A & A case reports
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A 42-year-old obese woman (body mass index = 30.2 kg/m) presented for urgent anterior cervical diskectomy and fusion. She had been taking oral naltrexone-bupropion extended-release (Contrave, Orexigen Therapeutics Inc, La Jolla, CA) for the past 6 months and continued using it until 12 hours preoperatively. Despite discontinuation of this medication, and employing an intraoperative and postoperative multimodal analgesia strategy, immediate pain control was inadequately achieved. Patients taking opioid antagonists who present for surgery pose unique challenges to the anesthesiologist and require extensive preoperative interdisciplinary discussions and planning for pain control throughout the perioperative period.
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Cardiogenic shock from acute severe mitral valve regurgitation can cause acute liver failure due to hypoperfusion. Impaired liver glycogenesis can then lead to profound hypoglycemia. ⋯ Thus, the clinical decision to provide further resuscitation in the setting of extreme hypoglycemia mainly depends on the patient's overall clinical condition, provider opinion, and/or institutional practice. Here, we report a case where the patient made complete neurologic recovery from extreme hypoglycemia (<5 mg/dL by central laboratory testing) secondary to acute cardiogenic shock and liver failure.
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This article describes 2 patients with severe acute right ventricular failure causing circulatory shock. Portal vein pulsatility assessed by bedside ultrasonography suggested clinically relevant venous congestion. Management included cardiac preload reduction and combined inhalation of milrinone and epoprostenol to reduce right ventricular afterload. Portal vein ultrasonography may be useful in assessing right ventricular function in the acutely ill patient.
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Editorial Case Reports
Uncommon Events May Be More Common Than You Think.
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A 28-year-old man presented with a penetrating injury by a nail gun to the head. Imaging revealed a nail abutting the superior sagittal sinus without active extravasation. ⋯ In the operating room, the nail was removed under general anesthesia, with blood products and equipment for craniotomy readily available, and imaging modalities reserved for immediate use. This case highlights the importance of a multidisciplinary approach to challenging penetrating head injuries and the crucial role anesthesiologists have as leaders in perioperative care.