Asim Esen

Total spinal block after lumbar plexus block: a case report

Lumbar plexus block (LPB) is a suitable method for elder patients for lower extremity surgery. Many complications could be seen during LPB, but not as many as central block. In this case report, we aimed to report a total spinal block, an unusual complication. LPB with sciatic block was planned for a male patient, 76 years old, scheduled for total knee replacement due to gonarthrosis. The patient became unconscious after psoas compartment block with Chayen technique for LPB. The operation ended at 145th minute. The patient was admitted to intensive care unit until postoperative second day and discharged to home on fifth day of surgery. Main concern of patient monitorization should be an anesthesiologist. In this manner, we conclude that contacting to the patient should be ensured during these procedures.

Practical use of remifentanil for pediatric patients.

extremes is an intermediate form of spinal defect, sometimes termed occult spinal dysraphism. Patients often have cutaneous defects such as dimples, sinus tracts or hair tufts and may also have a tethered or low-lying spinal cord (below L2–L3). Minor neurologic symptoms are sometimes present (lower extremity motor or sensory weakness or bladder symptoms), which may progress with age. It is not clear whether this child had spina bifida occulta or simply an isolated sacral dimple. Regardless, the presence of a dimple with a deep sinus tract would deter most anesthesiologists from performing a caudal block. While there are multiple case reports of neurologic complications from lumbar spinal and epidural blocks in patients with spina bifida occulta, because of a tethered or low-lying spinal cord (2–4), the literature is sparse when it comes to caudal blocks. The general belief is that caudals should be avoided in children with sacral dimples because of the increased possibility of a wet tap (1); this claim, as far as we can tell, is not evidence based. If an increased risk of dural puncture existed with caudal blocks in children with spina bifida occulta, that would imply that the dural sac ends in a more caudad position. Using portable ultrasound, we were able to visualize the dural sac and see that it was positioned normally. Had we found that it was more caudad, we would not have performed the block. Ultrasonography is a useful adjunct for placement of caudal blocks in infants and children with normal anatomy; in children with suspected abnormal anatomy, it is of even greater value. In our case, it revealed that the child had a normal appearing hiatus and sacral canal and a normally positioned dural sac. It also confirmed that the injectate was spreading normally within the canal. In children with known spina bifida occulta or with a dermal abnormality, a lumbar neuraxial anesthetic may be contraindicated, particularly, if an imagining study is not available. We do not believe the same is necessarily true for caudal blocks. The risk of neural injury is less, and the hypothetical risk of an inadvertent dural puncture may be mitigated by performing an ultrasound examination of the sacrum, looking specifically for the tip of the dural sac. This technique (longitudinal ultrasound over the sacrum to locate the dural sac) admittedly takes some practice. A caudal block is an elective procedure, and if any doubt exists, one should avoid it. In conclusion, we describe the placement of a caudal block in a child with a sacral dimple and possible spina bifida occulta. Ultrasound proved a valuable resource prior to and during the placement of the block.

Livedoid vasculopaty and anesthetic management in cesarean delivery

Livedoid vasculopathy (LV) is a hyalinizing vascular disease characterized by painful purple macules and papules that subsequently ulcerate. This vasculopathy may be associated with chronic venous insufficiency, deep venous thrombosis, factor V Leiden mutation, protein C deficiency, antiphospholipid syndrome, increased homocysteine levels, abnormalities in fibrinolysis, increased platelet activation and sickle cell disease. Difficult venous access, unreliable measurement of peripheral O2 saturation and increased susceptibility to venous embolic events may be a challenge for anesthetists. There is limited data about anesthetic management of livedoid vasculopathy in the literature. This case report describes successful anesthetic management of two patients with livedoid vasculopathy.

Inadvertent Venous Air Embolism during Cesarean Section: Collapsible Intravenous Fluid Bags Without Self-sealing Outlet have Risks. Case Report

The anesthesiologist must be aware of the causes, diagnosis and treatment of venous air embolism and adopt the practice patterns to prevent its occurrence. Although venous air embolism is a known complication of cesarean section, we describe an unusual inattention that causes iatrogenic near fatal venous air embolism during a cesarean section under spinal anesthesia. One of the reasons for using self-collapsible intravenous (IV) infusion bags instead of conventional glass or plastic bottles is to take precaution against air embolism. We also demonstrated the risk of air embolism for two kinds of plastic collapsible intravenous fluid bags: polyvinyl chloride (PVC) and polypropylene-based. Fluid bags without self-sealing outlets pose a risk for air embolism if the closed system is broken down, while the flexibility of the bag limits the amount of air entry. PVC-based bags, which have more flexibility, have significantly less risk of air entry when IV administration set is disconnected from the outlet. Using a pressure bag for rapid infusion can be dangerous without checking and emptying all air from the IV bag.

Embolia gasosa venosa inadvertida durante cesariana: bolsas retráteis para líquidos intravenosos sem saídas autovedantes oferecem riscos. Relato de caso

The anesthesiologist must be aware of the causes, diagnosis and treatment of venous air embolism and adopt the practice patterns to prevent its occurrence. Although venous air embolism is a known complication of cesarean section, we describe an unusual inattention that causes iatrogenic near fatal venous air embolism during a cesarean section under spinal anesthesia. One of the reasons for using self-collapsible intravenous (IV) infusion bags instead of conventional glass or plastic bottles is to take precaution against air embolism. We also demonstrated the risk of air embolism for two kinds of plastic collapsible intravenous fluid bags: polyvinyl chloride (PVC) and polypropylene-based. Fluid bags without self-sealing outlets pose a risk for air embolism if the closed system is broken down, while the flexibility of the bag limits the amount of air entry. PVC-based bags, which have more flexibility, have significantly less risk of air entry when IV administration set is disconnected from the outlet. Using a pressure bag for rapid infusion can be dangerous without checking and emptying all air from the IV bag.