Acute ascending aortic intramural hematoma as a complication of the endovascular repair of a Type B aortic dissection.

Endovascular aortic graft repair (EVAR) for patients with Type B aortic dissection is a less invasive surgical procedure (compared to traditional open surgical repair) that is associated with less morbidity and shortened recovery times. However, there are notable complications for the patients undergoing EVAR. We report a patient who was brought to our hospital with a Type B dissection and underwent a thoracic EVAR but suffered iatrogenic aortic injury resulting in cardiac tamponade. This case study highlights the importance of intraoperative transesophageal echocardiography to facilitate early detection of possible EVAR complications.

Regional Anesthesia to the Rescue: Phrenic Nerve Block to Prevent Wound Dehiscence From Intractable Hiccups-A Case Report.

Increased intra-abdominal pressure (IAP) following large abdominal surgeries can lead to postoperative complications, including wound dehiscence and surgical reoperation. Numerous factors can contribute to increased postoperative IAP, and intractable hiccups have been implicated as a culprit. Different treatment modalities have been widely used with variable success in addressing intractable hiccups. Here, we present a case in which postoperative hiccups leading to wound dehiscence and reoperation were successfully treated with an indwelling phrenic nerve catheter. Following placement, a significant reduction in hiccup severity and frequency was noted, improving the patient's quality of postoperative course and preventing further surgical intervention.

Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: a case series.

PURPOSE: The saphenous nerve, a branch of the femoral nerve, is a pure sensory nerve that supplies the anteromedial aspect of the lower leg from the knee to the foot. There is limited evidence of the effectiveness of ultrasound-guided techniques to block the saphenous nerve. We therefore undertook a retrospective case series to investigate the efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block. METHODS: During a four-month period, all patients receiving a subsartorial saphenous nerve block for lower extremity surgery at our institution had their medical records reviewed. Patient demographics and data were recorded, including block characteristics, intraoperative anesthetic management, pre-block, post-block, and postoperative pain scores, as well as postoperative analgesic dosing. Preoperative block success was defined by minimal intraoperative analgesic administration and a pain score of 0 in the postanesthesia care unit not requiring analgesic supplementation. Postoperative block success was defined by reduction of pain score to 0 without need for additional analgesic dosing. RESULTS: Thirty-nine consecutive patients were identified as receiving an ultrasound-guided subsartorial saphenous nerve block. Overall, this ultrasound-guided technique was found to have a 77% success rate. CONCLUSION: This case series shows that an ultrasound-guided subsartorial approach to saphenous nerve blockade is a moderately effective means to anesthetize the anteromedial lower extremity. The success rate is based on stringent criteria with an endpoint of postoperative analgesia. A randomized prospective study would provide a more definitive answer regarding the efficacy of this technique for surgical anesthesia.

Ketorolac, Oxymorphone, Tapentadol, and Tramadol: A Comprehensive Review.

Pain remains a tremendous burden on patients and for the health care system, with uncontrolled pain being the leading cause of disability in this country. There are a variety of medications that can be used in the treatment of pain, including ketorolac, oxymorphone, tapentadol, and tramadol. Depending on the clinical situation, these drugs can be used as monotherapy or in conjunction with other types of medications in a multimodal approach. A strong appreciation of pharmacologic properties of these agents and potential side effects is warranted for clinicians.

Pre-operative regional block anesthesia enhances operative strategy for arteriovenous fistula creation.

PURPOSE: We aim to assess the effect of regional block anesthesia on vein diameter, type of AVF placement, and fistula size and flow volume. METHODS: 30 patients presenting for AV access procedures were followed prospectively. Vein diameters via venous ultrasound and planned location for AV access were documented. Supraclavicular brachial plexus block was followed by repeat ultrasound and alterations in operative plan were noted. Patients returned to clinic for duplex ultrasound assessment. RESULTS: Average increase from baseline vein diameter with regional block was most pronounced in the lower cephalic (34%), upper cephalic (24.2%), and basilic veins (31.3%) and less in the brachial vein (8.7%). Type of AVF was modified following regional block in 14%. The rate of native AVF placement improved from 89% to 93% with regional block. Twenty-three AVF patients were available for follow-up (mean 24 weeks). Average fistula size was 7.9 mm (CI 6.9-8.9) and all patent fistulas developed flow volume >600 mL/min. Primary patency was attained in 83%. One thrombosis occurred after a basilic artery was lacerated during dialysis access. The average fistula increased 0.33 cm from post-block diameter (SD 0.22, P<.05). CONCLUSIONS: Vein diameter increases significantly in the basilic and cephalic veins following regional block anesthesia and may improve the rate of native fistula placement. Propensity to dilate after regional block anesthesia does not predict size of the fistula.