Journal of clinical anesthesia
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Randomized Controlled Trial
Ultrasound-guided single- vs double-level thoracic paravertebral block for postoperative analgesia in total mastectomy with axillary clearance.
Thoracic paravertebral block (TPVB) for breast surgery reduces acute and chronic postoperative pain. Using ultrasound for administering the block makes it easier, with its administration at multiple levels decreasing the number of unblocked segments. We conducted this study to evaluate the efficacy and safety of single- vs double-level ultrasound-guided TPVB in patients undergoing total mastectomy with axillary clearance under general anesthesia. ⋯ Patients receiving double-level TPVB had significantly less 24-hour analgesic consumption in the postoperative period than those in the single-level TPVB group. This could be due to decreased pain sensation to pinprick in significantly greater number of segments in the double-level TPVB group.
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Case Reports
Cardiac arrest during radical nephrectomy due to a mass in the right ventricular outflow tract.
We report cardiac arrest due to obstruction of the right ventricular outflow tract (RVOT) caused by an RVOT mass that was not identified preoperatively. A 62-year-old woman with renal cell carcinoma (RCC) experienced deteriorating hypotension and bradycardia during radical nephrectomy. Hemodynamic stability was maintained on extracorporeal membrane oxygenation, and after surgery, she was transferred to the intensive care unit. ⋯ Our findings suggest that it may be necessary to perform additional tests if RCC has invaded the renal vein and inferior vena cava or if a patient with RCC has abnormal cardiovascular symptoms without definite etiology for exclusion of cardiac metastasis or tumor thrombus. In addition, intraoperative transesophageal echocardiography might be the procedure of choice for the evaluation of these conditions because other diagnostic tests are difficult to perform during surgery. In conclusion, for patients with acute hemodynamic instability for whom other possible causes have been excluded, we recommend that anesthesiologists use transesophageal echocardiography to detect outflow tract obstruction or pulmonary thromboembolism and perform anesthetic management.
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Randomized Controlled Trial
Addition of buprenorphine to local anesthetic in adductor canal blocks after total knee arthroplasty improves postoperative pain relief: a randomized controlled trial.
For the hundreds of thousands of patients who undergo total knee arthroplasty (TKA) in the United States each year, early mobilization has been demonstrated to improve functional outcomes and reduce complications. Management of postoperative pain is a critical factor in achieving early mobilization. Recent studies have shown that the use of an adductor canal block (ACB) after TKA results in increased preservation of quadriceps muscle strength, without significant difference in postoperative pain when compared to femoral nerve block. This increased preservation of quadriceps muscle strength leads to earlier mobilization. Studies have also demonstrated a prolongation of analgesia with the addition of buprenorphine to local anesthetic for regional block placement. This study examined the effect on postoperative opioid consumption when adding buprenorphine to an ACB vs an ACB with local anesthetic alone, for postoperative analgesia after unilateral TKA. ⋯ The addition of buprenorphine to an adductor canal block decreases postoperative opioid consumption when compared to an ACB with local anesthetic alone. This reduction in opioid consumption, without significant increase in side effects, makes this an attractive anesthetic adjunct for TKA.
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The occurrence of lupus anticoagulant is associated with the hazard of developing an antiphospholipid syndrome, a severe prothrombotic condition which may particularly occur after major surgical trauma. This disease requires certain considerations regarding surgical strategy and anticoagulation management. We describe the perioperative management of a patient scheduled for elective aortic valve replacement and diagnosed for having antiphospholipid antibodies. The procedure was successfully performed using a minimally invasive approach via transapical aortic valve replacement and anticoagulation with the nonreversible short-acting direct thrombin Inhibitor bivalirudin.
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To investigate if the anesthetic/analgesic regimen is associated with the risk of reporting long-term chronic postmastectomy pain (CPMP). ⋯ In conclusion, our study confirms the high prevalence of CPMP, 4 to 9 years after surgery. Recall of preoperative pain, chemotherapy, and need for strong opioids in the postanesthesia care unit were all associated with the presence of chronic pain. Of the intraoperative analgesics/anesthetics studied, only use of halogenated agents was associated with a lower prevalence of CPMP.