ABSTRACT
Background: Intrathecal (IT) clonidine has been observed to reduce 24-hour opioid requirements and time to first analgesic request after cesarean delivery, but has not been specifically studied in patients with opioid use disorder (OUD). Methods: Patients with OUD undergoing cesarean delivery under spinal or combined spinal-epidural (CSE) anesthesia at our institution from 2011 to 2020 were identified, and only patients with OUD were included in this study. Subjects that received IT clonidine were compared to a control group that did not receive IT clonidine to observe potential differences in analgesic outcomes (24-hour opioid requirements, pain scores and time to first post-operative pain medication) or side-effects (hypotension, vasopressor dosing and bradycardia). Results: A total of 160 patients were included (clonidine n = 22, controls n = 138). For the clonidine group, the median IT clonidine dose was 30µg. Clonidine group patients were observed to have greater dose of IT bupivacaine (12 vs 12.75mg; p = 0.01) and IT morphine (100 vs 200µg; p < 0.001). The clonidine group was also observed to have greater incidence of intraoperative hypotension (20% vs 45%; p = 0.01) and maximum phenylephrine dose (50 vs 57.5 µg/min; p < 0.001). The time to first analgesic request (minutes) after surgery was significantly longer for the clonidine group (153.5 vs 207 min; p < 0.001). The average oral oxycodone equivalents taken per 24 hours of hospital admission were significantly less in the clonidine group (82.36 vs 41.67mg; p < 0.001), and the clonidine group also had significantly less oxycodone equivalents taken for each post-operative day. Conclusion: IT clonidine was observed to result in reduced 24-hour opioid consumption in patients with OUD and may be useful as part of a multimodal analgesic regimen. The incidence of hypotension and vasopressor doses were greater in patients receiving IT clonidine, and this should be anticipated if IT clonidine is being administered.
ABSTRACT
Anesthetic implications for morbidly obese parturients have been well described; however, the literature has not yet clarified whether there are additional or unique concerns if the body mass index (BMI) rises farther above the so-called super morbid obesity level: BMI >50 kg/m2. There have only been a few case reports focusing on patients with BMI close to or above 100. Parturients with BMI significantly greater than 50 are uncommon, but they represent an increasing proportion among the morbidly obese. In this report, we present the use of continuous spinal anesthesia in consecutive cesarean deliveries for a patient with a BMI of 102 at her first delivery and 116 at her second. For both deliveries, an intrathecal catheter dosing incrementally provided effective anesthesia with a cumulative dose of hyperbaric bupivacaine 12 mg, fentanyl 15 mcg, and morphine 100 mcg given in 0.25-ml increments over 12 minutes, with 0.25-ml sterile saline flushes between doses. While dosing the catheter, the patient was gradually lowered to a 30° semi-recumbent position for surgery. This strategy minimized the risk of high spinal block or respiratory distress. She did not develop any postdural puncture headache (PDPH). This case report offers an extreme example and provides estimates towards adjusting staffing, equipment, location, timing, positioning, anesthetic technique, and dosing for cesarean deliveries in patients with very high BMI levels.
ABSTRACT
INTRODUCTION: Parathyroid carcinomas are very rare tumors and may arise in the normally located or ectopic gland. The latter present certain diagnostic difficulties, and there are no specific guidelines on their management. We present a case of parathyroid carcinoma arising within an ectopically located intrathyroid gland and discuss the diagnosis, management, and difficulties encountered. Furthermore, we review all six previously reported cases of this rare event and demonstrate the patterns in presentation, as well as the differences in management. CASE PRESENTATION: A 39-yr-old male presented with a right neck mass with biochemical derangement suggestive of a parathyroid lesion. However, radiological investigations were inconclusive as to the true nature of this lesion because they demonstrated a mass within the right thyroid lobe. A sestamibi (99m)technetium subtraction study was performed, which suggested an intrathyroid parathyroid carcinoma. The patient underwent successful surgical intervention. CONCLUSION: Although rare, ectopically located parathyroid glands can harbor malignant disease. Those located within the thyroid gland can be difficult to diagnose, and thus a combination of radiological modalities, including sestamibi (99m)technetium studies, need to be utilized. Although surgical resection is the most effective treatment, there are no specific guidelines as to the radicality of such treatment.
