A & A case reports
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Patients receiving extended-release (XR) naltrexone who are having surgery present unique challenges to anesthesia providers, the most obvious of which is an altered response to the effects of opioid agonists. Based on the timing of the last XR naltrexone dose, patients may be refractory to the effects of opioid agonists or potentially more sensitive to dangerous side effects due to receptor upregulation and hypersensitivity. ⋯ We present a case of a 22-year-old woman receiving XR naltrexone for a history of heroin abuse undergoing a thyroidectomy and neck dissection. We discuss the intraoperative and postoperative anesthetic and analgesic planning, as well as solutions to some of the challenges these patients pose.
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In the United States, more than 100,000 tracheostomies are performed annually. Many patients undergoing tracheostomy are critically ill, making them higher risk surgical candidates. ⋯ In this report, we describe a technique to minimize the risk of airway loss by using an airway exchange catheter as an airway conduit during endotracheal tube removal. We present 2 clinical cases in which this technique was used successfully and made an important contribution to patient safety.
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At facilities that offer cardiac surgery services, minimally invasive cardiothoracic surgery is fast becoming commonplace, particularly in aortic, tricuspid, and mitral valve procedures. Use of a coronary sinus catheter, a specialized central venous catheter, to monitor hypothermic depth and provide retrograde cardioplegia has been widely adopted at Tufts Medical Center. ⋯ In contrast, complications of catheter removal, such as the catheter fracture that we report here, are not well described in the literature. In this case, the catheter tip was retrieved without further patient harm or additional invasive interventions.
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We report a significant complication that occurred during double guidewire insertion. The first guidewire (GW1) was inserted under ultrasonographic guidance, whereas the second guidewire (GW2) was inserted by the landmark-based method. ⋯ The first guidewire was found to be pointing in a cranial direction, indicating the manner in which the second guidewire's puncture needle had penetrated it. Thus, when double cannulation is performed, guidewire position should be confirmed.