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.
