A&A practice
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We describe refractory postoperative hypotension due to adrenal insufficiency in a patient treated with steroid-adulterated herbal medicine. A 62-year-old man underwent an elective total hip replacement. Surgery was uneventful, but he became profoundly hypotensive 8 hours later, requiring intensive care unit admission, intubation, vasopressor support, and renal replacement therapy. ⋯ Adrenal insufficiency secondary to chronic exogenous steroids was diagnosed following cortisol measurements and an adrenocorticotropic hormone stimulation test. He responded well to steroid therapy and made a full recovery. The use of herbal medicine should not be overlooked.
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A parturient with unknown thrombotic thrombocytopenic purpura (TTP) received spinal anesthesia for cesarean delivery with subsequent discovery of a platelet count of 7000 × 10/L. Neurologic recovery was normal. ⋯ There is reporting bias in the literature toward cases in which severely thrombocytopenic patients sustain complications after regional anesthesia. It is important to report all cases of neuraxial anesthesia in severely thrombocytopenic patients, including those such as ours, wherein patients recover normally.
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Case Reports
Management of Quebec Platelet Disorder for Cervical Facet Injections in the Outpatient Setting: A Case Report.
Quebec platelet disorder (QPD) is a condition that causes delayed-onset bleeding after hemostatic challenges. While there are interventional spine procedure (ISP) guidelines for managing patients on blood thinners or with common bleeding disorders, there are none for approaching patients with unique coagulopathies. ⋯ After consulting a hematologist and administering antifibrinolytic agent with platelet transfusions, the patient underwent medial branch nerve blocks (MBNBs) followed by radiofrequency ablation (RFA) without experiencing PPBCs. A comprehensive team approach is critical to maximize patient safety when performing an ISP in such a population.
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Case Reports
Fatal Clostridium perfringens Meningitis Following Caudal Anesthesia in an Infant: A Case Report.
Caudal anesthesia is referred to as a simple and safe method to obtain analgesia in infants during various surgical procedures. Here, we present a fatal course of a premature infant that received caudal anesthesia for inguinal hernia repair. ⋯ The infant died 17 days after surgery. Preoperative screening for C. perfringens and particular caution in infants with intracerebral hemorrhages are discussed as potential factors to be considered when anesthesia is planned.
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Case Reports
Actimetry-Documented Persistent Periodic Limb Movements During EEG-Confirmed Deep General Anesthesia: A Case Report.
Motor activity during general anesthesia (GA) without neuromuscular blockade is often interpreted as reflecting insufficient anesthesia. Here we present the case of an octogenarian undergoing deep sclerectomy with opioid-sparing electroencephalography (EEG)-guided anesthesia. Periodic leg movements (PLM) appeared during ongoing surgery while the patient's raw EEG displayed a pattern of deep anesthesia, evidenced by burst suppression. Recognizing PLM in the context of opioid-sparing GA is of importance for anesthesiologists, as deep anesthesia is not necessarily associated with a decrease in motor activity.