Postoperative pain after pediatric abdominal surgery includes both somatic and visceral components, making opioid-sparing strategies desirable. We report two pediatric cases in which ultrasound-guided rectointercostal fascial plane block was used alone or combined with modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) as part of multimodal analgesia. In a 9-year-old undergoing laparoscopic Meckel diverticulum excision, a bilateral rectointercostal block provided sustained low FLACC (Face, Legs, Activity, Cry, Consolability) scores with no opioid requirement. In a 5.5-year-old undergoing retroperitoneal tumor excision, combined M-TAPA and rectointercostal blocks resulted in excellent analgesia without rescue opioids. These observations suggest effective, feasible, opioid-sparing analgesia in selected pediatric abdominal procedures.
A male in his 30s underwent retroperitoneal mass excision. A T8-T9 epidural catheter was placed for postoperative analgesia, infusing 0.0625% bupivacaine and 2 µg/mL fentanyl at 8 mL/h. That evening, the patient left against medical advice (AMA) while declining epidural catheter removal. The patient returned 2.5 hours later for an uneventful epidural removal. We examine the clinical, legal, and ethical considerations of a patient leaving AMA with a neuraxial catheter. While medical ethics and US law guarantee patient autonomy, this situation conflicts with obligations to prevent harm including potential neuraxial infection, hematoma, or retained catheter fragments. We describe our response to this scenario and discuss steps to mitigate this uncommon but high-stakes situation.
Hemophilia A presents significant perioperative challenges, particularly for neuraxial anesthesia due to the risk of spinal or epidural hematoma. Extended half-life recombinant factor VIII products (EHL), such as efanesoctocog alfa, provide sustained FVIII activity. We report a 52-year-old man with severe hemophilia A on weekly EHL prophylaxis undergoing total knee arthroplasty under spinal anesthesia with an adductor canal block. FVIII levels were maintained with a combination of EHL and standard factor VIII replacement. The patient had no neurologic sequelae. Safe neuraxial anesthesia can be achieved in hemophilia A with a combination of EHL and standard factor VIII replacement.
Takotsubo cardiomyopathy (TTC) is a stress-induced cardiomyopathy characterized by transient left ventricular systolic dysfunction in the absence of obstructive coronary artery disease. Although recovery of left ventricular ejection fraction is common, TTC is associated with measurable morbidity and mortality. The condition accounts for approximately 1% to 2% of suspected acute coronary syndrome presentations and is increasingly recognized in oncology patients receiving systemic therapy. Chemotherapy-associated TTC has been reported with fluoropyrimidines, antivascular endothelial growth factor agents, platinum-based regimens, and immune checkpoint inhibitors. Proposed mechanisms include endothelial dysfunction, coronary vasospasm, inflammation, oxidative stress, and autonomic dysregulation. The perioperative environment may reproduce these triggers through sympathetic activation and hemodynamic instability, thereby increasing the risk of recurrence. Perioperative management should be guided by the timing and severity of TTC (active, recent, or remote). It should include structured preoperative assessment, individualized anesthetic planning, cautious selection of vasoactive agents, and vigilant postoperative monitoring. This review synthesizes current evidence and provides practical guidance for anesthesiologists managing patients with chemotherapy-associated TTC undergoing noncardiac surgery.
Pneumorrhachis, defined as the presence of air within the spinal canal, is generally regarded as a benign radiological finding. In obstetrics, it is most frequently associated with use of the loss of resistance (LOR) to air technique during neuraxial procedures. We present a unique case of symptomatic pneumorrhachis after inadvertent dural puncture using the LOR to saline technique. The patient developed severe, refractory neck pain that precluded effective maternal Valsalva efforts during the second stage of labor, ultimately necessitating an operative vaginal delivery. This case illustrates that pneumorrhachis, while typically asymptomatic, can produce significant morbidity capable of altering obstetrical management.
Currently, there is no consensus on the optimal tool for cognitive impairment (CI) screening in the perioperative setting. This case series describes the characteristics of surgical patients aged ≥65 who screened positive for CI on one or more of six screening tools at any perioperative time point up to 180 days postoperatively, and subsequently completed a formal cognitive evaluation by a neurologist at a memory clinic. Of 34 participants with probable CI, 32% were diagnosed with CI on objective assessment, and 68% had normal exams. The Montreal Cognitive Assessment (MoCA) was more predictive of CI diagnoses. These findings are exploratory, and further investigation is needed.
Through‑knee amputation is associated with severe postoperative pain and a high risk of phantom limb pain, particularly in patients with poorly controlled acute post-amputation pain. We describe the use of a novel regional plane block that targets a mix of nerve blocks - genicular+iPACK+vastus nerves, which we abbreviated Genivs. We targeted this location and performed a continuous distal femoral periosteal catheter technique in a pediatric patient following traumatic through‑knee amputation. We tried this novel approach after the patient's pain did not improve with targeted muscle re-innervation (TMR), epidural analgesia, systemic opioids, ketamine infusion, and conventional peripheral nerve blocks. Catheter placement adjacent to the anterior periosteum of the distal femur resulted in rapid opioid-sparing, improved participation in rehabilitation, and sustained reduction in phantom limb pain. Plausible anatomic mechanisms are discussed.
Super-obese patients are at an increased risk of perioperative complications due to underlying comorbidities and difficult airways. Regional anesthesia avoids airway manipulation and provides superior analgesia, but is technically demanding in this population. We report two super-obese trauma patients, in whom a preoperative scout scan failed to reveal the desired anatomy. Computed tomography (CT) identified the target depth and marked the needle trajectories for a successful regional block. This preoperative CT-based planning for anesthesia in super-obese patients has not been described previously. However, real-time CT-guided blocks have been used in challenging anatomy in nonobese patients.
Malignant hyperthermia (MH) is a rare, life-threatening anesthetic complication caused by dysregulated skeletal muscle calcium homeostasis. We report a 25-year-old trauma patient who developed refractory hypotension with rising Etco2 despite progressive increases in minute ventilation, followed by hyperthermia, 2.5 hours after exposure to succinylcholine and sevoflurane. Hemodynamic instability was unresponsive to fluids and vasopressors but reversed rapidly after treatment for probable MH with dantrolene (Ryanodex). This case highlights early hemodynamic instability as a prominent manifestation of MH and emphasizes rising Etco2 despite increased ventilation as a critical diagnostic clue requiring prompt dantrolene administration.
Suzetrigine selectively blocks the NaV1.8 voltage-gated sodium channel in peripheral neurons. Trigeminal neuralgia (TN) is a neuropathic pain syndrome affecting the trigeminal nerve and is traditionally treated with nonselective sodium channel blockers. No studies have evaluated Suzetrigine for TN, but potential involvement of NaV1.8 in TN signaling may represent a novel therapeutic target. We describe four patients with varying symptomatology of TN and previously failed responses to pharmacological and interventional treatments who exhibited notable symptomatic improvements with Suzetrigine, with no adverse effects. Further study is required in larger populations regarding the safety and efficacy of long-term Suzetrigine use for refractory TN.
Venous thrombosis is influenced by Virchow's triad, and a decrease in venous velocity is considered one of the risk factors. In this study, we examined three foot and leg movements-bending the ankle back and forth ("Bending"), squeezing the toes ("Squeezing"), and massaging and milking the calf ("Milking")-using healthy volunteers and ultrasound to determine which exercise increased venous velocity the most. The results showed that "Bending" produced the highest velocity, while "Squeezing" produced the lowest. We also compared left and right sides for each exercise, finding that left-side velocity during "Milking" was significantly lower than the right side.
Awake flexible bronchoscopic (FB) nasotracheal intubation is recommended for anticipated difficult airways, but its success depends on effective airway topicalization. We report a case of a patient with a severely distorted upper airway due to a maxillary tumor, where conventional topicalization techniques were impractical. Directed nasal nebulization of lidocaine using an uncuffed endotracheal tube (ETT) as a conduit, supplemented with spray-as-you-go (SAYGO) anesthesia and dexmedetomidine sedation, facilitated successful awake intubation. This case demonstrates the applicability of directed nasal nebulization in complex airway anatomy when alternative topicalization strategies are limited.
Coccygodynia may arise from traumatic or nontraumatic causes and can become refractory to conservative treatments, for which coccygectomy may be required. Providing effective anesthesia for this procedure can be challenging. These case reports describe the use of an ultrasound-guided sacral multifidus plane block (SMPB) as the primary anesthetic technique for coccygectomy in two patients with chronic coccygodynia. SMPB provided adequate surgical conditions and postoperative analgesia without conversion to general anesthesia or the need for additional intraoperative analgesics. These cases suggest that SMPB may be considered as an alternative anesthetic approach in selected patients.
Chronic abdominal myofascial pain syndrome is frequently underdiagnosed and often refractory to conventional pharmacological and superficial interventional treatments. While muscular trigger points are commonly implicated, growing evidence supports an active nociceptive role of deep fascial structures of the anterior abdominal wall. We report a case of refractory chronic suprapubic pain successfully treated by targeting the prevesical (Retzius) fascial compartment through a bilateral deep rectus sheath injection. The prevesical fascia may represent a clinically relevant but under-recognized pain generator, and targeting this compartment may be considered as a therapeutic option in refractory suprapubic myofascial pain.
Acquired diaphragmatic hernia (ADH) is a rare postoperative complication in pediatric patients and may cause abrupt respiratory and hemodynamic deterioration due to intrathoracic herniation of abdominal organs. We report the anesthetic management of a 17-month-old child who developed early postoperative gastric herniation after thoracoscopic resection of pulmonary sequestration. The patient presented with acute respiratory distress, hypoxemia, and mediastinal shift. Anesthetic management included rapid-sequence induction, invasive arterial monitoring, and lung-protective pressure-controlled ventilation with low tidal volumes. A 4-cm diaphragmatic defect was surgically repaired. This case underscores the anesthetic challenges of pediatric ADH and supports applying principles derived from congenital diaphragmatic hernia management.
Cerebrospinal fluid (CSF) leakage can be difficult to localize and may result in unexplained intracranial hypotension with intractable positional headache. Loss of CSF cushioning can cause brain sagging, leading to compression and traction of cranial nerves within the brain cisterns and mimicking Chiari malformation. This case report describes a patient presenting with trigeminal facial pain and positional headache who was ultimately diagnosed with a thoracic spinal CSF-venous fistula. Both headache and facial pain resolved following surgical intervention. This report highlights the importance of advanced diagnostic imaging and multidisciplinary management.
Hip fractures in elderly patients are associated with morbidity and mortality, and anesthetic management may be challenging when comorbidities or ongoing antiplatelet/anticoagulant therapy limit the use of general or neuraxial anesthesia. We report two cases of hip fracture fixation performed using a combination of sacral erector spinae plane (ESP) block and Quadro-Iliac Plane (QIP) block under dexmedetomidine sedation with spontaneous ventilation. Both patients reported minimal to no pain for several hours after surgery and only requested and received paracetamol at 12 and 18 hours after surgery.
Low back pain (LBP) is a leading cause of disability, with sacroiliac joint (SIJ) dysfunction contributing significantly to chronic symptoms. We present a case of a 63-year-old woman who underwent minimally invasive SIJ fusion performed using two approaches at different times: lateral fixation on the left and posterior allograft implantation on the right. Both procedures produced >80% sustained pain relief. The posterior technique yielded comparable symptomatic improvement to the lateral technique while offering the advantages of reduced recovery time and avoidance of hospitalization. This case highlights the posterior minimally invasive approach as a feasible alternative to traditional lateral SIJ fusion.
Patients with infective endocarditis may present with severe thrombocytopenia, identifying higher-risk groups with worse clinical outcomes and mortality rates. Frequently, in the surgical setting, these patients may benefit from platelet transfusions; however, this is not always feasible. Jehovah's Witness (JW) patients refuse blood component transfusions on religious grounds, making the management of these patients extremely complex, to the point of deeming them inoperable. Thrombopoietin receptor agonists are now available for the treatment of thrombocytopenia in a variety of diseases. We report our experience with the off-label use of avatrombopag in the setting of sepsis-induced thrombocytopenia in two JW patients.
BACKGROUND:Gabapentinoids have been widely incorporated into enhanced recovery after surgery (ERAS) pathways for total joint arthroplasty despite limited evidence of benefit and increasing concern for adverse hemodynamic effects. In response to frequent postoperative hypotension observed on inpatient units, a multidisciplinary team initiated a quality improvement effort to remove routine gabapentinoids from an orthopedic ERAS pathway. METHODS:This initiative was conducted at a tertiary academic medical center as part of ongoing medication safety monitoring within an established ERAS program. Routine perioperative gabapentinoids were removed from the orthopedic ERAS pathway following multidisciplinary review, education, and correction of an electronic order set autoselection defect. Outcomes were monitored using routinely collected clinical data from adult patients undergoing primary or revision total hip or knee arthroplasty. The primary outcome was postoperative hypotension occurring from postoperative day 1 to discharge. Gabapentinoid exposure rates and patient and procedural characteristics were tracked to contextualize changes over time. RESULTS:A total of 1246 total joint arthroplasty cases were included during the quality monitoring period. Following pathway modification, gabapentinoid exposure decreased from 532 of 589 (90.3%) to 102 of 543 (18.8%) (P < .0001). This change was accompanied by a descriptive decrease in postoperative hypotension from 59 of 589 (10.0%) to 36 of 543 (6.6%) with P values reported descriptively. Patient demographics, procedure types, and anesthesia distributions remained similar across monitoring periods, suggesting that observed changes were temporally associated with pathway modification rather than shifts in case mix. CONCLUSIONS:Eliminating routine gabapentinoids from a total joint arthroplasty ERAS pathway was associated with lower observed rates of postoperative hypotension and substantially lower gabapentinoid exposure. This quality improvement initiative demonstrates how multidisciplinary review, electronic order set evaluation, and structured monitoring can support safer medication use and improve the reliability of perioperative care pathways.
