A&A practice
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The outcome of upper limb tendon transfer surgery is improved when the patient is able to voluntarily contract specific muscles during the surgical procedure. Tumescent local anesthesia is suitable, but we describe an alternative option that involves the novel management of an axillary block. A 47-year-old man, injured in a motor vehicle crash, exhibited a thumb extensor deficit because of severe muscular trauma to the forearm. ⋯ First, individual injections of ropivacaine were performed around the musculocutaneous, radial, and ulnar nerves with ultrasound guidance. Second, a perineural catheter was placed near the median nerve and lidocaine injected. Voluntary flexor muscle contraction reappeared in time for the surgeon to adjust his suture tension.
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Tracheomalacia is characterized by the collapse of the tracheal wall due to the softening of the tracheal cartilage and myoelastic tissues. We describe the case of a 12-year-old morbidly obese boy, without previous medical issues, scheduled for elective laparoscopic cholecystectomy. ⋯ Intraoperative exploration with flexible bronchoscopy showed that the tip of the endotracheal tube was nearly occluded by the posterior tracheal wall bulging anteriorly. Anesthesiologists should be aware of undiagnosed tracheomalacia as a cause of sudden airway collapse, even after the airway is secured with an endotracheal tube.
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Directed discussion about advanced care planning in the preoperative setting is often lacking. We implemented an educational intervention pilot to increase the number of high-risk patients who have health care proxy and advanced directives documents completed. ⋯ Survey results showed that majority of patients felt the intervention increased their knowledge about advanced care planning (65%-70%) and that the video raised some topics worth discussing with family and health care providers. This intervention is scalable and could improve documentation and quality of care.
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Local anesthetic toxicity is a rare but serious complication of local anesthetic administration. Although lidocaine has a safety profile superior to other amide local anesthetics, we report a case of cardiac arrest after intranasal injection of lidocaine. ⋯ Resuscitative efforts were unsuccessful until a bolus of intralipid was given. This case emphasizes that even a "low" dose of a less lipophilic drug has the potential for severe toxicity.
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Local anesthetics are used throughout the health care system. In the perioperative setting and in other settings of exposure to local anesthetics, true allergy is reported very rarely. ⋯ This case illustrates that lidocaine may be a "hidden allergen" in the perioperative setting and should always be considered a potential culprit in cases of suspected perioperative hypersensitivity. The case also demonstrates that suspected perioperative hypersensitivity requires highly specialized investigation and close collaboration between allergists and anesthesiologists.