AANA journal
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Case Reports
Case report: anesthetic management of acute fatty liver of pregnancy in the postpartum period.
Acute fatty liver of pregnancy (AFLP) is a potentially fatal metabolic disorder that manifests during the third trimester. Early diagnosis, termination of pregnancy, and treatment of complications associated with AFLP significantly reduce maternal morbidity and mortality. ⋯ Anesthetic implications include early recognition of liver dysfunction and aggressive resuscitation and treatment of hypoglycemia, disseminated intravascular coagulopathy, and other associated complications and reduction or avoidance of medications with substantial hepatic metabolism. This is a case report describing the management of a woman with AFLP in whom acute liver failure rapidly developed after a vaginal delivery with epidural analgesia at a small overseas hospital.
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Complex regional pain syndrome (CRPS) is an enigmatic disease process affecting the upper and lower extremities. It consists of various combinations of sensory, autonomic, and motor abnormalities, the pathogenesis of which is unclear. Formally known as reflex sympathetic dystrophy or causalgia, CRPS has a revised taxonomy since 1994. ⋯ Various treatment modalities, including medication regimens, sympathetic nerve blocks, and physical therapy have met with differing degrees of success. Recent advances in spinal cord stimulation are promising. Although initially costly, this may prove to be the least expensive and most effective treatment in the long-term.
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Current fashion in body art includes low back tattoos of varying designs and colors, a trend that presents unique concerns for anesthesia providers. Does the placement of epidural catheters risk the introduction of tattoo pigment dyes into the epidural space through the process of coring? Are there specific risks associated with tattoo dyes and epidural needle placement? We performed a comprehensive review of the literature using multiple search databases with the intent to form guidelines for practice using a level of evidence taxonomy. ⋯ Continued investigation is necessary before comprehensive practice guidelines regarding the practice of placing epidural needles and catheters through lumbar tattoos can be developed. We suggest avoidance of piercing tattoos when performing epidural punctures until there is sound evidence of short-term and long-term safety.
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Comparative Study
Patient outcomes comparing CRNA-administered peripheral nerve blocks and general anesthetics: a retrospective chart review in a US Army same-day surgery center.
We compared outcomes between patients receiving general anesthesia (GA) vs regional block (RB) in a military same-day surgery unit (SDSU), where Certified Registered Nurse Anesthetists (CRNAs) delivered all RBs and GA. All patient charts from 2003 through 2006 were reviewed. Patients were included if they were 18 years or older, had an ASA physical status I or II, and underwent a shoulder or knee arthroscopy that used either RB or GA. ⋯ The GA group received more morphine equivalents of narcotic in the operating room (22.9 vs 15.1 mg, P < .001) yet still had higher pain scores postoperatively than the RB group (1.1 vs 0.3, P < .001). The GA group received a significantly greater number of antiemetic doses intraoperatively (0.58 vs 0.04, P < .001) but still had a higher, although nonsignificant, rate of emesis (15.5% vs 10.0%). Patients receiving RB had less pain and received less analgesia without any increase in postoperative nausea and vomiting, hospital time, or anesthesia-related complications.
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Visual loss is a traumatic occurrence that has been reported after prone spine surgical procedures performed under general anesthesia. The most common cause of postoperative visual loss is ischemic optic neuropathy. Although the incidence of postoperative visual loss is rare, this devastating injury has been reported more frequently. ⋯ Ischemic optic neuropathy usually presents with painless visual loss and visual field deficits during the immediate postoperative period. There is no definitive treatment. Prevention is the key.