A & A case reports
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Academic anesthesia departments have management responsibilities (e.g., coordinating sedation, directing the operating rooms [ORs], informatics, ongoing professional performance evaluation, staff scheduling, and workroom inventory management). For each of the 64 faculty, a survey sampled 10 weekdays and 4 weekend days of professional activity over N=56 days. ⋯ Corresponding bootstrap limits were 107%, 89%, and 90%, respectively. Thus, although our College of Medicine tripartite mission includes clinical care, education, and research, administrative activities constitute a "fourth mission" of our department.
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The number of patients with noncardiac implantable electronic devices is increasing, and the absence of perioperative management standards, guidelines, practice parameters, or expert consensus statements presents clinical challenges. A 69-year-old woman presented for latissimus dorsi breast reconstruction. The patient had previously undergone implantation of a spinal cord stimulator, a gastric pacemaker, a sacral nerve stimulator, and an intrathecal morphine pump. ⋯ Bipolar cautery was used intraoperatively. Postoperatively, all devices were interrogated to ensure appropriate functioning before home discharge. Perioperative goals include complete preoperative radiologic documentation of device component location, minimizing electromagnetic interference, and avoiding mechanical damage to implanted device components.
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Seizure-like behavior is an uncommon yet worrisome phenomenon during anesthesia with propofol. The current case report describes a 23-year-old man admitted for elective surgery who experienced several seizure-like episodes after induction with propofol and during a desflurane-based general anesthetic that were so severe it was not possible to complete the procedure. A second surgery was rescheduled 2 days later with simultaneous scalp electroencephalographic (EEG) recording and general anesthesia with propofol and fentanyl. ⋯ This is the first report of apparent seizure-like activity during anesthesia with propofol of an otherwise relatively healthy adult, in which concurrent EEG recording demonstrates the nonepileptic nature. The current case demonstrates that, at least in some instances, these concerning movements are not seizure related. Concurrent EEG monitoring may be helpful to evaluate the nature of the episodes in select cases.
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In this case report, we describe the use of the Draeger Apollo anesthesia machine to deliver bilevel positive airway pressure (BiPAP) to a patient with severe chronic obstructive pulmonary disease and a history of lung resection undergoing frontal craniotomy for the removal of a brain tumor under moderate to deep sedation. BiPAP in the perioperative period has been described for purposes of preoxygenation and postextubation recruitment. ⋯ We describe the intraoperative use of pressure support mode on the anesthesia machine to deliver noninvasive positive pressure ventilation through a standard anesthesia mask. Given its ease of access and effectiveness, it is our belief that intraoperative BiPAP may reduce hypoxemia and/or hypercarbia in patients with chronic obstructive pulmonary disease and obstructive sleep apnea undergoing moderate to deep sedation.
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A 70-year-old man was scheduled for open reduction and internal fixation of his right knee fracture. When the tourniquet was deflated after 150 minutes, his arterial blood pressure and heart rate decreased precipitously. The patient was deemed to exhibit pulseless electrical activity. ⋯ Transesophageal echocardiography showed a pulmonary embolism. Feedback from echo imaging improved the quality of chest compressions and motivated the resuscitation team to maintain the diastolic blood pressure>25 mm Hg. Although capnographic guidance was ineffective by itself, echocardiography monitoring was very helpful for showing the intracardiac events.