Case Reports in Anesthesiology The latest articles from Hindawi © 2017 , Hindawi Limited . 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. Cardiac Arrest after Local Anaesthetic Toxicity in a Paediatric Patient Mon, 31 Oct 2016 08:29:29 +0000 We report a case of a paediatric patient undergoing urological procedure in which a possible inadvertent intravascular or intraosseous injection of bupivacaine with adrenaline in usual doses caused subsequent cardiac arrest, completely reversed after administration of 20% intravenous lipid emulsion. Early diagnosis of local anaesthetics toxicity and adequate cardiovascular resuscitation manoeuvres contribute to the favourable outcome. Liana Maria Torres de Araújo Azi, Diego Grimaldi Figueroa, and Ana Amélia Souza Simas Copyright © 2016 Liana Maria Torres de Araújo Azi et al. 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.