Deceptive level after intrathecal block for cesarean section in a patient with prior abdominoplasty. a case report

Abdominoplasty is performed in an increasing number of patients, both male and female. The removal and hence rearrangement of abdominal skin may make assessment of the dermatome level of a subarachnoid block difficult. Also patients may hesitate, or even forget, to reveal cosmetic surgeries during the preanesthetic interview. Therefore it is important to maintain a high index of suspicion in patients who have had bariatric surgery. In this report we present the case of a deceptive anesthetic level in a parturient with an undisclosed history of abdominoplasty who presented for Cesarean section

Variants of pheochromocytoma and their anesthetic implications. A case report and literature review

Anesthesiologists are trained to appreciate and respond appropriately to the considerable consequences of pheochromocytomas. It is however, less well appreciated that these tumors may be associated with other syndromes that can also carry significant anesthetic risk. We describe the case of a young man who had a rare disease in combination with multiple pheochromocytomas and suffered a fatal outcome after anesthesia. Possible causes for this disaster are suggested

Radiation induced hypopharyngeal stenosis masquerading as the larynx: a case report

Radiation to the head and neck is commonly used in the treatment of cancers. A side effect in some patients is the development of pharyngeal and or esophageal strictures. Hypopharyngeal strictures can resemble edematous larynges. If mistakenly so identified, tracheal tubes placed through these structures are unlikely to result in tracheal intubation and more likely to cause obstruction, esophageal intubation or mediastinal damage. This report points out the development of hypopharyngeal stenosis following radiation. The location and appearance of hypopharyngeal stenosis during laryngoscopy are illustrated. The report points out the deficiencies of newer supraglotic laryngoscopes in this situation and underscores the benefits of flexible fiberoptic devices

Modern strategies for the anesthetic management of the patient with diabetes

Diabetes Mellitus [DM] is an endocrine disease with high incidence. Long-term complications involve the eyes, kidneys, nerves, and blood vessels, resulting in hypertension, cardiac ischemia, atherosclerosis, and renal failure, among other syndromes. Given this prevalence, anesthesiologists, especially those who work with older patients, may expect to encounter some aspect of diabetes almost every day. Appropriate preoperative evaluation and rational intraoperative and postoperative management of this complex disease in elective and emergency circumstances are essential. Recent studies have emphasized the need to maintain tight perioperative glycemic control and new guidelines have been presented

Anesthetic implications of acute methylenedioxymethamphetamine intoxication in a patient with traumatic intracerebral hemorrhage

The use of the street drug methylenedioxymethamphetamine [MDMA], commonly referred to as ecstasy, has become increasingly prevalent amongst teenagers and young adults in the United States and many other parts of the world. While most anesthesiologists are facile with the intricacies of managing patients intoxicated by alcohol, cocaine and narcotics the new "club" drugs present a challenge, especially under emergency conditions. MDMA, in particular, is the most commonly abused club drug and potentially one of the most dangerous in the perioperative period. We present a case report of traumatic subarachnoid hemorrhage in a patient with acute MDMA intoxication and a review of the anesthetic implications

simulation theatre: a means to enhanced learning in the 21[st] century

The increasing role of simulation in medical education has paralleled advancement of this technology. Full environment simulation [FES] can be employed to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex which is relatively impervious to extinction and thus forgetting. Theoretically the addition of emotional content to simulated crises during FES can be used to affect such changes in the participants and thus facilitate learning. We discuss the theoretic benefit and the use of FES with emotional enhancement as it relates to improved memory and learning

Management of the patient at high risk for postoperative nausea and vomiting

Postoperative nausea and vomiting continue to be problematic areas in anesthesia as evidenced by frequent reports of therapies in the literature. No single therapy has been proven curative for all cases, in part because of the several emetic centers, all of which may be blocked by different classes of drugs and the diverse risk factors which act alone or in combination to cause vomiting. Identification of the patient most at risk allows for cost effective prophylactic management. An appropriate anesthetic technique can be planned that, relying on evidence based medicine, will decrease if not prevent the incidence of this most troubling complication

Management of the patient reporting an allergy to penicillin

Recent emphasis on the prevention of surgical wound infection has highlighted the role of the anesthesiologist as the physician responsible for administering appropriate antibiotic prophylaxis. Patients often report a distant or unclear history of penicillin allergy. Administering an antibiotic to which the patient has a true allergy can provoke a life threatening reaction. The anesthesiologist should be aware of the prevalence, severity, and manifestations of allergies to antibiotics, as well as the available alternatives. Unnecessary administration of more powerful broad-spectrum antibiotics leads to the development of antimicrobial resistance and should be avoided. It is the anesthesiologists' duty to balance these issues when selecting appropriate antibiosis

Office-based surgery: expanding the role of the anesthesiologist

Office-based anesthesia [OBA] has developed in the United States as an important field for the anesthesia provider. Both the numbers and types of procedures performed in offices around the country have steadily increased, as has the invasiveness of these procedures. New anesthetic considerations arise. For example, most training programs have not addressed this area of practice. Indeed many practitioners are unfamiliar with practice outside the hospital operating room setting. Information as to how to provide quality care in a location where one may be the sole anesthesiologist must be readily available. Many of the safety mechanisms we take for granted in a hospital setting are often not present in a surgical office, and it becomes the responsibility of training centers to help in establishing standards. As the [safety] of many surgical offices where anesthesia care is provided has been challenged, medical societies have begun to issue recommendations as to the standards of care that should exist. Different anesthetic techniques are also emerging that are appropriate to the office setting. But as office-based anesthesia continues to mature as a specialty, we the anesthesia providers, must be proactive in establishing guidelines and recommendations to ensure safe practice

Herbal medicines and interactions with anesthetic agents

Herbal medicines have enormous presence world wide. Herbs are listed under the [supplement] category by the food and Drug Administration in the USA. The Dietary Supplement and Health Education Act signed into law in October 1994, requires no proof of efficacy, no demonstration of safety, and sets no standards for quality control for the products labeled as [supplements] thereby increasing the risk of adverse effects as quantities of active agents are unregulated. The United States has experienced an epidemic of over-the-counter [natural] products over the last two decades; but there is little motivation for the manufacturers to conduct randomized, placebo-controlled, double-blinded clinical trials to unequivocally prove the safety and efficacy of these drugs. Physicians must enquire and be aware of herbal/drug interactions. In addition, patient education of the potential interactions should be a routine component of preoperative assessment. The American Society of Anesthesiologists [ASA] recommends that all herbal medications should be discontinued 2-3 weeks prior to an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he/she should be urged to bring the container so that an attempt can be made to review the contents of the preparation. While such an action holds some promise in the elective setting, emergency care should be based on a thorough drug-intake history from the patient or a relative, if possible. Medical research and medical literature in general has not addressed this new group of health supplements, despite the fact that many of these herbs have the potential to cause serious health problems and drug interactions. There is a need to conduct scientific clinical trials to study the anesthetic drug responses to commonly used neutraceutical agents