Case Reports in Anesthesiology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Ultrasound-Guided Genicular Nerve Thermal Radiofrequency Ablation for Chronic Knee Pain Sun, 16 Oct 2016 15:19:32 +0000 Osteoarthritis (OA) of the knee is one of the most common joint diseases affecting adults in the United States. For elderly patients with multiple medical comorbidities who do not wish to undergo total knee arthroplasty (TKA), lifestyle modification, pharmacologic management, and injections are the mainstay of therapy. Previously, pain management interventions were limited to intra-articular joint injections and viscosupplementation with hyaluronic acid. Fluoroscopic-guided techniques for radiofrequency ablation (RFA) of the genicular nerves have been previously described and a recent cadaveric study suggests that ultrasound-guided genicular nerve blocks can be performed accurately. We performed an ultrasound-guided radiofrequency ablation of the genicular nerves in 88-year-old woman who had deferred surgical management given her age. Following successful ultrasound guided diagnostic genicular nerve blocks, she proceeded to RFA using the same ultrasound guided technique. The procedure resulted in significant pain relief and improvement in overall function for greater than 6 months. The use of ultrasound provides a relatively rapid and noninvasive method to directly visualize genicular nerves and surrounding vasculature. Our case suggests that, for genicular nerve blockade and RFA, ultrasound may be a useful alternative to fluoroscopy. Not only did the procedure result in significant pain relief that has persisted for greater than 6 months but also more importantly her function status and quality of life were improved. Joshua Wong, Nicholas Bremer, Paul D. Weyker, and Christopher A. J. Webb Copyright © 2016 Joshua Wong et al. All rights reserved. Ultrasound-Guided Femoral and Sciatic Nerve Blocks for Repair of Tibia and Fibula Fractures in a Bennett’s Wallaby (Macropus rufogriseus) Mon, 10 Oct 2016 14:19:51 +0000 Locoregional anesthetic techniques may be a very useful tool for the anesthetic management of wallabies with injuries of the pelvic limbs and may help to prevent capture myopathies resulting from stress and systemic opioids’ administration. This report describes the use of ultrasound-guided femoral and sciatic nerve blocks in Bennett’s wallaby (Macropus rufogriseus) referred for orthopaedic surgery. Ultrasound-guided femoral and sciatic nerve blocks were attempted at the femoral triangle and proximal thigh level, respectively. Whilst the sciatic nerve could be easily visualised, the femoral nerve could not be readily identified. Only the sciatic nerve was therefore blocked with ropivacaine, and methadone was administered as rescue analgesic. The ultrasound images were stored and sent for external review. Anesthesia and recovery were uneventful and the wallaby was discharged two days postoperatively. At the time of writing, it is challenging to provide safe and effective analgesia to Macropods. Detailed knowledge of the anatomy of these species is at the basis of successful locoregional anesthesia. The development of novel analgesic techniques suitable for wallabies would represent an important step forward in this field and help the clinicians dealing with these species to improve their perianesthetic management. Paolo Monticelli, Luis Campoy, and Chiara Adami Copyright © 2016 Paolo Monticelli et al. All rights reserved. An Unexpected Airway Complication in a Male Patient with Goltz Syndrome Sun, 18 Sep 2016 16:11:54 +0000 Goltz syndrome, also known as focal dermal hypoplasia, is a rare X-linked dominant multisystem syndrome presenting with cutaneous, skeletal, dental ocular, central nervous system and soft tissue abnormalities. This case report discusses an adult male patient with Goltz syndrome that was noted to have large, papillomatous, hypopharyngeal lesions upon induction of general anesthesia. We highlight challenges with airway management intraoperatively and postoperatively in patients with Goltz syndrome. Our aim is to increase awareness of the potential airway complications associated with this genetic disorder and to provide suggestions for optimal perioperative management for patients afflicted with Goltz syndrome. Sadie Smith, Kavita Gadhok, and Dmitri Guvakov Copyright © 2016 Sadie Smith et al. All rights reserved. Bronchoesophageal Fistula Stenting Using High-Frequency Jet Ventilation and Underwater Seal Gastrostomy Tube Drainage Thu, 08 Sep 2016 18:10:12 +0000 Managing a patient scheduled for bronchoesophageal fistula repair is challenging for the anesthetist. If appropriate ventilation strategy is not employed, serious complications such as hypoxemia, gastric distension, and pulmonary aspiration can occur. We present the case of a 62-year-old man with a bronchoesophageal fistula in the left main stem bronchus requiring the insertion of a Y-shaped tracheobronchial stent through a rigid bronchoscope, under general anesthesia. We successfully managed this intervention and herein report this case to demonstrate the effectiveness of underwater seal gastrostomy tube drainage used in conjunction with high-frequency jet ventilation during bronchoesophageal fistula stenting. Nitish Fokeerah, Xinwei Liu, Yonggang Hao, and Lihua Peng Copyright © 2016 Nitish Fokeerah et al. All rights reserved. Epidural Analgesia with Ropivacaine during Labour in a Patient with a SCN5A Gene Mutation Wed, 07 Sep 2016 14:04:43 +0000 SCN5A gene mutations can lead to ion channel defects which can cause cardiac conduction disturbances. In the presence of specific ECG characteristics, this mutation is called Brugada syndrome. Many drugs are associated with adverse events, making anesthesia in patients with SCN5A gene mutations or Brugada syndrome challenging. In this case report, we describe a pregnant patient with this mutation who received epidural analgesia using low dose ropivacaine and sufentanil during labour. A. L. M. J. van der Knijff-van Dortmont, M. Dirckx, J. J. Duvekot, J. W. Roos-Hesselink, A. Gonzalez Candel, C. D. van der Marel, G. P. Scoones, V. F. R. Adriaens, and I. J. J. Dons-Sinke Copyright © 2016 A. L. M. J. van der Knijff-van Dortmont et al. All rights reserved. Epidural Anesthesia Complicated by Subdural Hygromas and a Subdural Hematoma Mon, 29 Aug 2016 06:40:12 +0000 Inadvertent dural puncture during epidural anesthesia leads to intracranial hypotension, which if left unnoticed can cause life-threatening subdural hematomas or cerebellar tonsillar herniation. The highly variable presentation of intracranial hypotension hinders timely diagnosis and treatment. We present the case of a young laboring adult female, who developed subdural hygromas and a subdural hematoma following unintentional dural puncture during initiation of epidural anesthesia. Christine Vien, Paul Marovic, and Brendan Ingram Copyright © 2016 Christine Vien et al. All rights reserved. Anesthetic Management of a Surgical Patient with Chronic Renal Tubular Acidosis Complicated by Subclinical Hypothyroidism Sun, 28 Aug 2016 06:41:49 +0000 A 53-year-old man with chronic renal tubular acidosis and subclinical hypothyroidism underwent lower leg amputation surgery under general anesthesia. Perioperative acid-base management in such patients poses many difficulties because both pathophysiologies have the potential to complicate the interpretation of capnometry and arterial blood gas analysis data; inappropriate correction of chronic metabolic acidosis may lead to postoperative respiratory deterioration. We discuss the management of perioperative acidosis in order to achieve successful weaning from mechanical ventilation and promise a complete recovery from anesthesia. Hiroe Yoshioka, Haruyuki Yamazaki, Rie Yasumura, Kosuke Wada, and Yoshiro Kobayashi Copyright © 2016 Hiroe Yoshioka et al. All rights reserved. A Rare Case of C2 Sensory Blockade with Preserved Phrenic Nerve Function in an Obstetric Patient Sun, 31 Jul 2016 06:33:36 +0000 High neuraxial blockade is a serious complication in obstetric patients and requires prompt recognition and management in order to optimize patient outcomes. In cases of high neuroblockade, patients may present with significant hypotension, dyspnea, agitation, difficulty speaking or inability to speak, or even loss of consciousness. We report the unusual presentation of an obstetric patient that remained hemodynamically stable and had the preserved ability to initiate breaths despite sensory blockade up to C2. The presence of differential motor and sensory block documented in this case helped enable the patient to be managed with noninvasive ventilatory support until the high blockade regressed and we are not aware of any other similar reports in literature. John C. Coffman, Kasey Fiorini, Meghan Cook, and Robert H. Small Copyright © 2016 John C. Coffman et al. All rights reserved. The Auscultation of a Carbon Dioxide Embolization Event during Endoscopic Vein Harvest Tue, 31 May 2016 07:19:42 +0000 Endoscopic vein harvest in preparation for coronary artery bypass surgery has become a preferred method of procuring saphenous vein. Several case reports have documented carbon dioxide (CO2) embolization with this procedure as well as CO2 embolization during other laparoscopic surgeries (Markar et al., 2010). Although uncommon, the potential for CO2 entrainment through an open vein or through absorption by vascular structures exists and should be recognized (Lin et al., 2003). We report a case of CO2 embolization during EVH for a 77-year-old patient who underwent CABG that was identified early by the cardiac surgeon through the indirect auscultation of a mill-wheel murmur after the pericardium was opened. This may be the first reported case of a murmur related to air emboli identified without the use of a precordial Doppler probe or a stethoscope. This diagnosis was further supported by TEE before systemic hypotension or cardiovascular collapse occurred. Erik Strauss, Bradley Taylor, Michael Mazzeffi, Kenichi Tanaka, and Patrick Odonkor Copyright © 2016 Erik Strauss et al. All rights reserved. Sedation Monitoring and Management during Percutaneous Endoscopic Lumbar Discectomy Thu, 19 May 2016 08:58:09 +0000 Percutaneous endoscopic laser discectomy (PELD) is a painful intervention that requires deep sedation and analgesia. However, sedation should be light at some point because cooperation by the patient during the procedure is required for successful surgical treatment. Light sedation poses a problem for endotracheal intubation, while patients placed in the prone position during percutaneous endoscopic discectomy pose a problem for airway management. Therefore, under these conditions, sedation should be not deeper than required. Here we report the sedation management of three cases that underwent PELD, with a focus on deep and safe sedation that was monitored using bispectral index score and observer’s assessment of alertness/sedation score. Menekse Oksar, Tulin Gumus, and Orhan Kanbak Copyright © 2016 Menekse Oksar et al. All rights reserved. Thoracic Paravertebral Block, Multimodal Analgesia, and Monitored Anesthesia Care for Breast Cancer Surgery in Primary Lateral Sclerosis Thu, 21 Apr 2016 09:51:26 +0000 Objective. Primary lateral sclerosis (PLS) is a rare idiopathic neurodegenerative disorder affecting upper motor neurons and characterized by spasticity, muscle weakness, and bulbar involvement. It can sometimes mimic early stage of more common and fatal amyotrophic lateral sclerosis (ALS). Surgical patients with a history of neurodegenerative disorders, including PLS, may be at increased risk for general anesthesia related ventilatory depression and postoperative respiratory complications, abnormal response to muscle relaxants, and sensitivity to opioids, sedatives, and local anesthetics. We present a case of a patient with PLS and recent diagnosis of breast cancer who underwent a simple mastectomy surgery uneventfully under an ultrasound guided thoracic paravertebral block, multimodal analgesia, and monitored anesthesia care. Patient reported minimal to no pain or discomfort in the postoperative period and received no opioids for pain management before being discharged home. In patients with PLS, thoracic paravertebral block and multimodal analgesia can provide reliable anesthesia and effective analgesia for breast surgery with avoidance of potential risks associated with general anesthesia, muscle paralysis, and opioid use. Anis Dizdarevic and Anthony Fernandes Copyright © 2016 Anis Dizdarevic and Anthony Fernandes. All rights reserved. Anesthesiological Management of a Patient with Williams Syndrome Undergoing Spine Surgery Wed, 16 Mar 2016 12:10:45 +0000 Williams Syndrome (WS) is a complex neurodevelopmental disorder associated with a mutation on chromosome 7. Patients with WS usually display dysmorphic facial and musculoskeletal features, congenital heart diseases, metabolic disturbances and cognitive impairment. Structural cardiovascular abnormalities are present in the majority of the children and may provide a substrate for perioperative Sudden Cardiac Death, as presented by several reports, something that creates a great challenge to the anesthetic conduct. We present the case of a 12-year old girl who required anesthetic care for surgical correction of an acquired kyphoscoliosis. Potential anesthesiological implications of WS are subsequently reviewed. Federico Boncagni, Luca Pecora, Vasco Durazzi, and Francesco Ventrella Copyright © 2016 Federico Boncagni et al. All rights reserved. Use of an Esophageal Heat Exchanger to Maintain Core Temperature during Burn Excisions and to Attenuate Pyrexia on the Burns Intensive Care Unit Thu, 25 Feb 2016 12:42:57 +0000 Introduction. Burns patients are vulnerable to hyperthermia due to sepsis and SIRS and to hypothermia due to heat loss during excision surgery. Both states are associated with increased morbidity and mortality. We describe the first use of a novel esophageal heat exchange device in combination with a heater/cooler unit to manage perioperative hypothermia and postoperative pyrexia. Material and Methods. The device was used in three patients with full thickness burns of 51%, 49%, and 45% body surface area to reduce perioperative hypothermia during surgeries of >6 h duration and subsequently to control hyperthermia in one of the patients who developed pyrexia of 40°C on the 22nd postoperative day due to E. coli/Candida septicaemia which was unresponsive to conventional cooling strategies. Results. Perioperative core temperature was maintained at 37°C for all three patients, and it was possible to reduce ambient temperature to 26°C to increase comfort levels for the operating team. The core temperature of the pyrexial patient was reduced to 38.5°C within 2.5 h of instituting the device and maintained around this value thereafter. Conclusion. The device was easy to use with no adverse incidents and helped maintain normothermia in all cases. David Williams, Gordon Leslie, Dimitrios Kyriazis, Benjamin O’Donovan, Joanne Bowes, and John Dingley Copyright © 2016 David Williams et al. All rights reserved. Management of Anesthesia under Extracorporeal Cardiopulmonary Support in an Infant with Severe Subglottic Stenosis Thu, 18 Feb 2016 11:20:12 +0000 A 4-month-old female infant who weighed 3.57 kg with severe subglottic stenosis underwent tracheostomy under extracorporeal cardiopulmonary support. First, we set up extracorporeal cardiopulmonary support to the infant and then successfully intubated an endotracheal tube with a 2.5 mm inner diameter before tracheostomy by otolaryngologists. Extracorporeal cardiopulmonary support is an alternative for maintenance of oxygenation in difficult airway management in infants. Rie Soeda, Fumika Taniguchi, Maiko Sawada, Saeko Hamaoka, Masayuki Shibasaki, Yasufumi Nakajima, Satoru Hashimoto, Teiji Sawa, and Yoshinobu Nakayama Copyright © 2016 Rie Soeda et al. All rights reserved. Is It Possible to Maintain Consciousness and Spontaneous Ventilation with Chest Compression in the Early Phase of Cardiac Arrest? Thu, 11 Feb 2016 09:41:51 +0000 Chest compression is important in cardiopulmonary resuscitation. However, life support algorithms do not specify when chest compression should be initiated in patients with persistent spontaneous normal breathing in the early phase after cardiac arrest. Here we describe the case of a 69-year-old man who underwent femoral bypass surgery and was extubated at the end of the procedure. After extubation, the patient’s breathing pattern and respiratory rate were normal. The patient subsequently developed ventricular fibrillation, evident on two monitors. Because defibrillation was ineffective, chest compression was initiated even though the patient had spontaneous normal breathing and defensive motor reflexes, which were continued throughout resuscitation. He regained consciousness and underwent tracheal extubation without neurological sequelae on postoperative day 1. This case highlights the necessity of chest compression in the early phase of cardiac arrest. Menekse Oksar and Selim Turhanoglu Copyright © 2016 Menekse Oksar and Selim Turhanoglu. All rights reserved. Complex Perioperative Decision-Making: Liver Resection in a Patient with Extensive Superior Vena Cava/Right Atrial Thrombus and Superior Vena Cava Syndrome Wed, 20 Jan 2016 16:03:36 +0000 The perioperative management of patients suffering from extensive superior vena cava (SVC) thrombus complicated by SVC syndrome presents unique challenges. The anesthesiologist needs to be prepared for possible thrombus dislodgement resulting in pulmonary embolism and also has to assess the need for fluid resuscitation given the dangers of massive intravenous fluid application via the upper extremities. We present our perioperative approach in management of a patient scheduled for right hepatectomy who was previously diagnosed with extensive SVC and right atrial (RA) thrombus complicated by SVC syndrome. Benjamin Kloesel and Robert W. Lekowski Copyright © 2016 Benjamin Kloesel and Robert W. Lekowski. All rights reserved. Workup and Management of Persistent Neuralgia following Nerve Block Tue, 19 Jan 2016 08:57:07 +0000 Neurological injuries following peripheral nerve blocks are a relatively rare yet potentially devastating complication depending on the type of lesion, affected extremity, and duration of symptoms. Medical management continues to be the treatment modality of choice with multimodal nonopioid analgesics as the cornerstone of this therapy. We report the case of a 28-year-old man who developed a clinical common peroneal and lateral sural cutaneous neuropathy following an uncomplicated popliteal sciatic nerve block. Workup with electrodiagnostic studies and magnetic resonance neurography revealed injury to both the femoral and sciatic nerves. Diagnostic studies and potential mechanisms for nerve injury are discussed. Paul David Weyker, Christopher Allen-John Webb, and Thoha M. Pham Copyright © 2016 Paul David Weyker et al. All rights reserved. Anaesthetic Management of a Patient with Thyrotoxicosis for Nonthyroid Surgery with Peripheral Nerve Blockade Sun, 17 Jan 2016 09:00:25 +0000 Thyrotoxicosis is a hypermetabolic condition caused by an elevation in thyroid hormone levels. The disorder has a variety of causes, manifestations, and therapies. Several clinical features of thyrotoxicosis are due to sympathetic stimulation with increased beta-adrenoreceptor upregulation and sensitization to catecholamine. Anaesthetic management of thyrotoxicosis patients using neuraxial block has been described in literature; however, to our knowledge, there are no reports of peripheral nerve block utilization. Here, we report on the anaesthetic management of a patient with thyroiditis-associated thyrotoxicosis undergoing emergency surgery via a femoral and sciatic nerve block. Mehmet I. Buget, Bilge Sencan, Giray Varansu, and Suleyman Kucukay Copyright © 2016 Mehmet I. Buget et al. All rights reserved. Long-Term Intravenous Ketamine for Analgesia in a Child with Severe Chronic Intestinal Graft versus Host Disease Tue, 08 Dec 2015 13:56:35 +0000 Ketamine is reported to be an effective adjuvant to opioids in the treatment of refractory cancer pain; however, the use of high doses of ketamine for extended periods in pediatric patients has not been described. We present a five-year-old male with grade IV intestinal GVHD whose abdominal pain required both hydromorphone and ketamine for a period of over four months. There was no evidence of hepatotoxicity, hemorrhagic cystitis, or other adverse effects. Possible withdrawal symptoms were mild and were readily mitigated by gradually weaning ketamine. Jennifer Busse, Leroy Phillips, and William Schechter Copyright © 2015 Jennifer Busse et al. All rights reserved. Nosocomial Methemoglobinemia Resulting from Self-Administration of Benzocaine Spray Wed, 28 Oct 2015 11:43:48 +0000 Methemoglobinemia is life-threatening and bears pathognomonic signs difficult to diagnose in real time. Local anesthetics are widely used and are known for eliciting this condition. We report a case of methemoglobinemia secondary to self-administered use of benzocaine spray. A 27-year-old woman was found to be in respiratory distress during postoperative recovery. After desaturation persisted, arterial blood gas yielded a methemoglobin level of 47%. The patient was successfully treated with intravenous methylene blue. Review of the events revealed self-administered doses of benzocaine spray to alleviate discomfort from a nasogastric tube. We review this case in detail in addition to discussing methemoglobinemia and its relevant biochemistry, pathophysiology, clinical presentation, and medical management. Given the recognized risk of methemoglobinemia associated with benzocaine use, we recommend its removal from the market in favor of safer alternatives. Christopher Hoffman, Hawa Abubakar, Pramood Kalikiri, and Michael Green Copyright © 2015 Christopher Hoffman et al. All rights reserved. Use of Peripheral Nerve Blocks with Sedation for Total Knee Arthroplasty in a Patient with Contraindication for General Anesthesia Mon, 26 Oct 2015 06:40:16 +0000 Although peripheral nerve blocks are commonly used to provide postoperative analgesia after total knee arthroplasty (TKA) and other lower extremity procedures, these blocks are rarely used for intraoperative anesthesia. Most TKAs are performed under general anesthesia (GA) or neuraxial anesthesia (NA). The knee has a complex sensory innervation that makes surgical anesthesia difficult with peripheral nerve blocks alone. Rarely are both GA and NA relatively contraindicated and alternatives are considered. We present a patient who underwent TKA performed under peripheral nerve block and sedation alone. Eric Kamenetsky, Antoun Nader, and Mark C. Kendall Copyright © 2015 Eric Kamenetsky et al. All rights reserved. Uncommon Cause of Trigeminal Neuralgia: Tentorial Ossification over Trigeminal Notch Mon, 24 Aug 2015 11:13:04 +0000 Ossification of the tentorium cerebelli over the trigeminal notch is rare, but it may cause compression of the trigeminal nerve, leading to trigeminal neuralgia (TN). We were unable to find any previously reported cases with radiological evaluation, although we did find one case with surgically proven ossification of the tentorium cerebelli. Here, we present a case of TN caused by tentorial ossification over the trigeminal notch depicted on magnetic resonance imaging (MRI) and computed tomography (CT). Sun Woo Bang, Kyung Ream Han, Seung Ho Kim, Won Ho Jeong, Eun Jin Kim, Jin Wook Choi, and Chan Kim Copyright © 2015 Sun Woo Bang et al. All rights reserved. Anesthetic Approach for a Patient with Jeune Syndrome Sun, 23 Aug 2015 12:02:13 +0000 Jeune syndrome (JS) is an autosomal recessive disease also known as asphyxiating thoracic dystrophy. A narrow bell-shaped thoracic wall and short extremities are the most typical features of the syndrome. Prognosis in JS depends on the severity of the pulmonary hypoplasia caused by the chest wall deformity. Most patient deaths are due to respiratory problems at early ages. Herein, we report a case of JS patient, who was scheduled for femoral extension under general anesthesia. The severity of respiratory problems in JS patients is thought to diminish with age. Our case supported this theory, and we managed the anesthetic process uneventfully. Mehmet I. Buget, Emine Ozkan, Ipek S. Edipoglu, and Suleyman Kucukay Copyright © 2015 Mehmet I. Buget et al. All rights reserved. Paravertebral Block Combined with Sedation for a Myasthenic Patient Undergoing Breast Augmentation Mon, 17 Aug 2015 11:54:48 +0000 Paravertebral block is a unilateral analgesic technique that can provide adequate surgical anesthesia and great advantages in many types of surgery with a low side-effect profile. In this case we present combination of bilateral thoracic paravertebral block under ultrasound guidance with sedation which provides complete anesthesia and postoperative analgesia in a myasthenic patient undergoing cosmetic breast surgery. In myasthenic patients paravertebral blocks may be a better option for breast surgery with avoiding the need for muscle relaxants and opioids and risk of respiratory failure in postoperative period. Betul Kozanhan, Betul Basaran, Leyla Kutlucan, and Sadık Ozmen Copyright © 2015 Betul Kozanhan et al. All rights reserved. “High Frequency/Small Tidal Volume Differential Lung Ventilation”: A Technique of Ventilating the Nondependent Lung of One Lung Ventilation for Robotically Assisted Thoracic Surgery Wed, 12 Aug 2015 06:32:40 +0000 With the introduction of new techniques and advances in the thoracic surgery fields, challenges to the anesthesia techniques had became increasingly exponential. One of the great improvements that took place in the thoracic surgical field was the use of the robotically assisted thoracic surgical procedure and minimally invasive endoscopic thoracic surgery. One lung ventilation technique represents the core anesthetic management for the success of those surgical procedures. Even with the use of effective one lung ventilation, the patient hemodynamics and respiratory parameters could be deranged and could not be tolerating the procedure that could compromise the end result of surgery. We are presenting our experience in managing one patient who suffered persistent hypoxia and hemodynamic instability with one lung ventilation for robotically assisted thymectomy procedure and how it was managed till the completion of the surgery successfully. Bassam M. Shoman, Hany O. Ragab, Ammar Mustafa, and Rashid Mazhar Copyright © 2015 Bassam M. Shoman et al. All rights reserved. Bladder Explosion during Transurethral Resection of the Prostate with Nitrous Oxide Inhalation Thu, 30 Jul 2015 11:55:45 +0000 Bladder explosions are a rare complication of transurethral resection of the prostate. We report a patient who suffered a bladder rupture following transurethral resection of the prostate. Although explosive gases accumulate during the procedure, a high concentration of oxygen is needed to support an explosion. This rare phenomenon can be prevented by preventing the flow of room air into the bladder during the procedure to maintain a low concentration of oxygen inside the bladder. Eiko Hirai, Joho Tokumine, Alan Kawarai Lefor, Shinobu Ogura, and Miwako Kawamata Copyright © 2015 Eiko Hirai et al. All rights reserved. Case Report of Multiple Tracheostomy Revisions due to Persistent, Recurrent Cuff Leak Thu, 09 Jul 2015 13:38:27 +0000 This case is a patient with amyotrophic lateral sclerosis who was unable to be separated from mechanical ventilator support and required a tracheostomy. The patient underwent an initial open tracheostomy utilizing flexible fiberoptic tracheoscopy (FFT) in the operating room (OR). Subsequently, he developed recurrent leaks in the tracheal tube cuff requiring multiple trips back to the operating room. The recurrent cuff leak occurred following each tube placement until the etiology of the leak was discovered during the fourth procedure. In the fourth procedure, the wound was explored more extensively, and it was found that there was a sharp, calcified, aberrant fragment of a tracheal cartilage ring protruding into the tracheal lumen, which was damaging the cuff of each tube. This fragment was not visible by multiple FFTs, nor was it visible in the wound by the surgeons until wider exploration of the wound occurred. The cartilage fragment was ultimately excised and the patient had no further cuff leaks. Aberrant tracheal cartilage should be on the differential diagnosis for cuff leaks subsequent to surgical tracheostomy (ST) or percutaneous dilatational tracheostomy (PDT). Jian P. Azimi-Bolourian, Issa A. Hanna, and George W. Williams Copyright © 2015 Jian P. Azimi-Bolourian et al. All rights reserved. Right Breast Mastectomy and Reconstruction with Tissue Expander under Thoracic Paravertebral Blocks in a 12-Week Parturient Thu, 02 Jul 2015 10:42:37 +0000 Paravertebral blocks are becoming increasingly utilized for breast surgery with studies showing improved postoperative pain control, decreased need for opioids, and less nausea and vomiting. We describe the anesthetic management of an otherwise healthy woman who was 12 weeks pregnant presenting for treatment of her breast cancer. For patients undergoing breast mastectomy and reconstruction with tissue expanders, paravertebral blocks offer an anesthetic alternative when general anesthesia is not desired. Christopher Allen-John Webb, Paul David Weyker, Shara Cohn, Amanda Wheeler, and Jennifer Lee Copyright © 2015 Christopher Allen-John Webb et al. All rights reserved. Preterm Caesarean Delivery in a Parturient with Candida parapsilosis Endocarditis Mon, 29 Jun 2015 08:46:34 +0000 We present the first documented case of Candida parapsilosis infective endocarditis in a pregnant patient. While the incidence of infective endocarditis during pregnancy is rare, the incidence of C. parapsilosis endocarditis is even rarer. The numerous specific risks and decision making processes regarding this case are presented. Jason Fu, Lance M. Retherford, and Brigid Flynn Copyright © 2015 Jason Fu et al. All rights reserved. Excessive Dynamic Airway Collapse: An Unexpected Contributor to Respiratory Failure in a Surgical Patient Mon, 08 Jun 2015 13:47:40 +0000 Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients. Historically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large airways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of cartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction during exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing, difficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy has identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed consideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM, describe how this condition contributed to this patient’s respiratory failure, and review diagnosis and management options. Michael R. Lyaker, Victor R. Davila, and Thomas J. Papadimos Copyright © 2015 Michael R. Lyaker et al. All rights reserved.