This report describes the successful use of continuous spinal anesthesia (CSA) in a 70-year-old woman with severe pulmonary hypertension (PH), right ventricular (RV) dysfunction, and obstructive sleep apnea (OSA) undergoing hip fracture repair. The perioperative challenge was to manage a patient at high risk of hemodynamic decompensation and severe gas exchange impairment. CSA allowed preservation of spontaneous ventilation and incremental titration of local anesthetic, while hemodynamic stability was maintained with early norepinephrine support. This case illustrates the importance of individualized, pathophysiology-based anesthetic planning in high-risk cardiopulmonary patients.
Background:Elderly patients have a higher likelihood of undergoing surgical procedures compared to younger populations, a factor associated with increased perioperative mortality and anesthesia-related morbidity. Regional anesthesia in geriatric patients offers a favorable safety profile, optimizes analgesia, and contributes to reducing postoperative complications, particularly within the framework of enhanced recovery after surgery (ERAS) protocols. Nevertheless, local anesthetic systemic toxicity (LAST) remains a rare yet potentially life-threatening complication in the context of epidural analgesia. Its severity is amplified in scenarios involving prolonged local anesthetic infusion or in patients with elevated susceptibility due to age-related physiological changes or comorbidities. Case Presentation:A case report details an instance of LAST induced by continuous epidural administration of bupivacaine 0.1% in a 95-year-old female patient following surgery for bowel obstruction. We describe the clinical presentation, diagnostic considerations, therapeutic interventions, and subsequent recovery. Conclusion:Epidural analgesia is an effective method of pain relief, providing prolonged and continuous analgesia with a relatively low risk of systemic toxicity. Nevertheless, LAST may still occur, particularly during prolonged administration or in vulnerable populations, such as elderly patients and those with hepatic, renal, or cardiovascular dysfunction. In the critical care setting, clinicians should maintain a high index of suspicion for LAST while excluding other differential diagnoses, including shock, stroke, or pulmonary embolism. Importantly, the potential accumulation of local anesthetics during epidural analgesia should be considered even when dosing adheres to current recommendations, as age-related physiological and pharmacokinetic changes may increase susceptibility to toxicity. This case also highlights the important role of intravenous lipid emulsion (ILE) as an effective rescue therapy in the management of LAST, with rapid improvement in neurological manifestations following treatment.
Fibromuscular dysplasia (FMD) is a rare, nonatherosclerotic vascular disease that predisposes patients to arterial stenosis, dissection, and stroke, often with delayed diagnosis due to nonspecific symptoms. We present a 30-year-old female with a history of migraines and recent whiplash injury who developed acute ischemic stroke from right internal carotid artery occlusion. Following neurological deterioration, she underwent emergent mechanical thrombectomy under general anesthesia. Airway management incorporated manual in-line stabilization to minimize cervical vessel stress, and hemodynamics were tightly controlled to balance cerebral perfusion and hemorrhagic risk. Postoperative imaging revealed arterial irregularities and a dissecting pseudoaneurysm consistent with previously undiagnosed FMD. The patient recovered with supportive care and was discharged on dual antiplatelet therapy. This case highlights the anesthetic challenges of managing acute stroke in the setting of occult vascular pathology and underscores the importance of maintaining suspicion for FMD in young patients with cerebrovascular events.
A postintubation tracheal stenotic patient who requires surgical resection and anastomosis is a challenging case for an anesthesiologist, requiring meticulous planning during surgical correction due to a shared airway. This case report is about the anesthetic management of a 23-year-old male who developed severe tracheal stenosis following prolonged mechanical ventilation after decompressive craniectomy and presented with severe dyspnea, wheeze, and stridor five weeks later. Tracheal resection and anastomosis were the ultimate solution for this patient. For that, a sequential airway strategy was used. This strategy includes distal tracheal intubation under bilateral superficial cervical plexus block, along with conscious sedation, followed by general anesthesia with cross-field ventilation, bronchoscopy-guided resection, and intermittent apneic technique during anastomosis. The patient was extubated at the table, and total recovery was uneventful. This case demonstrates the successful application of a sequential airway strategy, which facilitates safe tracheal surgery and immediate extubation.
Background:Modern pacemakers incorporate a magnet-responsive switch that, on exposure to a sufficient static magnetic field, converts the device to fixed-rate asynchronous (magnet-mode) pacing. This is designed behaviour rather than malfunction. Interactions between this feature and magnet-containing medical equipment are underrecognised. The PICO 7 negative pressure wound therapy (NPWT) system contains a magnet in its pump unit, which the manufacturer states can interfere with nearby pacemakers. Case Presentation:An 81-year-old man was admitted to the High Dependency Unit after right hemicolectomy. He had atrial fibrillation with a slow ventricular response and a permanent pacemaker programmed VVI at 60 beats per minute. Overnight, telemetry showed a sustained paced rate of 100 beats per minute; he was asymptomatic. The PICO 7 pump unit was found resting on his chest, over the pacemaker generator. Repositioning the pump to the foot of the bed returned the paced rate to 60 beats per minute immediately, and device interrogation the following day confirmed normal pacemaker function. Discussion:The fixed rate of 100 beats per minute, its dependence on pump position and immediate resolution on removal are characteristic of magnet-mode activation rather than generic electromagnetic interference. Although the patient was asymptomatic, a sustained rate of 100 beats per minute carried a risk of myocardial ischaemia and heart failure decompensation given his cardiac history. Recognition and a simple bedside intervention resolved the episode. Conclusion:Magnet-containing medical equipment placed near a cardiac implantable electronic device can trigger magnet-mode pacing. The risk depends on the position of the magnet-bearing component, not on the wound site. An unexplained change in a paced rate should prompt early consideration of a nearby magnetic source, because the remedy may be immediate and at the bedside.
The clinical case of a young patient with intractable residual limb pain is presented. Following the initial administration of opioids and subsequent overuse, the patient was switched to intrathecal (IT) ziconotide infusion with complete opioid withdrawal. After 15 years of treatment with ziconotide infusion, the patient achieved sustained analgesic control and excellent functional recovery. IT ziconotide showed good long-term tolerability and safety.
Background:Perioperative management of patients with immune thrombocytopenia (ITP) is particularly challenging when complicated by recent coronary stenting requiring dual antiplatelet therapy (DAPT), due to competing risks of bleeding and thrombosis. Case Presentation:We report the case of an 80-year-old male with refractory ITP and recent drug-eluting stent placement who underwent elective laparoscopic splenectomy. Although preoperative optimization with corticosteroids and intravenous immunoglobulin increased platelet count from < 20 × 109/L to 177 × 109/L, functional hemostatic adequacy remained uncertain given concurrent ITP and ongoing antiplatelet therapy. Thromboelastography (TEG) was performed using the TEG 6s system with a Global Hemostasis Cartridge. Standard TEG parameters demonstrated preserved clot initiation, formation, and strength across multiple channels, supporting progression to surgery. Laparoscopic splenectomy was completed under general anesthesia without complications or need for transfusion. The patient recovered on the general surgical ward and was discharged on Postoperative Day 3 with a platelet count of 139 × 109/L. Platelet count 2 weeks postoperatively was 343 × 109/L. Conclusion:This case highlights the utility of TEG as a tool to guide perioperative decision-making in patients with ITP receiving antiplatelet therapy. By providing a functional assessment of coagulation, TEG can help individualize perioperative management in patients with complex hematologic conditions, facilitating safe surgical intervention.
Background:Thoracic surgery is conventionally performed under general anesthesia with one-lung ventilation. However, this approach may pose considerable perioperative risks in selected patients with advanced pulmonary disease and significant medical comorbidities. Thoracic segmental spinal anesthesia (TSSA), combined with adjunctive regional techniques, has emerged as a potential alternative in carefully selected high-risk patients undergoing nonintubated thoracic surgery [1-3]. Presentation:A 76-year-old man with spontaneous left-sided pneumothorax, persistent air leak despite chest tube drainage and two autologous blood patch pleurodesis attempts, resolving pneumonia, cerebellar atrophy, parkinsonian tremor, and anterior fascicular block was referred for surgical management. His respiratory reserve was severely compromised, with oxygen saturation decreasing to 72% before admission and persistent oxygen dependence despite chest drainage [1,2]. Pulmonary function testing could not be performed because of his clinical condition. Following multidisciplinary discussion, conventional general anesthesia with one-lung ventilation was considered to carry a substantial perioperative respiratory risk. The patient subsequently underwent awake video-assisted thoracoscopic surgery (VATS) under low-dose TSSA at the T5-T6 interspace using 6 mg isobaric bupivacaine, combined with an ultrasound-guided cervical vagus nerve block using 4 mL of 1% lidocaine to suppress the intraoperative cough reflex. The patient remained awake, maintained spontaneous ventilation throughout surgery, demonstrated stable hemodynamics, and required no conversion to general anesthesia. Wedge resection of a giant pulmonary bulla and mechanical pleurodesis were completed successfully without intraoperative complications. Postoperatively, lung re-expansion was achieved, the persistent air leak resolved, and the patient recovered without neurological complications, postdural puncture headache, urinary retention, dysphagia, hoarseness, or respiratory deterioration. He was discharged home on postoperative day two in stable condition. Conclusion:This case illustrates that TSSA combined with ultrasound-guided vagus nerve block may represent a feasible anesthetic option for carefully selected high-risk patients undergoing awake thoracoscopic surgery when conventional general anesthesia is considered undesirable. Larger prospective studies are required to further evaluate the safety, efficacy, and patient selection criteria for this approach [2,3].
Persistent left superior vena cava (PLSVC) is the most common congenital thoracic venous anomaly and is usually clinically silent. We report a critically ill patient in whom PLSVC was identified after left internal jugular central venous catheter placement. Chest radiography showed a vertically oriented catheter along the left mediastinum without expected midline crossover, raising concern for malposition. Review of prior imaging confirmed PLSVC draining into the coronary sinus. Recognition of this variant prevented unnecessary catheter removal and repeat instrumentation, underscoring the importance of correlating procedural findings with imaging during left-sided venous access.
Tethered spinal cord syndrome (TSCS) is a neurological disorder characterized by tissue attachments limiting spinal cord movement, which can result in the conus medullaris terminating at a level lower than the typical L1. This abnormality can cause significant complications during spinal anesthesia due to the risk of injury at the traditional puncture sites of L4-L5. This case report discusses the anesthetic management of a 65-year-old female patient diagnosed with TSCS with her spinal cord extending to L5-S1. She presented for a right total knee replacement. The patient had a history of successful spinal anesthesia for her previous left knee replacement but was apprehensive about repeating the procedure due to her spinal anatomy and the associated risks. A thorough preoperative assessment was conducted with this patient. This included a detailed MRI review by a radiologist and a neurosurgeon, which highlighted the risks associated with spinal anesthesia. Given the minimal cerebrospinal fluid around critical levels of the spinal cord, the risk of injury during spinal anesthesia was significant. After discussion with the patient about the risks and benefits of each anesthetic option, the care team and patient jointly decided that general anesthesia would offer the safest approach. General anesthesia was administered successfully with standard intraoperative monitoring and airway management. A preoperative adductor nerve block was also performed to manage postoperative knee pain. The patient emerged from anesthesia without complications, with stable vital signs and good neurovascular function. The interdisciplinary approach and careful preoperative planning were crucial to achieve a positive outcome in this case. This case highlights the importance of individualized anesthetic planning for patients with TSCS. It underscores the need for thorough preoperative assessment and patient-centered care to determine the safest anesthetic approach. This report also reviews the mechanisms of spinal cord injury during neuraxial anesthesia in TSCS, discusses epidural anesthesia as an alternative, and synthesizes evidence-based recommendations for preoperative assessment in the absence of formal guidelines. Further research and the development of formal guidelines for anesthetic management in TSCS are warranted to improve patient safety and outcomes.
Large ascending aortic aneurysms (AscAAs), defined as exceeding 8 cm, are exceedingly rare and carry high mortality due to the combined risks of rupture and mediastinal compression. Their management demands precise anesthetic, surgical, and perfusion coordination to prevent hemodynamic collapse and neurologic injury. We report an 83-year-old woman with an 8.9 × 7.7 cm AscAA producing marked right ventricular and pulmonary artery compression. Perioperative management emphasized advanced monitoring, preservation of venous return during induction, and readiness for immediate cardiopulmonary bypass (CPB). Given the aneurysm's proximity to the sternum and high rupture risk, CPB via right axillary cannulation was established prior to sternotomy, followed by deep hypothermic circulatory arrest and complex aortic reconstruction. Intraoperative transesophageal echocardiography (TEE)-guided cannulation assessed ventricular filling under dynamic compression and confirmed graft and valve function. The patient recovered without major complications. This case underscores the physiologic overlap between giant aneurysms and anterior mediastinal masses, where loss of spontaneous ventilation or preload reduction may precipitate cardiovascular collapse. Our report additionally provides multimodal imaging that demonstrates the degree of anatomic distortion caused by a giant AscAA and includes a concise review of previously published cases. Effective management of these rare, life-threatening aneurysms relies on anticipating dynamic obstruction physiology, preparing for rapid bypass initiation, and maintaining continuous interdisciplinary coordination throughout the perioperative course.
Background:Cold urticaria is a rare subtype of chronic inducible urticaria that is associated with the development of localized or systemic symptoms following exposure to cold stimuli. Although considered benign, it may be associated with severe reactions, including anaphylactoid reactions. This can occur upon direct or indirect exposure to cold temperatures, liquids, and objects. The perioperative environment contains multiple potential cold triggers which can cause generalized hypersensitivity reactions in these patients. Little is known of the perioperative course and management of these patients, and there are few reported cases. Treatment of cold urticaria involves the use of antihistamine medication and avoidance of cold triggers. Case Presentation:We describe the case of a young female with undiagnosed cold urticaria that was detected shortly before surgery. A detailed history revealed recurrent cold-induced symptoms, including a prior episode suggestive of airway compromise. A presumptive diagnosis was made based on clinical history and later confirmed with a cold stimulation test. Perioperative management was modified to minimize cold exposure and include prophylactic antihistamine and corticosteroid therapy. Despite these measures, localized urticarial changes occurred intraoperatively following exposure to cold antiseptic solution on the abdomen without progression to systemic manifestations. The patient remained hemodynamically stable throughout and had an uneventful postoperative recovery. Conclusion:This case highlights the importance of early recognition of cold urticaria and the implementation of targeted perioperative strategies to reduce the risk of adverse events. Currently, there are no standardized perioperative guidelines for cold urticaria, and given that patients may not spontaneously report cold-induced symptoms, specific screening questions during preoperative assessment should be considered to improve detection and optimize perioperative safety.
Difficult airways can cause severe hypoxia when inducing general anesthesia unless they are well managed, especially for pediatric patients. Successful management of pediatric difficult airways requires meticulous assessments and preparations. The GlideScope® Spectrum LoPro is a thin, hyperangulated blade. Although its utility has been demonstrated in previous studies on Pierre Robin manikins or patients with severely restricted mouth openings, as yet there have been no case reports on its efficacy for children with difficult airways. We encountered a 14-year-old female patient with giant facial rhabdomyosarcoma who was scheduled for tumor debulking surgery under general anesthesia. Her mouth opening was limited to 2 child finger-widths, with Mallampati Classification IV, meaning an anticipated difficult airway. For this anticipated difficult airway, we prepared several airway devices and planned our possible approaches carefully. When industry-standard options became untenable, we switched to the GlideScope® LoPro blade, completing oral intubation under spontaneous breathing without any complications. This result demonstrated that the GlideScope® Spectrum LoPro blade is useful and effective for at least some forms of difficult airways, with confirmation that it is useful in cases involving giant facial tumors. Its hyperangulated blade offered improved vocal cord visualization. Overall, we have concluded that its use in specialized cases could increase intubation success rates for pediatric patients.
We are presenting the case of a 28-year-old female patient who presented with refractory shock secondary to overdose of tricyclic antidepressants, calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors. After initial resuscitation, bicarbonate infusion for TCA toxicity was used; and CCB toxicity was managed with high-dose insulin euglycemia therapy (HIET) with simultaneous dextrose infusion and vasopressors in the intensive care unit.
Background:Double-chambered right ventricle (DCRV) is a rare congenital anomaly characterized by hypertrophied muscular bundles dividing the right ventricle into high- and low-pressure chambers. It is frequently associated with congenital heart disease, particularly tetralogy of Fallot (TOF), but rarely presents in late adulthood. Case Presentation:We report the case of a 78-year-old man with a history of prior pulmonary valvotomy who presented with progressive dyspnea and was found to have severe subvalvular right ventricular outflow tract obstruction. Multimodal imaging and cardiac catheterization confirmed DCRV with near-systemic right ventricular pressures and an anomalous left anterior descending coronary artery arising from the right coronary cusp. The patient underwent surgical resection of hypertrophied infundibular muscle bundles with patch augmentation of the main pulmonary artery. Intraoperative transesophageal echocardiography guided management and confirmed successful relief of obstruction. The patient had an uncomplicated postoperative course with resolution of symptoms. Discussion:This case highlights the late presentation of DCRV as a sequela of incompletely repaired TOF and underscores the importance of comprehensive imaging and careful surgical planning in the presence of anomalous coronary anatomy. Anesthetic management focused on maintaining right ventricular preload and coronary perfusion while avoiding dynamic right ventricular outflow tract obstruction. Conclusion:DCRV can present late in life in patients with prior congenital heart disease. Successful management requires a multidisciplinary approach with careful perioperative hemodynamic optimization.
We report the case of a previously healthy 27-year-old man who developed acute pulmonary edema shortly after receiving neostigmine-atropine for neuromuscular blockade reversal during appendectomy under general anesthesia. Before extubation, he developed severe hypoxemia, increased airway pressures, pink frothy tracheal secretions, and bilateral diffuse pulmonary infiltrates on chest radiography. Cardiogenic pulmonary edema, fluid overload, negative-pressure pulmonary edema, and perioperative hypersensitivity were considered unlikely based on the clinical findings, bedside cardiac ultrasound, limited intraoperative fluids, normal histamine and tryptase levels, and negative skin testing. The event was therefore considered a diagnosis of exclusion temporally associated with neostigmine administration. This case highlights the importance of careful differential diagnosis and cautious causal attribution when respiratory compromise occurs after reversal.
Background:Hereditary spastic paraplegia is an extremely rare, heterogenous, inherited, progressive neurologic disorder characterized by lower-extremity weakness and spasticity in pure forms, with complex forms including symptoms such as seizures, dementia, and ataxia. Due to its rarity, evidence guiding anesthetic management is limited, consisting of only eight published case reports. Case Report:We report the anesthetic management of a patient with pure hereditary spastic paraplegia undergoing renal mass cryoablation in the prone position. General endotracheal anesthesia was induced with propofol, maintained with isoflurane, and included nondepolarizing neuromuscular blockade with reversal using sugammadex. Conclusion:Patients with hereditary spastic paraplegia typically have experienced multiple anesthetic exposures prior to diagnosis, suggesting that standard anesthetic techniques are generally well-tolerated in this population without significant adverse effects. Given that pure HSP is an upper-motor neuron disorder-without involvement of the neuromuscular junction-extensive disease-specific modifications to anesthetic plans are likely unnecessary in the absence of additional comorbid risk factors.
The wake-up test (WKT) is an important intraoperative method for assessing spinal cord function during scoliosis surgery, particularly in settings where intraoperative neurophysiological monitoring (IONM) is unavailable. This short case series describes seven patients undergoing scoliosis surgery with a modified wake-up test (mWKT). Sugammadex was used to reverse neuromuscular blockade to facilitate motor assessment. All patients were able to follow commands and demonstrate lower-limb movement during the test. The duration of mWKT ranged from 15 to 35 min and decreased with increasing procedural familiarity. One patient required naloxone due to delayed recovery. Importantly, no episodes of bradycardia or clinically significant hemodynamic instability were observed following sugammadex administration. Only one patient reported limited postoperative recall. This case series suggests that the WKT remains a feasible and safe alternative when IONM is unavailable. Sugammadex may facilitate more efficient neuromuscular recovery and improve procedural control.
Introduction:Moyamoya disease is characterized by progressive stenosis of the internal carotid arteries and impaired cerebrovascular autoregulation, posing substantial challenges during cardiac surgery. Although coronary artery bypass grafting (CABG) has been reported in patients with moyamoya disease, anesthetic management during robot-assisted beating-heart CABG has not been reported. Case Presentation:A 44-year-old woman with untreated moyamoya disease underwent robot-assisted coronary artery bypass grafting (RACABG) for left anterior descending artery disease. One-lung ventilation with intrathoracic carbon dioxide insufflation was required. Intraoperative anesthetic management was guided by regional cerebral oxygen saturation (rSO2) monitoring to ensure adequate cerebral perfusion. Strict control of blood pressure and arterial partial pressure of carbon dioxide allowed cerebral oxygenation to be maintained within 20% of baseline throughout surgery. The patient was extubated without any neurological deficits. On Postoperative Day 4, the patient developed sudden cardiac arrest, most likely due to coronary artery spasm, which lasted for approximately 19 min. She recovered fully without neurological impairment after cardiopulmonary resuscitation and percutaneous ventricular assist support. Conclusions:This case highlights the usefulness of rSO2-guided anesthetic management with strict hemodynamic and carbon dioxide control during RACABG in patients with moyamoya disease. Vigilance for perioperative coronary vasospasm is essential in this population.
Patients with hypermobile Ehlers-Danlos syndrome (hEDS) have a higher reported prevalence of local anesthetic (LA) resistance and obstetric complications than the general population. We describe a 33-year-old G2P0010 ASA III parturient with a history of hEDS and lidocaine resistance who presented for an anesthesia consultation in anticipation of possible neuraxial anesthesia. We surmised that performing a neuraxial procedure would require effective skin infiltration of the patient's lumbar area. A skin infiltration test revealed that 3% 2-chloroprocaine provided a much greater numbing effect than 2% lidocaine. The patient desired an unmedicated birth and ultimately delivered in this fashion. Still, our findings highlight the potential benefit of testing multiple LAs in hEDS patients to guide anesthetic planning.
