A 20‐year‐old female with asthma, Ehlers–Danlos syndrome, Hashimoto’s thyroiditis, mast cell activation syndrome, and complex regional pain syndrome Type 1 (CRPS1) presented for left transfemoral amputation with osseointegration and nerve reconstruction. To limit CRPS1 exacerbation, neuraxial anesthesia with femoral and sciatic blocks was administered for analgesia. Given the reported history of convulsions following ketamine and propofol, sedation with midazolam, dexmedetomidine, and fentanyl was used. On POD 1, fascia iliaca and sciatic blocks were repeated to mitigate postoperative pain. There were no intraoperative or postoperative complications. With limited literature on anesthesia for osseointegration, this novel case highlights individualized planning, in the setting of adverse responses to anesthetic medications and challenging pain management.
Toddler abdominal aortic aneurysms (AAA) are rare and lack defined perioperative guidelines. Aneurysms may be associated with tuberous sclerosis complex (TSC) but rarely occur with concurrent dilated cardiomyopathy. This case report describes the anesthetic and surgical considerations for a two-year-old male with TSC and dilated cardiomyopathy with low ejection fraction undergoing open infrarenal AAA repair. Our most important perioperative considerations included advanced hemodynamic monitoring, management of intraoperative blood loss, and the physiological changes associated with aortic clamping. Transesophageal echocardiography was used throughout the operation to guide inotropic support and assess ventricular filling using renal-protective strategies and balanced transfusion.
Background Awake fiberoptic intubation (AFOI) remains the preferred technique for anticipated difficult airway management. However, severe restriction of mouth opening, fixed craniocervical anatomy, and sedation‐induced hypopharyngeal collapse may substantially impair endoscopic visualization and increase procedural difficulty. Simple mechanical maneuvers that improve upper airway patency may facilitate successful intubation in these highly challenging patients. Case Presentation We report the airway management of a 24‐year‐old woman with Ehlers–Danlos‐hypermobile type (EDS‐HT) syndrome, previous craniocervical fusion, severe temporomandibular dysfunction, and a history of a prior cannot intubate, cannot oxygenate event requiring emergency tracheostomy. Preoperative evaluation demonstrated extreme anatomical airway restriction, including complete absence of cervical extension, severely limited mouth opening, and ultrasonographic evidence of markedly reduced submandibular compliance (hyomental distance 2.8 cm; hyomental distance ratio 1.0). During the first‐stage spinal surgery, awake fiberoptic orotracheal intubation in the supine position, with dexmedetomidine‐light sedation and local anesthesia, was initially hindered by severe hypopharyngeal collapse. Application of lingual traction immediately restored glottic exposure, allowing successful first‐attempt intubation. Seven days later, during the second‐stage procedure, AFOI was performed in the left lateral decubitus position combined with lingual traction. This approach further improved airway patency, reducing the time to glottic visualization from 15 to 5 s and total intubation time from 90 to 30 s, while maintaining first‐pass success. Conclusion This case illustrates that combining lingual traction with lateral decubitus positioning can mechanically optimize upper airway patency during AFOI in patients with fixed craniocervical anatomy and EDS‐HT patients. These simple, low‐cost, and readily reproducible maneuvers may represent valuable adjuncts when conventional airway techniques are limited or contraindicated.
Introduction Accidental intrathecal injection of tranexamic acid (TXA) is a rare but catastrophic preventable adverse event associated with high mortality and severe neurological consequences. It represents a major neurological emergency that requires immediate specialized management. Case Presentation A 32‐year‐old man erroneously received an intrathecal injection of 300 mg of TXA instead of bupivacaine during a saphenous vein stripping procedure. He rapidly developed refractory myoclonic status epilepticus, sympathetic hyperactivity, and rhabdomyolysis. Management included multiple antiseizure medications, continuous EEG‐guided sedation, and targeted use of neuromuscular blockade. The patient recovered without immediate neurological deficit but developed persistent cognitive impairment and posttraumatic stress disorder at follow‐up. Conclusions This case highlights the severe neurotoxicity of intrathecal TXA and the importance of early and aggressive intensive care management. It also underscores the need for long‐term multidisciplinary follow‐up for the assessment of anesthetic procedure‐related complications.
Introduction Parapharyngeal space (PPS) tumors are rare and account for approximately 0.5% of all head and neck tumors. Their close proximity to the upper airway can result in significant anatomical distortions, making airway management challenging. Awake tracheal intubation is recommended when a difficult airway is anticipated; however, advanced airway devices such as flexible fiberoptic bronchoscopes and videolaryngoscopes may not be available in low‐resource settings. Awake blind nasal intubation (ABNI), although rarely practiced today, may be a feasible alternative in carefully selected patients. Objective We report successful airway management with ABNI in a patient with PPS tumor in a resource‐limited setting. Case Presentation A 45‐year‐old man presented with a progressively enlarging giant PPS tumor, associated with dysphagia, snoring, and oral airway obstruction. Preoperative airway evaluation revealed Mallampati Class III, preserved mouth opening, and unrestricted cervical spine mobility; however, the large intraoral mass suggested a potentially difficult airway. Because fiberoptic bronchoscopy and videolaryngoscopy were unavailable, ABNI was planned while maintaining spontaneous ventilation, and emergency surgical tracheostomy was performed as a rescue strategy. Airway topicalization was achieved using 2% lidocaine gargle and intravenous lidocaine, together with nasal vasoconstriction using adrenaline‐soaked gauze. A lubricated 6.0‐mm cuffed endotracheal tube was successfully inserted through the left nostril on the first attempt, without hypoxemia, airway trauma, or hemodynamic instability. General anesthesia was administered uneventfully, and complete tumor excision was successfully performed. The patient recovered without perioperative complications and was discharged on postoperative day six. Conclusion This case demonstrates that ABNI may represent a practical alternative for selected patients with anticipated difficult airways due to PPS tumors when advanced airway equipment is unavailable. Careful patient selection, meticulous airway assessment, adequate topical anesthesia, maintenance of spontaneous ventilation, and preparation for emergency surgical airway management remain essential. Although this case illustrates technical feasibility, broader conclusions regarding safety or effectiveness cannot be drawn from a single case.
