A&A practice
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Case Reports
Puerperium Stroke and Subsequent Tissue-Type Plasminogen Activator-Induced Hemorrhage: A Case Report.
We report a case of ischemic stroke in an apparently healthy 35-year-old gravida 2 para 1 who was treated with tissue-type plasminogen activator (tPA) 9 hours after vaginal delivery that resulted in severe hemorrhage. Limited data suggest use of thrombolytics in pregnancy is safe, but there is a paucity of evidence assessing their use immediately postpartum. We describe successful combination of tPA with endovascular mechanical thrombectomy (EMT) for treatment of postpartum stroke, which was followed by extensive uterine bleeding.
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Awake nasotracheal fiberoptic intubations are used to manage difficult airways. Nasopharyngeal airways can be placed into the nostril to facilitate fiberoptic intubation and has been shown to be a useful pathfinder. ⋯ Aspiration of the nasopharyngeal airway can lead to complete airway obstruction and devastating consequences. Simple techniques such as attaching a hemostat or using an assistant to hold on to the nasopharyngeal airway may prevent this occurrence.
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Careful airway risk assessment and procedural planning are vital to ensure patients' safety during airway management. Patients with known procedural difficulty during previous airway management or new anatomical changes pose challenges and risks. To improve communication and the value of documented information regarding difficult airway management for future clinical encounters, we utilized existing electronic health record functions to develop a "difficult airway Navigator." We describe this tool's creation and implementation, which allows clinicians to readily review past airway information and efficiently create difficult airway notes, bedside signs, flags, and orders.
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Goldenhar syndrome, or oculoauriculovertebral dysplasia, represents approximately 10% of craniofacial microsomia anomalies. These patients have a variety of clinical features that are relevant to anesthesia providers, including a high-arched palate, mandibular hypoplasia, micrognathia, and temporomandibular joint (TMJ) malformation. ⋯ Outside of the dental and oral surgery literature, the potential for TMJ ankylosis in Goldenhar patients is seldom emphasized. TMJ ankylosis impacts airway management, and anesthesia providers must be aware of this clinical phenotype when planning the anesthetic care of patients with Goldenhar syndrome.
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A central neuraxial block may be difficult to perform in elderly patients with lumbar spine deformities, calcified ligaments, and narrowing of the epidural space. We report a case of difficult epidural needle placement in an elderly patient scheduled for bilateral total knee replacement (TKR). We attempted epidural needle placement many times without success. However, when a modified technique was used, the epidural space was identified easily and confirmed, the epidural catheter was inserted and fixed, and the postoperative epidural analgesia was effective.