Case Reports in Anesthesiology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Case Report of Multiple Tracheostomy Revisions due to Persistent, Recurrent Cuff Leak Thu, 09 Jul 2015 13:38:27 +0000 This case is a patient with amyotrophic lateral sclerosis who was unable to be separated from mechanical ventilator support and required a tracheostomy. The patient underwent an initial open tracheostomy utilizing flexible fiberoptic tracheoscopy (FFT) in the operating room (OR). Subsequently, he developed recurrent leaks in the tracheal tube cuff requiring multiple trips back to the operating room. The recurrent cuff leak occurred following each tube placement until the etiology of the leak was discovered during the fourth procedure. In the fourth procedure, the wound was explored more extensively, and it was found that there was a sharp, calcified, aberrant fragment of a tracheal cartilage ring protruding into the tracheal lumen, which was damaging the cuff of each tube. This fragment was not visible by multiple FFTs, nor was it visible in the wound by the surgeons until wider exploration of the wound occurred. The cartilage fragment was ultimately excised and the patient had no further cuff leaks. Aberrant tracheal cartilage should be on the differential diagnosis for cuff leaks subsequent to surgical tracheostomy (ST) or percutaneous dilatational tracheostomy (PDT). Jian P. Azimi-Bolourian, Issa A. Hanna, and George W. Williams Copyright © 2015 Jian P. Azimi-Bolourian et al. All rights reserved. Right Breast Mastectomy and Reconstruction with Tissue Expander under Thoracic Paravertebral Blocks in a 12-Week Parturient Thu, 02 Jul 2015 10:42:37 +0000 Paravertebral blocks are becoming increasingly utilized for breast surgery with studies showing improved postoperative pain control, decreased need for opioids, and less nausea and vomiting. We describe the anesthetic management of an otherwise healthy woman who was 12 weeks pregnant presenting for treatment of her breast cancer. For patients undergoing breast mastectomy and reconstruction with tissue expanders, paravertebral blocks offer an anesthetic alternative when general anesthesia is not desired. Christopher Allen-John Webb, Paul David Weyker, Shara Cohn, Amanda Wheeler, and Jennifer Lee Copyright © 2015 Christopher Allen-John Webb et al. All rights reserved. Preterm Caesarean Delivery in a Parturient with Candida parapsilosis Endocarditis Mon, 29 Jun 2015 08:46:34 +0000 We present the first documented case of Candida parapsilosis infective endocarditis in a pregnant patient. While the incidence of infective endocarditis during pregnancy is rare, the incidence of C. parapsilosis endocarditis is even rarer. The numerous specific risks and decision making processes regarding this case are presented. Jason Fu, Lance M. Retherford, and Brigid Flynn Copyright © 2015 Jason Fu et al. All rights reserved. Excessive Dynamic Airway Collapse: An Unexpected Contributor to Respiratory Failure in a Surgical Patient Mon, 08 Jun 2015 13:47:40 +0000 Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients. Historically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large airways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of cartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction during exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing, difficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy has identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed consideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM, describe how this condition contributed to this patient’s respiratory failure, and review diagnosis and management options. Michael R. Lyaker, Victor R. Davila, and Thomas J. Papadimos Copyright © 2015 Michael R. Lyaker et al. All rights reserved. Anesthetic Management of a Child with Mitochondrial Neurogastrointestinal Encephalopathy Mon, 01 Jun 2015 10:53:53 +0000 Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an autosomal recessive disorder associated with deficiency of thymidine phosphorylase (TP). Associated manifestations include visual and hearing impairments, peripheral neuropathies, leukoencephalopathy, and malnutrition from concomitant gastrointestinal dysmotility and pseudoobstruction. Given the altered metabolic state in these patients, specific consideration of medication selection is advised. This case report will describe the anesthetic management used in a 10-year-old girl with MNGIE. She had multiple anesthetics while undergoing allogeneic hematopoietic stem cell transplantation. This case report will discuss the successful repeated use of the same anesthetic in this pediatric patient, with the avoidance of volatile anesthetic agents, propofol, and muscle relaxant. Vianey Q. Casarez, Acsa M. Zavala, Pascal Owusu-Agyemang, and Katherine Hagan Copyright © 2015 Vianey Q. Casarez et al. All rights reserved. Successful Ultrasound-Guided Femoral Nerve Blockade and Catheterization in a Patient with Von Willebrand Disease Sun, 31 May 2015 11:18:30 +0000 Peripheral nerve blockade (PNB) is superior to neuraxial anesthesia and/or opioid therapy for perioperative analgesia in total knee replacement (TKR). Evidence on the safety of PNB in patients with coagulopathy is lacking. We describe the first documented account of continuous femoral PNB for perioperative analgesia in a patient with Von Willebrand Disease (vWD). Given her history of opioid tolerance and after an informative discussion, a continuous femoral PNB was planned for in this 34-year-old female undergoing TKR. A Humate-P intravenous infusion was started and the patient was positioned supinely. Using sterile technique with ultrasound guidance, a Contiplex 18 Gauge Tuohy needle was advanced in plane through the fascia iliaca towards the femoral nerve. A nerve catheter was threaded through the needle and secured without complications. Postoperatively, a levobupivacaine femoral catheter infusion was maintained, and twice daily Humate-P intravenous infusions were administered for 48 hours; enoxaparin thromboprophylaxis was initiated thereafter. The patient was discharged uneventfully on postoperative day 4. Given documentation of delayed, unheralded bleeding from PNB in coagulopathic patients, we recommend individualized PNB in vWD patients. Multidisciplinary team involvement is required to guide factor supplementation and thromboprophylaxis, as is close follow-up to elicit signs of bleeding throughout the delayed postoperative period. Youmna E. DiStefano and Michael D. Lazar Copyright © 2015 Youmna E. DiStefano and Michael D. Lazar. All rights reserved. Transient Left-Sided Paralysis following Robotic-Assisted Laparoscopic Uteropexy Tue, 26 May 2015 06:28:58 +0000 We describe a case report of a 47-year-old ASA 2 female patient who exhibits severe headache and hemineurology during awakening following robotic pelvic prolapse surgery. The symptoms resolved spontaneously during the first postoperative day. We could not find any explicit root cause. Robotic surgery associated adverse events are discussed. Jasmina Kurdija and Jan G. Jakobsson Copyright © 2015 Jasmina Kurdija and Jan G. Jakobsson. All rights reserved. Anesthetic Management for Laser Excision of Ball-Valving Laryngeal Masses Sun, 24 May 2015 06:25:03 +0000 A 47-year-old obese woman with GERD and COPD presents for CO2-laser excision of bilateral vocal fold masses. She had a history of progressive hoarseness and difficulty in breathing. Nasopharyngeal laryngoscopy revealed large, mobile, bilateral vocal cord polyps that demonstrated dynamic occlusion of the glottis. We describe the airway and anesthetic management of this patient with a topicalized C-MAC video laryngoscopic intubation using a 4.5 mm Xomed Laser Shield II endotracheal tube. We examine the challenges of anesthetic management unique to the combined circumstances of a ball-valve lesion and the need for a narrow-bore laser compatible endotracheal tube. Benjamin B. Bruins, Natasha Mirza, Ernest Gomez, and Joshua H. Atkins Copyright © 2015 Benjamin B. Bruins et al. All rights reserved. A Multidisciplinary Approach to Anesthetic Management of a Parturient with Severe Aortic Stenosis Thu, 21 May 2015 07:52:47 +0000 In order to optimize anesthetic management and avoid adverse maternal and fetal outcomes, a clear understanding of the changes in cardiovascular physiology that occur during pregnancy is paramount. The effects of normal gestation on the cardiovascular system are particularly significant in a parturient with cardiac valvular pathology. We present a case of a 27-year-old G2P0 at 37 weeks with a past medical history of diabetes, macrosomia, congenital bicuspid aortic valve with severe stenosis (valve area 0.7 cm2) who was scheduled for elective C-section. A multidisciplinary discussion involving cardiologists, cardiac surgeons, obstetric surgeons, neonatal intensivists, perfusion staff, anesthesiologists, and nursing staff was held to formulate a plan for the perioperative management of this parturient. Also, contingency plans were formulated and discussed with the care providers, in the event of acute decompensation of the mother and baby and possible need for emergency aortic valvuloplasty and/or aortic valve replacement. Kalpana Tyagaraj, David A. Gutman, Lynn Belliveau, Adnan Sadiq, Alok Bhutada, and Dennis E. Feierman Copyright © 2015 Kalpana Tyagaraj et al. All rights reserved. Diagnosis and Rescue of a Kinked Pulmonary Artery Catheter Wed, 13 May 2015 08:06:23 +0000 Invasive hemodynamic monitoring with a pulmonary catheter has been relatively routine in cardiovascular and complex surgical operations as well as in the management of critical illnesses. However, due to multiple potential complications and its invasive nature, its use has decreased over the years and less invasive methods such as transesophageal echocardiography and hemodynamic sensors have gained widespread favor. Unlike these less invasive forms of hemodynamic monitoring, pulmonary artery catheters require an advanced understanding of cardiopulmonary physiology, anatomy, and the potential for complications in order to properly place, manage, and interpret the device. We describe a case wherein significant resistance was encountered during multiple unsuccessful attempts at removing a patient’s catheter secondary to kinking and twisting of the catheter tip. These attempts to remove the catheter serve to demonstrate potential rescue options for such a situation. Ultimately, successful removal of the catheter was accomplished by simultaneous catheter retraction and sheath advancement while gently pulling both objects from the cannulation site. In addition to being skilled in catheter placement, it is imperative that providers comprehend the risks and complications of this invasive monitoring tool. Nicolas J. Mouawad, Erica J. Stein, Kenneth R. Moran, Michael R. Go, and Thomas J. Papadimos Copyright © 2015 Nicolas J. Mouawad et al. All rights reserved. Successful Perioperative Management of a Patient with the Left Ventricular Assist Device for Brain Tumor Resection: Case Report and Review of the Literature Sun, 15 Mar 2015 12:51:32 +0000 Heart failure is the leading cause of death in the United States. Our increasingly aged population will contribute to an increased incidence and prevalence of heart failure, thereby augmenting the need for mechanical circulatory devices. Here we present the first successful resection of a brain tumor in a left ventricular device- (LVAD-) dependent patient with increased intracranial pressure and address pertinent perioperative anesthetic considerations and management. Rashmi Vandse and Thomas J. Papadimos Copyright © 2015 Rashmi Vandse and Thomas J. Papadimos. All rights reserved. Anesthesia Management of a 20-Month-Old Patient with Giant Unilateral Wilms Tumor Thu, 26 Feb 2015 06:41:46 +0000 Wilms tumour (WT) (or nephroblastoma) is one of the most common malignant kidney tumors in children. On subsequent stages clinically it is often characterized by abdominal hypertension syndrome, which, in turn, leads to development of respiratory insufficiency. Other symptoms comprise renal deficiency, hypertension, and abnormalities of hemostasis and hemogram. Treatment includes rounds of preoperative chemotherapy and subsequent surgery. We report a case of perioperative management for nephrectomy in 20-month-old patient with a giant unilateral WT. The complexity of anesthesia was determined by the size of tumor, increased intra-abdominal pressure, respiratory deficiency, and hypercoagulation. Nune Matinyan, Alexander Saltanov, Leonid Martynov, and Anatolij Kazantsev Copyright © 2015 Nune Matinyan et al. All rights reserved. Intralipid Therapy for Inadvertent Peripheral Nervous System Blockade Resulting from Local Anesthetic Overdose Thu, 12 Feb 2015 08:45:49 +0000 Although local anesthetics have an acceptable safety profile, significant morbidity and mortality have been associated with their use. Inadvertent intravascular injection of local anesthetics and/or the use of excessive doses have been the most frequent causes of local anesthetic systemic toxicity (LAST). Furthermore, excessive doses of local anesthetics injected locally into the tissues may lead to inadvertent peripheral nerve infiltration and blockade. Successful treatment of LAST with intralipid has been reported. We describe a case of local anesthetic overdose that resulted in LAST and in unintentional blockade of peripheral nerves of the lower extremity; both effects completely resolved with administration of intralipid. Ihab Kamel, Gaurav Trehan, and Rodger Barnette Copyright © 2015 Ihab Kamel et al. All rights reserved. Tracheal Intubation with Aura-i and aScope-2: How to Minimize Apnea Time in an Unpredicted Difficult Airway Tue, 06 Jan 2015 14:24:32 +0000 The supraglottic airway’s usefulness as a dedicated airway is the subject of continuing development. We report the case of an obese patient with unpredicted difficult airway management in which a new “continuous ventilation technique” was used with the Aura-i laryngeal mask and the aScope-2 devices. The aScope-2/Aura-i system implemented airway devices for the management of predictable/unpredictable difficult airway. The original technique required the disconnection of the mount catheter from Aura-i, the introduction of the aScope-2 into the laryngeal mask used as a conduit for video assisted intubation and then towards the trachea, followed by a railroading of the tracheal tube over the aScope-2. This variation in the technique guarantees mechanical ventilation during the entire procedure and could prevent the risk of hypoventilation and/or hypoxia. Vittorio Pavoni, Valentina Froio, Alessandra Nella, Martina Simonelli, Lara Gianesello, Andrew Horton, Luca Malino, and Massimo Micaglio Copyright © 2015 Vittorio Pavoni et al. All rights reserved. Congenital Microstomia in a Neonate with Impending Respiratory Compromise Sun, 28 Dec 2014 09:31:46 +0000 Microstomia is the term used to describe a reduction in the size of the oral aperture that is severe enough to compromise quality of life, nutrition, and cosmesis. Few cases of congenital microstomia have been reported as most microstomia cases are due to burn injuries. We are presenting a case of a neonate who was found to be in respiratory distress with severe congenital microstomia from no known cause. This case illustrates the rarity of this type of pathologic anatomy as well as the teamwork and tools necessary to treat these patients. Khoa N. Nguyen, Igor Semenov, Brian Blasiole, Jacob G. Robison, and David H. Chi Copyright © 2014 Khoa N. Nguyen et al. All rights reserved. Triad of Idiopathic Thrombocytopenic Purpura, Preeclampsia, and HELLP Syndrome in a Parturient: A Rare Confrontation to the Anesthetist Mon, 08 Dec 2014 07:17:42 +0000 Idiopathic thrombocytopenic purpura (ITP) with HELLP represents a rare complication that requires combined care of obstetrician, anesthesiologist, hematologist, and neonatologist. At 37-week gestation a 35-year-old parturient (G2A1P0) a known case of chronic ITP presented with severe pregnancy induced hypertension (PIH), thrombocytopenia, and elevated liver enzymes. We describe successful anesthetic management of this patient who was taken for emergency caesarean section. Tanu Mehta, Geeta P. Parikh, and Veena R. Shah Copyright © 2014 Tanu Mehta et al. All rights reserved. Immediate Return to Ambulation and Improved Functional Capacity for Rehabilitation in Complex Regional Pain Syndrome following Early Implantation of a Spinal Cord Stimulation System Mon, 24 Nov 2014 08:40:34 +0000 Complex regional pain syndrome (CRPS) is a neuropathic pain condition that is characterized by vasomotor, sensory, sudomotor, and motor symptoms. Spinal cord stimulation (SCS) has been successfully utilized for the treatment of pain refractory to conventional therapies. We present a case of a previously highly functioning 54-year-old female who developed a rarely reported case of idiopathic CRPS of the right ankle which spontaneously occurred four months after an uncomplicated anterior cervical disc fusion. This condition resulted in severe pain and functional impairment that was unresponsive to pharmacological management. The patient’s rehabilitation was severely stymied by her excruciating pain. However, with the initiation of spinal cord stimulation, her pain was adequately controlled allowing for progression to full unassisted ambulation, advancing functional capacity, and improving quality of life. This case report supports the concept that rapid progression to neuromodulation, rather than delays that occur due to attempts at serial sympathetic blocks, may better control symptoms leading allowing for a more meaningful recovery. Brandon Jesse Goff, Jeremy Wingseng Naber, John Patrick McCallin, Edward Michael Lopez, Kevin Brant Guthmiller, Karl Alan Lautenschlager, Tristan Toll Lai, Dean Harry Hommer, and Gonzalez Raul Marin Copyright © 2014 Brandon Jesse Goff et al. All rights reserved. Laparoscopic Cholecystectomy in a Patient with Previous Pneumonectomy: A Case Report and Discussion of Anaesthetic Considerations Sun, 09 Nov 2014 09:34:02 +0000 Increasing numbers of patients require cholecystectomy after previous pneumonectomy, but there are little data to guide anaesthetic management. A laparoscopic approach is associated with less postoperative respiratory compromise than open cholecystectomy but may be relatively contraindicated due to the undesirable effects of pneumoperitoneum on respiratory function. We describe the case of a 72-year-old patient who successfully underwent elective laparoscopic cholecystectomy 23 years after left pneumonectomy. An understanding of the combined physiological consequences of pneumonectomy and pneumoperitoneum facilitated the provision of safe and uneventful anaesthesia. We propose that laparoscopic cholecystectomy is feasible and safe to perform in patients with a single lung. Dash Faith Newington and Sanaa Ismail Copyright © 2014 Dash Faith Newington and Sanaa Ismail. All rights reserved. Postanesthetic Severe Oral Angioedema in Patient’s Taking Angiotensin-Converting Enzyme Inhibitor Thu, 06 Nov 2014 12:33:21 +0000 Angiotensin-converting enzyme (ACE) inhibitors are the leading cause of a drug-induced angioedema. This occurrence is frequently underdiagnosed, but its relapse can be life-threatening. The authors’ intention in reporting this clinical case is to sound a warning about reviewing attitudes and surveillance to try to improve patient perioperative safety. Acílio Marques, Carla Retroz-Marques, Sara Mota, Raquel Cabral, and Matos Campos Copyright © 2014 Acílio Marques et al. All rights reserved. Abdominal Aortocaval Vascular Injury following Routine Lumbar Discectomy Tue, 07 Oct 2014 08:23:06 +0000 Vascular complications following spinal surgery are potentially fatal; however, fortunately they are rare. This risk is often focused on the close proximity of the surgical field to retroperitoneal structures. Prompt diagnosis is essential; however, bleeding is often occult, and this may therefore delay management of this condition. Despite previous reports many clinicians may not be aware of this potentially fatal complication. The overall morbidity and mortality may be reduced by prompt diagnosis and treatment. Clinicians must, therefore, have a high degree of suspicion in all patients who undergo spinal surgery. We therefore present a case of a 51-year-old man who sustained an aortocaval injury during a revisional lumbar discectomy. The patient developed refractory hypotension, which deteriorated into PEA arrest. Emergency laparotomy was performed which revealed an aortocaval injury. Immediate primary vascular repair was successfully performed. The patient was resuscitated and made a full recovery. Matthew Leech, Marc James Whitehouse, Ruta Kontautaite, Mukesh Sharma, and Sumant Shanbhag Copyright © 2014 Matthew Leech et al. All rights reserved. Unilateral Hypoglossal Nerve Palsy after Use of the Laryngeal Mask Airway Supreme Sun, 31 Aug 2014 09:23:06 +0000 Purpose. Hypoglossal nerve palsy after use of the laryngeal mask airway (LMA) is an exceptionally rare complication. We present the first case of unilateral hypoglossal nerve palsy after use of the LMA Supreme. Clinical Features. A healthy 67-year-old female was scheduled for a hallux valgus correction under general anesthesia combined with femoral and sciatic nerve blocks. A size 4 LMA Supreme was inserted successfully at the first attempt and the cuff was inflated with air at an intracuff pressure of 60 cmH2O using cuff pressure gauge. Anesthesia was maintained with oxygen, nitrous oxide (67%), and sevoflurane under spontaneous breathing. The surgery was uneventful and the duration of anesthesia was two hours. The LMA was removed as the patient woke and there were no immediate postoperative complications. The next morning, the patient complained of dysarthria and dysphasia. These symptoms were considered to be caused by the LMA compressing the nerve against the hyoid bone. Conservative treatment was chosen and the paralysis recovered completely after 5 months. Conclusion. Hypoglossal nerve injury may occur despite correct positioning of the LMA under the appropriate intracuff pressure. A follow-up period of at least 6 months should be taken into account for the recovery. Kenichi Takahoko, Hajime Iwasaki, Tomoki Sasakawa, Akihiro Suzuki, Hideki Matsumoto, and Hiroshi Iwasaki Copyright © 2014 Kenichi Takahoko et al. All rights reserved. Anesthetic Management of a Patient with Sustained Severe Metabolic Alkalosis and Electrolyte Abnormalities Caused by Ingestion of Baking Soda Sun, 10 Aug 2014 13:23:10 +0000 The use of alternative medicine is prevalent worldwide. However, its effect on intraoperative anesthetic care is underreported. We report the anesthetic management of a patient who underwent an extensive head and neck cancer surgery and presented with a severe intraoperative metabolic alkalosis from the long term ingestion of baking soda and other herbal remedies. Jose Soliz, Jeffrey Lim, and Gang Zheng Copyright © 2014 Jose Soliz et al. All rights reserved. Tracheal Intubation through the I-gel for Emergency Cesarean Section in a Patient with Multidrug Hypersensitivity: A New Technique Sun, 20 Jul 2014 06:33:03 +0000 31-year-old female with hypersensitivity to local anesthetics and neuromuscular blocking agents presented for emergency Cesarean section. We successfully performed I-gel-assisted tracheal intubation without using neuromuscular blockers. We believe this method would be helpful in selected situations. Kartika Balaji Samala, Yuri Uchiyama, Yasuyuki Tokinaga, Yukitoshi Niiyama, Soshi Iwasaki, and Michiaki Yamakage Copyright © 2014 Kartika Balaji Samala et al. All rights reserved. Unintended Avulsion of Hypertrophic Adenoids in Posterior Nasopharynx: A Case Report of a Rare Complication Caused by Nasotracheal Intubation Wed, 25 Jun 2014 14:13:56 +0000 The enlarged adenoid serves as a mechanical obstacle on the nasopharynx to intricate nasotracheal intubation. No matter what video or direct laryngoscopic techniques are applied, nasotracheal tube navigation from the nasal valve area through the nasal cavity to the nasopharynx is always blind; trauma is not uncommon. Here we report a case of unintended avulsed adenoids that plugged the tube tip while the nasotracheal tube blindly navigated through the nasopharyngeal space. After failing to insert a bent tip of gum elastic bougie passing through the nasopharynx, an alternative method of NTI was performed by mounting the nasotracheal tube on a fiberoptic bronchoscope. The nasotracheal tube was successfully railroaded along the insertion tube of the fiberscope to the trachea. Hao-Hu Chen, Li-Chuan Chen, Yu-Hui Hsieh, Mao-Kai Chen, Chung-Ho Chen, and Kuang-I Cheng Copyright © 2014 Hao-Hu Chen et al. All rights reserved. Suspected Transfusion Related Acute Lung Injury Improving following Administration of Tranexamic Acid: A Case Report Wed, 04 Jun 2014 09:03:46 +0000 A 16-year-old woman with craniofacial injury developed severe acute respiratory failure under the primary reconstructive surgical procedure requiring several units of blood and plasma. A transfusion related acute lung injury (TRALI) was suspected and supportive treatment was initiated. Because of the severity of symptoms, acute extracorporeal membrane oxygenation (ECMO) was planned. During preparation for ECMO, a single intravenous dose, 1 g of tranexamic acid, was administered and a remarkable improvement was observed shortly thereafter. The patient was placed on ECMO for 16 hours. The further course was uncomplicated and the patient was discharged from ICU on the 6th day after admission fully and she recovered. A clinical improvement was observed in a timely fashion following the administration of tranexamic acid. The handling of a suspected TRALI and potential benefit from administration of tranexamic acid are discussed in this case report. Stan Ryniak, Piotr Harbut, Anders Östlund, Andrzej Mysiak, and Jan G. Jakobsson Copyright © 2014 Stan Ryniak et al. All rights reserved. Malignant Hyperthermia during Thoracoscopic Pulmorrhaphy in a 70-Year-Old Man Sun, 25 May 2014 08:50:17 +0000 Malignant hyperthermia (MH) is a rare but potentially fatal complication that may develop under general anesthesia (GA) and is rarely reported in elderly patients. We encountered a case of mild-onset MH in a 70-year-old patient who was receiving an elective thoracoscopic pulmorrhaphy and had a history of several GA procedures. Anesthesia was induced with propofol, fentanyl, and rocuronium and maintained with sevoflurane and remifentanil. His body temperature (BT) was 37.9°C after induction. During the procedure, the end-tidal CO2 (ETCO2) increased steadily to 47–50 mmHg, presumably in response to the single lung ventilation. At the end, BT was 38.1°C and ETCO2 was 47 mmHg under spontaneous breathing. After extubation, the patient wheezed on inspiration and expiration, and his trachea was reintubated. Sixty minutes after surgery, BT increased to 40.5°C and the arterial blood gas analysis showed severe metabolic acidosis. Based on these findings, MH was suspected and a bolus dose of dantrolene was administered. He responded to the dantrolene, and no complications or recurrence of MH was observed postoperatively. In this patient, the initial signs of MH were so subtle that making the diagnosis of MH was difficult. A high degree of suspicion is necessary to prevent a fulminant MH crisis. Michihiro Sakai, Noriko Murakami, Yuji Kitamura, Shin Sato, Hiroshi Iwama, and Akira Nomura Copyright © 2014 Michihiro Sakai et al. All rights reserved. Cardiac Arrest after Connecting Negative Pressure to the Subgaleal Drain during Craniotomy Closure Thu, 22 May 2014 11:18:08 +0000 A one-year-old child operated on for arachnoid cyst in right frontoparietotemporal region had sudden bradycardia followed by cardiac arrest leading to death after connecting negative pressure to the subgaleal drain during craniotomy closure. The surgical procedure was uneventful. It is a common practice to place epidural or subgaleal drains connected to a vacuum system towards the end of craniotomy to prevent accumulation of intracranial and extracranial blood. The phenomenon of bradycardia with hypotension is known to occur following negative pressure application to the epidural, epicranial, or subgaleal space after craniotomy closure. However cardiac arrest as a complication of negative pressure suction drain in neurosurgical patients is not described in the literature. Monu Yadav, Sapna A. Nikhar, Dilip Kumar Kulkarni, and R. Gopinath Copyright © 2014 Monu Yadav et al. All rights reserved. Spontaneous Recovery of Paraplegia Caused by Spinal Epidural Hematoma after Removal of Epidural Catheter Mon, 05 May 2014 07:06:35 +0000 We report a patient who developed paraplegia caused by a spinal epidural hematoma after removal of an epidural catheter, which resolved spontaneously. A 60-year-old woman underwent thoracoscopic partial resection of the left lung under general anesthesia combined with epidural anesthesia. She neither was coagulopathic nor had received anticoagulants. Paraplegia occurred 40 minutes after removal of the epidural catheter on the first postoperative day. Magnetic resonance images revealed a spinal epidural hematoma. Surgery was not required as the paraplegia gradually improved until, within 1 hour, it had completely resolved. Hypoesthesia had completely resolved by the third postoperative day. Kouhei Iwashita, Kenji Shigematsu, Kazuo Higa, and Keiichi Nitahara Copyright © 2014 Kouhei Iwashita et al. All rights reserved. Successful Treatment of Genitofemoral Neuralgia Using Ultrasound Guided Injection: A Case Report and Short Review of Literature Sun, 06 Apr 2014 07:17:50 +0000 A young male patient developed chronic, severe, and disabling right sided groin pain following resection of his left testicular cancer. Since there is considerable overlap, ultrasound guided, selective diagnostic nerve blocks were done for ilioinguinal, iliohypogastric, and genitofemoral nerves, to determine the involved nerve territory. It was revealed that genitofemoral neuralgia was the likely cause. As a therapeutic procedure, it was injected with local anesthetic and steroid using ultrasound guidance. The initial injection led to pain relief of 3 months. Subsequent blocks reinforced the existing analgesia and were sufficient to allow for maintenance with the use of analgesic medications. This case report describes the successful use of diagnostic selective nerve blocks for the assessment of groin pain, subsequent to which an ultrasound guided therapeutic injection of genitofemoral nerve led to long term pain relief. As a therapeutic procedure, genitofemoral nerve block is done in patients with genitofemoral neuralgia. Ultrasound allows for controlled administration and greatly enhances the technical ability to perform precise localization and injection. There are very few case reports of such a treatment in the published literature. Apart from the case report, we also highlight the relevant anatomy and a brief review of genitofemoral neuralgia and its treatment. Harsha Shanthanna Copyright © 2014 Harsha Shanthanna. All rights reserved. Erratum to “A Minimal-Invasive Metabolic Test Detects Malignant Hyperthermia Susceptibility in a Patient after Sevoflurane-Induced Metabolic Crisis” Mon, 31 Mar 2014 14:16:19 +0000 Frank Schuster, Stephan Johannsen, Norbert Roewer, and Martin Anetseder Copyright © 2014 Frank Schuster et al. All rights reserved.