and objective cognitive decline at one-month follow-up. This case highlights the EEG's crucial role in detecting severe cerebral vulnerability, informing unique management choices such as discontinuing all anesthetics.

Effective postoperative pain management in pediatric thoracic surgery remains challenging. We present 2 cases where the serratus posterior superior intercostal plane block (SPSIPB) was combined with other fascial plane blocks to enhance analgesia. In a 10-year-old undergoing thoracoscopic hydatid cyst excision, serratus anterior plane block plus SPSIPB provided analgesia for 24 hours. In a 2-year-old undergoing thoracoscopic neuroblastoma resection, subtransverse process interligamentary plane block plus SPSIPB delayed analgesic need until the nineth postoperative hour. These cases suggest that SPSIPB is a valuable adjunct in multimodal pediatric thoracic analgesia strategies.