A & A case reports
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The anesthetic implications of acute leukemia in pregnancy have not been reported. We describe the anesthetic management of a laboring primigravida at 34 weeks' gestation with new-onset acute myeloid leukemia. With multidisciplinary consultation, we recommend that neuraxial anesthesia be avoided in new-onset acute myeloid leukemia due to the risk of introducing malignant cells into the central nervous system, which can spread the disease and complicate management. We discuss the use of a fentanyl patient-controlled analgesia and dexmedetomidine as a method of labor analgesia, and the potential benefits of the latter medication in the obstetric population.
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A 44-year-old man undergoing ambulatory surgery sustained a 5% total body surface first-degree burn on his lower and lateral torso and upper thigh during routine use of a new forced-air warming Bair Paws™ flex gown system. We describe the likely mechanism of injury, intraoperative events suggesting special variation in the warming process, and a brief review of adverse events associated with forced-air warming systems.
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A 37-year-old woman underwent transsphenoidal surgery for recurrent pituitary adenoma. Postoperatively, she had a prolonged intensive care unit stay and repeated tracheal intubations because of inadequate airway reflexes. On postoperative day 25, she had difficulty maintaining her airway, and the nursing staff attempted orotracheal suctioning, which failed. ⋯ Computed tomography showed diffuse pneumocephalus and a new parenchymal hemorrhage. The only temporally related event was use of a nasotracheal catheter. This case suggests that nasotracheal suctioning may not be safe in patients who have recently undergone transsphenoidal procedures.
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A 20-year-old female underwent orthotopic liver transplantation for arginase deficiency, a urea cycle disorder. A hyperammonemic state was prevented by the administration of lipid and carbohydrate substrate and avoidance of protein loading (including human albumin) and prolonged fasting. Caval cross-clamping may have been tolerated poorly owing to the potential interaction between hyperargininemia (a nitric oxide precursor) and the lack of collateral venous drainage. Ammonia and arginine levels improved in parallel with hepatic function after reperfusion of the hepatic graft.