Anesthetic challenges in patients with ankylosing spondylitis requiring lower limb surgery – A case report and literature review

Ankylosing spondylitis is one of the global top health burdens and patients affected by it frequently require surgery related to disease progression, such as orthopedic surgery. These patients may prove difficult to manage from an anesthetic standpoint, regardless of the anesthetic technique employed, mainly given the potential for difficult airway access and related comorbidities. We present the case of a 52-year-old male posted for urgent cemented total hip arthroplasty with associated bilateral pulmonary fibrosis and an anticipated difficult airway in whom regional anesthesia was performed with satisfactory results, with a favorable intraoperative and postoperative course. The literature review explores the anesthetic techniques employed when a tailored approach is required in managing patients with ankylosing spondylitis

The Impact of Monitoring Depth of Anesthesia and Nociception on Postoperative Cognitive Function in Adult Multiple Trauma Patients

Background and Objectives: Patients with traumatic injuries have often been excluded from studies that have attempted to pinpoint modifiable factors to predict the transient disturbance of the cognitive function in the postoperative settings. Anesthetists must be aware of the high risk of developing postoperative delirium and cognitive dysfunction (POCD) in patients undergoing emergency surgery. Monitoring the depth of anesthesia in order to tailor anesthetic delivery may reduce this risk. The primary aim of this study was to improve the prevention strategies for the immediate POCD by assessing anesthetic depth and nociception during emergency surgery. Material and Methods: Of 107 trauma ASA physical status II–IV patients aged over 18 years undergoing emergency noncardiac surgery, 95 patients were included in a prospective randomized study. Exclusion criteria were neurotrauma, chronic use of psychoactive substances or alcohol, impaired preoperative cognitive function, pre-existing psychopathological symptoms, or expected surgery time less than 2 h. Entropy and Surgical Pleth Index (SPI) values were constantly recorded for one group during anesthesia. POCD was assessed 24 h, 48 h, and 72 h after surgery using the Neelon and Champagne (NEECHAM) Confusion Scale. Results: Although in the intervention group, fewer patients experienced POCD episodes in comparison to the control group, the results were not statistically significant (p < 0.08). The study showed a statistically significant inverse correlation between fentanyl and the NEECHAM Confusion Scale at 24 h (r = −0.32, p = 0.0005) and 48 h (r = −0.46, p = 0.0002), sevoflurane and the NEECHAM Confusion Scale at 24 h (r = −0.38, p = 0.0014) and 48 h (r = −0.52, p = 0.0002), and noradrenaline and POCD events in the first 48 h (r = −0.46, p = 0.0013 for the first 24 h, respectively, and r = −0.46, p = 0.0002 for the next 24 h). Conclusions: Entropy and SPI monitoring during anesthesia may play an important role in diminishing the risk of developing immediate POCD after emergency surgery

Biodetoxification Using Intravenous Lipid Emulsion, a Rescue Therapy in Life-Threatening Quetiapine and Venlafaxine Poisoning: A Case Report

The administration of intravenous lipid emulsion (ILE) is a proven antidote used to reverse local anesthetic-related systemic toxicity. Although the capacity of ILE to generate blood tissue partitioning of lipophilic drugs has been previously demonstrated, a clear recommendation for its use as an antidote for other lipophilic drugs is still under debate. Venlafaxine (an antidepressant acting as a serotonin–norepinephrine reuptake inhibitor (SNRI)) and quetiapine (a second-generation atypical antipsychotic) are widely used in the treatment of psychotic disorders. Both are lipophilic drugs known to induce cardiotoxicity and central nervous depression. We report the case of a 33-year-old man with a medical history of schizoaffective disorder who was admitted to the emergency department (ED) after having been found unconscious due to a voluntary ingestion of 12 g of quetiapine and 4.5 g of venlafaxine. Initial assessment revealed a cardiorespiratory stable patient but unresponsive with a GCS of 4 (M2 E1 V1). In the ED, he was intubated, and gastric lavage was performed. Immediately after the admission to the intensive care unit (ICU), his condition quickly deteriorated, developing cardiovascular collapse refractory to crystalloids and vasopressor infusion. Junctional bradycardia occurred, followed by spontaneous conversion to sinus rhythm. Subsequently, frequent ventricular extrasystoles, as well as patterns of bigeminy, trigeminy, and even episodes of non-sustained ventricular tachycardia, occurred. Additionally, generalized tonic–clonic seizures were observed. Alongside supportive therapy, antiarrhythmic and anticonvulsant therapy, intravenous lipid emulsion bolus, and continuous infusion were administered. His condition progressively improved over the following hours, and 24 h later, he was tapered off the vasopressor. On day 2, the patient repeated the cardiovascular collapse and a second dose of ILE was administered. Over the next few days, the patient’s clinical condition improved, and he was successfully weaned off ventilator and vasopressor support. ILE has the potential to become a form of rescue therapy in cases of severe lipophilic drug poisoning and should be considered a viable treatment for severe cardiovascular instability that is refractory to supportive therapy

Hemorrhagic Cardiac Tamponade—An Unusual Threat in the COVID-19 Recovery Phase

Cardiac tamponade is a rare presentation in patients with COVID-19, which may be induced by the associated exacerbated inflammatory response. The onset of cardiac tamponade may be concomitant with the acute phase of the disease or may develop subsequently as a new health condition secondary to the disease. We report four cases of cardiac tamponade that occurred late after the acute phase of the disease. One of them may be considered a post-acute complication of the disease, and three of them may be classified as a new health condition induced by COVID-19. Only two cases had a history of severe respiratory distress due to COVID-19. In all four cases, pericardiocentesis was imposed, and surprisingly, in every case, hemorrhagic fluid was evacuated. In this case, series, immune-mediated etiology is supported by histopathological results, where the main identified feature was fibrous pericarditis with inflammatory infiltrate. Only one patient included in this report died, and three of them were discharged after anti-inflammatory treatment was initiated