Journal of Anesthesiology and Clinical Research

Central Venous Catheterization in the ICU: A Comparison of Anatomical Landmark and Ultrasound-Guided Techniques

2024-11-08T06:38:22+00:00

Introduction: Central venous catheterization (CVC) is frequently required in intensive care units (ICUs) for administering medications, fluids, and monitoring central venous pressure. However, CVC insertion can lead to complications such as arterial puncture, hematoma formation, and pneumothorax. Ultrasound guidance has been advocated to reduce these complications, but its effectiveness in the ICU setting remains debated. This study compared the complication rates of anatomical landmark-guided versus ultrasound-guided CVC insertion in ICU patients.

Methods: A prospective cohort study was conducted in the ICU of a tertiary care hospital. Patients requiring CVC were divided into two groups: anatomical landmark-guided and ultrasound-guided insertion. The primary outcome was the incidence of complications, including arterial puncture, hematoma, and pneumothorax. Secondary outcomes included cannulation time and the number of cannulation attempts.

Results: A total of 39 patients were included in the study. The incidence of complications was significantly lower in the ultrasound-guided group (2 complications) compared to the anatomical landmark group (7 complications) (p=0.017). The most common complication was arterial puncture, occurring in 7 patients in the anatomical landmark group and 2 patients in the ultrasound-guided group.

Conclusion: Ultrasound guidance significantly reduces the risk of complications during CVC insertion in the ICU. This technique should be considered the standard of care for CVC insertion in this setting.

Perioperative Anesthetic Management of Brain Abscess Evacuation in a Child with Double Outlet Right Ventricle: A Case Report

2024-12-10T04:21:46+00:00

Introduction: Double outlet right ventricle (DORV) is a rare congenital heart defect where both the aorta and pulmonary artery arise from the right ventricle. This anomaly poses unique challenges for anesthetic management, especially during intracranial surgeries.

Case presentation: We present the case of a 7-year-old female child diagnosed with a brain abscess and DORV, who underwent open evacuation and cranioplasty. Anesthetic management focuses on maintaining hemodynamic stability and ensuring adequate oxygenation. The patient was successfully extubated postoperatively and transferred to the intensive care unit (ICU) for close monitoring.

Conclusion: Surgical interventions in patients with DORV require careful preoperative evaluation and close perioperative monitoring to minimize morbidity and mortality. This case highlights the importance of a multidisciplinary approach and meticulous anesthetic management in ensuring a successful outcome.

Successful Post-Resuscitation Care in End-Stage Renal Disease Patients: A Case Report

2024-12-20T01:28:10+00:00

Introduction: Cardiac arrest in end-stage renal disease (ESRD) patients presents unique challenges due to their complex medical conditions. Post-resuscitation care for these patients requires careful management of various factors, including hemodynamic instability, electrolyte imbalances, and fluid overload. This case report describes the successful post-resuscitation care of an ESRD patient who experienced cardiac arrest and achieved a return of spontaneous circulation (ROSC).

Case presentation: A 50-year-old female with ESRD on hemodialysis (HD) presented with acute dyspnea and cardiac arrest. After 8 minutes of cardiopulmonary resuscitation (CPR), ROSC was achieved. The patient was managed with a comprehensive post-resuscitation care protocol, including brain resuscitation (targeted temperature management, ventilation optimization, and hemodynamic control) and sustained low-efficiency dialysis for fluid balance. Despite the severity of her condition, the patient showed significant neurological recovery and was successfully extubated after 7 days of mechanical ventilation. She was discharged after 12 days with follow-up for her chronic conditions.

Conclusion: This case highlights the importance of individualized management strategies for ESRD patients post-cardiac arrest, including the need for prolonged resuscitation and careful monitoring to improve patient outcomes.

Airway Challenges and Solutions in Tracheal Reconstruction Surgery: A Case Report of Severe Post-Tracheostomy Stenosis

2024-12-27T04:36:34+00:00

Introduction: Tracheal stenosis, a narrowing of the trachea, can pose significant challenges for airway management, especially during tracheal reconstruction surgery. This case report presents the successful management of a complex airway in a patient with severe post-tracheostomy tracheal stenosis.

Case presentation: A 28-year-old male presented with severe tracheal stenosis following a tracheostomy two years prior. The patient was scheduled for tracheal reconstruction surgery. Intraoperatively, the initial challenge was the poor patency of the existing tracheostomy tube, necessitating its replacement with an uncuffed endotracheal tube (ETT). Further airway challenges arose during the stenting procedure, requiring innovative solutions to maintain airway patency while facilitating surgical access.

Conclusion: This case highlights the critical role of flexible and innovative airway management techniques in tracheal reconstruction surgery. Meticulous planning, close collaboration between the surgical and anesthesia teams, and the ability to adapt to unexpected intraoperative challenges are essential for successful outcomes in these complex cases.

Dexmedetomidine as a Neuroprotective Sedative Agent in Ultrasound-Guided Ulnar Nerve Block for a Patient with Traumatic Brain Injury: A Case Report

2025-01-22T06:31:57+00:00

Introduction: Traumatic brain injury (TBI) often presents alongside extracranial injuries requiring surgical intervention. General anesthesia in such cases poses significant challenges, particularly in patients with concomitant pulmonary complications. This case report describes the successful use of ultrasound-guided ulnar nerve block combined with dexmedetomidine sedation for a patient with moderate TBI and pulmonary contusion undergoing open reduction and internal fixation (ORIF) of a left-hand finger fracture.

Case presentation: A 50-year-old male presented with moderate TBI, pulmonary contusion, and an open fracture of the fifth digit of his left hand following a motor vehicle accident. Due to the risks associated with general anesthesia, an ultrasound-guided ulnar nerve block was performed using levobupivacaine 0.375%. Dexmedetomidine was used as a sedative agent due to its neuroprotective properties and minimal respiratory depressant effects. The procedure was successful, with the patient maintaining stable hemodynamics and adequate sedation throughout the surgery.

Conclusion: This case highlights the feasibility and safety of ultrasound-guided peripheral nerve block combined with dexmedetomidine sedation as an alternative to general anesthesia in patients with TBI and pulmonary contusion. Dexmedetomidine's neuroprotective effects and minimal respiratory depression make it a valuable tool in managing such complex cases.

Epidural Tunneling for Effective Management of Severe Cancer Pain: A Case Report

2025-03-19T01:41:55+00:00

Introduction: Severe pain is a common and debilitating symptom for many cancer patients, often requiring multimodal approaches for effective management. While oral opioids and adjunctive therapies are frequently the first line, some patients with refractory pain necessitate interventional procedures. This case report describes the successful use of epidural tunneling for long-term pain management in a patient with severe cancer pain due to bone metastases.

Case presentation: A 55-year-old woman with severe cancer pain secondary to bone metastases from breast cancer presented with intractable pain in her hips, buttocks, and legs, radiating to her feet with associated numbness. Despite high doses of oral opioids, paracetamol, amitriptyline, and a fentanyl syringe, her pain remained poorly controlled, significantly impacting her sleep and quality of life. A lumbosacral X-ray revealed osteolytic-blastic lesions with vertebral compression and other metastatic involvement. Given the severity and refractory nature of her pain, an epidural tunneling procedure was performed.

Conclusion: Epidural tunneling proved to be a safe and effective method for managing severe, chronic cancer pain in this patient, leading to a substantial reduction in pain intensity and a decreased need for systemic opioids. This technique offers a valuable option for patients with persistent pain who have failed conventional analgesic therapies, particularly in advanced stages of cancer.

Successful Anesthetic Management of a CT Scan Procedure in Pediatric Conjoined Twins: A Case Report

2025-03-25T08:26:44+00:00

Introduction: Conjoined twins represent a rare and complex congenital anomaly, posing significant challenges in medical management, particularly during diagnostic procedures requiring anesthesia. This case report details the successful anesthetic management of a four-month-old female thoracoabdominal conjoined twin pair undergoing a contrast-enhanced computed tomography (CT) scan in preparation for separation surgery. The rarity of this condition and the intricacies involved in providing safe and effective anesthesia for such patients warrant this report to contribute to the growing body of knowledge in this specialized area.

Case presentation: A four-month-old female conjoined twin pair, fused at the thorax and abdomen, was referred to Dr. Saiful Anwar General Hospital in Malang, Indonesia, for separation surgery. Prior to the planned surgical intervention, a contrast-enhanced CT scan of the thoracoabdominal region was deemed necessary by the surgical team to delineate the extent of organ fusion and vascular involvement. The twins, designated as Baby One and Baby Two for the purpose of this report, were born via Cesarean section. Physical examination revealed a shared thoracoabdominal connection and bilateral labiopalatoschisis. Pre-operative laboratory investigations showed stable hematological and biochemical parameters for both twins. An abdominal ultrasound indicated liver surface fusion with vascular involvement, while an echocardiogram revealed normal cardiac structure and function in both individuals. The American Society of Anesthesiologists (ASA) physical status for both twins was classified as Class III.

Conclusion: This case highlights the successful use of continuous dexmedetomidine infusion for sedation during an out-of-operating room CT scan procedure in pediatric thoracoabdominal conjoined twins. The meticulous pre-procedural planning, including simulation and the preparation of individualized equipment and monitoring for each twin, contributed significantly to the positive outcome. This case underscores the importance of a multidisciplinary team approach and tailored anesthetic strategies in managing complex cases of conjoined twins undergoing diagnostic imaging.

Management of Bungarus sp. Envenomation Presenting as Rapidly Progressing Respiratory Failure: An Intensive Care Case Report

2025-04-30T07:47:20+00:00

Introduction: Envenomation by snakes of the Bungarus genus (kraits) represents a critical medical emergency, particularly prevalent in South and Southeast Asia, including Indonesia. Krait venom is primarily neurotoxic, often containing potent presynaptic toxins (β-bungarotoxins) that disrupt neuromuscular transmission, leading to rapidly progressive descending paralysis. Respiratory failure due to diaphragmatic and intercostal muscle paralysis is the most life-threatening complication, necessitating immediate and expert intensive care management.

Case presentation: We report the case of a 55-year-old Indonesian male who presented to the emergency department approximately five hours after being bitten on his right hand by a snake suspected to be a Weling (Bungarus sp.). He exhibited rapidly deteriorating neurological function, including dysarthria and decreased consciousness, progressing swiftly to acute respiratory failure with paradoxical breathing and hypoxia. Emergent endotracheal intubation and mechanical ventilation were instituted. Subsequent management in the Intensive Care Unit (ICU) involved continued ventilatory support, administration of polyvalent snake antivenom (SABU), sedation, broad-spectrum antibiotics for complicating pneumonia, and comprehensive supportive care. Nerve conduction studies later confirmed bilateral phrenic nerve palsy and severe sensorimotor axonal polyneuropathy.

Conclusion: This case highlights the fulminant respiratory failure characteristic of severe Bungarus envenomation. Prompt recognition, aggressive airway management, and mechanical ventilation are paramount lifesaving interventions. While antivenom administration is a standard therapy, its efficacy in reversing established presynaptic neuromuscular blockade remains debated, underscoring the critical role of prolonged ventilatory support and meticulous ICU care until neuromuscular function recovers, which can be significantly delayed due to the nature of presynaptic toxins. This case reinforces the need for high vigilance and resource preparedness in managing neurotoxic snakebites in endemic regions.

Critical Care Approach to Severe Tetanus with Septic Shock: A Case Report

2025-05-05T06:20:49+00:00

Introduction: Tetanus, caused by Clostridium tetani neurotoxin, remains a life-threatening condition, particularly in regions with suboptimal vaccination coverage. Severe tetanus often necessitates intensive care unit (ICU) admission due to profound muscle spasms, respiratory failure, and autonomic nervous system dysfunction. Concomitant septic shock further complicates management and worsens prognosis. This report details the critical care management of a patient presenting with severe tetanus complicated by septic shock.

Case presentation: A 41-year-old male presented with generalized muscle rigidity, trismus, and recurrent severe spasms following a puncture wound from bamboo 10 days prior. He had no prior tetanus immunization history. Upon admission, he exhibited signs of respiratory distress (Sp90% on a 15L non-rebreather mask) and septic shock (tachycardia, hypotension requiring vasopressors, SOFA score 7). Diagnosis of severe tetanus (Ablett Grade III) with respiratory failure and septic shock was made. Management involved immediate intubation, mechanical ventilation, administration of human tetanus immunoglobulin (HTIG), intravenous metronidazole, aggressive sedation with benzodiazepines (diazepam infusion) and neuromuscular blockade (vecuronium infusion), hemodynamic support with intravenous fluids and noradrenaline infusion, early tracheostomy, and comprehensive supportive care including nutritional support and VTE prophylaxis. His ICU stay was complicated by autonomic instability and ventilator-associated pneumonia (VAP).

Conclusion: Managing severe tetanus complicated by septic shock requires a prompt, multidisciplinary critical care approach. Key elements include securing the airway, controlling spasms and rigidity, neutralizing toxins, eradicating the source, managing autonomic instability, aggressive sepsis management according to current guidelines, and providing meticulous supportive care. Despite significant challenges, a favorable outcome is possible with comprehensive ICU management.

Successful Application of Non-Invasive Ventilation in Acute Respiratory Failure Complicating Thyroid Storm-Induced Pulmonary Edema: A Case Report

2025-05-13T08:51:52+00:00

Introduction: Thyroid storm is a rare, life-threatening exacerbation of thyrotoxicosis characterized by severe multisystem organ dysfunction, including cardiovascular collapse and respiratory failure. Acute pulmonary edema is a recognized but challenging complication, often stemming from high-output cardiac failure or tachyarrhythmia-induced cardiomyopathy. Non-invasive ventilation (NIV) offers a crucial therapeutic modality for acute respiratory failure by improving oxygenation, reducing the work of breathing, and providing beneficial hemodynamic effects, potentially obviating the need for endotracheal intubation.

Case presentation: We present the case of a 23-year-old female who developed acute hypoxemic respiratory failure secondary to acute pulmonary edema precipitated by a thyroid storm, occurring post-operatively after a ureterorenoscopy. She presented with severe dyspnea, tachycardia (atrial fibrillation with rapid ventricular response), tachypnea, and significant hypoxemia (PaO₂/FiO₂ ratio of 106.4). Diagnosis of thyroid storm was confirmed by elevated free thyroxine (FT4), suppressed thyroid-stimulating hormone (TSH), and a Burch-Wartofsky Point Scale (BWPS) score of 80. The patient was managed with NIV, alongside standard medical therapy for thyroid storm, including antithyroid drugs, beta-blockers, iodine solution, and corticosteroids.

Conclusion: NIV was successfully utilized as primary respiratory support, leading to rapid clinical and radiological improvement, resolution of respiratory failure, and avoidance of invasive mechanical ventilation. The PaO₂/FiO₂ ratio improved to 260 within four days. This case highlights the efficacy and safety of early NIV initiation in patients with acute respiratory failure due to pulmonary edema in the complex setting of thyroid storm.

Navigating the Nexus: Anesthetic Management of Craniotomy for Brain Abscess in a Pediatric Patient with Uncorrected Tetralogy of Fallot

2025-05-28T04:04:31+00:00

Introduction: Tetralogy of Fallot (TOF) is the most prevalent cyanotic congenital heart disease, predisposing patients to brain abscesses via right-to-left shunting that bypasses pulmonary bacterial filtration. Anesthetic management for craniotomy in pediatric patients with uncorrected TOF and a concurrent brain abscess presents a formidable challenge, requiring meticulous integration of neuroanesthetic and cardiac anesthetic principles. Literature detailing comprehensive perioperative anesthetic strategies for this specific dual pathology remains scarce.

Case presentation: An 11-year-old male with uncorrected TOF and a large left frontoparietal brain abscess with significant mass effect underwent emergent craniotomy and abscess evacuation. Preoperative echocardiography confirmed TOF with severe pulmonary stenosis and right-to-left shunting. Anesthetic induction was achieved with titrated ketamine and propofol, followed by fentanyl and rocuronium. Maintenance involved sevoflurane, oxygen-air mixture, and intermittent fentanyl and rocuronium, focusing on normovolemia, normocapnia to slight hypocapnia, and invasive hemodynamic monitoring. Phenylephrine was utilized for blood pressure support. The perioperative period was uneventful, with the patient experiencing no neurological or cardiac complications.

Conclusion: This case underscores the critical importance of a tailored anesthetic approach, integrating neuroprotective strategies with meticulous cardiovascular management, in children with uncorrected TOF undergoing major neurosurgery. Comprehensive preoperative assessment, vigilant intraoperative monitoring, strategic pharmacological interventions, and a deep understanding of the complex pathophysiology are paramount to preventing cyanotic spells, managing intracranial pressure, and ensuring a successful outcome in this high-risk cohort.