Case Reports in Anesthesiology The latest articles from Hindawi © 2018 , Hindawi Limited . All rights reserved. Ultrasound-Guided Interscalene Catheter Complicated by Persistent Phrenic Nerve Palsy Wed, 03 Jan 2018 00:00:00 +0000 A 76-year-old male presented for reverse total shoulder arthroplasty (TSA) in the beach chair position. A preoperative interscalene nerve catheter was placed under direct ultrasound-guidance utilizing a posterior in-plane approach. On POD 2, the catheter was removed. Three weeks postoperatively, the patient reported worsening dyspnea with a subsequent chest X-ray demonstrating an elevated right hemidiaphragm. Pulmonary function testing revealed worsening deficit from presurgical values consistent with phrenic nerve palsy. The patient decided to continue conservative management and declined further invasive testing or treatment. He was followed for one year postoperatively with moderate improvement of his exertional dyspnea over that period of time. The close proximity of the phrenic nerve to the brachial plexus in combination with its frequent anatomical variation can lead to unintentional mechanical trauma, intraneural injection, or chemical injury during performance of ISB. The only previously identified risk factor for PPNP is cervical degenerative disc disease. Although PPNP has been reported following TSA in the beach chair position without the presence of a nerve block, it is typically presumed as a complication of the interscalene block. Previously published case reports and case series of PPNP complicating ISBs all describe nerve blocks performed with either paresthesia technique or localization with nerve stimulation. We report a case of a patient experiencing PPNP following an ultrasound-guided placement of an interscalene nerve catheter. Andrew T. Koogler and Michael Kushelev Copyright © 2018 Andrew T. Koogler and Michael Kushelev. All rights reserved. Unique Phrenic Nerve-Sparing Regional Anesthetic Technique for Pain Management after Shoulder Surgery Tue, 19 Dec 2017 00:00:00 +0000 Background. Ipsilateral phrenic nerve blockade is a common adverse event after an interscalene brachial plexus block, which can result in respiratory deterioration in patients with preexisting pulmonary conditions. Diaphragm-sparing nerve block techniques are continuing to evolve, with the intention of providing satisfactory postoperative analgesia while minimizing hemidiaphragmatic paralysis after shoulder surgery. Case Report. We report the successful application of a combined ultrasound-guided infraclavicular brachial plexus block and suprascapular nerve block in a patient with a complicated pulmonary history undergoing a total shoulder replacement. Conclusion. This case report briefly reviews the important innervations to the shoulder joint and examines the utility of the infraclavicular brachial plexus block for postoperative pain management. Jason K. Panchamia, David A. Olsen, and Adam W. Amundson Copyright © 2017 Jason K. Panchamia et al. All rights reserved. Inability to Utilize Retrograde Cardioplegia due to a Persistent Left Superior Vena Cava Sun, 03 Dec 2017 09:40:17 +0000 A persistent left superior vena cava is a congenital abnormality that affects a minority of the general population. While this finding is not hemodynamically significant in all patients, failure to recognize the altered anatomy in any of these patients can be consequential during procedures such as central venous catheter placement, pacemaker/defibrillator wire placement, and use of retrograde cardioplegia during cardiac surgery. We present a case of an intraoperative diagnosis of a persistent left superior vena cava that altered the original plan to arrest the heart using retrograde cardioplegia. Echocardiography was instrumental in this diagnosis and avoided potentially inadequate myocardial protection during cardiopulmonary bypass. Rohesh J. Fernando and Sean D. Johnson Copyright © 2017 Rohesh J. Fernando and Sean D. Johnson. All rights reserved. A Rare Complication of a TAP Block Performed after Caesarean Delivery Sun, 29 Oct 2017 00:00:00 +0000 The transversus abdominis plane block is a regional anesthesia technique that has become popular. Being a relatively simple procedure, the TAP block has an excellent safety profile and major complications are rare. We present a case of transient femoral nerve palsy occurring after a TAP block with involvement of the sacral plexus for a patient who had undergone a caesarean section. Osman Nawazish Salaria, Murlikrishna Kannan, Bryan Kerner, and Howard Goldman Copyright © 2017 Osman Nawazish Salaria et al. All rights reserved. Conducting Prolonged General Anesthesia without Intravenous Access in a Child with Hypoplastic Left Heart Syndrome Tue, 17 Oct 2017 00:00:00 +0000 Children with chronic medical conditions often need multiple intravenous (IV) access instances during their hospitalizations, both peripheral and central. Obtaining a working IV in this patient population undergoing general anesthesia can be challenging. In our case report, we describe a method of administering general anesthesia in an infant with partially repaired hypoplastic left heart syndrome without IV access. Phat T. Dang and Binjon Sriratana Copyright © 2017 Phat T. Dang and Binjon Sriratana. All rights reserved. An Undiagnosed Paraganglioma in a 58-Year-Old Female Who Underwent Tumor Resection Sun, 15 Oct 2017 07:03:47 +0000 Paragangliomas and pheochromocytomas are rare neuroendocrine tumors that can have high morbidity and mortality if undiagnosed. Here we report a case of an undiagnosed paraganglioma in a 58-year-old female who underwent tumor resection. The patient became severely hypertensive intraoperatively with paroxysmal swings in blood pressure and then later became acutely hypotensive after tumor removal. She was managed in the surgical intensive care unit (SICU) postoperatively and discharged from the hospital without acute complications. We briefly discuss the epidemiology, clinical presentation, perioperative management, and possible complications of these tumors to assist healthcare providers if one were to encounter them. William C. Fox, Matthew Read, Richard E. Moon, Eugene W. Moretti, and Brian J. Colin Copyright © 2017 William C. Fox et al. All rights reserved. Dexmedetomidine as Part of a Multimodal Analgesic Treatment Regimen for Opioid Induced Hyperalgesia in a Patient with Significant Opioid Tolerance Mon, 25 Sep 2017 09:41:24 +0000 Acute postoperative pain in patients with opioid tolerance creates a significant management challenge for anesthesiologists and pain medicine physicians. A multimodal approach is key; however other factors can complicate management such as opioid induced hyperalgesia. We present the case of a patient on large amounts of intrathecal opioids for chronic pain syndrome with opioid induced hyperalgesia after an exploratory laparotomy. Dexmedetomidine was utilized successfully as part of a controlled multimodal analgesic plan and should be a consideration for opioid tolerant patients experiencing opioid induced hyperalgesia. Richard K. Patch III, Jason S. Eldrige, Susan M. Moeschler, and Matthew J. Pingree Copyright © 2017 Richard K. Patch III et al. All rights reserved. Previously Undiagnosed Spinal and Bulbar Muscular Atrophy as a Cause of Airway Obstruction after Robot-Assisted Laparoscopic Prostatectomy Mon, 17 Jul 2017 00:00:00 +0000 Background. Preoperative vocal cord paralysis is a risk factor for postoperative respiratory distress following extubation after general anesthesia. We present an unusual case where a geriatric patient developed airway obstruction after robot-assisted laparoscopic prostatectomy. Case Presentation. A 67-year-old male, who had suffered from left vocal cord paralysis of unknown etiology, was scheduled for robot-assisted laparoscopic prostatectomy (RALP). General anesthesia was performed without any problems. The patient, however, developed airway obstruction one hour after extubation and was reintubated following commencement of mechanical ventilation for one day. At the age of 70 years, the patient received an emergency tracheostomy due to bilateral vocal cord paralysis and then was diagnosed with spinal and bulbar muscular atrophy (SBMA). Although no muscle weakness of either upper or lower extremities was observed, rocuronium showed hypersensitivity during total laryngectomy under general anesthesia. Conclusions. Vocal cord paralysis combined with postoperative laryngeal edema, the cause of which was presumed to be SBMA, likely caused airway obstruction after RALP. As neuromuscular symptoms progress gradually in patients with SBMA, muscle relaxants should be used carefully, even if patients with SBMA present no immobility of their extremities. Miyuki Niki, Taihei Tachikawa, Yuka Sano, Hiroki Miyawaki, Aisa Matoi, Yukari Okano, Nobutaka Kariya, Tsuneo Tatara, and Munetaka Hirose Copyright © 2017 Miyuki Niki et al. All rights reserved. Ultrasound-Guided Subclavian Vein Cannulation in Neonate via Supraclavicular Approach Sun, 09 Jul 2017 00:00:00 +0000 Central venous cannulation of infants may be challenging. Ultrasonography is recommended and has been found superior to classic landmark technique in pediatric central venous cannulation. The cannulation of the subclavian vein using supraclavicular approach under real-time ultrasound guidance is a novel technique. It may have advantages over ultrasound-guided jugular vein cannulation in specific patients. We report a case of 3200-gram 20-day-old anencephalic neonate who had a diffuse generalized edema. The neonate was cannulated successfully via subclavian vein using supraclavicular approach under ultrasound guidance. Onur Balaban and Tayfun Aydın Copyright © 2017 Onur Balaban and Tayfun Aydın. All rights reserved. Discharge against Medical Advice in Surgical Patients with Posttraumatic Stress Disorder: A Case Report Series Illustrating Unique Challenges Wed, 21 Jun 2017 09:08:24 +0000 Discharge against medical advice (DAMA) can have detrimental effects on patient outcomes. Recently, the diagnosis of posttraumatic stress disorder (PTSD) has been linked with DAMA in the mental health setting. However, PTSD as a risk factor for DAMA in surgical patients has not received much consideration, although such patients may be at risk for triggering or amplification of PTSD symptoms perioperatively. We present the first case report series of three surgical patients with PTSD who left the hospital AMA. These cases differ markedly from DAMA in non-PTSD patients. In all three subjects, the stress of feeling misunderstood by clinicians and the distress of public detainment by hospital security in the setting of chronic PTSD led to aggressive and risky behavior. All three subjects represented a risk to themselves and to others at the time of DAMA. Finally, all three subjects were difficult to contact for follow-up or medical care and missed appointments. Marek Brzezinski, Maren Gregersen, Luiz Gustavo Schuch, Ricarda Sawatzki, Joy W. Chen, Grant Gauger, Jasleen Kukreja, and Brian Cason Copyright © 2017 Marek Brzezinski et al. All rights reserved. Ketamine Use for Successful Resolution of Post-ERCP Acute Pancreatitis Abdominal Pain Tue, 20 Jun 2017 06:28:50 +0000 We report a case in which a patient with intractable pain secondary to post-endoscopic retrograde cholangiopancreatography (ERCP) acute pancreatitis is successfully treated with a subanesthetic ketamine infusion. Shortly after ERCP, the patient reported severe stabbing epigastric pain. She exhibited voluntary guarding and tenderness without distension. Amylase and lipase levels were elevated. Pain persisted for hours despite hydromorphone PCA, hydromorphone boluses, fentanyl boluses, and postprocedure anxiolytics. Pain management was consulted and a ketamine infusion was trialed, leading to a dramatic reduction in pain. This case suggests that ketamine may be a promising option in treating intractable pain associated with ERCP acute pancreatitis. Suneel M. Agerwala, Divya Sundarapandiyan, and Garret Weber Copyright © 2017 Suneel M. Agerwala et al. All rights reserved. Takotsubo Cardiomyopathy after Spinal Anesthesia for a Minimally Invasive Urologic Procedure Tue, 13 Jun 2017 07:41:19 +0000 We present the case of a patient who suffered from Takotsubo cardiomyopathy (TCM) immediately after the initiation of subarachnoid anesthesia for a minimally invasive urologic procedure (tension-free vaginal tape (TVT) surgery for stress urine incontinence). TCM mimics acute coronary syndrome and is caused by an exaggerated sympathetic reaction to significant emotional or physical stress. Our patient suffered from chest pain, palpitations, dyspnea, and hemodynamic instability immediately following subarachnoid anesthesia and later in the postanesthesia care unit. Blood troponin was elevated and new electrocardiographic changes appeared indicative of cardiac ischemia. Cardiac ultrasound indicated left ventricular apical akinesia and ballooning with severely affected contractility. The patient was admitted to coronary intensive care for the proper care and finally was discharged. TCM was attributed to high emotional preoperative stress for which no premedication had been administered to the patient. In conclusion, adequate premedication and anxiety management are not only a measure to alleviate psychological stress of surgical patients, but, more importantly, an imperative mean to suppress sympathetic nerve system response and its cardiovascular consequences. Emmanuel Lilitsis, Despina Dermitzaki, Georgios Avgenakis, Ioannis Heretis, Charalampos Mpelantis, and Charalampos Mamoulakis Copyright © 2017 Emmanuel Lilitsis et al. All rights reserved. Acute Abdominal Compartment Syndrome following Extraperitoneal Bladder Perforation Tue, 30 May 2017 08:52:20 +0000 Extraperitoneal bladder perforation is a known complication of a commonly performed rigid cystoscopy. If unrecognized, this complication can lead to continuous intra-abdominal fluid leakage with consequent organ function impairment and symptoms. This is the first case report in literature of a transurethral bladder perforation causing an acute abdominal compartment syndrome, which was subsequently managed conservatively with supportive management only. Case Presentation. We describe a clinical course of a 73-year-old Caucasian female whose initial acute presentation involved urinary symptoms. Surgery and general anaesthesia during rigid cystoscopy were complicated by an initially unrecognized extraperitoneal bladder perforation, resulting in fluid extravasation. This extravasation resulted in transurethral bladder resection syndrome with acute intra-abdominal free fluid accumulation. This complication caused acute abdominal compartment syndrome resulting in respiratory end-organ compromise and immediate postextubation respiratory failure. Patient required an emergency reintubation. During the management, diagnosis was considered through the use of the point of care abdominal ultrasound. Postoperatively, patient was managed conservatively in intensive care. Postoperative course included an approximate nine liters of urinary diuresis and supportive ventilation for four days. Conclusion. There is equipoise in the clinical management of abdominal compartment syndrome with regard to supportive medical management alone or invasive surgical treatment. Ana Licina Copyright © 2017 Ana Licina. All rights reserved. Pneumomediastinum and Bilateral Pneumothoraces Causing Respiratory Failure after Thyroid Surgery Mon, 24 Apr 2017 00:00:00 +0000 We report the first case of severe respiratory failure after thyroid surgery requiring venovenous extracorporeal membrane oxygenation (vvECMO). The patient was a 41-year-old woman with metastatic thyroid cancer. She underwent thyroidectomy, including left lateral and bilateral central neck dissection. During surgery, the patient developed pneumomediastinum with bilateral pneumothoraces. Despite early treatment with bilateral chest tubes and no evidence of a tracheal perforation, the patient developed severe respiratory failure after extubation on the intensive care unit. Because pneumothorax and pneumomediastinum might be more common than reported, and considering increasing cases of thyroid surgery, staff should remain vigilant of pulmonary complications after thyroid surgery. Michael Koeppen, Benjamin Scott, Joseph Morabito, Matthew Fiegel, and Tobias Eckle Copyright © 2017 Michael Koeppen et al. All rights reserved. Postoperative Airway Obstruction by a Bone Fragment Thu, 30 Mar 2017 12:16:51 +0000 Postoperative airway obstructions are potentially life-threatening complications. These obstructions may be classified as functional (sagging tongue, laryngospasm, or bronchospasm), pathoanatomical (airway swelling or hematoma within the airways), or foreign body-related. Various cases of airway obstruction by foreign bodies have previously been reported, for example, by broken teeth or damaged airway instruments. Here we present the exceptional case of a postoperative airway obstruction due to a large fragment of the patient’s maxillary bone, left accidentally in situ after transoral surgical tumor resection. Concerning this type of airway obstruction, we discuss possible causes, diagnosis, and treatment options. Although it is an exceptional case after surgery, clinicians should be aware of this potentially life-threatening complication. In summary, this case demonstrates that the differential diagnosis of postoperative airway obstructions should include foreign bodies derived from surgery, including tissue and bone fragments. Patrick Schober, K. Hakki Karagozoglu, Stephan A. Loer, and Lothar A. Schwarte Copyright © 2017 Patrick Schober et al. All rights reserved. Management of Residual Neuromuscular Blockade Recovery: Age-Old Problem with a New Solution Tue, 14 Mar 2017 10:08:05 +0000 Neostigmine has been traditionally used as the agent of choice to reverse Neuromuscular Blockade (NMB) after muscle paralysis during general anesthesia. However, the use of neostigmine has not been without untoward events. Sugammadex is a novel drug that selectively binds to aminosteroid nondepolarizing muscle relaxants and reverses even a deep level of NMB. Controversy exists regarding the optimal dose of sugammadex that is effective in reversing the NMB after the incomplete reversal with neostigmine and glycopyrrolate. We discuss a case where sugammadex reduced the time of the recovery from NMB in a patient who had incomplete antagonisms following adequate treatment with neostigmine, aiding timely extubation without persistent residual NMB, and hence prevented the requirement of postoperative ventilation and the improvement in patient care. More randomized control studies are needed in order to conclude the appropriate dose of sugammadex in cases of incomplete reversal. Michael S. Green, Archana Gundigi Venkatesh, and Ranjani Venkataramani Copyright © 2017 Michael S. Green et al. All rights reserved. Pitfalls in Interventional Pain Medicine: Hyponatremia after DDAVP for a Patient with Von Willebrand Disease Undergoing an Epidural Steroid Injection Tue, 14 Mar 2017 09:38:30 +0000 Desmopressin (DDAVP), a synthetic analog of vasopressin, has been used in patients with von Willebrand disease (VWD), mild hemophilia A, and platelet dysfunction to reduce the risk of bleeding associated with surgical and interventional procedures. We report the case of a patient with VWD presenting with a bulging disc and radicular pain that underwent transforaminal epidural steroid injections. Her course was complicated with the interval development of headaches and dizziness symptomatic of moderate hyponatremia, likely due to excessive fluid intake. This report highlights a relatively rare side effect of DDAVP when used for prophylaxis in patients with VWD and reinforces the need for vigilance in these patients. Talal W. Khan and Abdulraheem Yacoub Copyright © 2017 Talal W. Khan and Abdulraheem Yacoub. All rights reserved. In-Flight Hypoxemia in a Tracheostomy-Dependent Infant Tue, 28 Feb 2017 12:12:48 +0000 Millions of passengers board commercial flights every year. Healthcare providers are often called upon to treat other passengers during in-flight emergencies. The case presented involves an anesthesia resident treating a tracheostomy-dependent infant who developed hypoxemia on a domestic flight. The patient had an underlying congenital muscular disorder and was mechanically ventilated while at altitude. Although pressurized, cabin barometric pressure while at altitude is less than at sea level. Due to this environment patients with underlying pulmonary or cardiac pathology might not be able to tolerate commercial flight. The Federal Aviation Administration (FAA) has mandated a specific set of medical supplies be present on all domestic flights in addition to legislature protecting “Good Samaritan” providers. Jason Quevreaux and Christopher Cropsey Copyright © 2017 Jason Quevreaux and Christopher Cropsey. All rights reserved. Effect of Arm Positioning on Entrapment of Infraclavicular Nerve Block Catheter Tue, 28 Feb 2017 00:00:00 +0000 Continuous brachial plexus nerve block catheters are commonly inserted for postoperative analgesia after upper extremity surgery. Modifications of the insertion technique have been described to improve the safety of placing an infraclavicular brachial plexus catheter. Rarely, these catheters may become damaged or entrapped, complicating their removal. We describe a case of infraclavicular brachial plexus catheter entrapment related to differences in arm positioning during catheter placement and removal. Written authorization to obtain, use, and disclose information and images was obtained from the patient. Eric Kamenetsky, Rahul Reddy, Mark C. Kendall, Antoun Nader, and Jessica J. Weeks Copyright © 2017 Eric Kamenetsky et al. All rights reserved. The Anaesthesiologist and Palliative Care in a Newborn with the Adam “Sequence” Thu, 23 Feb 2017 07:55:35 +0000 Reports focusing on biomedical principlism and the role of anaesthesiologists in palliative care are rare. We present the case of a newborn with multiple craniofacial anomalies and a diagnosis of ADAM “sequence,” in which surgical removal of placental adhesions to the dura mater and the correction of meningocele was not indicated due to the very short life expectancy. After 48 hours, the odor from the placenta indicted a necrotic process, which prevented the parents from being close to the child and increased his isolation. Urgent surgery was performed, after which the newborn was transported to the ICU and intubated under controlled mechanical ventilation. The patient died a week later. The principles of beneficence, nonmaleficence, justice, and respect for autonomy are simultaneously an inspiratory and regulatory framework for clinical practice. Although only necessary procedures are defended, which suggests a position contrary to invasive interventions at the end of life, sometimes they are the best palliative measures that can be taken in cases like the one described here. Alberto Vieira Pantoja, Maria Emília Gonçalves Estevez, Bruno Lima Pessoa, Fernando de Paiva Araújo, Bruno Mendonça Barcellos, Ciro Augusto Floriani, and Marco Antonio Cardoso de Resende Copyright © 2017 Alberto Vieira Pantoja et al. All rights reserved. Anesthetic Considerations in a Patient with Myotonic Dystrophy for Hip Labral Repair Mon, 20 Feb 2017 00:00:00 +0000 Myotonic Dystrophy (DM) affects multiple organ systems. Disorders such as hyperthyroidism, progressive musculoskeletal weakness, cardiac dysrhythmias, hypoventilation, and cognitive-behavioral disorders may be present in these patients. Thorough preoperative assessment and anesthetic planning are required to minimize the risk of anesthetic complications. Patients with DM can exhibit exquisite sensitivity to sedatives, neuromuscular blocking agents, and volatile anesthetics, resulting in potential postoperative complications. There is limited literature available on successful anesthetic techniques for the DM patient. We present this case report to add to our current fund of knowledge. Ramon Go, David Wang, and Danielle Ludwin Copyright © 2017 Ramon Go et al. All rights reserved. From Bad to Worse: Paraganglioma Diagnosis during Induction of Labor for Coexisting Preeclampsia Wed, 18 Jan 2017 00:00:00 +0000 Pheochromocytomas and extra-adrenal paragangliomas are catecholamine-secreting tumors that rarely occur in pregnancy. The diagnosis of these tumors in pregnancy can be challenging given that many of the signs and symptoms are commonly attributed to preeclampsia or other more common diagnoses. Early diagnosis and appropriate management are essential in optimizing maternal and fetal outcomes. We report a rare case of a catecholamine-secreting tumor in which diagnosis occurring at the time labor was being induced for concomitant preeclampsia with severe features. Her initial presentation in hypertensive crisis with other symptoms led to diagnostic workup for secondary causes of hypertension and led to eventual diagnosis of paraganglioma. Obtaining this diagnosis prior to delivery was essential, as this led to prompt multidisciplinary care, changed the course of her clinical management, and ultimately enabled good maternal and fetal outcomes. This case highlights the importance of maintaining a high index of suspicion for secondary causes of hypertension and in obstetric patients and providing timely multidisciplinary care. Sasima Dusitkasem, Blair H. Herndon, Dalton Paluzzi, Joseph Kuhn, Robert H. Small, and John C. Coffman Copyright © 2017 Sasima Dusitkasem et al. All rights reserved. Surdity in the OR: An Unusual Case of Brainstem Anesthesia Mon, 09 Jan 2017 06:46:27 +0000 Brainstem anesthesia is a potentially life-threatening complication of regional ophthalmic anesthesia. This case report chronicles an unusual presentation of brainstem anesthesia following an eye block. The unique features of this case were the presenting symptoms of deafness and slurred speech in the absence of loss of consciousness, respiratory depression, or contralateral ophthalmoplegia. This report underscores two key points: first, the importance of ongoing patient monitoring after performance of an eye block; second, the exigency of supportive therapy in suspected cases of brainstem anesthesia. Howard D. Palte, Don P. Hoa, and Aldo Pavon Canseco Copyright © 2017 Howard D. Palte et al. All rights reserved. Bilateral Intra-Articular Radiofrequency Ablation for Cervicogenic Headache Mon, 09 Jan 2017 00:00:00 +0000 Introduction. Cervicogenic headache is characterized by unilateral neck or face pain referred from various structures such as the cervical joints and intervertebral disks. A recent study of patients with cervical pain showed significant pain relief after cervical medial branch neurotomy but excluded patients with C1-2 joint pain. It remains unclear whether targeting this joint has potential for symptomatic relief. To address this issue, we present a case report of C1-2 joint ablation with positive outcomes. Case Presentation. A 27-year-old female presented with worsening cervicogenic headache. Her pain was 9/10 by visual analog scale (VAS) and described as cramping and aching. Pain was localized suboccipitally with radiation to her jaw and posterior neck, worse on the right. Associated symptoms included clicking of her temporomandibular joint, neck stiffness, bilateral headaches with periorbital pain, numbness, and tingling. History, physical exam, and diagnostic studies indicated localization to the C1-2 joint with 80% decrease in pain after C1-2 diagnostic blocks. She underwent bilateral intra-articular radiofrequency ablation of the C1-C2 joint. Follow-up at 2, 4, 8, and 12 weeks showed improved function and pain relief with peak results at 12 weeks. Conclusion. Clinicians may consider C1-C2 joint ablation as a viable long-term treatment option for cervicogenic headaches. Charles A. Odonkor, Teresa Tang, David Taftian, and Akhil Chhatre Copyright © 2017 Charles A. Odonkor et al. All rights reserved. Orotracheal Intubation Using the Retromolar Space: A Reliable Alternative Intubation Approach to Prevent Dental Injury Sun, 25 Dec 2016 08:50:04 +0000 Despite recent advances in airway management, perianesthetic dental injury remains one of the most common anesthesia-related adverse events and cause for malpractice litigation against anesthesia providers. Recommended precautions for prevention of dental damage may not always be effective because these techniques involve contact and pressure exerted on vulnerable teeth. We describe a novel approach using the retromolar space to insert a flexible fiberscope for tracheal tube placement as a reliable method to achieve atraumatic tracheal intubation. Written consent for publication has been obtained from the patient. Linh T. Nguyen, Sudip D. Thakar, Angela T. Truong, and Dam-Thuy Truong Copyright © 2016 Linh T. Nguyen et al. All rights reserved. Epidural Catheter Migration in a Patient with Severe Spinal Stenosis Tue, 20 Dec 2016 09:11:48 +0000 Establishment of appropriate neuraxial catheter positioning is typically a straightforward procedural undertaking. It can, however, lead to deception of even the most experienced clinician and occur despite the most meticulous attention to detail. Written and verbal consent were obtained from the patient to prepare, discuss, and publish this case report; we describe the occurrence of what we believe was the intraoperative migration of an epidural catheter in the setting of significant tissue changes resulting from a previous spinal fusion. Daryl I. Smith and Ryan Anderson Copyright © 2016 Daryl I. Smith and Ryan Anderson. All rights reserved. Unilateral Vocal Cord Paralysis following Insertion of a Supreme Laryngeal Mask in a Patient with Sjögren’s Syndrome Sun, 27 Nov 2016 07:29:44 +0000 Since its introduction in 1988 by Dr. Archie Brain, the laryngeal mask airway (LMA) is being used with increasing frequency. Its ease of use has made it a very popular device in airway management and compared to endotracheal intubation it is less invasive. The use of LMA was on the rise, so has been the incidence of its related complications. We report severe unilateral vocal cord paralysis following the use of the supreme laryngeal mask (sLMA) in a patient with Sjögren’s syndrome. In addition, we propose possible mechanisms of injury, review the existing case reports, and discuss our findings. T. O. J. Masarwa, I. H. F. Herold, M. Tabor, and R. A. Bouwman Copyright © 2016 T. O. J. Masarwa et al. All rights reserved. High Dose, Prolonged Epsilon Aminocaproic Acid Infusion, and Recombinant Factor VII for Massive Postoperative Retroperitoneal Hemorrhage following Splenectomy Thu, 10 Nov 2016 11:46:19 +0000 The antifibrinolytic agent ε-aminocaproic acid is used to decrease procedural blood loss in a variety of high risk surgeries. The utility of recombinant factor VII administration in massive hemorrhage has also been reported in a variety of settings, though the impact in a surgical context remains unclear. We describe the case of a patient who underwent massive open splenectomy and developed diffuse retroperitoneal bleeding on postoperative day one. Massive transfusion was initiated, but attempts to control hemorrhage with surgical and interventional radiology approaches were unsuccessful, as was recombinant factor VII administration. Commencement of a high dose aminocaproic acid infusion was followed by a prominent rise in fibrinogen levels and stabilization of the hemorrhage. Indications, dosages, and adverse effects of ε-aminocaproic acid as described in the literature are reviewed. Alex T. Lee, Christopher R. Barnes, Shweta Jain, and Ronald Pauldine Copyright © 2016 Alex T. Lee et al. All rights reserved. Perioperative Severe Hypotension in a Patient with Multiple Endocrine Neoplasia Type IIb and Bilateral Adrenalectomies: Time to Review the Evidence for Stress Dose Steroids Wed, 09 Nov 2016 06:00:47 +0000 Multiple endocrine neoplasia type IIb (MEN IIb) is an endocrine disorder which can manifest with tumors such as pheochromocytomas and neuromas. We present the case of a patient with MEN IIb, after bilateral adrenalectomies, on maintenance steroid replacement, who underwent a neuroma resection and developed severe hypotension. There is persistent controversy regarding the general administration of perioperative “stress dose” steroids for patients with adrenal insufficiency. While the most recent literature suggests that stress dose steroids are unnecessary for secondary adrenal insufficiency, the rarer form of primary adrenal insufficiency always requires supplemental steroids, specifically hydrocortisone, when undergoing surgical procedures. Jens Tan, Acsa Zavala, Katherine B. Hagan, Antoinette Van Meter, Uduak Ursula Williams, Wei Zhang, and Pascal Owusu-Agyemang Copyright © 2016 Jens Tan et al. All rights reserved. An Unusual Lacerated Tracheal Tube during Le Fort Surgery: Literature Review and Case Report Tue, 08 Nov 2016 10:11:34 +0000 Maxillofacial surgeries can present unique anesthetic challenges due to potentially complex anatomy and the close proximity of the patient’s airway to the surgical field. Damage to the tracheal tube (TT) during maxillofacial surgery may lead to significant airway compromise. We report the management of a patient with a partially severed TT during Le Fort surgery for midfacial hypoplasia and management strategies based on peer-reviewed literature. This case illustrates the clinical clues associated with a damaged TT and explores the challenges of managing this potentially catastrophic issue. Preeta George, John E. Fiadjoe, and Allan F. Simpao Copyright © 2016 Preeta George et al. All rights reserved.