A&A practice
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Although originally described to assist airway management of fetal congenital malformations with life-threatening airway obstruction, the indications for an ex utero intrapartum treatment (EXIT) have expanded to include surgical resection of lesions that are potentially incompatible with life in the absence of uteroplacental circulatory support. We describe the case of an infantile fibrosarcoma (IFS) that presented with fetal hydrops and was successfully managed with an emergency EXIT that necessitated the initiation of a massive fetal blood transfusion both with and without the support of uteroplacental circulation.
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One of the many safety features of modern day anesthesia machines is the adjustable pressure limiting (APL) valve. This device regulates pressure within the anesthesia circuit during manual ventilation with the anesthesia bag. We report an unusual case where a crack in the APL valve allowed release of pressure from within the circuit resulting in ineffective bag-valve-mask ventilation of an infant. The appropriate steps to prevent such issues are reviewed, and an algorithm to quickly identify such intraoperative problems is presented.
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Case Reports
Repeated Intercostal Nerve Blocks With Liposomal Bupivacaine for Chronic Chest Pain: A Case Report.
Chronic chest pain is a debilitating condition that is poorly treated, resulting in opioid dependence and significantly decreased quality of life. In this case report, we describe the successful use of 266 mg of liposomal bupivacaine for 4 rounds of left-sided multilevel intercostal nerve blocks performed to treat chronic chest pain of a 21-year-old woman (150 kg, 163 cm). The sensory blockade duration was up to 7 days, analgesia lasted 2 months, and was described superior to that with ropivacaine intercostal blockade. The treatment improved satisfaction with pain control and quality of life.
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Postsurgical trigeminal neuralgia (TN), although rare, can lead to significant hemodynamic perturbations by triggering the trigeminocardiac reflex (TCR). The combination can lead to diagnostic as well as management challenges for clinicians. We present the case of a patient with a parotid abscess, which developed as a complication of his otolaryngologic surgery, and which led to repeated episodes of symptomatic bradycardia associated with cardiovascular collapse. This case highlights the importance of heightened awareness, early diagnosis, and timely treatment of postsurgical neuropathic pain syndromes to avoid life-threatening complications.
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This case demonstrates the airway management of a pediatric patient with short stature due to STAT5b deficiency, a rare genetic immunodeficiency associated with lung disease and endocrinopathy. The patient had recurrent pulmonary infections and pulmonary alveolar proteinosis (PAP) for which whole lung lavage (WLL) was recommended. Due to short stature and overall body habitus, the patient's airway would not accommodate a traditional double-lumen tube (DLT). Therefore, we placed 2 single-lumen breathing tubes: 1 endobronchial and 1 endotracheal, to mimic a DLT and facilitate WLL, demonstrating a viable option for lung isolation in the absence of purpose-built equipment.