Repeated dressing changes following anorectal surgery may result in severe procedural pain that is inadequately controlled with conventional systemic analgesia. Procedural sedation is often used when pain remains refractory but may be associated with adverse effects and increased resource utilization. We describe the use of patient-controlled epidural analgesia (PCEA) as an alternative strategy for managing severe procedural pain and avoiding repeated procedural sedation.We report the case of a 34-year-old male undergoing surgery for recurrent perianal fistula after three previous procedures. Postoperatively, he experienced severe pain, particularly during dressing changes, with Numerical Rating Scale (NRS) scores of 9–10 despite a multimodal non-opioid analgesic regimen consisting of intravenous paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) administered intravenously and rectally. Repeated procedural sedation was required for wound care but was complicated by respiratory adverse effects, nausea, vomiting, and dizziness. After discussion of available options, the patient consented to PCEA. Following initiation of PCEA, pain during dressing changes decreased from NRS 9–10 to 3–4, no further procedural sedation was required, no clinically apparent motor impairment or urinary retention was observed, and the patient reported high satisfaction with pain management.Epidural analgesia has well-established benefits in postoperative pain control and is associated with additional perioperative benefits. In this case, the principal benefit of PCEA extended beyond analgesia to facilitation of repeated wound care without recurrent exposure to procedural sedation.This case suggests that PCEA may be a feasible sedation-sparing option in selected patients with severe recurrent procedural pain when conventional systemic analgesia is inadequate and repeated procedural sedation is poorly tolerated.
Study objective To compare the postoperative analgesic efficacy of ultrasound-guided genicular nerve block (GNB) versus adductor canal block (ACB) in patients undergoing elective knee arthroscopy. Design Single-blind, randomized controlled trial. Setting Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico. Patients Fifty-six adults aged 18–80 years with ASA physical status I-II scheduled for elective knee arthroscopy. Interventions Patients were randomly assigned to GNB (ropivacaine 0.375%, 5 mL per nerve; three nerves; 15 mL total) targeting the superomedial, superolateral, and inferomedial genicular nerves, or ACB (ropivacaine 0.375%, 15 mL) within the adductor canal, both under real-time ultrasound guidance within a standardized anesthetic protocol including subarachnoid block. Measurements NRS (0−10) pain scores at 12 h and 24 h (co-primary); rescue tramadol requirements (50 mg IV, triggered at NRS ≥ 4) at 8, 12, and 24 h; block-related complications.Main results: Fifty-six patients completed follow-up (28 per group). At 12 h, median NRS was 3.0 in both groups (p = 0.464). At 24 h, median NRS was 2.0 (IQR 1.0–4.0) in the ACB group versus 3.0 (IQR 2.0–4.25) in the GNB group (U = 257.0; p = 0.025); because the two time points were co-primary, a Bonferroni-corrected threshold (α = 0.025) was applied and this difference did not reach significance. Rescue analgesia within 24 h was required by 25.0% (ACB) versus 39.3% (GNB) (OR 1.94, 95% CI 0.62–6.09; p = 0.39). Cumulative rescue tramadol was comparable (mean 17.9 vs 21.4 mg; p = 0.395). No major block-related complications occurred. Conclusion Both ultrasound-guided ACB and GNB provided effective postoperative analgesia in knee arthroscopy. The small 24-h difference favoring ACB did not remain significant after correction for multiplicity, and rescue requirements were comparable. These techniques may be used interchangeably within multimodal analgesic protocols.
Study objective To compare the analgesic efficacy of lumbar erector spinae plane block (ESPB) and fascia iliaca block (FIB) in elderly patients undergoing surgery for hip fractures. Design Prospective, exploratory, observational study. Setting Orthopedic Departments of a major Italian hospital (AORN Antonio Cardarelli, Naples). Patients Fifty patients aged ≥65 years (31 FIB, 19 ESPB) scheduled for hip fracture surgery. Intervention Preoperative ultrasound-guided FIB or lumbar ESPB with 30 mL of 0.25% ropivacaine, followed by standardized spinal anesthesia with 10 mg of 0.5% ropivacaine. Measurements The primary outcome was postoperative pain intensity assessed using the Numeric Rating Scale (NRS) at 12, 24, and 48 h. Secondary outcomes included time to first rescue analgesia, time to mobilization, return of bowel function, and adverse events within 48 h. Main results Baseline characteristics were comparable between groups. Postoperative NRS pain scores showed no statistically significant differences at rest or during mobilization at any time point. At 12 h, median NRS at rest was 1 for FIB and 0 for ESPB (p = 0.331), and during mobilization was 4 and 2, respectively (p = 0.236). However, the temporal distribution of the first rescue analgesic request differed significantly (p = 0.001); requests occurred earlier in the FIB group (48% within 12 h), whereas the ESPB group showed a more gradual distribution (37% requested between 12 and 24 h). All patients achieved early mobilization within 48 h. Adverse events were infrequent and comparable. Conclusion FIB and lumbar ESPB provide similar overall postoperative pain control and safety in elderly patients undergoing hip fracture surgery. ESPB may offer a more gradual analgesic profile, though procedural positioning challenges must be balanced against FIB's ease of supine execution.
Study objective To examine the association between local anesthetic admixture composition and postoperative analgesic duration in patients undergoing primary total hip arthroplasty (THA) with caudal epidural block. Design Single-center retrospective cohort study. Setting Department of Anesthesiology, Saiseikai Niigata Hospital, Japan, April 2016 to March 2018. Patients 162 adults who underwent elective primary THA with single-shot caudal epidural block, after excluding 54 patients (1 with sudden postoperative crisis, 37 with surgical duration >200 min, and 16 with inadequate immediate analgesia or block failure). Intervention Caudal epidural ropivacaine, with or without mepivacaine admixture, at the discretion of the attending anesthesiologist. Epidural morphine (1–3 mg) was added in selected cases. Measurements The primary outcome was time to first rescue analgesic use within 24 h. Cox proportional-hazards regression with robust standard errors was used for the primary analysis. Standardized mean differences (SMDs) assessed baseline balance, and the temporal distribution of exposures was examined for era effects. Main results Among 162 patients, 116 (71.6%) received mepivacaine admixture. Stratified analysis revealed meaningful imbalances (|SMD| > 0.20) in eight variables, most prominently epidural fentanyl use (51.7% vs 93.5%, SMD = 1.06) and bridging analgesia (91.4% vs 60.9%, SMD = 0.77); mepivacaine use increased over the study period (62.5% in 2016 to 78.6% in 2018, SMD = 0.33). In the adjusted Cox model, mepivacaine admixture was associated with earlier first rescue analgesic use (adjusted hazard ratio 2.11, 95% confidence interval 1.13–3.94; P = 0.019), whereas epidural morphine was associated with delayed rescue (adjusted HR 0.51, 95% CI 0.30–0.84; P = 0.008). Conclusion Mepivacaine admixture with ropivacaine was associated with shorter analgesic duration after caudal epidural block, whereas epidural morphine prolonged analgesia. Although substantial baseline imbalances and temporal practice changes were observed and adjusted for, these findings, consistent with peripheral nerve block meta-analyses, provide pharmacological insights relevant to contemporary regional anesthesia practice.
Situs inversus totalis (SIT) is a rare congenital anomaly associated with mirror-image reversal of the tracheobronchial anatomy, which may complicate lung isolation during thoracic surgery. We report a case of thoracoscopic right upper lobectomy in a patient with SIT in whom placement of a left-sided double-lumen tube (DLT) into the right main bronchus was unsuccessful despite fiberoptic guidance. The DLT passed through the glottis easily under video laryngoscopy, and a fiberoptic bronchoscope was advanced into the right main bronchus. However, the bronchial tip repeatedly encountered resistance near the carina and could not be advanced into the intended bronchus. After two unsuccessful attempts, the airway device was exchanged for a 35-Fr right-sided DLT. A fiberoptic bronchoscope was first advanced into the right main bronchus through the bronchial lumen, and the right-sided DLT was readily guided into position over the bronchoscope. Adequate placement was confirmed by fiberoptic bronchoscopy. One-lung ventilation was maintained without difficulty, and the surgical procedure was completed uneventfully. This case suggests that a left-sided DLT may not always be feasible in patients with SIT, even when bronchoscopic guidance is straightforward. A right-sided DLT may represent a practical rescue option when placement of a left-sided DLT is difficult, provided that its position is carefully confirmed by fiberoptic bronchoscopy.
Laparoscopic Roux-en-Y gastric bypass (RYGB) is a major surgical procedure performed for weight loss in morbidly obese patients. Most of these patients have underlying comorbidities such as ischaemic heart disease, diabetes, obstructive sleep apnoea (OSA), hypertension, and other conditions. Providing effective postoperative analgesia is crucial for optimal cardiorespiratory outcomes. Opioids may be detrimental in patients with OSA; therefore, opioid-sparing regional anaesthesia techniques may be advantageous. External oblique intercostal (EOI) plane block is a technique that provides effective analgesia for upper abdominal surgery. We describe the effective application of continuous EOI plane block in five morbidly obese patients with OSA on continuous positive airway pressure (CPAP) therapy who underwent laparoscopic RYGB.
Laryngomalacia is the most common cause of congenital stridor in infants and may present significant airway challenges during anesthesia. Severe cases often require supraglottoplasty, necessitating a secured airway in the presence of dynamic supraglottic collapse. We report the anesthetic management of a 3-month-old infant with severe laryngomalacia undergoing coblation-assisted supraglottoplasty. Direct laryngoscopy failed because of poor visualization of the glottis and rapid oxygen desaturation. Successful tracheal intubation was subsequently achieved using video laryngoscope-assisted flexible bronchoscopy intubation (VAFI) while maintaining spontaneous ventilation. This case highlights the utility of combining video laryngoscopy with flexible bronchoscopy for airway management in infants with difficult airway anatomy due to laryngomalacia.
Critical tracheal obstruction caused by anterior mediastinal masses constitutes one of the most life-threatening emergencies in airway management. The potential for complete airway collapse upon induction of anesthesia, coupled with the lack of a reliable rescue mechanism, should conventional intubation prove unsuccessful, necessitates meticulous pre-procedural planning. The Fourth National Audit Project (NAP4) identified human factors, namely communication failures, inadequate leadership, and poor team coordination, as contributors to 40% of major airway complications. An additional critical consideration concerns conceptual clarity regarding extracorporeal membrane oxygenation (ECMO): a prospectively planned standby ECMO, with personnel, a primed circuit, and vascular access pre-established, represents a viable contingency for anticipated difficult airways. Conversely, unplanned rescue ECMO during a Cannot Intubate, Cannot Oxygenate (CICO) crisis is unrealistic; even experienced centers require a minimum of fifteen to twenty minutes for cannulation, thus far exceeding the window before irreversible hypoxic brain injury. A 43-year-old male patient presented with severe dyspnea and 80–90% tracheal obstruction resulting from an undiagnosed mediastinal T-cell lymphoblastic leukemia. The multidisciplinary team employed structured pre-briefing in accordance with crisis resource management (CRM) principles, with explicit role assignments, standardized critical language, safe patient transport facilitated by high-flow nasal oxygenation (HFNO), prophylactic femoral vascular access for standby ECMO, and awake fiberoptic intubation, achieving first-pass airway success. Following thirty-five days of mechanical ventilation during chemotherapy, the patient was successfully extubated and discharged on the forty-ninth hospital day. Awake tracheal intubation with standby ECMO, combined with structured team coordination and a standardized critical language, exemplifies the optimal systems-based model for anticipated difficult airway emergencies.
Diabetic ketoacidosis in pregnancy (DKP) is a rare but potentially life-threatening condition. Physiological changes during pregnancy increase susceptibility to DKP and may result in presentation at relatively normal blood glucose levels, making diagnosis challenging.We report the case of a 33-year-old para 3 woman with type 1 diabetes managed with an insulin pump who presented preterm with regular contractions. She was diagnosed with DKP based on biochemical findings and the presence of multiple precipitating factors. Despite prompt fluid resuscitation, insulin therapy, and electrolyte replacement, maternal acidosis worsened and fetal heart rate abnormalities developed, necessitating emergency delivery.An unusual feature was the persistence of elevated blood ketone levels for more than 24 h despite correction of acidosis, requiring prolonged insulin infusion. This case highlights the importance of early recognition, multidisciplinary management, and careful assessment of maternal and fetal status when considering the timing of delivery in DKP.
Congenital sensorineural hearing loss (SNHL), the most common congenital sensory deficit. In cases of absent cochlear nerves/labyrinthine aplasia, cochlear implantation is ineffective, and auditory brainstem implantation (ABI) provides an alternative by directly stimulating the cochlear nucleus. Anesthetic management in infants is challenging due to brainstem manipulation, immature autonomic regulation, syndromic features, and coexisting congenital heart disease.We report the perioperative management of a 1-year-old child with bilateral cochlear nerve aplasia, dysmorphism, global developmental delay, and acyanotic congenital heart disease undergoing ABI. Anesthesia was induced with propofol, fentanyl, and atracurium, and maintained with total intravenous anesthesia to facilitate neurophysiological monitoring. Transient bradycardia and hypotension during electrode placement were managed conservatively. The postoperative course was uneventful. This case underscores the importance of meticulous planning, titrated anesthesia, and preparedness for brainstem reflexes to optimise outcomes in this high-risk population.
Vertebrobasilar Dolichoectasia is a rare pathology characterized by elongation and dilatation of Vertebrobasilar system. It can present as ischemic stroke, cranial nerve deficits or features of brainstem compression. Catastrophic complications such as subarachnoid and intracranial hemorrhage have also been reported. Anesthetic management is challenging due to compromised posterior circulation and brainstem mediated cardiovascular reflexes. We report the case of a 67-year-old female who presented with symptomatic vertebrobasilar dolichoectasia and underwent endovascular stenting under general anesthesia in our hospital. Perioperative management focused on strict hemodynamic stability, minimizing head and neck movements, smooth induction and emergence to prevent blood flow compromise in vertebrobasilar system. A braided stent was placed across the dilated arterial segment with good flow across the stent on check angiogram. Patient showed significant clinical improvement postoperatively and was discharged without any complications. This case highlights the importance of meticulous anesthetic planning, invasive monitoring and controlled hemodynamic management during endovascular procedures in patients with vertebrobasilar dolichoectasia.
Landmark palpation for spinal anaesthesia is difficult in morbidly obese patients due to excessive subcutaneous fat obscuring the lumbar spine. Ultrasound guidance is ideal but not universally available. This case series describes bilateral subcutaneous fat retraction, a manual technique to improve landmark identification in 15 morbidly obese patients scheduled for surgery under spinal anaesthesia. After informed consent, 15 ASA III patients with BMI >40 kg/m2 with impalpable lumbar landmarks in sitting position and two assistants manually retracted bilateral flank/abdominal fat pads laterally and cephalad using both palms, exposing the midline. The L3-L4/ L4-L5 interspace was identified and spinal anaesthesia performed with a 25G Quincke needle. Primary outcome was first-attempt success. Mean BMI was 44.2 ± 3.8 kg/m2. First-attempt dural puncture succeeded in 13/15 (86.7%). No post-operative neurological complications occurred. Bilateral subcutaneous fat retraction is a minimal cost maneuver that facilitates landmark-guided spinal anaesthesia in morbidly obese patients with impalpable spine.
Study Objective To identify perioperative variables independently associated with postoperative hypothermia in adults undergoing elective surgery at a tertiary referral hospital. Design Prospective observational study. Setting Operating rooms and post-anesthesia care unit (PACU) of a tertiary university hospital in Colombia. Patients A total of 210 adults undergoing elective surgery under general or regional anesthesia between June 1 and December 31, 2025, were prospectively enrolled. Postoperative hypothermia was predefined as a tympanic temperature < 36.0 °C measured on admission to the PACU. Intervention None. Measurements Demographic, clinical, anesthetic, surgical, and perioperative thermal management variables were prospectively collected using standardized case report forms. Univariable analyses were followed by multivariable logistic regression to identify variables independently associated with postoperative hypothermia. Candidate variables were selected according to clinical relevance and the prespecified statistical analysis plan. Main Results Postoperative hypothermia occurred in 61 patients (29.1%). In the multivariable model, higher preoperative tympanic temperature was independently associated with lower odds of postoperative hypothermia (OR 0.09, 95% CI 0.02–0.48; P = 0.005), whereas procedures performed during the afternoon were independently associated with higher odds of postoperative hypothermia (OR 2.34, 95% CI 1.12–4.91; P = 0.025). No independent associations were observed for age, sex, body mass index, ASA physical status, anesthesia technique, anesthesia duration, surgical duration, operating room temperature, use of active warming systems, or dipyrone administration. Because detailed implementation of perioperative warming interventions was not systematically recorded, these findings should not be interpreted as evidence regarding the effectiveness of active warming strategies. Conclusions Higher preoperative body temperature and afternoon surgical scheduling were independently associated with postoperative hypothermia in this prospective observational study. These findings should be considered exploratory because of the observational design and require confirmation in larger multicenter studies incorporating standardized perioperative temperature monitoring and protocolized thermal management.
Study objective To determine the incidence of residual neuromuscular blockade (rNMB) on post-anesthesia care unit (PACU) admission using quantitative train-of-four (TOF) monitoring and to examine its association with reversal agent choice. Design Single-center ambidirectional observational cohort study with a prospective cohort and a retrospective cohort for contextual comparison. Setting Academic tertiary care center. Patients Adults (≥18 years) undergoing surgery with general anesthesia with nondepolarizing neuromuscular blockade (n = 622; 311 retrospective, 311 prospective). Intervention Prospective patients underwent quantitative TOF monitoring on PACU admission. Measurements Primary outcome was rNMB (TOF <0.9). Secondary measures included neuromuscular blockade reversal agent use and postoperative outcomes. Main results In the prospective cohort, rNMB was observed in 20.3% of patients. rNMB was more frequent in patients who received neostigmine compared with sugammadex (24.9% vs. 3.0%). Most patients with rNMB achieved recovery following supplemental sugammadex in the PACU. Differences in postoperative outcomes between cohorts were observed; however, these findings should be interpreted cautiously given potential confounding and differences in cohort characteristics. Conclusion Residual neuromuscular blockade remains common in routine practice when assessed with qualitative monitoring. Qualitative TOF assessment alone may not reliably exclude rNMB. These findings support broader use of quantitative neuromuscular monitoring and careful selection of neuromuscular blockade reversal strategies to enhance perioperative safety.
Mechanical causes of intraoperative anuria are typically excluded by inspection of visible components of the urinary drainage system. However, a malfunction arising from the non-visible intravesical portion of a Foley catheter may escape routine assessment while producing a clinical picture indistinguishable from true anuria. We report a case of intraoperative anuria caused by a reversible Foley catheter obstruction associated with retention balloon inflation. Balloon deflation resulted in immediate restoration of urine drainage, while reinflation reproducibly interrupted flow. This finding emphasized the limitations of external catheter inspection alone. Temporary deflation of the retention balloon may represent a simple diagnostic maneuver when unexplained intraoperative anuria persists despite exclusion of more common causes. Incorporating this step into catheter troubleshooting may facilitate earlier diagnosis and help avoid unnecessary diagnostic or therapeutic interventions.
A 37-year-old woman with recurrent left upper limb swelling and occlusive thrombosis of the subclavian and cephalic veins due to venous thoracic outlet syndrome underwent first rib resection for definitive decompression.To minimise peri-operative opioid exposure due to a history of substance dependence, a combined regional anaesthesia and general anaesthesia technique was used. Preoperatively, ultrasound-guided superficial cervical plexus, Pectoralis 1 (PECS1), and T1 intercostal nerve blocks were performed using 30 ml ropivacaine 0.375%. General anaesthesia was induced and maintained with propofol and remifentanil, with additional multimodal analgesia including ketamine, paracetamol, NSAIDs, and minimal further opioids. A paraclavicular surgical approach was used. The procedure and anaesthesia were uneventful, with minimal blood loss and stable intra-operative conditions.Postoperatively, excellent analgesia was achieved with very limited opioid requirements. She mobilised early, had no neurological deficits, and was discharged home on day three. At eight-week follow-up, duplex ultrasound demonstrated a widely patent axillary and subclavian vein with normal neurovascular function.Despite the complex innervation and anatomy, this case highlights the role of effective multimodal regional techniques as an opioid-sparing strategy in first rib resection. The regional block combination assisted anaesthesia and post-operative analgesia while avoiding potentially riskier approaches in non-compressible locations, such as neuraxial or paravertebral approaches.
Airway Scope® facilitates intubation when neck extension is restricted, but adult Intlock insertion may be difficult with limited mouth opening. We used a pediatric Intlock with a gum elastic bougie in three adults with restricted mouth opening and limited neck extension. Intubation succeeded without complications. Visualization was favorable when the hyomental distance was relatively short, whereas blade reach appeared limited when it was longer (approximately 45 mm); bougie guidance nonetheless enabled intubation. This technique may be a useful option in selected adults with shortened hyomental distance, and preoperative bedside measurement of the hyomental distance may help anticipate anatomical suitability. These preliminary observations warrant further evaluation.
Central venous catheterization via the internal jugular vein (IJV) is a routine procedure in critical care and anesthesia. However, inadvertent catheter malposition remains a concern when landmark-based (blind) cannulation is performed. We report two cases of unintended catheter placement into the external jugular vein (EJV) during attempted IJV access. The first case involved a 72-year-old male with severe pneumonia requiring central venous access for vasoactive therapy. Blind IJV cannulation appeared uneventful, with successful venous blood aspiration and smooth guidewire passage; however, post-procedural chest radiography revealed an abnormally lateral and superficial catheter trajectory—a characteristic “cervicothoracic hairpin turn” —with the tip projecting over the right shoulder region, consistent with EJV placement. The second case involved a 52-year-old female with septic shock. Mild resistance was encountered during guidewire advancement, which resolved after minor redirection. In both cases, blood aspiration, catheter flushing, and infusion were unremarkable before radiographic confirmation. Chest radiography subsequently confirmed catheter malposition into the EJV. Both catheters were promptly removed, and alternative central venous access was successfully established. These cases demonstrate that EJV malposition may be clinically silent prior to imaging. Guidewire resistance should prompt immediate reassessment, and whenever available, ultrasound or fluoroscopic confirmation should be obtained before dilation or catheter insertion. When continuous real-time ultrasound guidance is not feasible, post-procedural radiographic assessment is essential for detecting this malposition.
