A&A Practice最新文献

Complex regional pain syndrome (CRPS) poses a diagnostic and management challenge for many clinicians, particularly when disease symptomatology waxes and wanes. Monitoring symptom variations with digital and infrared thermal images allows for more accurate evaluation of disease progression overtime. We present the case of a patient who developed CRPS and catalog his symptoms using a digital and infrared thermal imaging diary. The images were instrumental toward establishing the initial diagnosis of CRPS, monitoring disease progression, and assessing response to treatment. We discuss the present understanding of infrared thermography in CRPS and advocate for its routine use at the beside.

The erector spinae plane block (ESPB) is described as a safe and effective alternative when epidural or paravertebral blocks are contraindicated by anticoagulation therapy. We present a case of subcutaneous hematoma after ESPB catheter placement. The patient received bilateral ESPB catheters for perioperative pain control. Postoperatively, the patient developed tenderness to palpation at the left catheter site. Physical examination revealed a well circumscribed, fluctuant mass that produced bloody material during incision and drainage. This case report describes hematoma as a potential complication of the ESPB. After the procedure, patients should be closely monitored for complications, including hematoma.

Patients with cold agglutinin disease who undergo total hip arthroplasty (THA) are rarely encountered. Patients with cold agglutinin disease are very sensitive to cold ambient temperatures and require scrupulous perioperative body-temperature management. However, THA requires a cementing procedure that exposes patients to cold temperatures during surgery and may result in autoimmune hemolytic anemia in these patients. Thus, perioperative management of patients with cold agglutinin disease undergoing THA requires more than just scrupulous systemic temperature management. Here, we present the successful perioperative management of a patient with severe cold agglutinin disease who underwent THA with a cemented stem.

Malignant hyperthermia (MH) is a rare but life-threatening genetic disorder of the skeletal muscles triggered by inhalation anesthetics or succinylcholine. A 49-year-old female developed symptoms of MH shortly after a lumbar surgery. Despite being insidious, MH was diagnosed based on the clinical grading scale. We incidentally discovered fine fasciculations in extremities while inserting an ultrasound-guided arterial catheter. On receiving dantrolene, her symptoms improved within 20 minutes; a subsequent ultrasound revealed no fasciculations. Although halothane contracture testing was not available, the fasciculations that resolved with dantrolene administration in a MH suspected patient opens up a new potential avenue of diagnostics.

We present a 54-year-old man who developed an unexpected thenar space compartment syndrome after robotic laparoscopic surgery, which was caused when the radial arterial pressure tubing was pulled too tightly around the base of the thumb while changing the surgical position. A conventional method of securing the tubing by looping it around the thumb appeared to be the primary cause. This complication went unnoticed during the surgery because the arm was tucked out of sight; there were no remarkable findings on monitoring. This case highlights the risks of looping tubing around the thumb, especially if continual inspection is not possible.

A 50-year-old man with muscle-invasive bladder cancer was scheduled for a robotic radical cystectomy. Four hours into the surgery, his electrocardiogram showed rhythm disturbances. Arterial blood gas analysis showed a serum potassium concentration of 6.6 mEq/L. Hyperkalemia was managed immediately with intravenous 10% calcium gluconate, insulin, and glucose administrations, and levosalbutamol was administered through the tracheal tube. Subsequently, normal sinus rhythm returned. The procedure was completed after conversion to an open surgery. The postoperative serum potassium concentration was reduced to 4.6 mEq/L, and the patient was extubated. The remainder of his hospital stay was uneventful.

Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is a complex and painful procedure that can cause postoperative hypotension and coagulopathy. Epidural analgesia may worsen hypotension and is contraindicated in the setting of coagulopathy. While alternative regional techniques are being explored, the use of erector spinae plane blocks has not been reported. We present a case series of 6 patients who had erector spinae plane catheters for cytoreduction surgery with hyperthermic intraperitoneal chemotherapy. They remained stable intraoperatively and had adequate pain control postoperatively. Erector spinae plane catheters may be a suitable alternative for epidural analgesia for these patients.

The management of patients on direct oral anticoagulants (DOACs) who require emergent cardiac surgery is slowly evolving. The introduction of andexanet alfa, a novel antidote for apixaban and rivaroxaban, added a specific reversal agent to our armamentarium, but its safety and efficacy are still being investigated. We report 2 patients on DOAC treatment who required emergency cardiac surgery. Both received perioperative andexanet alfa together with prothrombin complex concentrate (PCC) at some time during 6 hours before operative management. Heparin resistance was noted in each instance, and pump thrombosis developed in 1 case.