A&A practice
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We present a patient with sudden cardiovascular collapse during cesarean delivery that was attributed to amniotic fluid embolism (AFE). The syndrome of AFE may be initiated by an anaphylactoid response to amniotic fluid in the maternal circulation that triggers the release of pulmonary vasoconstrictors, with transient pulmonary vasospasm, causing hemodynamic collapse and profound left ventricular failure. Milrinone, a pulmonary vasodilator used in the management of emergent right ventricular failure, was administered via a nebulizer in an effort to decrease pulmonary vascular resistance. If used immediately after AFE, inhaled milrinone may mitigate pulmonary vasoconstriction, providing a bridge to extracorporeal membrane oxygenation.
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We present the case of a 7-month-old infant undergoing thoracotomy and left lower lobe lobectomy who experienced a significant complication related to lung isolation with a bronchial blocker. Despite good isolation and seemingly appropriate positioning, the bronchial blocker became entrapped within the staple line at the bronchial stump. Fortunately, the surgeon was able to free the blocker. Going forward, we recommend clinicians be vigilant in positioning the blocker just distal to the carina in all cases and, further, consider retracting the blocker into the trachea before surgical intervention on the airway to avoid inadvertent entrapment of the device.
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Endoscopic nasal septoplasty is a commonly performed otolaryngology procedure, not known to cause persistent postsurgical pain or hypersensitivity. Here, we discuss a unique case of persistent nasal pain that developed after a primary endoscopic septoplasty, which then progressed to marked mechanical and thermal allodynia following a revision septoplasty. Pain symptoms were found to be mediated by the maxillary division of the trigeminal nerve and resolved after percutaneous radiofrequency ablation (RFA) of bilateral maxillary nerves. To the best of our knowledge, this is the first report of maxillary nerve-mediated nasal allodynia after septoplasty.
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Case Reports
Continuous Intrathecal Morphine Infusion for Pain Management in a Polytrauma Patient: A Case Report.
Polytrauma patients are at high risk for neurologic complications as a result of the primary mechanism of their trauma and/or delirium caused by subsequent pain, sedatives and analgesic exposure, sleep disturbances, infections, metabolic derangements, organ dysfunctions, withdrawal syndromes, or other factors. The high prevalence of delirium within trauma intensive care units increases risks for both patients and providers and is associated with worsened patient outcomes. This case report explains the rationale and utilization of continuous intrathecal morphine administration to improve pain control while reducing and eliminating intravenous (IV) analgesics and sedatives to enable wakefulness in a polytrauma patient with refractory agitated delirium.
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Case Reports
First Bite Syndrome Relief With Trigeminal Nerve Branch Block and Ablation: A Case Report.
First bite syndrome (FBS) is intense facial pain at the first bite of each meal. Currently, no guidelines exist for treating FBS, although botulinum toxin injection has shown benefit. ⋯ Our treatment may have disrupted somatic sensory input from the parotid carried by the auriculotemporal nerve or lesioned the otic ganglion resulting in decreased parasympathetic hyperactivation. Further studies are warranted to evaluate the use of this procedure for FBS.