A&A practice最新文献

Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia [HHT]) is a rare autosomal dominant vascular disorder characterized by mucocutaneous telangiectasias and arteriovenous malformations. A 47-year-old woman with recurrent epistaxis and telangiectasias underwent total hip arthroplasty for severe osteoarthritis. No visceral malformations were detected. General anesthesia combined with suprainguinal fascia iliaca and sacral erector spinae plane blocks provided effective intra- and postoperative pain management and minimized opioid use. Surgery and recovery were uneventful. This case underscores the importance of thorough preoperative evaluation and tailored anesthetic strategies in patients with HHT, given their increased risk of bleeding and systemic complications.

Multiple comorbidities and limited information at first contact with elderly hip-fracture patients have made it difficult to create safe perioperative plans. Various risk-stratification calculators, laboratory tests and imaging modalities are used to aid anesthesiologists in identifying which patients may need further evaluation and testing before surgery. Delaying surgical intervention in this population for >24 to 48 hours significantly increase perioperative complications such as myocardial infarction, deep venous thrombosis, pulmonary embolism, or pneumonia. Transthoracic echocardiograms (TTEs) are commonly used to identify pertinent cardiac pathologies that could alter anesthetic management. However, their use can often delay care, and its clinical utility has remained a subject of debate. Point-of-care ultrasound (POCUS) has been recognized as an effective tool to efficiently screen patients who might have underlying cardiac pathologies. Thus, anesthesiologists should utilize POCUS skill sets to guide their clinical decision-making and perioperative planning.

Medical students often have limited exposure to advanced ultrasound-guided vascular access techniques within their preclinical curriculum. We evaluated the changes in confidence scores among 15 preclinical medical students before and after undertaking a novel ultrasound-guided cadaver-based training program for vascular access. Pre- and posttraining surveys showed significant confidence increases (P < .05) in understanding vascular anatomy, using ultrasound clinically, and performing femoral, radial, and internal jugular catheterizations. Cadaver-based training is an accessible and promising avenue to teach complex procedural skills in preclinical medical education.

A 45-year-old deaf man presented with a right cerebral glioma to be resected via an awake craniotomy with language mapping. Deaf patients require special consideration of their unique communication needs. We describe the anesthetic management in detail, including operating room environment accommodations of lighting, positioning, pulse oximetry probe placement, and obviating the operating room mask protocol for the sign language interpreter. We describe a novel anesthetic approach with an awake-awake-asleep technique. The patient was able to communicate and tolerated the successful procedure well. For the safety and well-being of the surgical deaf patient, the anesthesia provider must make appropriate accommodations.

Hypercoagulability in lung cancer has been well described, but multiple arterial emboli are uncommon complications of pneumonectomy. A 59-year-old man underwent a pneumonectomy for squamous cell lung cancer and an intraoperative brachial artery embolism was diagnosed after an abrupt loss of pulse oximeter signal and arterial line waveforms. A cerebral embolization, manifested as a unilateral motor deficit, was noted during the emergence from anesthesia. We hypothesize that thrombus formation within the pulmonary venous system may have been causative. Anesthesiologists should promptly recognize and treat the rare possibility of multiple arterial embolizations during lung cancer surgery. .

American Society of Regional Anesthesia and Pain Medicine guidelines recommend holding most antiplatelet therapy before inserting an epidural catheter; however, guidance for patients acutely initiated on antiplatelet therapy with a catheter in situ is limited. Here, we describe the management of 2 cases of patients with indwelling epidural catheters for pain management who developed acute myocardial infarctions necessitating emergent antiplatelet therapy. Established pharmacokinetics demonstrate maximal platelet inhibition occurs within 30 minutes in ticagrelor and 4 to 6 hours in clopidogrel, suggesting early removal results in decreased the risk of epidural hematoma.