Transvaginal oocyte retrieval (TVOR) is typically performed under ambulatory intravenous (IV) sedation with preservation of spontaneous ventilation. We retrospectively identified five medically complex patients who received remimazolam as part of individualized anesthetic management for TVOR at a tertiary academic center. Comorbidities included cardiomyopathy, Fontan physiology, pheochromocytoma, difficult airway, and renal transplantation. Spontaneous ventilation was preserved in all cases without airway intervention. Two patients required intermittent phenylephrine, and one required flumazenil for delayed emergence. Median time from operating room exit to discharge readiness was 128 minutes (range 39-149). These cases illustrate clinical scenarios in which remimazolam may support individualized anesthetic strategies for medically complex patients undergoing TVOR.
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.
Complex regional pain syndrome (CRPS) is a multifactorial neuropathic disorder characterized by pain disproportionate to injury. We report a 58-year-old man with CRPS type II of the right lower extremity after traumatic nerve injury, diagnosed via Budapest criteria. After limited response to medical and rehabilitative therapy, ultrasound-guided percutaneous cryoneurolysis was performed on saphenous, deep peroneal, sural, and superficial peroneal nerves. The procedure yielded >80% pain reduction within 1 week and sustained analgesia with improved function at 9 months. This case suggests cryoneurolysis may represent a safe, minimally invasive option for refractory CRPS, warranting further controlled investigation.
BACKGROUND: Perioperative myocardial injury (PMI) is associated with a higher mortality after noncardiac surgery. Ischemic symptoms are uncommon postoperatively due to analgesics used perioperatively, necessitating nonsymptomatic surveillance. Although ST-segment deviation indicates myocardial ischemia, its association with PMI remains poorly understood. This study explored the association between continuous perioperative ST-segment monitoring and PMI in patients undergoing intermediate- to high-risk vascular surgery. METHODS: This was a prospective, single-center cohort study. In addition to standard monitoring, all patients were monitored using a six-lead continuous electrocardiography (ECG) with ST-segment analysis perioperatively. ST events were analyzed according to the fourth universal myocardial infarction definition and as individualized deviations from lead-specific baseline values. The primary outcome was PMI, defined by an increase in high-sensitivity cardiac troponin T measured preoperatively and at 4 to 6, 24, and 48 hours postoperatively. Multivariable Poisson regression was used for primary analysis. RESULTS: In total, 498 patients were included, and 46 (9%) incurred PMI. ST-elevation was seen in 89 (18%) and not significantly associated with PMI (adjusted relative risk [RR], 1.75; 95% confidence interval [CI], 0.87–3.53; P = .12), whereas ST-depression was seen in 38 (8%) and showed a significant association with PMI (adjusted RR, 3.85; 95% CI, 1.86–7.94; P < .001). Absolute ST-segment deviation >1 mm from individualized lead baseline was also associated with PMI (RR, 2.03; 95% CI, 1.01–4.06; P = .046). When ST-depression was added to the baseline model, including age and the American Society of Anesthesiologists (ASA) physical status classification system, overall net risk classification improved (NRI, 0.50; 95% CI, 0.16–0.86). CONCLUSIONS: ST-depression meeting universal myocardial infarction criteria and ST deviations >1 mm from individualized baseline were associated with PMI. Intra- and postoperative ST-segment monitoring may facilitate detection of PMI.
