The Challenges of Spinal Surgery Requiring Ventral Decubitus in the Critical Trauma Patient on Extracorporeal Membrane Oxygenation: A Case Report.

Extracorporeal membrane oxygenation (ECMO) provides a bypass of the lungs, ensuring blood oxygenation and carbon dioxide removal in cases of respiratory failure. The nature of the device itself creates many perioperative challenges, including fluid management and the management of anticoagulation. Surgery via the posterior approach for an unstable spinal fracture requiring the ventral decubitus position comes with its own set of difficulties, among which are the need for stability and craniocaudal alignment when rotating the patient, the risk of increased abdominal pressure, and the damage to vulnerable soft tissues like the eyes, nose, and others. The combination of these two situations creates a synergistic effect, which adds to the difficulty of the management of the situation and requires a personalized, multidisciplinary approach. We present a case of a critical trauma patient who was on venovenous ECMO as a consequence of refractory respiratory hypoxemia with an unstable mid-thoracic spinal fracture requiring surgical intervention via the posterior approach (demanding intra-operative ventral decubitus).

Anesthetic Management of the Surgical Correction of Idiopathic Scoliosis in a Teenager With Ornithine Transcarbamalyse Deficiency.

Ornithine transcarbamylase (OTC) deficiency is the most common genetic disorder of the urea cycle. These disorders are characterized by an inability to metabolize ammonia into urea, leading to hyperammonemia with variable physiological consequences and presenting important anesthetic challenges, especially the perioperative prevention of hyperammonemia and management of its consequences, should it occur. Idiopathic scoliosis (IS) is the most common spinal deformity requiring surgical treatment. This paper presents the case of a 16-year-old female with OTC deficiency who underwent spinal fusion for IS. The chosen anesthetic strategy was combined anesthesia with total intravenous general anesthesia using target-controlled infusion pumps, an erector spinae plane block (ESPB), and a multi-pronged approach to ensure metabolic control while avoiding hyperammonemia. The existing literature regarding major surgery in patients with OTC deficiency is sparse, and this paper provides one of the first case reports of a scoliosis correction surgery, as well as one of the first descriptions of prolonged propofol infusion and locoregional anesthesia with an erector spinae plane block in this context.

Synergic Difficulties in an Anticipated Physiologically and Anatomically Difficult Airway in a Trauma Patient: A Case Report.

The American Society of Anesthesiologists (ASA) defines a difficult airway as a clinical situation in which a physician who is trained in anesthesiology experiences difficulty or fails in either face mask ventilation, laryngoscopy, using a supraglottic airway, tracheal intubation, extubation, or front-of-neck airway. Classically, this has been defined in relation to anatomic factors, but the concept of a physiologically difficult airway has been growing in relevance, in which physiologic factors, such as hypoxemia and hypercapnia, act to reduce safe apnea times. The case reports on a trauma patient with an unstable thoracic vertebral fracture requiring correction via the posterior approach. Our patient had multiple anatomical difficult airway predictors, namely, a short neck, greatly limited neck mobility, and a Mallampati class IV airway, among others, and multiple physiological difficult airway predictors, such as a baseline hypoxemic respiratory failure and severe sleep apnea, in addition to the restrictions on mobility imposed by the fracture itself. We describe a successful perioxygenation strategy, using high-flow nasal oxygen (HFNO) during the preoxygenation, intubation, extubation, and post-anesthesia care phases, and with an awake fiberoptic intubation technique for securing the airway.