Journal of clinical anesthesia
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Case Reports
Lack of electrical interference between spinal cord stimulators and other implanted electrical pulse devices.
Spinal cord stimulators (SCSs) have been used for decades to treat chronic pain. SCSs are often used to treat patients with chronic back pain caused by failed back surgery syndrome, patients with complex regional pain syndrome, or individuals who are not candidates for surgery. SCSs are a relative contraindication in patients with another electrical pulse device. ⋯ The second case was a nonsurgical candidate with a pacemaker who received an SCS to help with lower back pain due to an occupational injury. The third case was a patient with complex regional pain syndrome and a bladder stimulator with a previous SCS who received a revision to help manage the pain. In all these patients, pain scores significantly improved after the trial.
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We present a series of 3 cases in which the impact in outcome was, first of all, related to the capacity to offer early and safer treatment to some hip fracture high-risk patients using a fascia iliaca block (FIB; ropivacaine 0,5% 20 cc and mepivacaine 1,3% 15 cc, given 30 minutes before incision) associated only with deep sedation, contributing to better practice and outcome. ⋯ In these cases, surgery would be postponed if the choice was neuroaxial anesthesia, particularly because of P2Y12 receptor inhibitors' effect. FIB puncture site is distal to the fracture and incision site, but proximal local anesthetic migration through the interfascial planes allows for constant block of femoral nerve and lateral cutaneous of femur nerve and, less constantly, block of obturator. FIB may reduce the risk of perineural hematoma associated with several injections in nerve vicinity of different lumbar plexus branches. Frequently, indications for extramedullary or IMF are overlapping, but IMF is associated with less blood loss and may be managed using a low anesthetic depth if an FIB is done, increasing safety. This way, these less invasive surgical techniques combined with an adjusted anesthetic technique may have a crucial role in high-risk patients, particularly if taking P2Y12 receptor inhibitors. In these cases of IMF, surgical manipulation of sciatic and/or inferior subcostal nerves territories was managed with systemic analgesia and deep sedation.
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A 69-year-old woman undergoing treatment for hypertension and epilepsy was scheduled to undergo cataract surgery. All preoperative examination results were within normal limits. Despite being tense, she walked to the operating room. ⋯ The respiratory depression and bradycardia were thought to be due to an inadvertent bolus of remifentanil. We surmised that the patient had received a slight amount of retained medication when the anesthesia resident established the intravenous line, which caused severe respiratory depression. It is important to note that adverse effects such as severe respiratory depression and bradycardia can be caused by even small doses of remifentanil.
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Letter Case Reports
Unpredictable interference of new transcranial motor-evoked potential monitor against the implanted pacemaker.
Recently, NuVasive NV-M5 nerve monitoring system, a new transcranial motor-evoked potential (TcMEP) monitor, has been introduced with the spread of flank-approach spinal operations such as extreme lateral interbody fusion, to prevent nerve damage. Conventional TcMEP monitors use changes in MEP wave patterns, such as amplitude and/or latency, whereas the NV-M5 nerve monitor system first measures the MEP baseline waveform from the transcranial-evoked potential then measures the electric current necessary to obtain the standard of the previous baseline wave pattern at subsequent monitoring times. ⋯ In this way, various electrical stimulations with various durations and frequencies are used, and electrical noise may result in unpredictable interference with cardiac pacemakers. We performed anesthetic management of extreme lateral interbody fusion surgery using the NV-M5 in a patient with an implanted pacemaker, during which TcMEP stimulation caused interference with the implanted pacemaker.
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The GlideScope (GVL; Saturn Biomedical Systems, Burnaby, British Columbia, Canada) is a rigid indirect video laryngoscope device that facilitates exposure of the larynx for placement of the endotracheal tube. This blade also reduces the requirement for anterior displacement of the tongue. A unique feature is the acutely angled blade which provides an improved glottic view. ⋯ Use of the GlideScope requires less lifting force (approximately 0.5-1.5 kg) than direct laryngoscopy to achieve visualization of the glottis, so less traction is applied to soft tissue. However, meticulous care must be taken even by experienced operators to ensure correct use to decrease the incidence of oropharyngeal injuries, especially in patients with difficult airways. Increased vigilance makes the GlideScope an invaluable tool despite its potential complications.