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A venous air embolism (VAE) is a potentially life-threatening event caused by air in the vascular system. The entrainment of air from an operative site into the venous vasculature produces a wide array of systemic effects. This chapter presents a case study of a 37-year-old female with a right-sided acoustic neuroma presenting for a suboccipital approach to tumor resection. VAE was historically most often associated with craniotomies performed in the sitting position. Clinical presentation depends on the severity of the air embolus. There are several monitors that are capable of detecting venous air emboli. The most sensitive is transesophageal echocardiography (TEE). The presence of TEE also enables direct visualization of air aspiration through a central catheter if a VAE should occur. Monitors for high-risk cases should be chosen depending on the expertise of the anesthesiologist, the surgery being performed, and the position of the patient.
Encephalopathies are commonly encountered in the intensive care unit (ICU) and portend worse outcomes. This chapter presents a case study of a 54-year-old man with a history of alcohol abuse and cirrhosis who was admitted to the neurologic ICU after drainage of a large right-sided subdural hematoma. His mental status returned to baseline after treatment with lactulose and neomycin. A general physical examination should search for evidence of trauma or intoxication. Meningismus should be evaluated. A fundoscopic examination may reveal papilledema. Electroencephalographic monitoring during administration of flumazenil can be used to determine if an occasional subclinical seizure can be detected. Inflammatory mediators have also been implicated in the etiology of hepatic encephalopathy. Ruling out physiologic, pharmacologic, and neurologic etiologies requires a thorough history, careful physical examination, and the appropriate use of laboratory and imaging tests. Treatment should be tailored to the underlying etiology of the encephalopathy.
Spinal cord injury (SCI) is a devastating, life-threatening condition that produces a number of physiologic and anatomical derangements that must be acutely managed by the anesthetic team. This chapter presents a case study of a 26-year-old male with a loss of sensation and motor control from the neck down. The patient was scheduled for an immediate posterior cervical decompression and stabilization by the neurosurgical service. The patient was evaluated in the emergency room for other associated injuries and high-dose methylprednisolone was started. Maintenance of anesthesia included propofol and remifentanil infusions, in order to facilitate spinal cord monitoring with somatosensory and motor evoked potentials. The postoperative care of these patients might be extensive requiring multiple further anesthetics. Anesthesiologists must be familiar with the unique long-term complications of SCI such as spasticity, autonomic hyperreflexia, and chronic ventilator support that may alter anesthetic management.