A&A practice
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This case describes an anticoagulation strategy in a postpartum patient on venoarterial extracorporeal membrane oxygenation (VA ECMO) for a pulmonary embolism (PE) with a concurrent ischemic stroke. After receiving systemic lysis, the patient had impending cardiovascular collapse, right heart strain, worsening clinical picture, prompting VA ECMO cannulation and subsequent cautious management of the patient's anticoagulation. There have been no similar cases published describing an ECMO anticoagulation strategy and management for this complex clinical situation. By withholding a heparin bolus and delaying initiation of a heparin drip for 24 hours, thromboelastogram (TEG) R-time and partial thromboplastin time (PTT) could be closely monitored while the patient began to recover.
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Aromatic L-amino acid decarboxylase deficiency (AADCD) is a rare autosomal recessive disorder of neurotransmitter synthesis with lack of sympathetic autoregulation. Owing to hemodynamic regulatory dysfunction and impairment of sympathetic regulation of heart rate, anesthesia is challenging. ⋯ Neuraxial anesthesia was administered, as she had not developed complications previously. Thus, neuraxial anesthesia can also be used safely for a cesarean delivery with appropriate anticipation of potential autonomic disturbances and lack of adrenergic neurotransmission.
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Complex regional pain syndrome (CRPS) has the potential to spread from the initial site to distant areas of the body. However, there is a paucity of data reporting the patterns and underlying cause of the spread. This case describes spontaneous, ipsilateral spread of CRPS from the right lower extremity to the orbit, leading to corneal abrasion.
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We present 3 cardiothoracic surgery cases during which the Drager Perseus A500 anesthesia machine and the iNOmax Delivery System were used concurrently, resulting in ventilator failures while attempting to separate from cardiopulmonary bypass (CPB). The failure was found to be caused by the iNOmax Delivery System sampling line, where negative pressure on the Perseus A500 breathing circuit precipitated a ventilator failure when the machine was brought out of "standby mode." To our knowledge, there is no discussion of this interaction in the literature, and we find this to be an important issue for patient safety during cardiothoracic surgery.
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Surgical resection of arteriovenous malformations (AVMs) is indicated in the presence of life-threatening and severe morbidity, including symptomatic heart failure, ischemic pain, and recurrent bleeding, where other less invasive treatment strategies have been unable to halt the progression of disease. We present the challenges encountered in the perioperative care of a 23-year-old man with high output cardiac failure, gangrenous hand, and severe chronic pain undergoing shoulder disarticulation for a high-flow complex AVM of the upper limb.