Case Reports in Anesthesiology The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Anaesthetic Management of Two Patients with Pompe Disease for Caesarean Section Thu, 20 Mar 2014 09:18:01 +0000 The introduction of enzyme replacement therapy and the resultant stabilisation or improvement in mobility and respiratory muscle function afforded to patients with late-onset Pompe may lead to an increased number of Pompe patients prepared to accept the challenges of parenthood. In this case report, we describe our anaesthetic management of two patients with Pompe disease for a caesarean section. I. J. J. Dons-Sinke, M. Dirckx, and G. P. Scoones Copyright © 2014 I. J. J. Dons-Sinke et al. All rights reserved. Paraplegia after Gastrectomy in a Patient with Cervical Disc Herniation: A Case Report and Review of Literature Tue, 18 Mar 2014 11:39:45 +0000 Paraplegia is a rare postoperative complication. We present a case of acute paraplegia after elective gastrectomy surgery because of cervical disc herniation. The 73-year-old man has the medical history of cervical spondylitis with only symptom of temporary pain in neck and shoulder. Although the patient’s neck was cautiously preserved by using the Discopo, an acute paraplegia emerged at about 10 hours after the operation. Severe compression of the spinal cord by herniation of the C4-C5 cervical disc was diagnosed and emergency surgical decompression was performed immediately. Unfortunately the patient showed limited improvement in neurologic deficits even after 11 months. Qingfu Zhang, Wei Jiang, Quanhong Zhou, Guangyan Wang, and Linlin Zhao Copyright © 2014 Qingfu Zhang et al. All rights reserved. Sugammadex and Reversal of Neuromuscular Block in Adult Patient with Duchenne Muscular Dystrophy Thu, 13 Mar 2014 07:31:42 +0000 Duchenne’s muscular dystrophy (DMD) is the most common and severe form of myopathy. Patients with DMD are more sensitive to sedative, anesthetic, and neuromuscular blocking agents which may result in intraoperative and early postoperative cardiovascular and respiratory complications, as well as prolonged recovery from anesthesia. In this case report, we describe a 25-year-old male patient admitted for cholecystectomy under general anesthesia. We induced our anesthesia by oxygen, propofol, fentanyl, and rocuronium bromide. Maintenance was done by fentanyl, rocuronium bromide, sevoflurane, and O2. We report in this case the safety use of sugammadex to antagonize the neuromuscular block and rapid recovery in such category of patients. Ahmed Abdelgawwad Wefki Abdelgawwad Shousha, Maria Sanfilippo, Antonio Sabba, and Paolo Pinchera Copyright © 2014 Ahmed Abdelgawwad Wefki Abdelgawwad Shousha et al. All rights reserved. A New Biplane Ultrasound Probe for Real-Time Visualization and Cannulation of the Internal Jugular Vein Thu, 13 Mar 2014 06:53:27 +0000 Ultrasound guidance is recommended for cannulation of the internal jugular vein. Use of ultrasound allows you to identify relevant anatomy and possible anatomical anomalies. The most common approach is performed while visualizing the vein transversely and inserting the needle out of plane to the probe. With this approach needle tip visualization may be difficult. We report the use of a new biplane ultrasound probe which allows the user to simultaneously view the internal jugular vein in transverse and longitudinal views in real time. Use of this probe enhances needle visualization during venous cannulation. Jeremy Kaplowitz and Paul Bigeleisen Copyright © 2014 Jeremy Kaplowitz and Paul Bigeleisen. All rights reserved. Prothrombin Complex Concentrate for Rapid Reversal of Warfarin Anticoagulation to Allow Neuraxial Blockade Tue, 04 Mar 2014 09:33:08 +0000 The development of Prothrombin Complex Concentrates (PCCs) has led to better outcomes in patients receiving emergency reversal of warfarin. However, most published data describes the use of PCCs in the setting of major bleeding or emergent major surgery, with little information on neuraxial blockade. We describe a case of rapid warfarin reversal using PCC and subsequent surgery under spinal anaesthesia in an 87-year-old lady, for whom general anaesthesia was deemed high risk. Her international normalised ratio (INR) on the morning of surgery was 1.8, precluding neuraxial blockade; however, it was felt that given, the need for imminent surgery, immediate reversal of the warfarin was indicated. We administered a single dose of 23 units/kg PCC and 5 mg vitamin K. Her INR 1 hour following PCC was 1.2, and spinal anesthetic was administered. The patient then underwent excision of melanoma deposits from her leg and groin dissection. There were no complications, the patient recovered satisfactorily, and there were no thrombotic or hemorrhagic events at 30 days postoperatively. This case study demonstrates a novel use of PCCs; in certain patients, PCCs may be safely used for immediate reversal of warfarin to allow for neuraxial blockade, safer anaesthesia, and better outcomes. Conor Skerritt and Stephen Mannion Copyright © 2014 Conor Skerritt and Stephen Mannion. All rights reserved. Negative Pressure Pulmonary Edema after Reversing Rocuronium-Induced Neuromuscular Blockade by Sugammadex Thu, 13 Feb 2014 10:03:54 +0000 Negative pressure pulmonary edema (NPPE) is a rare complication that accompanies general anesthesia, especially after extubation. We experienced a case of negative pressure pulmonary edema after tracheal extubation following reversal of rocuronium-induced neuromuscular blockade by sugammadex. In this case, the contribution of residual muscular block on the upper airway muscle as well as large inspiratory forces created by the respiratory muscle which has a low response to muscle relaxants, is suspected as the cause. Manzo Suzuki, Toshiichiro Inagi, Takehiko Kikutani, Takuya Mishima, and Hiroyasu Bito Copyright © 2014 Manzo Suzuki et al. All rights reserved. Treatment of Digital Ischemia with Liposomal Bupivacaine Wed, 05 Feb 2014 13:51:42 +0000 Objective. This report describes a case in which the off-label use of liposomal bupivacaine (Exparel) in a peripheral nerve block resulted in marked improvement of a patient’s vasoocclusive symptoms. The vasodilating and analgesic properties of liposomal bupivacaine in patients with ischemic symptoms are unknown, but our clinical experience suggests a role in the management of patients suffering from vasoocclusive disease. Case Report. A 45-year-old African American female was admitted to the hospital with severe digital ischemic pain. She was not a candidate for any vascular surgical or procedural interventions. Two continuous supraclavicular nerve blocks were placed with modest clinical improvement. These effects were also short-lived, with the benefits resolving after the discontinuation of the peripheral nerve blocks. She continued to report severe pain and was on multiple anticoagulant medications, so a decision was made to perform an axillary nerve block using liposomal bupivacaine (Exparel) given the compressibility of the site as well as the superficial nature of the target structures. Conclusions. This case report describes the successful off-label usage of liposomal bupivacaine (Exparel) in a patient with digital ischemia. Liposomal bupivacaine (Exparel) is currently FDA approved only for wound infiltration use at this time. José Raul Soberón, Scott F. Duncan, and W. Charles Sternbergh Copyright © 2014 José Raul Soberón et al. All rights reserved. Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion—A Case Report and Review of Relevant Literature Thu, 30 Jan 2014 09:47:54 +0000 Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early. Saptarshi Biswas, Marwa Sidani, and Sunil Abrol Copyright © 2014 Saptarshi Biswas et al. All rights reserved. Ultrasound-Guided Multiple Peripheral Nerve Blocks in a Superobese Patient Wed, 22 Jan 2014 08:54:20 +0000 The number of obese patients has increased dramatically worldwide. Morbid obesity is associated with an increased incidence of medical comorbidities and restricts the application choices in anesthesiology. We report a successfully performed combined ultrasound-guided blockade of the femoral, tibial, and common peroneal nerve in a superobese patient. We present a case report of a 31-year-old, ASA-PS II, super obese man (190 kg, 180 cm, BMI: 58 kg/m2) admitted to the emergency department with a type II segmental tibia shaft fracture and ankle dislocation after a vehicle accident. After two failed spinal anesthesia attempts, we decided to apply a femoral block combined with a sciatic block. Femoral blocks were successfully performed with US guided in-plane technique. Separate blocks of the tibial and common peroneal nerves were planned after the sciatic nerve could not be located due to the thick subcutaneous tissue. We performed a tibial nerve block at 2 cm above the popliteal crease and common peroneal nerve at the level of the fibular head with US guided in-plane technique. The blocks were successful and no block-related complications were noted. Ultrasound guidance allows new approaches for multiple peripheral nerve blocks with low local anesthetic doses in obese patients. Alper Kilicaslan, Ahmet Topal, Atilla Erol, Hale Borazan, Onur Bilge, and Seref Otelcioglu Copyright © 2014 Alper Kilicaslan et al. All rights reserved. X-Ray of One-Sided “White Lung” after Central Venous Catheterization Sun, 19 Jan 2014 14:00:10 +0000 Complications during insertion of a subclavian central venous line are rare but potentially serious. This case report describes the radiological abnormality of a one-sided pleural effusion during a routine control directly after a difficult central venous catheterization. We illustrate the findings, the initial emergency management, and our procedure to rule out an iatrogenic hemothorax. Possible differential diagnoses and strategies for management of a suspected complication are discussed. Michel Casanova and Wolfgang Ummenhofer Copyright © 2014 Michel Casanova and Wolfgang Ummenhofer. All rights reserved. Thoracic Anesthesia and Cross Field Ventilation for Tracheobronchial Injuries: A Challenge for Anesthesiologists Sun, 12 Jan 2014 13:19:13 +0000 Tracheobronchial injuries are rare but life threatening sequel of blunt chest trauma. Due to the difficult nature of these injuries and the demanding attributes of the involved surgery, the anesthesiologist faces tough challenges while securing the airway, controlling oxygenation, undertaking one-lung ventilation, maintaining anesthesia during tracheal reconstruction, and gaining adequate postoperative pain control. Amongst the few techniques that can be used with tracheobronchial injuries, cross field ventilation is a remotely described and rarely used technique, especially in injuries around the carina. We effectively applied cross field ventilation in both our cases and the outcome was excellent. Sankalp Sehgal, Joshua C. Chance, and Matthew A. Steliga Copyright © 2014 Sankalp Sehgal et al. All rights reserved. Inadvertent Subdural Injection during Cervical Transforaminal Epidural Steroid Injection Tue, 31 Dec 2013 08:21:02 +0000 Serious complications following cervical epidural steroid injection are rare. Subdural injection of local anesthetic and steroid represents a rare but potentially life threatening complication. A patient presented with left sided cervical pain radiating into the left upper extremity with motor deficit. MRI showed absent lordosis with a broad left paramedian disc-osteophyte complex impinging the spinal cord at C5-6. During C5-6 transforaminal epidural steroid injection contrast in AP fluoroscopic view demonstrated a subdural contrast pattern. The needle was withdrawn slightly and repositioned. Normal lateral epidural and nerve root contrast pattern was subsequently obtained and injection followed with immediate improvement in radicular symptoms. There were no postoperative complications on subsequent clinic follow-up. The subdural space is a potential space between the arachnoid and dura mater. As the subdural space is larger in the cervical region, there may be an elevated potential for inadvertent subdural injection. Needle placement in the cervical subdural space during transforaminal injection is uncommon. Failure to identify aberrant needle entry within the cervical subdural space may result in life threatening complications. We recommend initial injection of a limited volume of contrast agent to detect inadvertent subdural space placement. Kesavan Sadacharam, Jeffrey D. Petersohn, and Michael S. Green Copyright © 2013 Kesavan Sadacharam et al. All rights reserved. A Minimal-Invasive Metabolic Test Detects Malignant Hyperthermia Susceptibility in a Patient after Sevoflurane-Induced Metabolic Crisis Thu, 26 Dec 2013 08:33:13 +0000 Malignant hyperthermia is a rare but life-threatening complication of general anesthesia in predisposed patients usually triggered by potent inhalation anesthetics and/or the depolarizing muscle relaxant succinylcholine. The authors present a case of delayed sevoflurane-induced malignant hyperthermia in a 21-year-old male patient that was sufficiently treated by discontinuation of trigger agent application and dantrolene infusion. After surviving an MH episode diagnostic procedures are indicated to increase patient safety. In the presented case, the use of a novel minimal-invasive metabolic test with intramuscular injection of halothane and caffeine successfully confirmed MH susceptibility and hence might be an alternative for invasive in vitro contracture testing in selected cases. Frank Schuster, Stephan Johannsen, and Norbert Roewer Copyright © 2013 Frank Schuster et al. All rights reserved. Perioperative Management of Interscalene Block in Patients with Lung Disease Thu, 28 Nov 2013 10:12:07 +0000 Interscalene nerve block impairs ipsilateral lung function and is relatively contraindicated for patients with lung impairment. We present a case of an 89-year-old female smoker with prior left lung lower lobectomy and mild to moderate lung disease who presented for right shoulder arthroplasty and insisted on regional anesthesia. The patient received a multimodal perioperative regimen that consisted of a continuous interscalene block, acetaminophen, ketorolac, and opioids. Surgery proceeded uneventfully and postoperative analgesia was excellent. Pulmonary physiology and management of these patients will be discussed. A risk/benefit discussion should occur with patients having impaired lung function before performance of interscalene blocks. In this particular patient with mild to moderate disease, analgesia was well managed through a multimodal approach including a continuous interscalene block, and close monitoring of respiratory status took place throughout the perioperative period, leading to a successful outcome. Eric S. Schwenk, Kishor Gandhi, and Eugene R. Viscusi Copyright © 2013 Eric S. Schwenk et al. All rights reserved. Axillary Block as the Sole Anesthetic for Peripherally Inserted Central Catheter Placement in an Infant with Goldenhar Syndrome Mon, 25 Nov 2013 14:23:30 +0000 The use of peripheral nerve block as the sole anesthetic in infants is not very common. Studies have demonstrated that ultrasound guided (USG) peripheral nerve block is associated with higher overall success rate when compared with nerve stimulation (Rubin et al., 2009, and Gelfand et al., 2011). Described below is a medically complex infant who had an USG axillary brachial plexus block for peripherally inserted central catheter (PICC) placement. Ma. Carmen Bernardo-Ocampo Copyright © 2013 Ma. Carmen Bernardo-Ocampo. All rights reserved. Iatrogenic Left Main Bronchus Injury following Atraumatic Double Lumen Endotracheal Tube Placement Thu, 31 Oct 2013 13:49:43 +0000 Tracheobronchial disruption is an uncommon but severe complication of double lumen endotracheal tube placement. The physical properties of a double lumen tube (large external diameter and length) make tracheobronchial injury more common than that associated with smaller single lumen endotracheal tubes. Here we present the case of an iatrogenic left main bronchus injury caused by placement of a double lumen tube in an otherwise unremarkable airway. William R. Hartman, Michael Brown, and James Hannon Copyright © 2013 William R. Hartman et al. All rights reserved. Phaeochromocytoma Crisis: Two Cases of Undiagnosed Phaeochromocytoma Presenting after Elective Nonrelated Surgical Procedures Mon, 28 Oct 2013 18:51:01 +0000 Phaeochromocytoma is a catecholamine producing tumour and an uncommon cause of hypertension. We present two cases of relatively asymptomatic individuals, in which previously undiagnosed phaeochromocytoma was unmasked by elective nonadrenal surgical procedures, manifesting as postoperative hypertensive crisis and subsequent cardiogenic shock. The initial management in intensive care is discussed, in addition to the clinical and biochemical diagnostic challenges present. Successful adrenalectomy was performed in each case. P. C. Johnston, J. A. Silversides, H. Wallace, P. A. Farling, A. Hutchinson, S. J. Hunter, F. Eatock, and K. R. Mullan Copyright © 2013 P. C. Johnston et al. All rights reserved. Subarachnoid Fluid Lactate and Paraplegia after Descending Aorta Aneurysmectomy: Two Compared Case Reports Thu, 03 Oct 2013 10:29:55 +0000 We report a comparison of two cases regarding subjects who underwent thoracoabdominal aorta aneurysmectomy. During the procedure we monitored cerebrospinal fluid lactate concentration. One patient experienced postoperative paraplegia and his cerebrospinal fluid lactate concentration was much higher than that in the other case, whose postoperative outcome was uneventful. Consequently we consider that monitoring the lactate concentration in cerebrospinal fluid during thoracic aorta surgical procedures may be a helpful tool to predict the ischemic spine-cord injury allowing for trying to recover it precociously. Enrico Giustiniano, Silvia Eleonora Malossini, Francesco Pellegrino, and Franco Cancellieri Copyright © 2013 Enrico Giustiniano et al. All rights reserved. Transient Femoral Nerve Palsy Complicating “Blind” Transversus Abdominis Plane Block Wed, 04 Sep 2013 15:18:32 +0000 We present two cases of patients who reported quadriceps femoris weakness and hypoesthesia over the anterior thigh after an inguinal hernia repair under transversus abdominis plane (TAP) block. Transient femoral nerve palsy is the result of local anesthetic incorrectly injected between transversus abdominis muscle and transversalis fascia and pooling around the femoral nerve. Although it is a minor and self-limiting complication, it requires overnight hospital stay and observation of the patients. Performing the block under ultrasound guidance and injecting the least volume of local anesthetic required are ways of minimizing its incidence. Dimitrios K. Manatakis, Nikolaos Stamos, Christos Agalianos, Michail Athanasios Karvelis, Michael Gkiaourakis, and Demetrios Davides Copyright © 2013 Dimitrios K. Manatakis et al. All rights reserved. GlideScope and Frova Introducer for Difficult Airway Management Wed, 07 Aug 2013 11:54:32 +0000 The introduction into clinical practice of new tools for intubation as videolaringoscopia has dramatically improved the success rate of intubation and the work of anesthesiologists in what is considered the most delicate maneuver. Nevertheless intubation difficulties may also be encountered with good anatomical visualization of glottic structures in videolaringoscopia. To overcome the obstacles that may occur both in a difficult provided intubation such as those unexpected, associated endotracheal introducer able to facilitate the passage of the endotracheal tube through the vocal cords into the trachea may be useful. We report 4 cases of difficult intubation planned and unplanned and completed successfully using the GlideScope videolaryngoscope associated with endotracheal Frova introducer. Alessandra Ciccozzi, Chiara Angeletti, Cristiana Guetti, Roberta Papola, Paolo Matteo Angeletti, Antonella Paladini, Giustino Varrassi, and Franco Marinangeli Copyright © 2013 Alessandra Ciccozzi et al. All rights reserved. An Unusual Case of Sudden Collapse in the Immediate Postoperative Period in a Young Healthy Female with Myxofibroma of the Maxilla Tue, 30 Jul 2013 09:59:56 +0000 Benign myxofibromas of heart are well known to cause systemic inflammatory mediator release causing multiple complications ranging from fever and widespread effusions to DIC and shock. We report that in a particular case of maxillary myxofibroma, a shock-like state and widespread serous cavities effusion presented in the immediate postoperative period. The occurrence was possibly due to release of inflammatory mediators by the tumour, disseminated during tumour resection causing diffuse capillary leak, precipitated by fluid resuscitation, leading to decrease in plasma oncotic pressure. Manila Singh and Saket Singh Copyright © 2013 Manila Singh and Saket Singh. All rights reserved. Open Tracheostomy after Aborted Percutaneous Approach due to Tracheoscopy Revealing Occult Tracheal Wall Ulcer Wed, 17 Jul 2013 08:18:19 +0000 Tracheostomy is a common procedure for intensive care patients requiring prolonged mechanical ventilation. In this case report, we describe a 78-year-old female patient admitted for an aneurysm of the cerebral anterior communicating artery. Following immediate endovascular coiling, she remained ventilated and was transferred to the neurological intensive care unit. On postoperative day ten, a percutaneous tracheostomy (PCT) was requested; however, a large ulcer or possible tracheoesophageal fistula was identified on the posterior tracheal wall following bronchoscopic assessment of the trachea. Therefore, the requested PCT procedure was aborted. An open tracheostomy in the operating room was completed; however, due to the position and depth of the ulcer, a reinforced endotracheal tube (ETT) was placed via the tracheostomy. Four days later, the reinforced ETT was replaced with a Shiley distal extended tracheostomy tube to bypass the ulceration. Careful inspection and evaluation of the tracheostomy site before PCT prevented a potentially life-threatening issue in our patient. John Schweiger, Collin Sprenker, Devanand Mangar, Rachel Karlnoski, Naga Pullakhandam, and Enrico M. Camporesi Copyright © 2013 John Schweiger et al. All rights reserved. Myoclonus following a Peripheral Nerve Block Thu, 11 Jul 2013 13:41:24 +0000 Myoclonus is an extremely rare perioperative complication following neuraxial anesthesia. It has also been reported to occur due to peripheral nerve lesions. We report a case of self-limiting myoclonus following a routine peripheral nerve block in an otherwise healthy patient. Arlene J. Hudson, Kevin B. Guthmiller, and Marian N. Hyatt Copyright © 2013 Arlene J. Hudson et al. All rights reserved. Intraoperative Alcohol Withdrawal Syndrome: A Coincidence or Precipitation? Wed, 10 Jul 2013 10:21:54 +0000 As the prevalence of alcohol dependence is approximately half in surgical patients with an alcohol use disorder, anesthetist often encounters such patients in the perioperative settings. Alcohol withdrawal syndrome (AWS) is one of the most feared complications of alcohol dependence and can be fatal if not managed actively. A 61-year-old man, alcoholic with 50 h of abstinence before surgery, received spinal anesthesia for surgery for femoral neck fracture. To facilitate positioning for spinal anesthesia, fascia iliaca compartmental block with 0.25% bupivacaine (30 mL) was administered 30 min prior to spinal block. Later, in the intraoperative period the patient developed AWS; however, the features were similar to that of local anesthetic toxicity. The case was successfully managed with intravenous midazolam, esmolol, and propofol infusion. Due to similarity of clinical features of AWS and mild local anesthetic toxicity, an anesthetist should be in a position to differentiate the condition promptly and manage it aggressively. Asish Subedi and Balkrishna Bhattarai Copyright © 2013 Asish Subedi and Balkrishna Bhattarai. All rights reserved. Myocardial Dysfunction in Acute Traumatic Brain Injury Relieved by Surgical Decompression Tue, 04 Jun 2013 12:29:55 +0000 Traumatic brain injury (TBI) is a major public health issue and is a leading cause of death in North America. After a primary TBI, secondary brain insults can predispose patients to a worse outcome. One of the earliest secondary insults encountered during the perioperative period is hypotension, which has been directly linked to both mortality and poor disposition after TBI. Despite this, it has been shown that hypotension commonly occurs during surgery for TBI. We present a case of intraoperative hypotension during surgery for TBI, where the use of transthoracic echocardiography had significant diagnostic and therapeutic implications for the management of our patient. We then discuss the issue of cardiac dysfunction after brain injury and the implications that echocardiography may have in the management of this vulnerable patient population. Vijay Krishnamoorthy, Deepak Sharma, Sumidtra Prathep, and Monica S. Vavilala Copyright © 2013 Vijay Krishnamoorthy et al. All rights reserved. Delayed Onset Malignant Hyperthermia after Sevoflurane Thu, 30 May 2013 12:25:56 +0000 Malignant hyperthermia is a hypermetabolic response to inhalation agents (such as halothane, sevoflurane, and desflurane), succinylcholine, vigorous exercise, and heat. Reactions develop more frequently in males than females (2 : 1). The classical signs of malignant hyperthermia are hyperthermia, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, muscle rigidity and rhabdomyolysis. In this case report, we present a case of delayed onset malignant hyperthermia-like reaction after the second exposure to sevoflurane. K. Sanem Cakar Turhan, Volkan Baytaş, Yeşim Batislam, and Oya Özatamer Copyright © 2013 K. Sanem Cakar Turhan et al. All rights reserved. A Novel Anaesthetical Approach to Patients with Brugada Syndrome in Neurosurgery Tue, 28 May 2013 15:19:08 +0000 Brugada syndrome (BrS) is one of the most common causes of sudden death in young people. It usually presents with life-threatening arrhythmias in subjects without remarkable medical history. The need for surgical treatment may unmask BrS in otherwise asymptomatic patients. The best anaesthesiological treatment in such cases is matter of debate. We report a case of neurosurgical treatment of cerebello pontine angle (CPA) tumor in a BrS patient, performed under total intravenous anesthesia (TIVA) with target controlled infusion (TCI) modalities, using midazolam plus remifentanil and rocuronium, without recordings of intraoperative ECG alterations in the intraoperative period and postoperative complications. Pietro Paolo Martorano, Edoardo Barboni, Giovanni Buscema, and Alessandro Di Rienzo Copyright © 2013 Pietro Paolo Martorano et al. All rights reserved. Anaesthetic Management of Parturient with Acute Atrial Fibrillation for Emergency Caesarean Section Mon, 27 May 2013 13:32:36 +0000 A 31-year-antenatal lady with critical mitral stenosis presented for emergency caesarean section with fetal distress. She had acute onset atrial fibrillation. She was given a combined spinal epidural (CSE) anaesthesia and her arrhythmia was successfully managed after delivery of the baby with intravenous calcium channel blocker. Mitral stenosis is the most common valvular heart disease complicating pregnancy in developing countries. The physiological changes during pregnancy may exacerbate their cardiac symptoms. They may present with complications like congestive cardiac failure, atrial fibrillation, or pulmonary thromboembolism during the antenatal, intrapartum, or postpartum period. Here we discuss the management of parturient woman with high maternal and fetal risk presenting for emergency caesarean. The merits of regional anaesthesia and the importance of invasive monitoring are also discussed. Madhu Gupta, Shalini Subramanian, and Preeti Adlakha Copyright © 2013 Madhu Gupta et al. All rights reserved.