Grade 1C)'. It assumes equal risk for a lumbar plexus block when compared with an upper limb plexus block and does not consider the potential benefits of ultrasound in mitigating vascular injury.In the absence of robust evidence, it is our assertion that, by identifying current practice across the country, confidence can be gained that we are operating in a way similar to our colleagues. Thus, it allows the application of the Bolam principle. For upper limb blocks, the authors recommend:(i) ultrasound-guided technique in patients with altered coagulation; (ii) INR ,2.5 (88% concordance); (iii) platelet count ≥50 000 (65% concordance); (iv) concomitant use of clopidogrel is not necessarily a contraindication (50% concordance); (v) a national audit project similar to the Royal College of Anaesthetists' third national audit project, identifying major complications of central neuraxial blockade, would be of benefit.
Orolingual angioedema (OLA) is a known complication of intravenous alteplase used to treat ischaemic stroke. The incidence may be as high as 5.1%. ACE inhibitors are thought to increase the risk of developing this potentially life-threatening complication. This case report demonstrates how we may improve in the identification of risk factors in the history; the counselling of patients appropriately; in seeking alternative therapies such as mechanical thrombectomy; and in the monitoring of patients for signs of OLA once alteplase has been given.
A sixty-year-old female presented to the emergency department with a perforated duodenal ulcer. Whilst awaiting surgery she developed chest pain and ST segment changes consistent with an inferior myocardial infarction. It was considered necessary to continue with surgical management, however general anaesthesia was complicated postoperatively by an episode of pulseless ventricular tachycardia, that appeared to be triggered by intravenous metaraminol. Subsequent coronary angiography demonstrated no evidence of coronary artery disease but findings were suggestive of Takotsubo cardiomyopathy, which was probably exacerbated by intravenous metaraminol.
Mesenteric ischemia is a severe condition associated with abdominal pain which often requires multimodal analgesia, including opioids or sympathetic blocks such as celiac plexus blocks. The erector spinae plane (ESPB) has emerged as a potentially effective alternative for managing pain in various surgical and non-surgical conditions. This case report explores the use of ultrasound-guided ESPB as a novel approach to pain management in a patient with acute on chronic mesenteric ischemia. A 70-year-old male with a history of mesenteric ischemia and multiple comorbidities presented with worsening diffuse abdominal pain. Despite medical and surgical treatment, the patient required a high dose of opioids for pain control. Bilateral ESPBs with continuous infusions were performed at the T6 level under ultrasound guidance. The patient reported immediate and complete relief from abdominal pain following the block, with a significant drop in the pain score. The use of opioids was significantly reduced. This case report demonstrates the potential benefits of ultrasound-guided ESPB as an alternative to traditional pain management techniques in patients with mesenteric ischemia. ESPB may provide safe, simple, and effective analgesia, reducing the need for high-dose opioids and their associated side effects. Further studies are warranted to validate these findings and explore the broader application of ESPB in the management of mesenteric ischemia pain.
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