Primary pulmonary hypertension (PPH) is a progressive disease with frequent morbidity and mortality, including the risk of cardiac decompensation and death, during general anesthesia. Administration of IV epoprostenol (Flolan) improves symptoms and survival of patients with PPH and thus is an increasingly used long-term treatment for this condition. This therapy is associated with impaired platelet aggregation, which may complicate the perioperative management of patients with PPH. We present a case report of a patient with severe PPH receiving a continuous epoprostenol infusion undergoing skin grafting for a leg ulcer under spinal anesthesia. An IV infusion of vasopressin was given to prevent systemic hypotension resulting from sympathetic blockade while avoiding increases in pulmonary vascular resistance that may have resulted from catecholamine usage.
IDDS has the potential to improve cancer pain in a variety of patients and should be strongly considered as an option for those with cancer pain intractable to conservative medical management.
Background: Fluoroscopy-guided lumbar transforaminal epidural steroid injections (L-TFESI)
result in radiation exposure that carries risks to patients, physicians, and procedural staff.
Objective: We aim to evaluate the feasibility of using pulsed fluoroscopy to safely reduce
radiation exposure during L-TFESI.
Study Design: This is a prospective, double-blind, randomized controlled trial.
Setting: This study took place in a single-center, academic, outpatient interventional pain
management clinic.
Methods: Patients undergoing L-TFESI were randomly assigned to either continuous mode
fluoroscopy (high-dose), pulsed fluoroscopy with 8 pulses per second (medium-dose), or pulsed
fluoroscopy with one pulse per second (low-dose). Data on radiation doses and other clinical and
demographic factors were also collected.
Results: In total, 231 cases were analyzed in the high-dose group (n = 81), medium-dose group
(n = 72), and low-dose group (n = 78). Mean radiation effective dose (µSv) was 121 in the highdose group, 57.9 in the medium-dose group, and 34.8 in the low-dose group (P < 0.001). The
incidence of inadequate image quality in the pulsed groups was 6% (9/150). The body mass index
(BMI, mean ± SD) was significantly higher in patients with inadequate image quality (37.3 ± 7.2)
than with adequate quality (30.5 ± 7.2, P = 0.005).
Limitations: Radiation doses were measured using the meter on C-arm fluoroscopes rather than
by direct measurement.
Conclusions: The use of pulsed fluoroscopy during L-TFESI resulted in radiation dose reduction
of up to 72.1% without causing any significant adverse events. Pulsed fluoroscopy should be
considered as an initial fluoroscopic setting for L-TFESI to reduce radiation exposure.
Key words: Radiation, epidural, fluoroscopy, injection, exposure, pulse
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