Horner's syndrome and epidural anesthesia in labor and cesarean section.

Homer's syndrome (HS) is based on dysfunction of symphathetic nervous system at the cervical canal. The signs of the syndrome occur on the same side as the lesion of the sympathetic trunk and include: a constricted pupil, a weak-droopy eyelid, apparent decreased sweating, and with or without inset eyeball. HS has been observed as a rare complication of epidural anaesthesia in obstetrics during labour or cesarean section. In parturients, it warrants further investigation as other serious causes must be excluded, such as pancoast tumours, thoracic aortic aneurysms, carotid dissection, neuroblastoma, and brainstem vascular malformation. Management involves early diagnosis of the underlying benign condition while treatment is based on appropriate conservative observation, as most often the syndrome resolves spontaneously. However in very rare cases immediate medical or surgical management is needed.

Anesthesia management of a patient with left ventricular assist device for emergency open appendectomy: a case report.

OBJECTIVE: The objective of this case report is to describe the management of anesthesia of a patient with an LVAD that underwent an emergency open appendectomy. Literature regarding emergency anesthesia management of such patients is still limited. A search in the PubMed engine with the keywords "LVAD appendectomy anesthesia management" revealed no results. CASE REPORT: The case regards a 54 years old male patient that received an LVAD implant 2 months before the current incident. Close monitoring was applied including invasive arterial pressure measurement. Etomidate was selected for induction thanks to its' insignificant hemodynamic effects. Careful titrated drug and liquids administration was applied to avoid hemodynamic destabilization. Anticoagulation treatment cannot be stopped in these patients, and there was no time for anticoagulation treatment changes. Two units of fresh frozen plasma were issued as preventive bleeding measures. RESULTS: No hemodynamic destabilization (targeted MAP: 65-90 mmHg) and bleeding were registered. The patient was extubated without any complications. CONCLUSIONS: Anesthesia management of similar cases should be focused around bleeding and hemodynamic destabilization and is harder in emergency surgery due to narrow time limits. Drug and liquids titration and use of drugs with minimum hemodynamic effects are advised, as well as close cardiovascular monitoring.

[Comparing Onset Times and Vascular Punctures in axillary Blocks with Nerve Stimulation or Ultrasound: Randomised Trial].

The use of ultrasound (US) guidance in regional anaesthesia has evolved in the last then years and has even been considered the fatest and safest way to identify peripheral nerves and vascular structures thus eliminating the risk of injuring them. Prior to US guidance, peripheral nerve stimulation (PNS) was the gold standard procedure of the last twenty years, still being used in the present alone or alongside US guidance. However, sometimes -especially in vessel rich areas such as the axillary plexus- it is hard to avoid injuring vascular structures with blind techniques such as PNS. The study's hypothesis was that out-of-plane US guided peri-neural axillary plexus block has a better success rate, faster onset and less intravascular punctures than the PNS method.

Anesthesia management of a patient with a femoral neck fracture and hered-itary hemorrhagic telangiectasia.

BACKGROUND: The hereditary hemorrhagic telangiectasia (HHT) or Osler-Weber-Rendu syndrome is an autosomal dominant genetic disorder affecting the small blood vessels due to mutations in specific genes that lead to angiogenesis errors. HHT represents a clinical entity with great clinical interest as severe, unpredicted, and life-threatening bleeding, sepsis, ischemia, and hemodynamic failure might occur. Literature regarding anesthesia and perioperative management of such patients is limited, with no published papers for orthopedic surgery in patients with HHT. CASE REPORT: An 82-year-old HHT female patient with femoral neck fracture was scheduled for hemiarthroplasty. Computerized tomography scan revealed an arteriovenous malformation (AVM) in the right lung. The nature of surgery in association with AVM presence suggested the use of regional anesthesia (RA) as the optimal choice. Midazolam (2 mg) was administered as premedication. Perioperatively, Levobupivacaine hydrochloride (15 mg) was administered in the subarachnoid space, at the L4-L5 lumbar intervertebral space, using a 29 Gauge needle. The patient was in lateral position with close monitoring of her blood pressure, electrocardiogram, oxygen saturation, and urine output. Two units of blood were transfused perioperatively. Her recovery was uneventful and she was discharged after ten days. CONCLUSION: Patients with HHT require careful preoperative evaluation to identify and appreciate possible symptoms as well as to assess their pulmonary and cardiac function accurately. Meticulous preoperative planning is required to minimize perioperative risks and additionally close perioperative monitoring is essential. RA was preferred to general anesthesia as positive pressure ventilation could lead to hypoxia, AVM rupture, embolism, and hemodynamic collapse, while RA offers absence of respiratory stress, excellent muscle relaxation, and decreases blood loss, lowers probability of venal thrombosis and pulmonary embolism, and assists to better perioperative management of analgesia, thus contributing to positive outcome of surgery. Hippokratia 2016, 20(4): 303-305.