A&A practice
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We report persistent postoperative paraplegia on recovery from anesthesia after emergent exploratory laparotomy for large bowel obstruction in a cachectic patient with an abdominal aortic aneurysm. Postoperative cervical, thoracic, and lumbar spine magnetic resonance imaging revealed only cervical spinal stenosis. We hypothesize that intraoperative embolization possibly caused by manipulation of an atherosclerotic aorta, and a brief episode of intraoperative hypotension resulted in spinal cord ischemia. This report highlights the importance of maintaining intraoperative hemodynamic stability and careful handling of the abdominal aorta, especially in underweight patients with an abdominal aortic aneurysm.
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We present a case of a 63-year-old man with nasocutaneous fistula located outside the area covered by a large adult facemask. The patient was uncooperative for the standard airway assessment and any attempt at awake intubation. ⋯ Although the incidence of overall complications, including fistula formation, following free flap reconstruction for oropharyngeal cancer is reported as high as 20%, few case reports detailing airway management exist. We demonstrate that it is possible to use conventional techniques to induce and ventilate a patient with a large, externalized, airway fistula by covering the defect with an occlusive transparent dressing.
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Prolonged cardiac arrest (CA) in patients with acute myocardial infarction can be associated with poor prognosis. Successful revascularization with primary percutaneous coronary intervention (pPCI) remains the reference therapy for these patients. However, performing a pPCI during CA is challenging and the use of automatic chest compression devices or mechanical support systems might be warranted to facilitate the pPCI procedure and achieve good outcomes. We present a patient with inferior myocardial infarction and cardiogenic shock, followed by refractory CA who underwent successful pPCI with a novel approach integrating the simultaneous use of an automated chest compression system and intra-aortic balloon pump counterpulsation.
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Central pain syndromes affect several million people worldwide. A 52-year-old woman had central pain manifest as burning pain from her left foot to the knee for 12 years after treatment for a medullary cavernoma diagnosed after a right-sided brainstem bleeding episode. ⋯ Her baseline pain stayed at 2/10 at 140 days with spikes only to 5/10, and no additional medications. Scrambler (Calmare) Therapy deserves further study in central pain.
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A 15-year-old boy with X-linked myotubular myopathy associated with severe hypotonia and pectus excavatum presented for posterior spinal fusion of T2-sacrum because of rest pain and severe progressive neuromuscular scoliosis. Previously, he experienced 2 separate instances of cardiac arrest after prone positioning under general anesthesia. A preoperative computed topography angiogram in the supine and prone positions revealed inferior vena cava and right ventricular outflow tract obstruction on prone positioning. Successful positioning and posterior spinal fusion occurred by staging the procedure, correction of volume status, early use of vasoactive and inotropic agents, and oblique prone positioning.