A&A practice
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Plasma transfusion is commonly used to correct elevated international normalized ratio (INR) before invasive procedures. A 54-year-old woman presented to the emergency department with abdominal pain. Workup revealed Streptococcus pneumoniae peritonitis. ⋯ Four units of plasma were transfused to correct an INR of 3.0 (goal 1.5) for a transjugular intrahepatic portosystemic shunt procedure. INR remained at 1.9, and she developed acute pulmonary edema and died within 24 hours. Prothrombin complex concentrates may have been a more appropriate treatment option in this case.
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Correction of profound hyponatremia requires careful planning and close monitoring to reduce the risks of neurologic injury. Although there are various suggested treatment strategies in the setting of a medical ward or intensive care unit, reports of intraoperative management to prevent rapid increases in serum sodium are lacking. We present a case of profound hyponatremia of 102 mmol/L in a patient who required emergent operative repair for bowel obstruction. This is the first case to our knowledge that demonstrates a perioperative fluid and desmopressin treatment strategy to prevent overly rapid changes of sodium concentration in a patient with severe hyponatremia.
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Case Reports
Perioperative Management of a Child With Glucose Transporter Type 1 Deficiency Syndrome: A Case Report.
Glucose transporter type 1 deficiency syndrome (GLUT1DS) causes central nervous system dysfunction including intractable epilepsy caused by impaired glucose transport to the brain. To prevent convulsions and maintain an energy source for the brain in patients with GLUT1DS, the maintenance of adequate ketone body concentrations, compensation of metabolic acidosis, and reduction of surgical stress are essential. We here report the perioperative management of a child with GLUT1DS.
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Case Reports
Fluctuating Pulse Oximetry Readings in an Adolescent With Hemoglobin Bibba: A Case Report.
Hemoglobinopathies caused by unstable hemoglobins represent a wide group of diseases that include hemoglobin Bibba. Hemoglobin instability may cause chronic hemolytic anemia and conformational changes in hemoglobin that affect affinity for oxygen and absorption of wavelengths of light used in pulse oximetry devices. We report the case of an adolescent with hemoglobin Bibba and α-thalassemia. SpO2 was unexpectedly low despite stable vital signs when his hemoglobin was closer to 10 g/dL and normal when his hemoglobin was lower, presumably when there was less unstable hemoglobin because of hemolysis.
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Case Reports
A Subarachnoid Hemorrhage Presenting as Massive Nasopharyngeal Bleeding: A Case Report.
Patients who present with a subarachnoid hemorrhage may have more than 1 intracranial aneurysm at risk, which may not be appreciated until a subsequent aneurysmal bleeding event occurs. We describe a patient who underwent successful aneurysmal clipping, but later presented urgently with large-volume epistaxis 48 hours after the procedure. After successful intubation of the patient, subsequent angiographic imaging determined that the massive intranasal/oral hemorrhage was due to bleeding through the former operative site, from rupture of a previously unrecognized aneurysm. This series of events demonstrates the importance of selecting the most at-risk aneurysm for surgical intervention.