Dental injury is a recognized complication of airway management during general anesthesia. We report the case of a 50-year-old woman undergoing elective hysterectomy under general anesthesia with endotracheal intubation, in whom a loose upper incisor with active gingival bleeding was identified after airway management. Oxidized regenerated cellulose (ORC) Surgicel, placed between the tooth and gingiva, achieved hemostasis and stabilization. The material was removed during emergence to permit direct visualization of tooth stability and to avoid unintended retention within the oral cavity. This case describes a simple intraoperative technique for managing unexpected dental bleeding and loose dentition during anesthesia.
BACKGROUND:Optimal analgesia after total hip arthroplasty (THA) remains uncertain. This trial evaluated whether adding ultrasound-guided pericapsular nerve group (PENG) and iliohypogastric nerve blocks (IHGNBs) to standardized multimodal analgesia improves postoperative analgesia after THA. METHODS:In total, 215 patients undergoing THA were randomized to receive PENG plus IHGNB or no block. The primary outcome was pain intensity at rest assessed using a numeric rating scale (NRS) on arrival in the postanesthesia care unit (PACU), at 1, 2, and 3 hours after arrival, at ward admission, in the evening on the day of surgery, on the morning of postoperative day 1, at 14:00 on postoperative day 1, and on day 14. Secondary outcomes included oral morphine equivalent (OME) consumption, length of stay, and adverse events. RESULTS:Median NRS on arrival in the PACU was as follows: 0 interquartile range (IQR) 0 to 0 vs 0 IQR 0 to 2.25, P = .022 at 1 hour; 0 IQR 0 to 2 vs 0 IQR 0 to 3, P = .914 at 2 hours; 0 IQR 0 to 2.75 vs 0.5 IQR 0 to 3.25, P = . 568 at 3 hours; 2 IQR 0 to 3 vs 2 IQR 0 to 3.25, P = .551 at ward admission; 2.5 IQR 1.25 to 5 vs 4 IQR 2 to 5, P = .743 in the evening on the day of surgery; 3 IQR 1.25 to 4.75 vs 4 IQR 2 to 5, P = .600 on the morning of postoperative day 1; 3 IQR 2 to 4.5 vs 2.5 IQR 1 to 4, P = .216 at 14:00 on postoperative day 1; 2 IQR 1 to 4 vs 2 IQR 1 to 3, P = .706 on day 14; and 1 IQR 0 to 2 vs 1 IQR 0 to 2, P = .219. OME consumption was lower in the block group among patients who received general anesthesia (mean [standard deviation {SD}], 23.4 [11.2] mg vs 34.7 [12.8] mg, P = .014). Sensory deficits were more prevalent in the nerve block group on day 1, 13/92 (14.1%) vs 2/86 (2.3%), P = .006, and on day 14, 13/89 (14.6%) vs 1/87 (1.1%), P = .001, whereas motor deficits were infrequent. CONCLUSIONS:Adding the PENG block and IHGNB to multimodal analgesia did not provide consistent analgesic benefits after THA. Sensory deficits were more frequent after block placement. The finding of lower opioid consumption in patients receiving general anesthesia warrants further investigation.
Positive pressure ventilation through a Montgomery T-tube remains a clinical challenge. This report highlights a successful case of positive pressure ventilation through a Montgomery tube with the aid of a cuffless endotracheal tube inserted into the proximal end of the T-tube. In cases where removal of the T-tube is not possible due to surgical indications, this technique can be used to maintain effective ventilation.
Carnitine deficiency syndromes are a group of rare metabolic disorders characterized by impaired β-oxidation and increased reliance on glucose during metabolic stress. Published literature on anesthetic management in patients with congenital carnitine deficiency is limited. We report the case of a 10-year-old boy with carnitine deficiency undergoing bronchoscopy, tonsillectomy, and adenoidectomy. A nontriggering anesthetic was used due to concern for malignant hyperthermia risk with carnitine palmitoyltransferase deficiency; a diagnosis used interchangeably with primary carnitine deficiency for this patient. This case documents successful anesthetic management with meticulous metabolic support in a patient with a complex metabolic disorder.
Chronic pain after spinal cord injury (SCI) is often refractory to medication, and spinal cord stimulation (SCS) may provide relief. We report a 48-year-old man with complete thoracic SCI who underwent an SCS trial for severe bilateral lower-extremity-pain. Although pain improved, low-grade fever, elevated inflammatory markers, and purulent drainage developed on day 7. Magnetic resonance imaging revealed a spinal epidural abscess (SEA). SCS leads were removed, and cultures grew methicillin-resistant Staphylococcus aureus . As the abscess was small without significant compression, conservative treatment with vancomycin was successful. This case highlights the diagnostic difficulty of SEA in complete SCI.
The Warburg effect describes the phenomenon in which cancer cells preferentially use glycolysis even under aerobic conditions, leading to excessive lactate production. Though more frequently described in hematologic malignancies, this mechanism can also be seen in solid tumors. Here we report a case of an 84-year-old man who developed a profound intraoperative lactic acidosis during glioblastoma resection, likely attributable to the Warburg effect. This case highlights the importance of maintaining broad differential diagnoses of lactic acidosis. Anesthesiologists, surgeons, and intensivists should be aware of this phenomenon, as failure to recognize the diagnosis may result in unnecessary and potentially harmful interventions.
BACKGROUND: Clinical critical incidents in anesthesiology practice may adversely affect clinician well-being. Post-critical incident debriefing may support staff and patient safety. However, implementing programs in high-acuity environments remains challenging. We aimed to determine baseline post-clinical critical incident practices at our institution, develop and implement a context-adapted program, and evaluate its integration into practice and its impact. METHODS: We undertook a mixed-methods study. The baseline survey measured psychological safety, prior experiences with critical incidents, and debriefing practices. Focus groups deepened our understanding of key stakeholder needs. These findings informed the design of an adapted post-incident support program. A post-implementation evaluation using surveys and focus groups examined perceived impacts. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically to identify determinants of feasibility and acceptability, as well as contextual barriers. RESULTS: The baseline survey (N = 55/111; 50% response rate) generally demonstrated high psychological safety. Debriefing was a highly emotional experience, logistical barriers were common, and the purpose of debrief sessions was sometimes ambiguous. Following program refinement, duty relief after critical incidents increased (N = 10/37; 27% at baseline, N = 27/42; 64% post-program, χ 2 (1) = 10.97, P < .001 ) and most respondents reported feeling supported despite persistent logistical barriers to post-incident responses. Observed vulnerability in senior staff in post-incident support sessions was welcomed by trainees, but sometimes challenging for senior clinicians. Although critical incidents had negative impacts on respondents (N = 28/54, 52% professional and N = 20/54, 37% personal adverse impact), we also identified potential for post-traumatic professional growth (N = 26/54, 48% positive professional impact). CONCLUSIONS: Our stakeholder-informed, contextually adapted debriefing program was acceptable, feasible, and may mitigate the adverse effects of critical incidents while fostering professional growth. Persisting challenges included logistics, the tension between a well-being and clinical review focus, and differential risks and benefits by career stage.
Difficult laryngoscopy in syndromic children is usually attributed to mandibular or cervical abnormalities; however, supraglottic malformations may also impair laryngeal exposure. We describe three syndromic pediatric cases in which difficult laryngoscopy was associated with abnormal epiglottic morphology. In the index neonate with suspected left-sided branchial arch hypoplasia, bronchoscopy demonstrated ipsilateral hypoplasia of the epiglottis and arytenoid region, with the epiglottis arising unusually deep from the tongue base. These findings suggest that supraglottic malformation should be considered and that primary use of an age-appropriate video laryngoscope, with early flexible bronchoscopic guidance when needed, may facilitate safe airway management.
We describe the case of a 38-year-old patient who developed a delayed localized cutaneous hypersensitivity reaction after she underwent lumbar trigger point injections (TPIs). This patient had undergone numerous TPIs in the past without adverse reactions. Notably, she had one prior similar episode; in both episodes, a larger volume of chlorhexidine was used during skin preparation. These findings suggest that the combined effects of a longer dry time and inadvertent subcutaneous chlorhexidine exposure were the likely drivers of these reactions. This case presents a unique manifestation of chlorhexidine hypersensitivity via subcutaneous introduction.
We present a 14-year-old girl with a history of acute lymphoblastic leukemia who developed chronic pain from several overlapping conditions, including chemotherapy-related neuropathy, sacroiliitis, lumbar degenerative changes, and post-surgical complex regional pain syndrome (CRPS). Her pain was largely nonmalignant and remained difficult to control despite prior treatment measures. She underwent spinal cord stimulation (SCS) implantation with concurrent pain psychology support. After implantation, her reported pain scores improved from 10/10 to 5/10, opioid use remained minimal, and she demonstrated greater day-to-day functional participation. Cognitive behavioral therapy (CBT) and family-centered behavioral strategies were incorporated throughout treatment to strengthen coping skills and support rehabilitation goals. This case illustrates the potential benefit of combining neuromodulation with structured psychological support in the treatment of complex pediatric chronic pain.
Neuraxial anesthesia is commonly used for labor analgesia, and postpartum back pain is often experienced, with or without an epidural. Although it usually improves with supportive care, back pain coupled with other findings (such as radiculopathy, bowel or bladder dysfunction, or inability to ambulate) warrants further investigation post epidural. Here, we present a 37-year-old patient who experienced inadequate pain relief with multiple epidural blocks during labor and worsened back pain after delivery, and was later determined to have a lumbar myxopapillary ependymoma. Neuraxial anesthesia in the setting of a spinal tumor imposes a high risk for serious complications.
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality, complicating 2% to 4% of US deliveries and exacerbating iron deficiency anemia. Ferritin is the primary biomarker for iron deficiency (ferritin <30 µg/mL), yet its reliability as a marker of iron deficiency in the acute setting of PPH remains uncertain because it also functions as an acute-phase reactant. In this case series, 10 iron-deficient women who experienced PPH following cesarean delivery all maintained ferritin <30 µg/mL postoperatively. Ferritin remained a reliable marker for iron deficiency following acute PPH in women with pre-existing iron deficiency. These observations highlight the need for larger, prospective studies to further validate ferritin's reliability following PPH.
