Erythroxylum coca
Case reports; page 1 1.    Patient with Severe Restrictive Lung Disease, and Lumbar Syringomyelia, presenting for Total Hip Replacement: The  Anesthesia, Ethical, and Professional Challenges. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-3-17) There are two elements of interest in this unusual case, performed in 2012. The first element concerns the patient’s multiple co-morbid diseases affecting her anesthesia care with high potential for perioperative mortality. The 60-y old lady weighed 51 kg and suffered foremost from (1) severe thoracic scoliosis, (2) post-polio syndrome causing severe weakness in her left arm, (3) an Arnold-Chiari malformation at the base of her skull, (4) cervical hydro-syringomyelia with a fluid-drainage tube into a cerebral ventricle, (5) a lumbar spinal syrinx extending into the cord conus, with a (6) tethered spinal cord, (7) severe restrictive respiratory disease with (8) chronic CO2 retention, and (9) mild respiratory failure. The anesthetic consisted of (a) general anesthesia and ventilation, (b) regional anesthesia consisting of a parasacral sciatic nerve block, a subcostal nerve block and a psoas compartment block combined with (c) a substantive anti-hyperalgesia and opioid avoidance pharmacological strategy. The surgery took 5½ hours, and the patient lost more than 50% of their blood red-cell mass.  The final outcome was excellent. The second interesting aspect of the case is; the anesthesiologist chose to ignore surgeon’s scientifically baseless objections to the sciatic nerve block component, generating discussion of ethical and professionalism aspects of the surgeon’s behavior afterwards.   Full text PDF 2. Winged scapula folowing total shoulder arthroplasty and regional anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-4). A tiny 70-year old lady underwent a right total shoulder arthroplasty. She received an interscalene block and general anesthesia for the surgery. After surgery the patient developed a winging of the right scapula, sugesting she had a paralyzed serratus anterior muscle, secondary to a long throacic nerve injury. The surgeon attributed the presumed nerve injury to the interscalene block that the patient received. The case is reviewed applying forensic rationale, as well as studying the existing published scientific literature pertinent to the problem.  The strong conclusion is that the long thoracic nerve nerve was most likely injured by the surgical retractor being over-vigorously used during surgery that pulled on the medial aspect of the wound. It would have compressed the long thoracic nerve against the chest wall, thus injuring it. Full text PDF 3.  Pastor with undiagnosed civilian-PTSD from childhood abuse, screams uncontrollably after spinal surgery. AUTHOR: Dr. Robert M Raw MD. ABSTRACT -(2021-5-25) A 58-year-old pastor undergoes posterior approach thoracolumbar spinal fusion. Despite substantial pre-emptive analgesia he awakens wide-eyed screaming tearfully and won’t respond to instructions. The physician anesthesiologist treats him with tranquilizer rather than with added opiates. He becomes peaceful. In the following days his childhood abuse is discovered and the diagnosis of PTSD is made. The late-phase residual anesthesia drugs are believed to have caused an emotional disinhibition which brought out his emotions about his last childhood thoughts that he had as anesthesia was being induced. The back-surgery was connected to his childhood traumas. Full text PDF.  4. A 60-yer-old lady with undiagnosed civilian-PTSD from childhood abuse, screams uncontrolably after breast surgery. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-20) The lady underwent 13-hours of surgery to reconstruct her one breast with tissue from the abdomen, following a mastectomy 9-years earlier.  Despite substantial pre-emptive analgesia, she awoke screaming tearfully, and could not respond to words spoken to her. She just looked wide-eyed at the persons speaking. On the erroneus presumption that she had severe pain, additional opiates were injected causing respiratory arrest. Intensive care management got her safely through the night. In the following days its discovered she was having thoughts of childhood sexual abuse and was very emotional for that reason, during her post-anesthesia recovery period. She was then diagnosed as having civilian-PTSD. Full text PDF  5. Obese lady injected epidural hydromorphone for surgical analgesia develops respiratory arrest and 3rd degree heart block after anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-28) The 62-year-old lady was administered both epidural, and intravenous hydrophylic long-acting opiates, all before awakening her from anesthesia. Fentanyl was also adminstered throughout her surgery. She was on 28 classes of drugs for multiple co-morbid diseases, and was morbidly obese witha BMI of 33. Shortly after extubation she went into critical respiratory failure. That was treated with fullresuscitation and 2-ampules of naloxone, and a further naloxone infusion for the next 24-hours. That induced hypertension, and the treatment of that caused a 3rd-degree heart block. The actions of neuraxial opiates are discussed. Full Text PDF  6. Awake breast and axilla surgery in an ASA-4 patient, using landmark nerve-blocks. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2019). A 53-year-old lady required right-side breast surgical re-excision of a malignant breast lump, together with an axilla dissection for sentinel lymph nodes. She had a BMI of 44 and multiple co-morbid diseases critical to anesthesia planning. She had end-stage emphysema, was chronically cyanotic and on permanetnsupplimentary oxygen. She had had an earlier myocardial infarction and significant coronary artery disease. The surgery was succesfully performed awake with minimal sedation under three peripheral nerve blocks; (1) a T4 level paravertebral nerve block with catheter placement using landmarks and electrostimulation, (2) a T5 paravertebral single-shot nerve-block, (3) a T3 paravertebral single-shot nerve-block,(4) a nerve to subscapularis nerve-block using only land-marks and nerve-electrostimulation, (5) a superficial cervical plexus block, (6) a pectoral nerve block using an ultrasound guided nerve stimulator verified proximal PECS-2 proximal block. The surgery and anesthetic went well. The regional anesthesia techniques are described in detail and are well illustrated.  Full text PDF. 7. Man with severe heart failure, severe aortic stenosis, mitral stenosis, critical bilateral carotid stenosis needs emergency leg amputation preceeding his urgent multiple vascular surgical repairs: Regional anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT: (written 2003, revised May 2021) A 73-year-old man presents to the emergency room with severe shortness of breath and inability to walk. He is diagnosed as being in cardiac failure and intense diuretic therapy, with inotropic drugs are administered. His heart failure improves but he developes right foot ischemia, then gangreen with sepsis. Interim investigations reveal he has bilateral critical carotid stenosis needing surgery, severe aortic and mitral valve stenosis needing surgery, and severe four-vessel coronary artery disease needing  surgery. The sequence or combination of the vascualr surgeries to be done is unclear,  however their urgency is exceded by the more urgent need to eliminate the sepsis in the foot. Concurrent purelent sepsis is an absolute contra-indication to all reparitve cardiac and vascular surgery as that prohibits the cardiac and vascular surgeries being done.  Due to his extreme critical diseases the foot surgery must be highly and immediately succesful, as well as fast and physiologically as little stressing to the patient as posible. It is decided to do a through-the-knee right leg amputation under regional anesthesia. The case discussion evalautes the regional anesthesia options, and describes the case’s successful management. Full text PDF.  8. Wrong diagnosis of Local Anesthetic Systemic Toxicity (LAST): Volatile anesthesia induced ankle clonus. AUTHOR: Dr. Robert M Raw. ABSTRACT: (written 2008, revised 2021-5-16) In 2008 a 54-year-old lady underwent a left revision hip-arthroplasty. She was morbidly obese with BMI of 44, and was further healthy except for the fact she had chronic hip and back pain and was a chronic user of prescribed oral analgsic medications. The surgeon was going to perform a lateral aproach at cutaneous level, but with deeper elements of a posterior approach on the joint capsule. The first anesthesia plan was to perform a  L3 psoas compartment block and a paravertebral sciatic nerve block, paired with general anesthesia. The surgeon objected to the sciatic nerve block as he feared it would cause sciatic nerve injury for which he would be surgically blamed. Accordingly in lieu of the missing sciatic nerve block the anesthesiologist substituted a second psoas compartment injection at L5 hoping to cover suffient elements of the sacral plexus to still provide posterio analgesia after the hip arthroplasty. Thus the patient got two psoas compartment catheters.  Surgery and the rest of the anesthesia care was uneventful. Upon awakening the patient had severe posterior hip pain, and also demonstrated bilateral ankle clonus. The ankle clonus was initially incorrectly labled as being part of LAST. The entity of ankle clonus will be fully discussed, with its etiology and meaning.    Full text PDF. 9. Numb inner-thigh after knee arthroscopic surgery, operated under general anesthesia with nerve blocks, and a tourniquet in a super-athlete: What is to blame? AUTHOR: Dr. Robert M Raw. ABSTRACT: (written 2021-4-28) A lady underwent arthroscopic knee surgery for chronic medial side joint pain that had worsoned following running a marathon a week prior. For the surgery she received femoral and obturator nerve blocks, combined with general anesthesia. After surgery she was 100% pain free. She was also noted to have an area of numbness in the lower third of the medial aspect of her thigh.  The surgeons proposed that the numbness was the consequence of a nerve block induced injury to the obturator nerve. Closer scientific review of the case and its clinical course strongly suggest the numbness was in fact a tournequet induced injury of the medical cutaneous nerve of the thigh. Tourniquet induced nerve injuries are under diagnosed.  Full text PDF.  10. Ehlers-Danlos patient manifests Central Pain and Spontaneous Pain after repeat Achilles Tendon surgery and Working Nerve Blocks. AUTHOR: Dr. Robert M Raw MD. ABSTRACT: (written 2021-6-9) This patient represents an extremely challenging acute-on-chronic pain incident. The case is presented via the experience of the acute-pain physician who provided anesthesia care for the last of four Achilles Tendon surgeries. A 35-year-old patient with Ehlers-Danlos syndrome underwent an Achilles Tendon for the fourth time since her birth. She received general anesthesia and two nerve blocks to fully anesthetize her leg belwo the knee, for post- operative analgesia. She woke up after surgery and anesthesia in severe pain from the operated Achilles tendon. that was despite having evidence of total motor block to the leg below the knee,  and full evidence of loss of sensation in that lower leg as indicated by tsting with light touch, needle pricking, and with ice for sensation of coldness. The two nerve blcoks were repeated, with the sciaitic nerve blcok more distal to the firts one in order to use a nerve stimulator. That did not alter her pain. Then small bolus ketamine was administered and it dramatically eliminated the pain within 45 minutes. On the fourth day after surgery she developed shooting pains into her ipsilateral vaginal labia majora. The pudendal had been touched by the block needle during the firts parasacral sciaitc nerve blok eliciting sharp pain, until the needle was withdrawn and redirected.  All the possible explanations for these events is discussed. Full text PDF 11. Broken Heart Syndrome repeating after anesthetic and surgery - How to prevent Takotsuba syndrome. Author: Dr. Robert M Raw MD. ABSTRACT: (written2021-6-10) A 57-year-old woman experienced a recurrence of Takotsubo Cardiomyopathy (TCM) following a thyroidectomy. She developed frothy lung edema following a re-intubation for poor oxygenation. The patient later described her concealed extreme pre-operative anxiety. The first TCM event had followed a stressful job interview. The most common TCM patient is a highly stressed post-menopausal woman not using estrogen. Studies suggest the TCM left ventricle apical ballooning, is caused by high catecholamine levels inducing left ventricle apical inflammation and suppressed contractility. It is speculated that pre-operative estrogen medication, corticosteroid therapy, and intense anxiolytic therapy could prevent postoperative TCM in risk patients. Full text PDF 12. Lady with pronounced foot and hand muscle dystrophy presents for emergency appendicectomy: What is the best anesthetic? Author: Dr. Robert M Raw MD. ABSTRACT: (Written 2021-6-10) A 45-year-old lady presented with abdominal pain and a clinical picture suggesting she had acute appendicites. The surgeon wanted to operate immedately. Upon inserting the peripheral IV the anesthesiologist noted marked waisting of herthenar and hypothenar muscles. Upon further questioning she admitted to having many life struggles with matters requiring a firm hand grip or a steady foot stance. The anesthesiologist labled her as having an undefined myopathy. She thus needed a malignant hyperthermia safe anesthetic technique as well as a safe airway management plan for her risk of having a full stomach. What is the best anesthesia technique, and the best post-surgical management. Full test PDF. 13. Two cases of differential desaturation: Acrocyanosis and Multiple Epiphyseal Dysplasia as possible causes. Author: Dr. Robert M Raw MD. ABSTRACT: (Written 2012) The pulse-oximeter may read significantly differrent values when applied to different body parts in a one patient. The body parts may be left hand and a right hand, or an ear and a foot.  Two patients are presented where the first pulseoximeter gave false low reading.  The mechanism of differential desaturation is explained and understanding this well will lead to best patient anesthesia management. Full Text PDF. 14. Perioperative Ketamine and Tramadol causes a lady to have nightmares for 6-months long after surgery. Author: Dr. Robert M Raw MD.  ABSTRACT: (event = 2014. Written 2021-6-13) A 61-year-old lady presented for total knee arthroplasty. She received general anaesthesia with full regional anesthesia peripheral nerve blocks for the with omission of the sciatic nerve upon the surgeons insistence. Everything went generally well except for her having severe posterior knee pain after surgery. Three different teams of anesthesiologists attended to her preoperatively, intra-operatively and postoperatively. All three teams administered ketamine to a final total of 250mg for the full perioperative period. Six months later the lady contacted the hospital about her nightmares which had lasted for the full six months and had started immediately after her hospitalization. The cause of, and the treatment of her nightmares is discussed.   Full text PDF.            Next page (2) of case reports.
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https://www.regional-anesthesia.com            Editor: Dr. Robert Maurice Raw   
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Case reports; page 1 1.    Patient with Severe Restrictive Lung Disease, and Lumbar Syringomyelia, presenting for Total Hip Replacement: The  Anesthesia, Ethical, and Professional Challenges. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-3-17) There are two elements of interest in this unusual case, performed in 2012. The first element concerns the patient’s multiple co-morbid diseases affecting her anesthesia care with high potential for perioperative mortality. The 60-y old lady weighed 51 kg and suffered foremost from (1) severe thoracic scoliosis, (2) post-polio syndrome causing severe weakness in her left arm, (3) an Arnold-Chiari malformation at the base of her skull, (4) cervical hydro-syringomyelia with a fluid-drainage tube into a cerebral ventricle, (5) a lumbar spinal syrinx extending into the cord conus, with a (6) tethered spinal cord, (7) severe restrictive respiratory disease with (8) chronic CO2 retention, and (9) mild respiratory failure. The anesthetic consisted of (a) general anesthesia and ventilation, (b) regional anesthesia consisting of a parasacral sciatic nerve block, a subcostal nerve block and a psoas compartment block combined with (c) a substantive anti- hyperalgesia and opioid avoidance pharmacological strategy. The surgery took 5½ hours, and the patient lost more than 50% of their blood red-cell mass.  The final outcome was excellent. The second interesting aspect of the case is; the anesthesiologist chose to ignore surgeon’s scientifically baseless objections to the sciatic nerve block component, generating discussion of ethical and professionalism aspects of the surgeon’s behavior afterwards.   Full text PDF 2. Winged scapula folowing total shoulder arthroplasty and regional anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-4). A tiny 70-year old lady underwent a right total shoulder arthroplasty. She received an interscalene block and general anesthesia for the surgery. After surgery the patient developed a winging of the right scapula, sugesting she had a paralyzed serratus anterior muscle, secondary to a long throacic nerve injury. The surgeon attributed the presumed nerve injury to the interscalene block that the patient received. The case is reviewed applying forensic rationale, as well as studying the existing published scientific literature pertinent to the problem.  The strong conclusion is that the long thoracic nerve nerve was most likely injured by the surgical retractor being over-vigorously used during surgery that pulled on the medial aspect of the wound. It would have compressed the long thoracic nerve against the chest wall, thus injuring it. Full text PDF 3.  Pastor with undiagnosed civilian-PTSD from childhood abuse, screams uncontrollably after spinal surgery. AUTHOR: Dr. Robert M Raw MD. ABSTRACT -(2021-5-25) A 58-year-old pastor undergoes posterior approach thoracolumbar spinal fusion. Despite substantial pre-emptive analgesia he awakens wide-eyed screaming tearfully and won’t respond to instructions. The physician anesthesiologist treats him with tranquilizer rather than with added opiates. He becomes peaceful. In the following days his childhood abuse is discovered and the diagnosis of PTSD is made. The late-phase residual anesthesia drugs are believed to have caused an emotional disinhibition which brought out his emotions about his last childhood thoughts that he had as anesthesia was being induced. The back- surgery was connected to his childhood traumas. Full text PDF.  4. A 60-yer-old lady with undiagnosed civilian-PTSD from childhood abuse, screams uncontrolably after breast surgery. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-20) The lady underwent 13-hours of surgery to reconstruct her one breast with tissue from the abdomen, following a mastectomy 9-years earlier.  Despite substantial pre-emptive analgesia, she awoke screaming tearfully, and could not respond to words spoken to her. She just looked wide-eyed at the persons speaking. On the erroneus presumption that she had severe pain, additional opiates were injected causing respiratory arrest. Intensive care management got her safely through the night. In the following days its discovered she was having thoughts of childhood sexual abuse and was very emotional for that reason, during her post-anesthesia recovery period. She was then diagnosed as having civilian-PTSD. Full text PDF  5. Obese lady injected epidural hydromorphone for surgical analgesia develops respiratory arrest and 3rd degree heart block after anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-28) The 62-year-old lady was administered both epidural, and intravenous hydrophylic long- acting opiates, all before awakening her from anesthesia. Fentanyl was also adminstered throughout her surgery. She was on 28 classes of drugs for multiple co-morbid diseases, and was morbidly obese witha BMI of 33. Shortly after extubation she went into critical respiratory failure. That was treated with fullresuscitation and 2-ampules of naloxone, and a further naloxone infusion for the next 24-hours. That induced hypertension, and the treatment of that caused a 3rd-degree heart block. The actions of neuraxial opiates are discussed. Full Text PDF  6. Awake breast and axilla surgery in an ASA-4 patient, using landmark nerve-blocks. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2019). A 53-year-old lady required right-side breast surgical re-excision of a malignant breast lump, together with an axilla dissection for sentinel lymph nodes. She had a BMI of 44 and multiple co-morbid diseases critical to anesthesia planning. She had end-stage emphysema, was chronically cyanotic and on permanetnsupplimentary oxygen. She had had an earlier myocardial infarction and significant coronary artery disease. The surgery was succesfully performed awake with minimal sedation under three peripheral nerve blocks; (1) a T4 level paravertebral nerve block with catheter placement using landmarks and electrostimulation, (2) a T5 paravertebral single-shot nerve-block, (3) a T3 paravertebral single-shot nerve- block,(4) a nerve to subscapularis nerve-block using only land-marks and nerve- electrostimulation, (5) a superficial cervical plexus block, (6) a pectoral nerve block using an ultrasound guided nerve stimulator verified proximal PECS-2 proximal block. The surgery and anesthetic went well. The regional anesthesia techniques are described in detail and are well illustrated.  Full text PDF. 7. Man with severe heart failure, severe aortic stenosis, mitral stenosis, critical bilateral carotid stenosis needs emergency leg amputation preceeding his urgent multiple vascular surgical repairs: Regional anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT: (written 2003, revised May 2021) A 73-year-old man presents to the emergency room with severe shortness of breath and inability to walk. He is diagnosed as being in cardiac failure and intense diuretic therapy, with inotropic drugs are administered. His heart failure improves but he developes right foot ischemia, then gangreen with sepsis. Interim investigations reveal he has bilateral critical carotid stenosis needing surgery, severe aortic and mitral valve stenosis needing surgery, and severe four-vessel coronary artery disease needing  surgery. The sequence or combination of the vascualr surgeries to be done is unclear,  however their urgency is exceded by the more urgent need to eliminate the sepsis in the foot. Concurrent purelent sepsis is an absolute contra-indication to all reparitve cardiac and vascular surgery as that prohibits the cardiac and vascular surgeries being done.  Due to his extreme critical diseases the foot surgery must be highly and immediately succesful, as well as fast and physiologically as little stressing to the patient as posible. It is decided to do a through-the- knee right leg amputation under regional anesthesia. The case discussion evalautes the regional anesthesia options, and describes the case’s successful management. Full text PDF.  8. Wrong diagnosis of Local Anesthetic Systemic Toxicity (LAST): Volatile anesthesia induced ankle clonus. AUTHOR: Dr. Robert M Raw. ABSTRACT: (written 2008, revised 2021-5-16) In 2008 a 54-year-old lady underwent a left revision hip-arthroplasty. She was morbidly obese with BMI of 44, and was further healthy except for the fact she had chronic hip and back pain and was a chronic user of prescribed oral analgsic medications. The surgeon was going to perform a lateral aproach at cutaneous level, but with deeper elements of a posterior approach on the joint capsule. The first anesthesia plan was to perform a  L3 psoas compartment block and a paravertebral sciatic nerve block, paired with general anesthesia. The surgeon objected to the sciatic nerve block as he feared it would cause sciatic nerve injury for which he would be surgically blamed. Accordingly in lieu of the missing sciatic nerve block the anesthesiologist substituted a second psoas compartment injection at L5 hoping to cover suffient elements of the sacral plexus to still provide posterio analgesia after the hip arthroplasty. Thus the patient got two psoas compartment catheters.  Surgery and the rest of the anesthesia care was uneventful. Upon awakening the patient had severe posterior hip pain, and also demonstrated bilateral ankle clonus. The ankle clonus was initially incorrectly labled as being part of LAST. The entity of ankle clonus will be fully discussed, with its etiology and meaning.    Full text PDF. 9. Numb inner-thigh after knee arthroscopic surgery, operated under general anesthesia with nerve blocks, and a tourniquet in a super-athlete: What is to blame? AUTHOR: Dr. Robert M Raw. ABSTRACT: (written 2021-4-28) A lady underwent arthroscopic knee surgery for chronic medial side joint pain that had worsoned following running a marathon a week prior. For the surgery she received femoral and obturator nerve blocks, combined with general anesthesia. After surgery she was 100% pain free. She was also noted to have an area of numbness in the lower third of the medial aspect of her thigh.  The surgeons proposed that the numbness was the consequence of a nerve block induced injury to the obturator nerve. Closer scientific review of the case and its clinical course strongly suggest the numbness was in fact a tournequet induced injury of the medical cutaneous nerve of the thigh. Tourniquet induced nerve injuries are under diagnosed.  Full text PDF.  10. Ehlers-Danlos patient manifests Central Pain and Spontaneous Pain after repeat Achilles Tendon surgery and Working Nerve Blocks. AUTHOR: Dr. Robert M Raw MD. ABSTRACT: (written 2021-6-9) This patient represents an extremely challenging acute-on-chronic pain incident. The case is presented via the experience of the acute-pain physician who provided anesthesia care for the last of four Achilles Tendon surgeries. A 35-year-old patient with Ehlers-Danlos syndrome underwent an Achilles Tendon for the fourth time since her birth. She received general anesthesia and two nerve blocks to fully anesthetize her leg belwo the knee, for post-operative analgesia. She woke up after surgery and anesthesia in severe pain from the operated Achilles tendon. that was despite having evidence of total motor block to the leg below the knee,  and full evidence of loss of sensation in that lower leg as indicated by tsting with light touch, needle pricking, and with ice for sensation of coldness. The two nerve blcoks were repeated, with the sciaitic nerve blcok more distal to the firts one in order to use a nerve stimulator. That did not alter her pain. Then small bolus ketamine was administered and it dramatically eliminated the pain within 45 minutes. On the fourth day after surgery she developed shooting pains into her ipsilateral vaginal labia majora. The pudendal had been touched by the block needle during the firts parasacral sciaitc nerve blok eliciting sharp pain, until the needle was withdrawn and redirected.  All the possible explanations for these events is discussed. Full text PDF 11. Broken Heart Syndrome repeating after anesthetic and surgery - How to prevent Takotsuba syndrome. Author: Dr. Robert M Raw MD. ABSTRACT: (written2021-6-10) A 57-year-old woman experienced a recurrence of Takotsubo Cardiomyopathy (TCM) following a thyroidectomy. She developed frothy lung edema following a re-intubation for poor oxygenation. The patient later described her concealed extreme pre-operative anxiety. The first TCM event had followed a stressful job interview. The most common TCM patient is a highly stressed post-menopausal woman not using estrogen. Studies suggest the TCM left ventricle apical ballooning, is caused by high catecholamine levels inducing left ventricle apical inflammation and suppressed contractility. It is speculated that pre-operative estrogen medication, corticosteroid therapy, and intense anxiolytic therapy could prevent postoperative TCM in risk patients. Full text PDF 12. Lady with pronounced foot and hand muscle dystrophy presents for emergency appendicectomy: What is the best anesthetic? Author: Dr. Robert M Raw MD. ABSTRACT: (Written 2021-6-10) A 45-year-old lady presented with abdominal pain and a clinical picture suggesting she had acute appendicites. The surgeon wanted to operate immedately. Upon inserting the peripheral IV the anesthesiologist noted marked waisting of herthenar and hypothenar muscles. Upon further questioning she admitted to having many life struggles with matters requiring a firm hand grip or a steady foot stance. The anesthesiologist labled her as having an undefined myopathy. She thus needed a malignant hyperthermia safe anesthetic technique as well as a safe airway management plan for her risk of having a full stomach. What is the best anesthesia technique, and the best post-surgical management. Full test PDF. 13. Two cases of differential desaturation: Acrocyanosis and Multiple Epiphyseal Dysplasia as possible causes. Author: Dr. Robert M Raw MD. ABSTRACT: (Written 2012) The pulse-oximeter may read significantly differrent values when applied to different body parts in a one patient. The body parts may be left hand and a right hand, or an ear and a foot.  Two patients are presented where the first pulseoximeter gave false low reading.  The mechanism of differential desaturation is explained and understanding this well will lead to best patient anesthesia management. Full Text PDF. 14. Perioperative Ketamine and Tramadol causes a lady to have nightmares for 6-months long after surgery. Author: Dr. Robert M Raw MD.  ABSTRACT: (event = 2014. Written 2021-6-13) A 61-year-old lady presented for total knee arthroplasty. She received general anaesthesia with full regional anesthesia peripheral nerve blocks for the with omission of the sciatic nerve upon the surgeons insistence. Everything went generally well except for her having severe posterior knee pain after surgery. Three different teams of anesthesiologists attended to her preoperatively, intra-operatively and postoperatively. All three teams administered ketamine to a final total of 250mg for the full perioperative period. Six months later the lady contacted the hospital about her nightmares which had lasted for the full six months and had started immediately after her hospitalization. The cause of, and the treatment of her nightmares is discussed.   Full text PDF.            Next page (2) of case reports.
https://www.regional-anesthesia.com            Editor: Dr. Robert Maurice Raw   
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Case reports; page 1 1.    Patient with Severe Restrictive Lung Disease, and Lumbar Syringomyelia, presenting for Total Hip Replacement: The  Anesthesia, Ethical, and Professional Challenges. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-3-17) There are two elements of interest in this unusual case, performed in 2012. The first element concerns the patient’s multiple co-morbid diseases affecting her anesthesia care with high potential for perioperative mortality. The 60-y old lady weighed 51 kg and suffered foremost from (1) severe thoracic scoliosis, (2) post-polio syndrome causing severe weakness in her left arm, (3) an Arnold-Chiari malformation at the base of her skull, (4) cervical hydro-syringomyelia with a fluid-drainage tube into a cerebral ventricle, (5) a lumbar spinal syrinx extending into the cord conus, with a (6) tethered spinal cord, (7) severe restrictive respiratory disease with (8) chronic CO2 retention, and (9) mild respiratory failure. The anesthetic consisted of (a) general anesthesia and ventilation, (b) regional anesthesia consisting of a parasacral sciatic nerve block, a subcostal nerve block and a psoas compartment block combined with (c) a substantive anti-hyperalgesia and opioid avoidance pharmacological strategy. The surgery took 5½ hours, and the patient lost more than 50% of their blood red-cell mass.  The final outcome was excellent. The second interesting aspect of the case is; the anesthesiologist chose to ignore surgeon’s scientifically baseless objections to the sciatic nerve block component, generating discussion of ethical and professionalism aspects of the surgeon’s behavior afterwards.   Full text PDF 2. Winged scapula folowing total shoulder arthroplasty and regional anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-4). A tiny 70-year old lady underwent a right total shoulder arthroplasty. She received an interscalene block and general anesthesia for the surgery. After surgery the patient developed a winging of the right scapula, sugesting she had a paralyzed serratus anterior muscle, secondary to a long throacic nerve injury. The surgeon attributed the presumed nerve injury to the interscalene block that the patient received. The case is reviewed applying forensic rationale, as well as studying the existing published scientific literature pertinent to the problem.  The strong conclusion is that the long thoracic nerve nerve was most likely injured by the surgical retractor being over-vigorously used during surgery that pulled on the medial aspect of the wound. It would have compressed the long thoracic nerve against the chest wall, thus injuring it. Full text PDF 3.  Pastor with undiagnosed civilian-PTSD from childhood abuse, screams uncontrollably after spinal surgery. AUTHOR: Dr. Robert M Raw MD. ABSTRACT -(2021-5-25) A 58-year-old pastor undergoes posterior approach thoracolumbar spinal fusion. Despite substantial pre-emptive analgesia he awakens wide- eyed screaming tearfully and won’t respond to instructions. The physician anesthesiologist treats him with tranquilizer rather than with added opiates. He becomes peaceful. In the following days his childhood abuse is discovered and the diagnosis of PTSD is made. The late-phase residual anesthesia drugs are believed to have caused an emotional disinhibition which brought out his emotions about his last childhood thoughts that he had as anesthesia was being induced. The back-surgery was connected to his childhood traumas. Full text PDF.  4. A 60-yer-old lady with undiagnosed civilian-PTSD from childhood abuse, screams uncontrolably after breast surgery. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-20) The lady underwent 13-hours of surgery to reconstruct her one breast with tissue from the abdomen, following a mastectomy 9-years earlier.  Despite substantial pre-emptive analgesia, she awoke screaming tearfully, and could not respond to words spoken to her. She just looked wide-eyed at the persons speaking. On the erroneus presumption that she had severe pain, additional opiates were injected causing respiratory arrest. Intensive care management got her safely through the night. In the following days its discovered she was having thoughts of childhood sexual abuse and was very emotional for that reason, during her post-anesthesia recovery period. She was then diagnosed as having civilian-PTSD. Full text PDF  5. Obese lady injected epidural hydromorphone for surgical analgesia develops respiratory arrest and 3rd degree heart block after anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2021-5-28) The 62-year-old lady was administered both epidural, and intravenous hydrophylic long-acting opiates, all before awakening her from anesthesia. Fentanyl was also adminstered throughout her surgery. She was on 28 classes of drugs for multiple co-morbid diseases, and was morbidly obese witha BMI of 33. Shortly after extubation she went into critical respiratory failure. That was treated with fullresuscitation and 2-ampules of naloxone, and a further naloxone infusion for the next 24-hours. That induced hypertension, and the treatment of that caused a 3rd-degree heart block. The actions of neuraxial opiates are discussed. Full Text PDF  6. Awake breast and axilla surgery in an ASA-4 patient, using landmark nerve-blocks. AUTHOR: Dr. Robert M Raw MD. ABSTRACT-(2019). A 53-year-old lady required right-side breast surgical re-excision of a malignant breast lump, together with an axilla dissection for sentinel lymph nodes. She had a BMI of 44 and multiple co-morbid diseases critical to anesthesia planning. She had end-stage emphysema, was chronically cyanotic and on permanetnsupplimentary oxygen. She had had an earlier myocardial infarction and significant coronary artery disease. The surgery was succesfully performed awake with minimal sedation under three peripheral nerve blocks; (1) a T4 level paravertebral nerve block with catheter placement using landmarks and electrostimulation, (2) a T5 paravertebral single-shot nerve-block, (3) a T3 paravertebral single-shot nerve-block,(4) a nerve to subscapularis nerve-block using only land-marks and nerve-electrostimulation, (5) a superficial cervical plexus block, (6) a pectoral nerve block using an ultrasound guided nerve stimulator verified proximal PECS-2 proximal block. The surgery and anesthetic went well. The regional anesthesia techniques are described in detail and are well illustrated.  Full text PDF. 7. Man with severe heart failure, severe aortic stenosis, mitral stenosis, critical bilateral carotid stenosis needs emergency leg amputation preceeding his urgent multiple vascular surgical repairs: Regional anesthesia. AUTHOR: Dr. Robert M Raw MD. ABSTRACT: (written 2003, revised May 2021) A 73-year-old man presents to the emergency room with severe shortness of breath and inability to walk. He is diagnosed as being in cardiac failure and intense diuretic therapy, with inotropic drugs are administered. His heart failure improves but he developes right foot ischemia, then gangreen with sepsis. Interim investigations reveal he has bilateral critical carotid stenosis needing surgery, severe aortic and mitral valve stenosis needing surgery, and severe four-vessel coronary artery disease needing  surgery. The sequence or combination of the vascualr surgeries to be done is unclear,  however their urgency is exceded by the more urgent need to eliminate the sepsis in the foot. Concurrent purelent sepsis is an absolute contra-indication to all reparitve cardiac and vascular surgery as that prohibits the cardiac and vascular surgeries being done.  Due to his extreme critical diseases the foot surgery must be highly and immediately succesful, as well as fast and physiologically as little stressing to the patient as posible. It is decided to do a through-the-knee right leg amputation under regional anesthesia. The case discussion evalautes the regional anesthesia options, and describes the case’s successful management. Full text PDF.  8. Wrong diagnosis of Local Anesthetic Systemic Toxicity (LAST): Volatile anesthesia induced ankle clonus. AUTHOR: Dr. Robert M Raw. ABSTRACT: (written 2008, revised 2021-5-16) In 2008 a 54-year-old lady underwent a left revision hip-arthroplasty. She was morbidly obese with BMI of 44, and was further healthy except for the fact she had chronic hip and back pain and was a chronic user of prescribed oral analgsic medications. The surgeon was going to perform a lateral aproach at cutaneous level, but with deeper elements of a posterior approach on the joint capsule. The first anesthesia plan was to perform a  L3 psoas compartment block and a paravertebral sciatic nerve block, paired with general anesthesia. The surgeon objected to the sciatic nerve block as he feared it would cause sciatic nerve injury for which he would be surgically blamed. Accordingly in lieu of the missing sciatic nerve block the anesthesiologist substituted a second psoas compartment injection at L5 hoping to cover suffient elements of the sacral plexus to still provide posterio analgesia after the hip arthroplasty. Thus the patient got two psoas compartment catheters.  Surgery and the rest of the anesthesia care was uneventful. Upon awakening the patient had severe posterior hip pain, and also demonstrated bilateral ankle clonus. The ankle clonus was initially incorrectly labled as being part of LAST. The entity of ankle clonus will be fully discussed, with its etiology and meaning.    Full text PDF. 9. Numb inner-thigh after knee arthroscopic surgery, operated under general anesthesia with nerve blocks, and a tourniquet in a super-athlete: What is to blame? AUTHOR: Dr. Robert M Raw. ABSTRACT: (written 2021-4-28) A lady underwent arthroscopic knee surgery for chronic medial side joint pain that had worsoned following running a marathon a week prior. For the surgery she received femoral and obturator nerve blocks, combined with general anesthesia. After surgery she was 100% pain free. She was also noted to have an area of numbness in the lower third of the medial aspect of her thigh.  The surgeons proposed that the numbness was the consequence of a nerve block induced injury to the obturator nerve. Closer scientific review of the case and its clinical course strongly suggest the numbness was in fact a tournequet induced injury of the medical cutaneous nerve of the thigh. Tourniquet induced nerve injuries are under diagnosed.  Full text PDF.  10. Ehlers-Danlos patient manifests Central Pain and Spontaneous Pain after repeat Achilles Tendon surgery and Working Nerve Blocks. AUTHOR: Dr. Robert M Raw MD. ABSTRACT: (written 2021-6-9) This patient represents an extremely challenging acute-on-chronic pain incident. The case is presented via the experience of the acute-pain physician who provided anesthesia care for the last of four Achilles Tendon surgeries. A 35-year-old patient with Ehlers-Danlos syndrome underwent an Achilles Tendon for the fourth time since her birth. She received general anesthesia and two nerve blocks to fully anesthetize her leg belwo the knee, for post-operative analgesia. She woke up after surgery and anesthesia in severe pain from the operated Achilles tendon. that was despite having evidence of total motor block to the leg below the knee,  and full evidence of loss of sensation in that lower leg as indicated by tsting with light touch, needle pricking, and with ice for sensation of coldness. The two nerve blcoks were repeated, with the sciaitic nerve blcok more distal to the firts one in order to use a nerve stimulator. That did not alter her pain. Then small bolus ketamine was administered and it dramatically eliminated the pain within 45 minutes. On the fourth day after surgery she developed shooting pains into her ipsilateral vaginal labia majora. The pudendal had been touched by the block needle during the firts parasacral sciaitc nerve blok eliciting sharp pain, until the needle was withdrawn and redirected.  All the possible explanations for these events is discussed. Full text PDF 11. Broken Heart Syndrome repeating after anesthetic and surgery - How to prevent Takotsuba syndrome. Author: Dr. Robert M Raw MD. ABSTRACT: (written2021-6-10) A 57-year-old woman experienced a recurrence of Takotsubo Cardiomyopathy (TCM) following a thyroidectomy. She developed frothy lung edema following a re-intubation for poor oxygenation. The patient later described her concealed extreme pre-operative anxiety. The first TCM event had followed a stressful job interview. The most common TCM patient is a highly stressed post-menopausal woman not using estrogen. Studies suggest the TCM left ventricle apical ballooning, is caused by high catecholamine levels inducing left ventricle apical inflammation and suppressed contractility. It is speculated that pre-operative estrogen medication, corticosteroid therapy, and intense anxiolytic therapy could prevent postoperative TCM in risk patients. Full text PDF 12. Lady with pronounced foot and hand muscle dystrophy presents for emergency appendicectomy: What is the best anesthetic? Author: Dr. Robert M Raw MD. ABSTRACT: (Written 2021-6-10) A 45-year-old lady presented with abdominal pain and a clinical picture suggesting she had acute appendicites. The surgeon wanted to operate immedately. Upon inserting the peripheral IV the anesthesiologist noted marked waisting of herthenar and hypothenar muscles. Upon further questioning she admitted to having many life struggles with matters requiring a firm hand grip or a steady foot stance. The anesthesiologist labled her as having an undefined myopathy. She thus needed a malignant hyperthermia safe anesthetic technique as well as a safe airway management plan for her risk of having a full stomach. What is the best anesthesia technique, and the best post-surgical management. Full test PDF. 13. Two cases of differential desaturation: Acrocyanosis and Multiple Epiphyseal Dysplasia as possible causes. Author: Dr. Robert M Raw MD. ABSTRACT: (Written 2012) The pulse-oximeter may read significantly differrent values when applied to different body parts in a one patient. The body parts may be left hand and a right hand, or an ear and a foot.  Two patients are presented where the first pulseoximeter gave false low reading.  The mechanism of differential desaturation is explained and understanding this well will lead to best patient anesthesia management. Full Text PDF. 14. Perioperative Ketamine and Tramadol causes a lady to have nightmares for 6-months long after surgery. Author: Dr. Robert M Raw MD.  ABSTRACT: (event = 2014. Written 2021-6-13) A 61-year-old lady presented for total knee arthroplasty. She received general anaesthesia with full regional anesthesia peripheral nerve blocks for the with omission of the sciatic nerve upon the surgeons insistence. Everything went generally well except for her having severe posterior knee pain after surgery. Three different teams of anesthesiologists attended to her preoperatively, intra-operatively and postoperatively. All three teams administered ketamine to a final total of 250mg for the full perioperative period. Six months later the lady contacted the hospital about her nightmares which had lasted for the full six months and had started immediately after her hospitalization. The cause of, and the treatment of her nightmares is discussed.   Full text PDF.            Next page (2) of case reports.
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