Case Reports in Anesthesiology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. 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.