A&A practice
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Case Reports
Transesophageal Echocardiography-Guided Cardiopulmonary Resuscitation After Rocuronium Anaphylaxis.
Anaphylaxis is a life-threatening hypersensitivity reaction that can quickly progress to circulatory collapse, even in the presence of timely epinephrine administration. This report describes a case of rocuronium anaphylaxis which progressed to circulatory arrest despite intravenous epinephrine and crystalloid resuscitation. Transesophageal echocardiography performed during cardiopulmonary resuscitation enabled rapid identification of the cause of shock and redirected management to prioritize further fluid administration, leading to return of spontaneous circulation with a good outcome. The etiology of shock in anaphylaxis can be variable, and transesophageal echocardiography can rapidly identify the likely mechanism and guide treatment without interrupting ongoing resuscitative efforts.
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Verbal orders in the operating room between the surgeon and circulating nurse are prevalent at many institutions. We present a case in which a communication breakdown involving a verbal order resulted in the patient receiving an excessively high dose of epinephrine via subcuticular infiltration. ⋯ The hemodynamic changes were treated, and the patient suffered no long-term sequelae. This report emphasizes the need to have strategies in place to prevent medication errors.
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We present the anesthetic management of a 23-year-old gravida 2 para 0-0-1-0 with a history of mitral valve replacement secondary to congenital mitral dysplasia. The hemodynamic changes of pregnancy had resulted in severe functional mitral stenosis of her mechanical valve, which was significantly undersized for her current body surface area. Her complex cardiac history required our multidisciplinary team to focus on peripartum anticoagulation management, extracorporeal membrane oxygenation (ECMO) preparation under a dural puncture epidural (DPE) technique, and managing the hemodynamic changes that are critical for a congenital heart disease parturient.
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Guidelines on the management of lumbar drain in patients receiving antithrombotic therapy are lacking, with American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines for regional anesthesia providing the best possible guidance for this scenario. However, the risk-benefits of placing a lumbar drain in the context of vascular surgery differ from placement of neuraxial blockade. One of the changes included in the recently published ASRA guidelines is that clopidogrel can be started on a patient with an indwelling neuraxial catheter. We report a case of slowly evolving epidural hematoma following the initiation of clopidogrel therapy in a patient with an indwelling lumbar drain.
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A 69-year-old man underwent total laryngopharyngectomy with radial forearm free flap reconstruction. He had lost 15 kg over a period of 6 months and did not receive any preoperative nutritional workup or management. ⋯ Diagnostic workup only revealed hypoalbuminemia and hypoproteinemia. We hypothesized relative overdosage of sedative anesthetic drugs due to preoperative malnutrition accentuated by intraoperative fluid administration.