Continuous Tunneled Infraclavicular Nerve Catheter for Palliative Management of Critical Limb Ischemia: A Case Report.

Critical limb ischemia (CLI) is limb pain occurring at rest or impending limb loss as a result of lack of blood flow to the affected extremity. CLI pain is challenging to control despite multimodal pharmacologic analgesia and surgical intervention. We describe the successful use of a continuous local anesthetic infusion via an infraclavicular nerve catheter to control severe refractory ischemic upper limb pain in a patient with metastatic lung cancer for whom surgical and pharmacological intervention was unsuccessful. As her opioid requirements increased due to worsening ischemic pain, she subsequently developed opioid toxicity, hence prompting the palliative use of a tunneled infraclavicular nerve catheter under ultrasound guidance to minimize opioid requirements. Her opioid requirements tailed down subsequently with the successful insertion of the infraclavicular nerve catheter and she remained pain free till her death. Palliative use of nerve catheters is a safe and an effective alternative in patients with refractory cancer pain, and we describe our methods to prolong its use and minimizing its associated long-term complications.

Postoperative cardiorespiratory complications and continuous positive airway pressure efficacy in obese patients undergoing noncardiac surgery.

BACKGROUND AND AIMS: One in six Singaporeans has obstructive sleep apnoea (OSA) due to obesity compounded by inherent craniofacial features. We assessed the incidence of cardiopulmonary complications and the effectiveness of continuous positive airway pressure (CPAP) therapy in minimising such complications within an obese population. METHODS: A retrospective study of elective noncardiac surgical patients with a body mass index ≥32 kg/m2 was conducted. Patients at moderate to severe risk of OSA were offered CPAP therapy. CPAP therapy adherence, postoperative complications, length of hospital stay, and type of anaesthesia were analysed. RESULTS: In total, 1400 patients comprising 174 with low risk of OSA (L-OSA) and 1226 with moderate to high risk of OSA were included. Of these, 332 were started on CPAP therapy (C-OSA) while 894 declined CPAP use (R-OSA). There were 10 (0.05%) cardiac events - one (0.6%) in the L-OSA group, six (0.6%) in the R-OSA group and three (0.9%) in the C-OSA group. There were 37 (2.6%) respiratory events - 2 (1.1%) in the L-OSA group, 23 (2.6%) in the R-OSA group, and 12 (3.6%) in the C-OSA group. Multivariate analysis showed no statistical significance in CPAP therapy minimising cardiac (P = 0.147) and respiratory (P = 0.255) complications, when analysed by intention-to-treat. CPAP therapy adherence was 13.6 and 10.2% pre- and postoperatively, respectively. When analysed per protocol, none of the nine patients compliant with both pre- and postoperative CPAP therapy developed cardiopulmonary complications. CONCLUSIONS: Amongst patients with moderate to severe risk of OSA, those who were compliant to perioperative CPAP therapy demonstrated a reduction in cardiopulmonary complications.

Perioperative considerations for COVID-19 patients: lessons learned from the pandemic -a case series.

Background: As the coronavirus disease 2019 (COVID-19) pandemic spreads globally, hospitals are rushing to adapt their facilities, which were not designed to deal with infections adequately. Here, we present the management of a suspected COVID-19 patient. Case: A 66-year-old man with a recent travel history, infective symptoms, and chest X-ray was presented to our hospital. Considering his septic condition, we decided to perform an emergency surgery. The patient was given supplemental oxygen through a face mask and transported to an operating theatre on a plastic-covered trolley. An experienced anesthetist performed rapid sequence intubation using a video laryngoscope. Due to the initial presentation of respiratory distress, the patient remained intubated after surgery to avoid re-intubation. Precautions against droplet, contact, and airborne infection were instituted. Conclusions: Our objective was to facilitate surgical management of patients with known or suspected COVID-19 while minimizing the risk of nosocomial transmission to healthcare workers and other patients.

The effects of gel-based manicure on pulse oximetry.

INTRODUCTION: Pulse oximetry is the standard monitoring technique of functional oxygen saturation (SpO2). As the use of fingernail polish has been described to alter SpO2 readings, its removal is commonly recommended prior to measurement. Gel-based manicures have gained popularity in recent years due to their attractiveness and longevity. However, the removal of gel nail polish requires a specialised procedure. Valuable time and resources can be saved if removal can be avoided. To our knowledge, there are no available studies on the effect of gel-based manicures on pulse oximetry readings. Hence, we evaluated the effect with two oximeters, using different technology and wavelength combinations. METHODS: 17 healthy female adult volunteers were recruited for this single-blind randomised controlled trial. Subjects with hypothermia, hypotension, poor plethysmographic waveform and nail pathology were excluded. Colours tested were: black, purple, navy blue, green, light blue, white, yellow, orange, pink and red. Pulse oximetry was measured at 15- and 30-second intervals using two different pulse oximeters, the Philips M1191BL and Masimo SET®. Means were compared using paired t-tests. RESULTS: Using the Masimo oximeter, light blue (ΔM = 0.97% ± 0.96%; p = 0.001) and orange (ΔM = 0.76 ± 1.17%; p = 0.016) gel nail polish resulted in a statistically significant increase from baseline SpO2 readings. With the Philips oximeter, the limits of agreement ranged from 2% for pink to 17% for black, indicating imprecision. CONCLUSION: Gel-based manicures can result in overestimations of actual readings, delaying detection of hypoxaemia. Gel nail polish should be routinely removed or an alternative monitoring technique sought.