Anticoagulation for cardiopulmonary bypass is maintained with heparin. The primary mechanism of action of this drug is the activation of antithrombin III, which prevents thrombin transformation from prothrombin. Thus, it reduces the formation of clot. However, in some cases, despite a standard heparin dose, the intended active coagulation time cannot be obtained which is known as heparin resistance. Heparin resistance occurs in up to 22% of patients undergoing cardiac surgery requiring cardiopulmonary bypass and it is associated with decreased levels of antithrombin. Heparin resistance, although seen rare, can occur in varying severity in clinic. Treatment options for heparin resistance include administration of antithrombin or fresh frozen plasma. In this case presentation, we have reported the strategy for a planned pulmonary artery reconstruction operation under cardiopulmonary pypass in a patient that we could not maintain the adequate ACT levels despite a cumulative dose of 12 mg/kg heparin and 20 ml/kg fresh frosen plasma transfusion.

A 51-year-old man with obstructive jaundice who underwent an endoscopic retrograde cholangiopancreatography (ERCP).

A 6 month old patient with multiple congenital anomalies and adrenal neuroblastoma with hepatic metastasis underwent subclavian port placement under general anesthesia. During routine placement of the device into the vessel the patient developed acute hypotension progressing to bradycardic arrest due to cardiac tamponade. Hemodynamic compromise resolved immediately after pericardiocentesis and placement of a pericardial drain. This rare complication of central access placement should be considered with hemodynamic changes during these procedures.

Pain management in patients who have undergone hip surgery is a difficult and challenging aspect of post operative care. The Fascia Iliaca Compartment Block (FICB), placed either prior to, or after hip surgery, as a means to control post-operative pain, has been well defined in the evidence to be a very successful approach in controlling post-operative pain. The use of this block reduces opioid requirements and incidents of delirium in elderly patients. The evidence compares FICB to alternative approaches such as neuraxial anesthesia and General Anesthesia (GA). Among the benefits for the anesthetist performing the FICB is the relative technical ease of placing the block, and cost the established efficacy. A review of the current evidence regarding the use of FICB demonstrates that the FICB is highly effective in controlling post-operative pain following hip surgeries.

According to the National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center, the overall prevalence of chronic kidney disease is approximately 14 percent in the general population of the United States [1] This prevalence has remained relatively stable since 2004 [1] with approximately 468,000 Americans on dialysis as of 2015. [2] With diabetes and hypertension being the most common primary causes of End-Stage Renal Disease (ESRD), patients undergoing procedures for arteriovenous access tend to present with multiple co morbidities. For this specific patient population, these comorbidities may have specific anesthetic implications. This article focuses on the anesthetic considerations throughout the entire perioperatively period with special emphasis on the role of regional anesthesia.