A&A practice
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We present the anesthetic management of a 23-year-old gravida 2 para 0-0-1-0 with a history of mitral valve replacement secondary to congenital mitral dysplasia. The hemodynamic changes of pregnancy had resulted in severe functional mitral stenosis of her mechanical valve, which was significantly undersized for her current body surface area. Her complex cardiac history required our multidisciplinary team to focus on peripartum anticoagulation management, extracorporeal membrane oxygenation (ECMO) preparation under a dural puncture epidural (DPE) technique, and managing the hemodynamic changes that are critical for a congenital heart disease parturient.
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Guidelines on the management of lumbar drain in patients receiving antithrombotic therapy are lacking, with American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines for regional anesthesia providing the best possible guidance for this scenario. However, the risk-benefits of placing a lumbar drain in the context of vascular surgery differ from placement of neuraxial blockade. One of the changes included in the recently published ASRA guidelines is that clopidogrel can be started on a patient with an indwelling neuraxial catheter. We report a case of slowly evolving epidural hematoma following the initiation of clopidogrel therapy in a patient with an indwelling lumbar drain.
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Case Reports
Advanced Progression of Scoliosis After Intrathecal Baclofen in an Adult With Stiff Person Syndrome: A Case Report.
Stiff person syndrome is a neuroimmunological disorder characterized by progressive muscular rigidity and spasms that affect axial/limb muscles, resulting in severe pain and functional limitations. When refractory to conservative treatments, intrathecal baclofen is a viable option to treat the increased tone. ⋯ This adverse effect has never been reported in adults with stiff person syndrome. We report a case of an adult with stiff person syndrome and underlying scoliosis who experienced accelerated progression of scoliosis after initiation of intrathecal baclofen, subsequently requiring neurosurgical intervention.
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Case Reports
Effective Use of Angiotensin II in Coronavirus Disease 19-Associated Mixed Shock State: A Case Report.
The rapid spread of Coronavirus Disease 2019 (COVID-19) has sparked a search for effective therapies. The discovery that the virus binds the angiotensin-converting enzyme 2 (ACE2) receptor has led to investigation of the renin-angiotensin system for possible therapeutic targets. ⋯ She rapidly demonstrated significant hemodynamic improvement without noted adverse effects. Thus, we propose further investigation into possible benefits of angiotensin II in shock secondary to COVID-19.
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Case Reports
Pectoral Nerve Block Type II as the Sole Anesthetic for Removal of a Large Axillary Tumor: A Case Report.
The pectoral nerve block type II (Pecs II block) combined with general anesthesia provides analgesia during breast and axillary surgery. This report describes the first use of the Pecs II block as the sole anesthetic for axillary surgery. A patient needed resection of axillary masses. ⋯ An ultrasound-guided Pecs II block was performed. Both masses were resected without additional sedation or analgesia. This case report suggests that, in selected cases, the Pecs II block can be used as the sole anesthetic for axillary surgery.