Search

Anesthetic management of laboring parturients with Arnold-Chiari type I malformation poses a difficult challenge for the anesthesiologist. The increase in intracranial pressure during uterine contractions, coughing, valsalva maneuvers, and expulsion of the fetus can be detrimental to the mother during the process of labor and delivery. No concrete evidence has implicated high cerebral spinal fluid pressure on maternal and fetal complications. The literature on the use of neuraxial techniques for managing parturients with Arnold-Chiari is extremely scarce. While most anesthesiologists advocate epidural analgesia for management of labor pain and spinal anesthesia for cesarean section, we are the first to report the use of combined spinal-epidural analgesia for managing labor pain in a pregnant woman with Arnold-Chiari type I malformation. Also, we have reviewed the literature and presented information from case reports and case series to support the safe usage of neuraxial techniques in these patients.

We are reporting two patients presented with intractable cancer pain that was treated with a novel application of an ultrasound-guided peripheral nerve block using corticosteroid. This technique offered relief to both patients whom otherwise their cancer pain was difficult to manage. The first patient developed lymphedema to the right axilla from metastatic squamous cell carcinoma. After multiple injections were deposited around the brachial plexus, lymphedema on the right axilla decreased slightly in size; however, range of motion improved post-procedure prior to his discharge one week later. In the second patient with left inguinal lymphadenopathy from metastatic left ureteral transitional cell carcinoma, there was a dramatic reduction in lymphedema in the left groin and leg as well as a considerable decrease in pain score during a two week follow-up after the peri-neural and peri-lymphatic femoral block. A 75% improvement in patient satisfaction was reported in the office visit’s questionnaire form. Corticosteroids can be used as an adjuvant to peripheral nerve block to decrease the pain secondary to lymphedema caused by the inflammatory response from metastatic cancer. This application can provide an alternative way to manage severe cancer-related pain caused by lymphedema in both upper and lower limbs.

Previous studies have suggested that electronic medical records (EMR) can lead to a greater reduction of medical errors and better adherence to regulatory compliance than paper medical records (PMR). In order to assess the organizational performance and regulatory compliance, we tracked different clinical pertinence indicators (CPI) in our anesthesia information management system (AIMS) for 5 years. These indicators comprised of the protocols from the Surgical Care Improvement Project (SCIP), elements of performance (EP) from The Joint Commission (TJC), and guidelines from the Centers for Medicare and Medicaid Services (CMS). A comprehensive AIMS was initiated and the CPI were collected from October 5, 2009 to December 31, 2010 (EMR period) and from January 1, 2006 to October 4, 2009 (PMR period). Fourteen CPI were found to be common between the EMR and PMR periods. Based on the statistical analysis of the 14 common CPI, there was a significant increase (p?0.001) in overall compliance after the introduction of EMR compared to the PMR period. The increase in overall compliance was significantly progressive (p?=?0.013) from year to year over 2006 and 2010. Of the 14 CPI, Documentation of a) medication doses, and b) monitoring of postoperative physiological status, mental status, and pain scores showed significant improvement (p?