A&A practice最新文献

Right ventricular myocardial work is an echocardiographic technique yielding significant insights into cardiac mechanics, energetics, and efficiency. Combining right ventricular myocardial strain with loading conditions correlates with invasively measured myocardial work and myocardial oxygen consumption. This method has not yet been described intraoperatively by transesophageal echocardiography. We describe this technique during a left ventricular assist device implantation. This case demonstrates that right ventricular myocardial work indices can be monitored intraoperatively and might assist decisions during left ventricular assist device implantation.

Referred chronic shoulder pain may arise from diaphragmatic irritation. It can potentially be alleviated by blockade of the phrenic nerve. There is literature describing its use in acute pain conditions; yet for chronic pain, there are no reports. We present 2 cases of chronic diaphragmatic irritation causing ipsilateral referred shoulder pain. Patients experienced significant pain relief and a reduction in opioid consumption after receiving an ultrasound-guided phrenic nerve block. While the phrenic nerve block shows promise for pain relief, carefully evaluating its benefits and risks is recommended before considering its application in selected cases.

Cerebral venous sinus thrombosis (CVST) is an exceedingly rare complication of epidural anesthesia, with only a handful of known cases after epidural steroid injection (ESI). We report a case of CVST in a 33-year-old male patient that presented with headache after lumbar ESI. His clinical status initially improved on anticoagulation in the intensive care unit. However, he had a sudden worsening of cerebral edema that required an emergent hemicraniectomy. Ultimately, the patient was pronounced dead by neurologic criteria. This case highlights the importance of keeping this rare but potentially fatal diagnosis in the differential even in lower-risk patient populations.

A female teenager with a history of polysubstance use, including a recent overdose, is scheduled for multilevel posterior spinal fusion surgery due to idiopathic scoliosis and has asked to avoid the use of opioids in the context of her upcoming surgery. This problem-based learning discussion (PBLD) focuses on the examination of the care of a spinal fusion patient that allowed for the successful provision of opioid-obviating care.

Incomplete neurological awakening manifested as aberrant patterns of electroencephalography (EEG) at emergence may be responsible for an unresponsive patient in the postanesthesia care unit (PACU). We describe a case of an individual who remained unresponsive but awake in the PACU. Retrospective, intraoperative EEG analysis showed low alpha power and a sudden shift from deep delta to arousal preextubation. We explored parallels with diminished motivation disorders and anesthesia-induced sleep paralysis due to imbalances in anesthetic drug sensitivity between brain regions. Our findings highlight the relevance of end-anesthesia EEG patterns in diagnosing delayed awakening.

We report the case of a term neonate who was somnolent at birth with ventilatory distress and experienced 2 seizures shortly after delivery. Laboratory tests revealed the neonate had a serum sodium of 113 mmol/L. The seizures stopped after treatment with midazolam, and the sodium was corrected slowly with 3% hypertonic saline without further sequelae. The severe neonatal hyponatremia and seizures were attributed to maternal consumption of excessive amounts of coconut water during labor. This case demonstrates the importance of careful consideration of both fluid volume and fluid electrolyte composition during labor to prevent adverse maternal and neonatal outcomes.

While Title VI of the Civil Rights Act of 1964 mandates use of interpreters for patients with limited English proficiency, significant disparities persist in intensive postsurgical care. We present the case of a 60-year-old Vietnamese-speaking man with a Type A aortic dissection requiring postoperative mechanical ventilation and stroke care. Despite use of a remote video interpreter, our language-discordant nursing and physician providers faced challenges in managing agitation and delirium and assessing neurological function. This case highlights the need for adequate interpretation equipment, linguistic diversity among providers, and interventions to promote and enable consistent certified and professional medical interpreter use.

A 53-year-old woman underwent a thoracic epidural placement for a scheduled laparotomy. Postoperatively the patient had no appreciable epidural level after multiple epidural boluses and was noted to be severely hypotensive with right upper extremity weakness and numbness. She subsequently developed right-sided Horner's syndrome with worsening right upper extremity weakness and decreased sensation from C6 to T1. She regained full motor and sensory function in her right upper extremity with epidural removal. This unusual case raises awareness of the variability in the presentation of subdural spread and provides an example of an epidural complication that can mimic a cerebrovascular accident (CVA).