A&A practice
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A central neuraxial block may be difficult to perform in elderly patients with lumbar spine deformities, calcified ligaments, and narrowing of the epidural space. We report a case of difficult epidural needle placement in an elderly patient scheduled for bilateral total knee replacement (TKR). We attempted epidural needle placement many times without success. However, when a modified technique was used, the epidural space was identified easily and confirmed, the epidural catheter was inserted and fixed, and the postoperative epidural analgesia was effective.
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Goldenhar syndrome, or oculoauriculovertebral dysplasia, represents approximately 10% of craniofacial microsomia anomalies. These patients have a variety of clinical features that are relevant to anesthesia providers, including a high-arched palate, mandibular hypoplasia, micrognathia, and temporomandibular joint (TMJ) malformation. ⋯ Outside of the dental and oral surgery literature, the potential for TMJ ankylosis in Goldenhar patients is seldom emphasized. TMJ ankylosis impacts airway management, and anesthesia providers must be aware of this clinical phenotype when planning the anesthetic care of patients with Goldenhar syndrome.
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Case Reports
Acute Intraoperative Hypoxemia During Right Pneumonectomy-The Heart and Lung Interaction: A Case Report.
A 75-year-old woman with a history of right-upper lobectomy for adenocarcinoma presented for a right completion pneumonectomy due to 2 new fluorodeoxyglucose-avid densities on the remaining lung. After uneventful anesthetic induction and surgical resection with modest blood loss, the patient developed refractory hypoxemia on emergence without significant hemodynamic changes. ⋯ An emergent transesophageal echocardiogram revealed a significant intracardiac shunt due to a patent foramen ovale. Specific cardiorespiratory management to achieve a positive left-right heart pressure gradient resulted in prompt normoxemia and successful extubation.
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Snorkel masks have become an option for personal protective equipment (PPE) due to the shortage of air filtration at least 95% of airborne particle (N95) masks as a result of the coronavirus disease 2019 (COVID-19) pandemic. We developed a 3D design of a triheaded adapter that connects a snorkel mask to 3 different National Institute for Occupational Safety and Health (NIOSH)-approved air filtration at least 99% of airborne particles (N99) filters with the aim of improving wearer comfort. We measured the resistance of the new triheaded adapter to be one-third the resistance of the single adapter. Interdepartmental survey of anesthesiologists showed an improvement in perceived comfort when using the triheaded adapter as compared to the single adapter.
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Hi-flow nasal oxygen (HFNO) has revolutionized tubeless field anesthesia for airway surgery without the complications of jet ventilation. However, its use in third trimester parturients undergoing open airway surgery has been limited to an apneic technique (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange [THRIVE]) in current publications. We used SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) in the management of tracheal dilatation in a near-term parturient at 36 weeks of gestation. Transferring this established protocol for spontaneous ventilation in the obstructed airway onto near-term parturients may mitigate the risks of apnea with hypercapnia, subsequent acidosis, and potential fetal harm.