Periprocedural management of patients with subarachnoid hemorrhage

Purpose of review Anesthesiologists and intensivists may be involved in the management of aneurysmal subarachnoid hemorrhage (aSAH) patients at various stages of care. This article will review the recent advances in the periprocedural management of aSAH patients. Recent findings New scoring systems to assess gravity and prognosis of aSAH patients have been evaluated and proposed. Rebleeding still remains, with early aneurysmal treatment, a major challenge in the first hours of aSAH management. In the last decades, the treatment of the aSAH has shifted from clipping to coiling and more recently, the use of flow diversion technique has been introduced in selected patients. Although these improvements allow treatment of more complex aneurysms, they have implications for the anesthesiologist, including requiring the management of anticoagulation with its inherent risks. Even though knowledge, monitoring, and management of postprocedural phase of aSAH patients has improved, vasospasm and cerebral-delayed ischemia still remain the major and devastating complications in the postoperative course of aSAH patients. Summary Despite recent progress in the scoring, diagnosis, and treatment of aSAH patients, the periprocedural management of these patients is still a major challenge for anesthesiologists and intensivists, who are involved from the first phase of the aneurysm rupture through the postoperative phases and vasospasm period. Correspondence to Dr Paolo Gritti, Department of Anaesthesia and Critical Care Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy. Tel: +39 035 2675160/+39 339 8707380; fax: +39 035 2674979; e-mail: Grittip@libero.it Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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An update on regional analgesia for rib fractures

Purpose of review To provide an update on new strategies for pain management after rib fractures utilizing regional analgesia. Recent findings Pain management for patients with rib fractures can be very challenging. Traditionally, intravenous patient-controlled analgesia (IVPCA) with opioids, epidural, and paravertebral blocks have been used. These techniques, however, may be contraindicated or have limited application in certain patient populations. Recently, ultrasound-guided myofascial plane blocks such as the erector spinae plane (ESP) block and the serratus anterior plane (SAP) block have emerged as alternatives; providing excellent analgesia with minimal side effects. These blocks have the flexibility to be employed in a wide variety of circumstances where epidural and paravertebral approaches may not be feasible such as in anticoagulated patients and in patients with vertebral fractures where positioning options are limited. Myofascial blocks are less invasive and allow for broader and earlier application (e.g. in the emergency department). Further research on myofascial plane blocks is a priority. Summary Until recently, epidural, paravertebral, and intercostal blocks have been advocated as primary management techniques for pain associated with rib fractures. Newer myofascial plane blocks may play a key role in the future as part of alternative pain management strategies. Correspondence to Sanjib Das Adhikary, Department of Anaesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, 500, Univ. Drive, Hershey, PA 17033, USA. Tel: +1 717 8294201; e-mail: sadhikary1@pennstatehealth.psu.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Anesthesia for stroke rescue

Purpose of review To highlight the potential implications of recent advances in the management of large vessel occlusions for intraprocedural anesthetic management. Recent findings Stroke remains the leading cause of disability in the United States and the second leading cause of death in the world. Several randomized control trials published within the past decade have helped to make endovascular thrombectomy the standard of care for all eligible patients. However, whether intraprocedural anesthesia care practices may significantly improve in-hospital and out-of-hospital morbidity and mortality outcomes are not clear. Summary Management strategies that shorten the time to intervention and maintain blood pressure to preserve penumbral tissue may be beneficial. Future well powered studies are necessary to enable inferences on what type of anesthetic management is harmless, neurotoxic, or neural plasticity promoting. Correspondence to Ayòtúndé B. Fadayomi, MBBS, MPH, Center for Epidemiology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. E-mail: ayofadayomi@mail.harvard.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Intraoperative neurophysiological monitoring in neuroanesthesia

Purpose of review The purpose of this review is to highlight the importance of making informed choices of anesthetics and evaluating the impact of depth of anesthesia, hemodynamic status and other factors capable of interfering with signal capture during intraoperative neurophysiological monitoring (IONM). Recent findings Over the last decades, neuromonitoring has advanced considerably, allowing for insights into neurological function during anesthesia and making it possible to assess intraoperative consciousness and neural integrity in real time. IONM is indicated in surgeries posing risk to targeted neural tissues and adjacent structures. The technique helps correlate surgical maneuvers with neurophysiological changes at high levels of sensitivity and specificity and can identify risk situations early enough to prevent postoperative neurological deficits. Summary Experience with IONM, the use of an adequate IONM modality, and knowledge of the effect of anesthetic techniques and agents on neurophysiological parameters are fundamental for reliable measurements. The current gold standard in IONM is total intravenous anesthesia without neuromuscular block. Correspondence to Rogean R. Nunes, MD, PhD, Rua Comendador Francisco d'Angelo 1185, De Lourdes, Fortaleza, Ceará, Brazil, CEP: 60.177-130. E-mail: rogean@yahoo.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Outcomes of regional anesthesia in cancer patients

Purpose of review To summarize the current evidence on the impact of regional anesthesia or analgesia on cancer recurrence. Recent findings Preclinical investigations suggest that regional anesthesia could have a positive impact on reducing cancer growth and progression. Regional anesthesia is also associated with better immunological and stress-related outcomes in patients undergoing major oncological surgery. Most recent retrospective studies do not show any benefit of regional anesthesia or analgesia on cancer recurrence or recurrence-free survival. Summary The available clinical evidence does not support the use of any anesthesia technique to improve the cancer-related survival after major oncological surgery. The results from four randomized controlled trials will shed light on this critical topic in perioperative medicine. Correspondence to Juan P. Cata, MD, Department of Anesthesiology and Perioperative Medicine, The University of Texas – MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77401, USA. Tel: +713 792 4582; e-mail: jcata@mdanderson.org Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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A challenging coexistence of central diabetes insipidus and cerebral salt wasting syndrome: a case report

Combined central diabetes insipidus and cerebral salt wasting syndrome is a rare clinical finding. However, when this happens, mortality is high due to delayed diagnosis and/or inadequate treatment.

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Extracorporeal membrane oxygenation support in a newborn with lower urinary tract obstruction and pulmonary hypoplasia: a case report

Survival of neonates with intrauterine renal insufficiency and oligo- or anhydramnios correlates with the severity of secondary pulmonary hypoplasia. Early prenatal diagnosis together with repetitive amnioinfu...

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Carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis overlap in a Filipino with positive HLA-B75 serotype

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two related mucocutaneous disorders with different severities. Although the incidence is low, SJS and TEN are life-threatening and predominantly drug-induced conditions. There is a strong relationship between the HLA-B*1502 allele and carbamazepine-induced SJS and TEN in different Southeast Asian populations. Here, we report a case of Filipino with SJS/TEN overlap probably induced by carbamazepine. The condition was treated with hydrocortisone followed by prednisone. The HLA-B*1502 allele was not found in this case. The patient tested positive for the HLA-B75 serotype, suggesting that carbamazepine-induced SJS/TEN may be serotype specific. Establishing the genotype before initiation of the drug may be advantageous for some patients and will aid physicians in determining the optimal drug therapy. Prevention of adverse drug reactions (ADR) may be done if pharmacists and other healthcare professionals work as a multidisciplinary ADR team to ensure that safe medication practices are realised.

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Acute hepatitis E infection as a cause of unexplained neurological symptoms

Neurological disease is the most common extrahepatic manifestation of autochthonous infection with hepatitis E virus (HEV). The association between acute neurological symptoms and hepatitis E is not well known, and hence HEV testing is often omitted. This case describes aberrant neurology in a 35-year-old woman with a background of HEV infection, highlighting the need for increased awareness of acute hepatitis E infection as a cause of unexplained neurological illness.

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Spontaneous gall bladder perforation with ischaemic bowel disease: a rare cause of acute abdomen with pneumoperitoneum in elderly

Perforation of the gall bladder can occur due to a complication of acute (in 3%–10%) or chronic cholecystitis, presenting with or without gallstones. Other causes include trauma, neoplasms, steroid therapy or vascular compromise. In 1934, Niemeier classified the condition into three types: type I, acute perforation into the free peritoneal cavity; type II, subacute perforation with abscess formation; and type III, chronic perforation with fistula formation between the gall bladder and another viscus with type I experiencing the highest mortality rate. In particular, there are very few cases of gall bladder perforation associated with ischaemic bowel disease. We present a case of type I gall bladder perforation in a 70-year-old woman, without any apparent comorbidities, presenting with acute abdomen consistent with perforated duodenal ulcer with pneumoperitoneum on a plain abdominal radiograph and contrast-enhanced CT with eventual discovery of fundal perforation and ischaemic small bowel at laparotomy.

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