A&A Practice

Franklin, Andrew D.; Llobet, J. Rodrigo; Sobey, Christopher M.; Daniels, Jessica M.; Kannankeril, Prince J.

doi: 10.1213/XAA.0000000000001036pmid: 31162228

Ventricular tachycardia (VT) storm, defined as recurrent VT requiring electrical cardioversion ≥3 times within 24 hours, is a rare presentation of long-QT syndrome. Pharmacologic autonomic modulation and/or left cardiac sympathetic denervation are established therapies in long-QT syndrome in adults but may not be effective or practical in the emergent treatment of VT storm. We present a novel case of a child with drug-refractory VT storm and prolonged QT requiring extracorporeal membrane oxygenation (ECMO) support. Continuous stellate ganglion blockade was remarkably effective in stabilizing his rhythm and should be considered in similar pediatric cases.

Sukumar, Vasanth

doi: 10.1213/XAA.0000000000001037pmid: 31265444

A middle-aged man with acute inferior wall myocardial infarction was admitted in cardiac arrest and in an unresponsive state to the hospital. Cardiopulmonary resuscitation (CPR) was initiated. Patient showed signs of consciousness throughout the CPR. The impact of awareness during CPR on the neuropsychological status of a patient with a favorable neurological outcome is yet to be studied on a large scale. Sedation protocol without compromising hemodynamic status may prove a fair choice in such cases.

Eklund, Susan E.; Levin, David N.

doi: 10.1213/XAA.0000000000001044pmid: 31265442

This case demonstrates the airway management of a pediatric patient with short stature due to STAT5b deficiency, a rare genetic immunodeficiency associated with lung disease and endocrinopathy. The patient had recurrent pulmonary infections and pulmonary alveolar proteinosis (PAP) for which whole lung lavage (WLL) was recommended. Due to short stature and overall body habitus, the patient’s airway would not accommodate a traditional double-lumen tube (DLT). Therefore, we placed 2 single-lumen breathing tubes: 1 endobronchial and 1 endotracheal, to mimic a DLT and facilitate WLL, demonstrating a viable option for lung isolation in the absence of purpose-built equipment.

D’Mello, Ajay J.; Raman, Vidya T.; Tobias, Joseph D.

doi: 10.1213/XAA.0000000000001045pmid: 31206378

One of the many safety features of modern day anesthesia machines is the adjustable pressure limiting (APL) valve. This device regulates pressure within the anesthesia circuit during manual ventilation with the anesthesia bag. We report an unusual case where a crack in the APL valve allowed release of pressure from within the circuit resulting in ineffective bag-valve-mask ventilation of an infant. The appropriate steps to prevent such issues are reviewed, and an algorithm to quickly identify such intraoperative problems is presented.

Visoiu, Mihaela; Verdecchia, Nicole

doi: 10.1213/XAA.0000000000001047pmid: 31206386

Chronic chest pain is a debilitating condition that is poorly treated, resulting in opioid dependence and significantly decreased quality of life. In this case report, we describe the successful use of 266 mg of liposomal bupivacaine for 4 rounds of left-sided multilevel intercostal nerve blocks performed to treat chronic chest pain of a 21-year-old woman (150 kg, 163 cm). The sensory blockade duration was up to 7 days, analgesia lasted 2 months, and was described superior to that with ropivacaine intercostal blockade. The treatment improved satisfaction with pain control and quality of life.

Gokul, Sheila R.; Riccio, Christina A.

doi: 10.1213/XAA.0000000000001048pmid: 31206379

Postpartum hemorrhage is a leading cause of maternal and fetal mortality. Although rare, peripartum splenic rupture (PSR) is a lethal cause of bleeding due to variable presentation and delayed diagnosis. A 22-year-old gravida 2, para 0, abortus 1 (G2P0A1) woman presented for premature rupture of membranes and was diagnosed with Influenza A and chorioamnionitis. She underwent emergent cesarean delivery under general anesthesia. Postoperatively, her condition worsened despite treatment for presumed sepsis. She was taken to the operating room for an exploratory laparotomy, and a splenectomy was performed for splenic rupture. We discuss management, risk factors, challenges, and importance of prompt treatment of PSR.

Oster, Andrew S.; Reina, Eduardo; Fehr, James J.; Moore, Robert P.; Cox, Thomas E.; George, Preeta

doi: 10.1213/XAA.0000000000001050pmid: 31206387

Although originally described to assist airway management of fetal congenital malformations with life-threatening airway obstruction, the indications for an ex utero intrapartum treatment (EXIT) have expanded to include surgical resection of lesions that are potentially incompatible with life in the absence of uteroplacental circulatory support. We describe the case of an infantile fibrosarcoma (IFS) that presented with fetal hydrops and was successfully managed with an emergency EXIT that necessitated the initiation of a massive fetal blood transfusion both with and without the support of uteroplacental circulation.

Flaherty, Devon; Connors, Jean M.; Singh, Steve; Sylvester, Katelyn W.; Rimsans, Jessica; Cornella, Lauren

doi: 10.1213/XAA.0000000000001052pmid: 31265446

Andexanet alfa is a recombinant factor Xa decoy molecule capable of reversing direct and indirect factor Xa–inhibiting anticoagulants. We present an adult patient on apixaban for nonvalvular atrial fibrillation who required urgent reoperative aortic surgery for an aortic root pseudoaneurysm. Apixaban was reversed with andexanet alfa. A second dose of andexanet alfa was required before surgical incision for persistently elevated antifactor Xa levels. Intraoperative management required use of cardiopulmonary bypass (CPB). No major adverse cardiovascular, cerebrovascular, hemorrhagic, or thromboembolic events were observed.

Kaiser, Heiko A.; Hirschi, Trevor; Hartwich, Volker; Stucki, Monika; Rummel, Christian; Reineke, David; Hight, Darren

doi: 10.1213/XAA.0000000000001053pmid: 31274512

Depth of anesthesia (DoA) monitors are widely used during general anesthesia to guide individualized dosing of hypnotics. Other than age and specific drugs, there are few reports on which comorbidities may influence the brain and the resultant electroencephalogram (EEG) of patients undergoing general anesthesia. We present a case of a patient undergoing 3 cardiac operations within 7 months with severe illness and comorbidity, leading to pronounced physical frailty and significant changes of frontal alpha power in the EEG and increased sensitivity to volatile anesthetics. These findings may have important clinical implications and should trigger further investigations on this topic.

Duggan, Elizabeth W.; Vadlamudi, Ratna; Spektor, Boris; Sharifpour, Milad

doi: 10.1213/XAA.0000000000001055pmid: 31361662

A 44-year-old man, American Society of Anesthesiologists physical status class IV, presented for fulguration of anal condyloma and diverting colostomy. The patient’s medical history includes World Health Organization (WHO) class I pulmonary hypertension (PH), right heart failure, and bilateral lower extremity paralysis due to Pott’s disease. The patient was not a candidate for neuraxial anesthesia due to sacral decubitus ulcers, and alternative options to general anesthesia (GA) were considered to avoid the high risk of right ventricular (RV) failure and ensuing complications. The case was successfully performed under sedation with dexmedetomidine infusion and bilateral rectus sheath blocks for surgical anesthesia.