A&A practice
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Regional procedures for postthoracotomy pain control have classically focused on paravertebral blocks and thoracic epidurals; however, these techniques may be challenging in an increasingly obese population and contraindicated with numerous anticoagulant and antiplatelet agents. While less studied, truncal blocks allow analgesic intervention for this growing patient cohort. This case report describes placement of a deep serratus anterior plane catheter in an intubated, morbidly obese patient with a lumbar drain who failed extubation secondary to acute postthoracotomy pain. The serratus plane catheter facilitated extubation and adequate analgesia without prohibiting anticoagulant use or interfering with the monitoring of spinal cord function.
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Anaphylaxis occurs in 1/5000-1/20,000 of anesthesia cases and may evolve with shock and cardiovascular collapse in up to 54% of cases. Mortality varies from 3% to 10%. ⋯ Exaggerated activation of the nitric oxide-cyclic guanosine monophosphate pathway is observed in refractory shock. Methylene blue selectively inhibits this pathway.
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Permanent pacemakers are used for a variety of conditions and are commonly encountered in the perioperative period. This report describes the anesthetic management of a patient with a permanent pacemaker with a rate drop response (RDR) who presented for a laparoscopic left adrenalectomy. The RDR setting is a novel pacemaker mode often used in patients with a history of vasovagal syncope. ⋯ This case report describes the features of the RDR setting with the goal of educating clinicians who may encounter patients with this type of pacemaker. The patient described in this case report had large swings in blood pressure intraoperatively due to the natural function of his pacemaker. This report highlights the importance of understanding pacemaker modes in patients about to undergo surgery, especially because pacemaker functions are becoming increasingly sophisticated and more personalized to meet patients' specific needs.
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Placement of Stimulating Epidural Catheter for a Patient With Large Scapular Sarcoma: A Case Report.
We report the use of continuous electrical stimulation to assist with the preoperative placement of a thoracic epidural which was used to provide postoperative analgesia in a patient undergoing excision of a large scapular sarcoma. The size of the sarcoma and the surrounding area required to maintain a sterile surgical field necessitated that the epidural catheter be inserted several vertebral interspaces caudal to the level of desired catheter tip termination. The use of electrical stimulation allowed for sequential intercostal muscle stimulation during threading, which enabled the placement of the catheter tip at the appropriate spinal level to optimize analgesia.