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Background: Gender-affirming mastectomy, performed on transgender men and non-binary individuals, frequently leads to considerable postoperative pain. This pain can significantly affect both patient satisfaction and the overall recovery process. The study examines the efficacy of four analgesic techniques pectoral nerve (PECS) 2 block, erector spinae plane (ESP) block, thoracic wall local anesthesia infiltration (TWI), and systemic multimodal analgesia (SMA) in managing perioperative pain, with special consideration for the effects of chronic testosterone therapy on pain thresholds. Methods: A retrospective analysis was conducted on patients aged 18 - 45 who underwent gender-affirming bilateral mastectomies at a New York City community hospital. The study compared intraoperative and post-anesthesia care unit (PACU) opioid consumption, postoperative pain scores, the interval to first rescue analgesia, and total PACU duration among the four analgesic techniques. Results: The study found significant differences in intraoperative and PACU opioid consumption across the groups, with the PECS 2 block group showing the least opioid requirement. The PACU morphine milligram equivalent (MME) consumption was highest in the SMA group. Postoperative pain scores were significantly lower in the PECS and ESP groups at earlier time points post-surgery. However, by postoperative day 2, pain scores did not significantly differ among the groups. Chronic testosterone therapy did not significantly impact intraoperative opioid requirements. Conclusion: The PECS 2 block is superior in reducing overall opioid consumption and providing effective postoperative pain control in gender-affirming mastectomies. The study underscores the importance of tailoring pain management strategies to the unique physiological responses of the transgender and non-binary community. Future research should focus on prospective designs, standardized block techniques, and the complex relationship between hormonal therapy and pain perception.
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This case report aims to highlight an atypical presentation of deceleration-dependent aberrancy (DDA) following the induction of general anesthesia in a patient with no known cardiac history. It emphasizes the critical role of intraoperative monitoring and the potential effects of anesthetic agents on the cardiac conduction system. A 46-year-old Hispanic male with no significant past medical or surgical history presented for surgical repair of a comminuted radial fracture. Following anesthesia induction with propofol, midazolam, and fentanyl, he developed a transient left bundle branch block (LBBB) exhibiting deceleration-dependent characteristics. Despite stable hemodynamics, the LBBB pattern appeared at heart rates below 60 beats per minute and resolved with heart rates above 90 beats per minute. This was managed intraoperatively with glycopyrrolate. Postoperative evaluations, including a 12-lead ECG, echocardiogram, and nuclear stress test, indicated normal biventricular function with a small to moderate reversible perfusion defect. The patient did not report cardiac symptoms postoperatively and did not prefer to undergo a coronary angiogram. This report underscores the importance of recognizing rate-dependent LBBB as a potential intraoperative complication, even in patients without pre-existing cardiac conditions. The transient nature of DDA, influenced by anesthetic agents and managed through careful monitoring and pharmacological intervention, highlights the necessity for vigilance in perioperative settings. This case contributes to a growing body of evidence suggesting that anesthetic management may require tailored approaches for patients experiencing or at risk for conduction abnormalities. This case illustrates the complexities of cardiac conduction disturbances such as DDA in the context of general anesthesia, serving as a reminder of the importance of thorough monitoring and the judicious use of rate-modifying drugs. It fosters a deeper understanding of the interaction between anesthesia and cardiac electrophysiology. Further research is needed to explore the mechanisms and management strategies for anesthetic-related cardiac conduction abnormalities.
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Perioperative pulmonary aspiration of regurgitated gastric contents is the presence of gastric contents in the tracheobronchial tree. It is diagnosed by direct examination of the airway, bronchoscopy of the tracheobronchial tree, or postoperative imaging which reveals previously not identified lung infiltrates. Our case report describes a novel and successful method to manage perioperative pulmonary aspiration.
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Propofol and midazolam are commonly used drugs in procedural sedation. Midazolam is widely used for its five principal pharmacologic effects: anxiolysis, sedation and hypnosis, anticonvulsant actions, spinal cord-mediated skeletal muscle relaxation, and anterograde amnesia. Increased talkativeness, emotional release, excitement, and excessive movement are the common paradoxical reactions to all kinds of benzodiazepines, which are reported since the introduction of chlordiazepoxide (Librium), the first benzodiazepine in 1955. In the United States, sedation with a combination of midazolam with opioids accounts for approximately 75% of routine procedural sedations. Most cases are distinctive. However, some data indicate that these reactions are due to serotonin imbalance, a central cholinergic effect, or a reflection of genetically determined variability in benzodiazepine receptor density or affinity (isoreceptors) throughout the brain. The idea of isoreceptors is comparable to that of isoenzymes like genetic variants of pseudocholinesterase. We report a case in which midazolam administration resulted in paradoxical reactions, which manifested as profound delirium with extrapyramidal symptoms after cessation of propofol sedation in a term parturient during cesarean section. This case report describes paradoxical reactions to benzodiazepines in a term parturient promptly reversed with a small dose of flumazenil. Even though paradoxical reactions to benzodiazepines have low prevalence and are not life-threatening, they have to be treated promptly with flumazenil. Therefore, anesthesiologists performing procedural sedation should be aware of untoward reactions and be prepared to manage them promptly.
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Arrhythmogenic right ventricular dysplasia (ARVD) is caused by mutations in genes coding for components of desmosomes in the myocardium. Mutations in these genes make desmosomes dysfunctional and account for myocyte detachment, followed by inflammation and apoptosis when it encounters undue mechanical stress. This is why ARVD is a common cause of sudden cardiac death in athletes with undiagnosed ARVD, as increased physical activity exacerbates this progression of ARVD and associated arrhythmias. We describe a case of ARVD in a 36-year-old woman who presented with an unusual sensation in her chest due to non-sustaining ventricular tachycardia, which her smartwatch failed to pick up. Many smartwatches use photoplethysmography (PPG) to monitor heart rate (HR). A typical PPG device contains two light sources (green light and infrared) and a photodetector to measure the reflected light, proportional to the beat-to-beat variation in blood volume. HR is then calculated from these variations. In ambulatory settings, smartwatches underestimate HR in most tachyarrhythmias, mainly when the HR is more than 100 beats/min. Patients using smartwatches for ambulatory heart monitoring should know that the absence of an irregular pulse notification does not exclude possible arrhythmias. Management of ARVD is mainly focused on the prevention of syncope and cardiac arrest through antiarrhythmic medications and an implantable cardioverter defibrillator.