A & A case reports
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Case Reports
Blood-Conservation Strategies in a Blood-Refusal Parturient with Placenta Previa and Placenta Percreta.
Abnormal placentation can be associated with significant blood loss and massive blood transfusions. Caring for parturients with abnormal placentation who refuse blood transfusion is very challenging. ⋯ A multidisciplinary team developed a plan, including the use of perioperative erythropoietin and IV iron dextran, intraoperative acute normovolemic hemodilution, cell salvage, tranexamic acid, and uterine artery embolization. This strategy was successful in avoiding the need for allogeneic transfusion and ensuring an uneventful recovery after both surgical procedures.
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The relationship of care coordination activities and outcomes to resource utilization and personnel costs has been evaluated for a number of pediatric medical home practices. One of the first tools designed to evaluate the activities and outcomes for pediatric care coordination is the Care Coordination Measurement Tool (CCMT). It has become widely used as an instrument for health care providers in both primary and subspecialty care settings. ⋯ We successfully adapted and implemented the CCMT for a pediatric surgical population and measured nonface-to-face, nonbillable encounters performed by perioperative nursing staff. The care coordination activities integrated into the preoperative process include elaboration of care plans and identification and remediation of discrepancies. Capturing the activities and outcomes of care coordination for preoperative care provides a framework for quality improvement and enables documentation of the value of nonface-to-face perioperative nursing encounters that comprise care coordination.
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Ventricular assist devices (VADs) are associated with conditions that may complicate the perioperative course of pediatric heart transplants. A 7-year-old girl with dilated cardiomyopathy supported by a Toyobo-NCVC left VAD (Toyobo-National Cardiovascular Center, Osaka, Japan), a pulsatile extracorporeal device, and preoperatively anticoagulated with warfarin presented for orthotopic heart transplant. ⋯ Preoperative anticoagulation and the presence of a VAD are associated with postbypass coagulopathy and vasoplegia. We describe a case in which these conditions were successfully treated with no thrombotic complications and minimal need of vasopressors for hemodynamic stability.
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In this report, we describe the case of a young female with Down syndrome who presented to the anesthesia service after pulseless electrical activity arrest with a King LT(S)-D extraglottic airway device in situ. She had multiple predictors of difficult intubation, including what appeared to be a submental mass consistent with Ludwig's angina. She went on to receive an urgent tracheotomy because of those predictors but had full resolution of the submental mass on removal of the extraglottic airway device, which had been overinflated at the time of insertion. We outline the various techniques to establish a definitive airway with an extraglottic device in place.