A&A practice
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Primary leiomyosarcomas of the inferior vena cava (IVC) are rare sarcomas, none of which have been described in literature during a third-trimester pregnancy. Here, we describe the complex care of a patient at 30 weeks of gestation who presented to her obstetrician with shortness of breath and lower extremity swelling. She was found to have a 5.0 × 5.0 × 13 cm heterogeneous mass of her IVC, ultimately diagnosed as a leiomyosarcoma. She underwent a cesarean delivery under combined spinal epidural and a subsequent tumor resection and IVC reconstruction requiring multidisciplinary surgical and anesthetic care.
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Case Reports
Pregnancy With Large Arteriovenous Malformation of Tongue: Anesthetic Challenges and Conduct.
A pregnant woman with large intraoral arteriovenous malformation of tongue obliterating the oral cavity presented for elective cesarean delivery shortly after experiencing spontaneous, large-volume, oral bleeding. This case report describes the unconventional method of securing the airway for ensuring perioperative airway protection and the anesthetic management of the case.
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A tourniquet is used during surgery to produce a bloodless surgical field and decrease intraoperative blood loss. Although useful, tourniquets are associated with various physiological alterations both during inflation and deflation phases which may be poorly tolerated in compromised patients. We report a case of transient neurological dysfunction and intracranial hypertension after tourniquet deflation in a 15-year-old patient with a head injury. Intracranial hypertension under general anesthesia was diagnosed based on bradyarrhythmia and elevated ultrasonographic optic nerve sheath diameter as compared to preoperative values.
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Case Reports
Mouthpiece Noninvasive Ventilation in a Patient With Traumatic Cervical Spinal Cord Injury: A Case Report.
The use of noninvasive ventilation (NIV) has been associated with improved patient satisfaction and comfort compared to tracheostomy in patients who are ventilator dependent. We present a case of a young man who fell off a platform and sustained a traumatic third and fourth cervical vertebrae (C3/4) fracture dislocation with bilateral facet dislocation, in whom a trial of mouthpiece NIV was attempted. We discuss the issues surrounding this method of ventilation in ventilator-dependent patients.
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Approximately 15% of patients with a code status of do-not-resuscitate (DNR) or do-not-intubate (DNI) present for surgery. Despite professional guidelines requiring discussions with patients regarding perioperative resuscitation, it is unclear whether these recommendations are consistently followed. Our review of 158 patient encounters with established DNR/DNI code status found that code status discussions (CSDs) were documented only 70% of the time, and code status orders were inconsistently entered to reflect those discussions. We present solutions to improve CSD documentation, including refining perioperative workflows, simplifying code status choices, optimizing electronic health record order entry, and a supplementary consent form to facilitate code status review.