A&A practice
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Neonatal airways present unique management challenges that can be compounded by limitations of an underresourced facility. While little clinical data exist on the safety and efficacy of stylet use, they are commonly utilized to facilitate endotracheal intubation in neonates and anticipated difficult airways. As pediatric airway equipment is often understocked in hospitals, innovative thinking can provide creative solutions to these shortages. We present the use of a 16-gauge intravenous catheter as an intubating stylet for a 2.0-millimeter endotracheal tube in the management of a difficult airway in the neonatal intensive care unit.
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A 60-year-old woman with a 5-year history of anxiolytic use, a diazepam-equivalent daily dose of 15 mg, was scheduled for esophageal stent removal. She was given remimazolam (0.5 mg/kg) but remained fully alert. She only lost consciousness with propofol (40 mg). ⋯ He was given remimazolam (0.3 mg/kg) but remained fully alert. He only lost consciousness after desflurane inhalation. In a patient with a history of long-term benzodiazepine use, anesthetic or sedative agents aside from remimazolam should be considered.
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Multiple disease processes can contribute to coagulopathy in the setting of intrauterine fetal demise. A 34-year-old woman with multiple prior uterine surgeries presented for dilation and evacuation of a fetal demise at 17 weeks. Her case was complicated by significant hemorrhage and coagulopathy requiring massive transfusion and hysterectomy. ⋯ Pathology identified a focal placenta accreta. While not known to present together, fetal demise, placenta accreta, and atypical hemolytic-uremic syndrome can occur in the same patient with an overlapping presentation. Early hematology consultation is recommended in the setting of ongoing hemolysis and renal dysfunction.
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Celiac plexus neurolysis has been associated with orthostatic hypotension but has not been quantified prospectively or evaluated for persistence after the immediate postprocedural period. Our objective was to quantify persistent hemodynamic changes induced by celiac plexus neurolysis. In this case series of 16 patients with cancer, 8 (50%) had orthostatic hypotension alone, 3 (18.75%) developed an exaggerated postural heart rate increase (>30 beats per min), and 1 (6.25%) had both orthostatic hypotension and an increased heart rate. While the analgesic benefit of celiac plexus neurolysis is clear, the observed hemodynamic changes may be poorly tolerated in some individuals.
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A 6-year-old male undergoing bilateral hydrocelectomy was to receive caudal analgesia after induction of general anesthesia. After insertion of the caudal needle, cerebrospinal fluid was unexpectedly aspirated and the caudal was abandoned. The surgeon performed bilateral ilioinguinal nerve blocks just before incision. ⋯ A lumbosacral magnetic resonance imaging (MRI) revealed a sacral meningocele. By the next morning, quadriceps function had returned, and he was ambulating normally. The ilioinguinal block was most likely deep to the internal oblique muscle and produced femoral nerve dysfunction.