Paula Craigo

Intrathecal injection of epidural blood patch: a case report and review of the literature

Epidural blood patch (EBP) is a commonly performed procedure for the treatment of persistent severe post- dural-puncture headache (PDPH). It has a high success rate with a low incidence of complications. We report the case of a 27-year-old woman who developed progressive back pain and radicular symptoms after an EBP was performed for PDPH. An emergency MRI showed a subarachnoid hematoma. Gradual recovery occurred without the need for intervention. To our knowledge, this is the only case demonstrating the MRI findings of a rare complication of a common procedure. Radiologists may benefit from familiarity with epidural blood patching, including the technique, risks, benefits, and potential complications

A case series of the anesthetic management of parturients with surgically repaired tetralogy of Fallot.

BACKGROUND: Most case reports of pregnancies after surgical repair of tetralogy of Fallot have focused on cardiovascular and obstetric concerns, with relatively few authors focusing on specific intrapartum and postpartum anesthetic management strategies. METHODS: The Mayo Clinic Congenital Heart Disease Clinic and the Boston Adult Congenital Heart Disease Service databases were cross-referenced with the Mayo Clinic and the Brigham and Womens Hospital Department of Anesthesiology databases to identify patients with tetralogy of Fallot who delivered at their respective hospital from January 1, 1994, to January 1, 2008. We reviewed each medical record to evaluate parturient care during pregnancy, labor, and delivery with a focus on anesthetic management. RESULTS: During the 14-year study period, a total of 27 deliveries in 20 patients with repaired tetralogy of Fallot were identified. Twenty-one deliveries (78%) among 15 parturients (75%) involved a trial of labor; all parturients received neuraxial analgesia for labor and delivery, including 18 (86%) epidural, 2 (10%) combined spinal–epidural, and 1 (5%) continuous spinal anesthetic after an unintended dural puncture. Of the 21 patients undergoing labor, 3 (14%) received invasive arterial blood pressure monitoring; 5 (24%) received continuous telemetry; 3 (14%) experienced congestive heart failure that required diuresis; 4 (19%) had obstetric or neonatal complications; and 3 (14%) had anesthesia complications. Cesarean delivery was required in 4 patients (19%) because of labor complications. Concurrent cardiovascular, obstetric, and anesthetic complications in 1 patient resulted in neonatal death. Six (22%) parturients underwent elective cesarean delivery; 4 received epidural and 2 received spinal anesthesia; no anesthetic or immediate obstetric complications occurred. Among all parturients, 5 deliveries in 5 separate parturients (19% of deliveries) reported symptoms of congestive heart failure at the time of delivery. CONCLUSIONS: Pregnancy outcomes for patients with repaired tetralogy of Fallot were found to be generally favorable. All patients undergoing a trial of labor or cesarean delivery had neuraxial analgesia or anesthesia. Recognition and management of congestive heart failure was necessary in 19% of deliveries.

Anesthetic management of parturients with congenitally corrected transposition of the great arteries: three cases and a review of the literature.

Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity for congestive heart failure and cardiac dysrhythmias during pregnancy, labor, and delivery. We report the successful obstetric and anesthetic management of three women with CCTGA, review the pertinent medical literature, and discuss important issues surrounding the anesthetic management of parturients with CCTGA.

Simulation in Anesthesiology

The specialty of anesthesiology has been at the forefront of healthcare simulation from its development and early applications to pioneering simulation for residency training requirements and maintenance of specialty board status. As such, the specialty of anesthesiology has a rich and mature experience with simulation. In this chapter we will explore the application of simulation to the field of anesthesiology with regard to training, assessment, and maintenance of competence. Given the specialty’s extensive experience, much of the chapter will be devoted to the “art” of simulation with a detailed discussion of scenario, course, and curricular development.

Regional anesthesia emergencies.

CURRICULAR INFORMATION Educational Rationale Large doses of local anesthetics during regional anesthetics can produce complications including seizure, cardiac toxicity, or high spinal. Symptoms associated with toxicity must be recognized immediately and differentiated from other etiologies. This lesson acquaints providers with presentations of local anesthetic toxicity, to emphasize the importance of a broad differential diagnosis and a systematic approach to therapy. Scenarios encourage teamwork and development of crisis resource management (CRM) skills as trainees work with team members with varying degrees of experience. This lesson has been used at our institution for approximately 18 months. In that time, we have seen and reported on its effectiveness in successful resuscitation of a patient with cardiovascular collapse from local anesthetic toxicity.1

Obstetric anesthesia: outside the labor and delivery unit.

The maternal mortality rate in the United States has stagnated for the past 2 decades. To further lower morbidity and mortality, we must take a broader perspective. When a pregnant woman is treated in a nonobstetric part of the hospital, care must adapt quickly to her special needs. Excessive concern as to medication, radiation, and litigation may render her care neither safe, timely, efficient, effective, nor patient-centered. Anesthesiologists can significantly improve the care of the pregnant patient by applying their uniquely broad-based skills, experience, and knowledge outside the labor unit.