A&A practice
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A 70-year-old Jehovah's Witness was treated with iron carboxymaltose intravenously, recombinant human erythropoietin alpha subcutaneously, and vitamin B12 and folate orally for 9 weeks to raise hemoglobin (Hb) from 10.8 to 17.0 g/dL before explantation of an infected hip joint prosthesis. The target Hb was calculated from the following formula: Hbtarget = Hbfinal/(1 - ABL/EBV), where Hbtarget= Hb to achieve before surgery, Hbfinal = lowest Hb patient could tolerate taking into consideration his comorbidities (7 g/dL), ABL = volume of blood the surgeon estimated the patient would lose intra- and postoperatively (3000 mL), and EBV = estimated blood volume (75 mL/kg for an adult man). Spinal anesthesia was provided with a single shot hyperbaric bupivacaine and fentanyl. ⋯ Surgical blood loss was estimated to be 2500 mL. Hb at the end of surgery was 13.3 g/dL; on postoperative day 5, 11.7 g/L. No blood products were utilized.
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Thoracolumbar interfascial plane block (TLIPB) has recently been described for postoperative analgesia after thoracolumbar spine surgery. This block is minimally invasive, relatively safe, and easy to perform. ⋯ We describe the sonoanatomic landmarks of this technique, and we report results of this retrospective case series on analgesic impact of this block in patients undergoing implantation of spinal cord stimulation systems. Clinical studies are required to investigate the analgesic role of TLIPB for spinal thoracolumbar surgery.
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Near-infrared spectroscopy (NIRS) is a noninvasive monitor of regional brain tissue oxygenation, and jugular venous oximetry (SjvO2) is a monitor of global cerebral oxygenation. We report the role of intraoperative multimodal monitoring of cerebral oxygenation in the anesthetic management of a patient with grade III intracranial arteriovenous malformation (AVM) presenting for surgical excision. Real-time monitoring of cerebral oxygenation is of much relevance in high-grade AVMs where anesthetic management is focused on neuroprotection and prevention of cerebral hypoxia. Besides, it also helps in prediction, early detection, and judicious management of perioperative complications, which are commonly encountered in high-grade AVMs.
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A 65-year-old man undergoing posterior cervical decompression and fusion demonstrated absent lower extremity evoked potential (EP) after prone positioning and before incision. Localized EP change pointed to either a technical or positional culprit. ⋯ During the test, we observed both symmetrical and asymmetrical hemispheric changes in density spectral array β and γ bands that correlated with awakening, eye-opening, and extremity movements. By providing real-time information on brain state, processed electroencephalogram (EEG) can facilitate a safe wake-up test by showing high-power β and γ activities that precede awakening.
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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.