A & A case reports
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We report the case of 2 pediatric patients with coexisting diagnoses of malignant hyperthermia susceptibility and mitochondrial disease in 2 different surgical settings. Due to the rare occurrence of each disorder, and even more so together, we reviewed evidence-based anesthetic concerns and described our perioperative management, with the goal of aiding future practitioners in safely caring for these patients. Consent was obtained for both patients, as well as IRB approval before publication.
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Case Reports
Malignant Hyperthermia in a Morbidly Obese Patient Depletes Community Dantrolene Resources: A Case Report.
During resection of a duodenal carcinoid tumor, a 28-year-old morbidly obese woman developed suspected malignant hyperthermia. This hypermetabolic state posed a diagnostic challenge given the similar intraoperative presentation of carcinoid crisis and malignant hyperthermia. ⋯ Current dantrolene dosing recommendations are based on actual body weight despite a paucity of literature in obese patients. We speculate that the prolonged need for dantrolene redosing was from the continuous release of the volatile anesthetic from the patient's adipose tissue.
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A 28-year-old man presented with a penetrating injury by a nail gun to the head. Imaging revealed a nail abutting the superior sagittal sinus without active extravasation. ⋯ In the operating room, the nail was removed under general anesthesia, with blood products and equipment for craniotomy readily available, and imaging modalities reserved for immediate use. This case highlights the importance of a multidisciplinary approach to challenging penetrating head injuries and the crucial role anesthesiologists have as leaders in perioperative care.
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Case Reports
Use of 23.4% Saline in Symptomatic Vasospasm and Cushing's Triad to Prevent Herniation and Death: A Case Report.
A 53-year-old woman with migraines presented with Hunt-Hess grade 5 and Fisher grade 4 subarachnoid hemorrhage with intraventricular hemorrhage. She experienced severe vasospasm requiring intra-arterial medications. Continued vasospasm and edema resulted in Cushing's triad with profound tachypnea. ⋯ Despite the general practice to wait until complete neurologic deterioration before administering 23.4% saline, it was administered on 2 separate occasions, once after the failure of the 2 boluses of 3% saline and once on the reappearance of Cushing's triad 24 hours later, and on each occasion produced overall clinical improvement. The patient was subsequently discharged to a rehabilitation facility and then home. A paradigm shift to earlier intervention with 23.4% saline may improve overall outcomes in patients with severe intracranial hypertension refractory to 3% saline and impending herniation.
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Early diagnosis of aortic dissection is important to reduce mortality, with surgical management representing standard treatment. Current methods of diagnosing type A aortic dissection include computed tomography angiography (CTA), magnetic resonance imaging, catheter-based arteriography, and transesophageal echocardiography. ⋯ We present a case of a patient who was diagnosed with type A aortic dissection by CTA, but was found to not have an aortic dissection by transesophageal echocardiography under general anesthesia, preventing an unnecessary sternotomy. The echocardiographic findings suggested CTA artifact.