Journal of clinical anesthesia
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Regional anesthetic techniques for children have recently enjoyed a justified resurgence in popularity. Intraoperative blockade of the neuraxis, whether by the spinal or epidural route, provides excellent analgesia with minimal physiologic alteration and, with an indwelling catheter, can provide continuous pain relief for many days postoperatively. ⋯ Although some practitioners contend that a regional block on an already anesthetized child adds to the risk of the general anesthetic itself, in experienced hands the risks are negligible and the benefits dramatic. In this review of caudal and lumbar epidural and subarachnoid blockade in infants and children, anatomy, physiologic alterations, and pharmacology pertinent to the three types of neuraxial blockade are described, with the aim of providing the practicing anesthesiologist with the foundation needed to perform these blocks with relative confidence.
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Pregnancy carries substantial maternal and fetal risks in patients with uncorrected or palliatively corrected cyanotic congenital heart disease (CHD). In tricuspid valve Ebstein's anomaly, pregnancy is well tolerated. Maternal mortality in tetralogy of Fallot seems to be less than 10%, but it exceeds 50% in Eisenmenger's syndrome and primary pulmonary hypertension (PPH). ⋯ Prevention of excessive erythrocytosis, volume and blood loss substitution, cardiocirculatory pharmacologic support, prophylaxis of infective endocarditis, and judicious use of anticoagulant drugs should be applied as indicated by the type and presentation of CHD. Poor outcome of pregnancy in PPH requires an early consideration of heart-lung or lung transplantation. Multidisciplinary team effort and prolonged monitoring in the intensive care unit are mandatory to ensure a favorable outcome for cyanotic CHD and PPH parturients.
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Review Case Reports
Adult epiglottitis and postobstructive pulmonary edema in a patient with severe coronary artery disease.
Epiglottitis is a rare cause of upper airway obstruction that may lead to death in the adult. We report the case of a patient with severe coronary artery disease with adult epiglottitis who required emergency endotracheal intubation. Relief of the airway obstruction was followed by the development of postobstructive pulmonary edema. ⋯ All others should be observed in an intensive care unit with a skilled anesthesiologist available to carry out emergency endotracheal intubation. Inhalation induction with halothane in oxygen should be considered initially; failing that, rigid bronchoscopy, tracheostomy, or transtracheal ventilation should be available. Postobstructive pulmonary edema should be anticipated after relief of airway obstruction has occurred; it can be treated with fluid restriction, diuretics, and continuous positive airway pressure.
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Review Case Reports
Intraoral vascular malformation and airway management: a case report and review of the literature.
A patient with a large airway venous malformation underwent anesthesia for a tooth extraction. The procedure was uneventful until extubation, immediately after which complete airway obstruction resulted. After unsuccessful attempts to relieve the problem, the patient's trachea was reintubated. ⋯ Anesthesiologists must be concerned with any airway vascular abnormality. Most abnormalities involving the airway are either hemangiomas or venous malformations. The anesthesiologist must diagnose the problem correctly because even minor manipulation of a venous malformation may result in exsanguination, or the malformation may become engorged and compromise the airway.
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Although digoxin remains one of the most widely prescribed drugs in the United States, potential pharmacodynamic and pharmacokinetic interactions between this compound and other drugs, diseases, and events commonly encountered in the perioperative period remain largely unappreciated. Furthermore, the therapeutic benefit of discontinuing or initiating digoxin treatment preoperatively remains unclear. We present a basic review of current knowledge regarding digoxin pharmacology and examine those concepts from the perspective of clinical anesthesiologists.