A&A Practice

Boretsky, Karen R.; Perlas, Anahi

doi: 10.1213/XAA.0000000000001100pmid: 31592830

Pulmonary aspiration of gastric contents carries significant risk in children in the perioperative period. Ultrasound imaging of the gastric antrum has been validated to predict gastric content and volume in both pediatric and adult patients, and yet clinical applications in pediatric patients are sparse. We report 2 cases of children presenting for elective surgery with uncertain volume of gastric contents. Bedside gastric imaging successfully identified “full stomachs,” and the information was used to direct care.

Thawale, Roshan; Alva, Sachin; Niraj, Gopinath

doi: 10.1213/XAA.0000000000001102pmid: 31592828

Persistent cervicothoracic myofascial pain is a common condition that causes loss of function and can result in significant health care costs. The underlying cause is tender trigger points that result in impaired muscle function. Standard treatment includes physiotherapy, medications, acupuncture, and trigger point injections. Patients who fail to respond have very limited treatment options. The authors present a novel treatment in 2 patients presenting with severe unilateral cervicothoracic myofascial neck pain that failed to respond to standard treatment. The novel treatment, ultrasound-guided intermediate cervical plexus block with depot steroids, produced significant and durable pain relief in the 2 patients.

Pena, Israel; Knoepfler, Matthew L.; Irwin, Anna; Zhu, Xiaoying; Kohan, Lynn R.

doi: 10.1213/XAA.0000000000001106pmid: 31609721

Head and neck cancer can be painful, debilitating, and refractory to oral medications. Due to the association of the sphenopalatine ganglion (SPG) with maxillary nerve sensory fibers, SPG blocks may be used to treat the pain of the hard and soft palate, tonsils, nasal cavity, paranasal sinuses, oral gingiva, premaxillary soft tissue, maxilla, and orbital floor. We present the first case series of performing SPG blocks utilizing TX360 nasal atomizers or angiocatheters to treat head and neck cancer–related pain. Pain scores were reduced by 38% to 80% with an average pain relief duration of 23 days.

Gupta, Abhinav; Joseph Thomas, James

doi: 10.1213/XAA.0000000000001114pmid: 31703005

Virtual reality (VR), a computer-generated simulation of a 3-dimensional environment, is a relatively new method of providing distraction before and during procedures. We describe the use of a VR multiuser application, Oculus Rooms, to calm an anxious 10-year-old boy during transportation to the operating room and induction of anesthesia. The use of VR could lessen the perioperative anxiety of children by maintaining a virtual child-parent connection while avoiding the potential drawbacks to having parents actually in the operating room before and during induction of anesthesia. The success of this novel technique has important implications for future clinical trials and practice.

Baribeau, Yanick; Chaudhry, Daawar; Sharkey, Aidan; Chaudhary, Omar; Chu, Louis; Mahmood, Feroze

doi: 10.1213/XAA.0000000000001120pmid: 31651414

The angle correction feature in ultrasound systems is used when there is difficulty accurately aligning the Doppler beam with the flow to be interrogated. The operator can manually “correct” the angle to the actual direction of flow. Subsequently, the machine corrects the peak velocity for the angle. We present a case of aortic valve replacement (AVR) in which falsely high transaortic gradients were obtained immediately after separation from cardiopulmonary bypass (CPB). We recommend that there be a more prominent notification when the angle correction feature is used with machine prompts confirming when a peak velocity is obtained using angle correction.

Morano, Jacqueline M.; Tung, Avery

doi: 10.1213/XAA.0000000000001123pmid: 31688027

Intraoperative neurophysiological monitoring involves electrical stimulation of nerve pathways and is used to assess the integrity of both motor and sensory pathways. Whereas motor pathway monitoring involves transcranial stimulation and peripheral nerve monitoring, somatosensory monitoring involves peripheral nerve stimulation and cranial monitoring. Arrhythmias are a known complication of motor-evoked potential monitoring but have not been reported with somatosensory monitoring. We describe a case of bradycardic arrest with somatosensory-evoked potential monitoring using median nerve electrodes in a patient with no previous rhythm abnormality. Clinicians caring for patients receiving somatosensory monitoring should be aware of the potential for severe arrhythmias.

Bortman, Jeffrey; Chaudhry, Omar; Sharkey, Aidan; Sohail, Mahad; Bose, Ruma; Matyal, Robina

doi: 10.1213/XAA.0000000000001125pmid: 31651416

Spinal drain placement to prevent spinal cord ischemia during thoracic aorta surgery is a necessary yet complex undertaking in patients with coagulopathies. Thromboelastography (TEG) can be used as a point-of-care management tool to monitor coagulation status before drain placement and removal. We present 2 cases: a case of a patient with factor VII deficiency and a case of a patient with thrombocytopenia for whom TEG was an important procedural adjunct during coagulopathy reversal. TEG parameters are also discussed to encourage more frequent TEG use as an adjunct during these complex cases.

Gerber, Thomas J.; Friedrich, Marie; Herren Gerber, Renate; Sartoretti-Schefer, Sabine; Ganter, Michael T.

doi: 10.1213/XAA.0000000000001124pmid: 31688028

Here we present the case of a 76-year-old woman with pancreatic cancer receiving epidural analgesia for chronic cancer pain treatment. Attempts of running the epidural catheter sequentially resulted in unexpected and extensive sensory block together with sympathicolysis but insufficient pain control. Finally, after 3 failed attempts of epidural catheter placements with insufficient pain control and uncommon neurological signs, a magnetic resonance imaging (MRI) scan of the spine was ordered. The MRI showed subdural catheter displacement with extensive liquid accumulation in the subdural space and consequent significant spinal cord compression. Findings normalized after removing the subdural catheter.

Baribeau, Yanick; Mahmood, Faraz; Sharkey, Aidan; Bortman, Jeffrey; Matyal, Robina; Laham, Roger; Mahmood, Feroze

doi: 10.1213/XAA.0000000000001105pmid: 31651413

Supplemental Digital Content is available in the text.

Levy, Jerrold H.; Welsby, Ian

doi: 10.1213/XAA.0000000000001115pmid: 31688025

Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, [email protected] Conflicts of Interest: J.H.L. serves on research steering committees for Boehringer Ingelheim, CSL Behring, Instrumentation Labs, and Octapharma. I.W. receives research support from CSL Behring.