Search

The novel coronavirus disease 2019 first emerged in Wuhan, China, and is now an emerging pandemic globally. This has strained health-care services leading to restrategizing anesthesia care and management of patients. We describe the anesthetic management of a 30-year-old COVID positive, multigravida, with term pregnancy taken up for elective cesarean section under the subarachnoid block in a dedicated operating room earmarked for COVID cases. For such a case, challenges in the modification of standard procedures to minimize exposure of the health-care professionals are delineated.

The anesthetic management of patients with a mediastinal mass represent a challenge due to the potential for difficult ventilation and intubation, as well as the risk of cardiovascular collapse upon induction of general anesthesia. Different strategies and alternatives have been described. We present the case of a 70-year-old man with a right para-tracheal mass extending into the anterior mediastinum with 90% mid-tracheal lumen obstruction who was successfully managed with venous-venous extra-corporeal membrane oxygenation (ECMO) during mass debulking and tracheal stent placement.

Hecht–Beals syndrome (HBS) is a rare disorder characterized by trismus and deformity of the extremities. The etiology of trismus is unknown; theories suggest invasion of enlarged coronoid processes into the zygomatic bone. Of primary concern is the limited mouth opening and possible difficult airway. Since the syndrome was first described in 1969, there have been several articles in the pediatrics and dental literature but only 6 case reports describing the anesthetic management of these patients. Successful airway approaches have utilized various techniques including blind nasal intubation, fiberoptic intubation, and tracheal tube introducer guidance. In this case report, we discuss a multidisciplinary approach to the anesthetic management of a child with HBS undergoing MRI and outpatient surgery.

Conjoined twins are one of the most fascinating human malformations. Here, we report the anesthetic management and challenges faced in performing the successful separation surgery of 4-day-old thoraco-omphalopagus conjoined twins, born at term to a multigravida by elective caesarean section weighing 3.5 kg with APGAR score of more than 7. Computerized tomography scan revealed fused anterior surface of the left lobe of liver with common left portal vein. Confirmation of cross-circulation between the twins was done by giving intravenous midazolam to one of the conjoined twins, but no effect seen in the other one. We highlighted the responsibility of anesthesia team in anesthetizing sequentially the two patients who are joined together, technical difficulty of intubating the twins facing each other, need of careful monitoring, anticipation of complications such as massive blood loss, hemodynamic instability, desaturation, and hypothermia, and preparedness for their management and vigilant postoperative care.

Coronavirus disease-2019 (COVID-19) is a world epidemic disease and is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In addition to the respiratory manifestations, it may also cause cardiovascular complications, such as, myocarditis, arrhythmias, myocardial infarction, heart failure, and venous thromboembolic events. This review article will discuss in detail pathophysiology, manifestations, and management of these cardiac complications. A literature review was performed, it included meta-analyses studies, cohort studies, publications, and case series from the largest COVID-19 outbreak centers around the world. Cardiac complications of COVID-19 disease can lead to significant cardiovascular morbidity and mortality. It is important to recognize and treat these complications as early as possible.

A 51-year-old woman presented with symptomatic GB stone was planned for elective laparoscopic cholecystectomy. She had known osteum secondum type atrial septal defect, moderate pulmonary hypertension, and atrial fibrillation. We report the case of a patient with a large atrial septal defect (65 mm) and hemodynamic instability who underwent laparoscopic cholecystectomy under total intravenous anesthesia with careful hemodynamic monitoring. Thorough surveillance and effort could help to make the surgery successful.

Extra-adrenal paraganglioma is a rare neuroendocrine tumor that produces stores and secretes catecholamine. The mainstay in the management of the patients posted for resection of these tumors includes adequate preoperative preparation, good collaboration between the surgeons and the anesthesiologist, and use of modern anesthetic drugs and advanced monitoring to avoid any hemodynamic fluctuations intraoperatively. These will decrease the rate of complications and improve the overall outcome of such surgeries.

The anesthetic management of dilated cardiomyopathy (DCM) is challenging and is associated with a high mortality rate. We present a case of a 44-year-old pregnant female known for DCM with low ejection fraction who underwent an elective cesarean section and tubal ligation. The patient was transferred to the intensive care unit in a stable condition with a favorable outcome. Awareness about the appropriate anesthetic management for this type of patients is of paramount importance because similar cases are likely to be encountered with the advances in modern medicine.

The da Vinci Surgical System is a robotic surgical system made by the American company Intuitive Surgical. Approved by the Food and Drug Administration (FDA) in 2000, it is designed to facilitate surgery using a minimally invasive approach, and is controlled by a surgeon from a console. Robotic surgery has gained popularity worldwide recently in different surgical domains, the mastering of robotic manipulation by the surgeons has been a challenging when it first emerged but training and practice led to improvement in both the efficiency and efficacy of surgical techniques. The idea of anesthesia for robotic thoracic surgery could be frightening to anesthetists who have never done it before, but learning the technical difficulties and the specific considerations will help building the confidence towards a safe anesthetic management. In this overview we will discuss the interaction between the robot and the patient, patient position, anesthetic management, expected complications and troubleshooting them.

The ex utero intrapartum treatment (EXIT) procedure is performed in cases of fetal congenital malformation. The anesthetic management is much more challenging and involves providing profound uterine relaxation, maintenance of Uteroplacental blood flow and fetal anesthesia. The aim of the article is to review the literature and compare the efficacy of both the anesthetic techniques with respect to maternal and fetal outcomes. The literature source for this review was obtained via PubMed, Medline, Google scholar and Cochrane database of systematic reviews until January 2017. In our literature review we found that both GA and Regional anesthesia were successfully described for EXIT procedure but GA was performed in the majority of cases. Consideration for anesthetic technique should be done on a case-by-case basis.

A conjoint twin is a rare congenital anomaly. The separation of conjoint twins presents a unique challenge to anesthesiologists. We report the anesthetic management of successful separation of thoraco-omphalopagus conjoint twins, along with challenges and limitations that we faced in perioperative period. We highlight the importance of a multidisciplinary approach, proper preoperative planning, and perioperative vigilance regarding monitoring and complication.

Morphological electrocardiological changes and arrhythmias are commonly encountered in patients with aneurysmal subarachnoid hemorrhage. These, if undetected and unaddressed, can cause cardiovascular ailments, postsurgical poor neurological outcomes and long term medical complications.

Mitral stenosis (MS) is the most common valvular heart disease associated with pregnancy. The increase in cardiac output during pregnancy results in deterioration of the patient's condition with progress to higher New York Heart Association class. Both general and regional anesthesias have been described for cesarean section in these patients. Anesthetic management of these patients depends upon the severity of the disease. General anesthesia has traditionally been preferred for cesarean section in patients with severe MS. Regional anesthesia has become popular as a safe choice in the recent past for cesarean section in all parturients including those with heart disease. We report three parturients with severe MS who underwent cesarean delivery under graded epidural block successfully. The parturients and the neonates were fine after the procedure.

Anesthetic management of patients with acute pulmonary hypertension (PH) for noncardiac surgery has received little attention in the literature. We present a case of acute PH due to pulmonary embolism for laparoscopic low anterior resection. A thorough preoperative assessment followed by invasive hemodynamic monitoring was done. Factors precipitating pulmonary vasoconstriction were avoided, and intravenous nitroglycerine infusion was used to control PH perioperatively. The problems encountered were increased airway pressure caused by pneumoperitoneum and Trendelenburg position.

Kartagener sendromu bronsektazi, sinuzit ve situs inversusla karakterize otozomal resesif gecisli bir hastaliktir. Bu yazida kombine genel ve torakal epidural anestezi altinda pulmoner rezeksiyon yapilan Kartagener send- romu ve bronsektazisi olan hastamiz sunuldu. Bu nadir hastalikta akciger izolasyon teknikleri; hastaya ve anesteziste gore degismektedir. Olgumuz- da; sol orta ve alt lobektomi icin sag ana bronsa, sol cift lumenli tupun bronsiyal lumeni sagda olacak sekilde yerlestirildi. Toraks cerrahisi geciren KGS'li hastada sevofluran ile kombine genel ve torakal epidural anestezi- nin avantajlari ve uygun anestezik yaklasimlar tartisildi.

Liposuction or lipoplasty is one of the most popular treatment modalities in aesthetic surgery which brings the certain unique anesthesia considerations. The patient should be assessed by the same standards as anyone else who is undergoing any surgery including a complete preoperative history and physical examination. The patients undergoing major liposuction procedure have a greater associated comorbid condition with the incidence of obesity. Moreover, intraoperative fluid management in liposuction procedure is also different from other surgeries where this procedure has the higher risk for fluid overload. Some complications related to liposuction are pulmonary complications. This case report describes an obese class I (BMI >30.3 kg/m2) patient who was undergoing an elective tumescent liposuction surgery under general anesthesia. During surgery, this patient received total subcutaneous infiltration of 1,200 mL tumescent solution and the total lipoaspirate was 3,300 mL. The surgery was uneventful without any certain complication. The anesthetic management of liposuction includes the preoperative evaluation, with particular attention to anything that might predispose the patient to complications, being essential to avoid unwanted occurrences.

In this case report, we report the anesthetic management of an emergency cesarean section of a parturient who presented with preterm labor and had inadvertently received rapid intravenous administration of ritodrine.

Kearns–Sayre syndrome (KSS), a rare form of mitochondrial myopathy, is a triad of chronic progressive external ophthalmoplegia, bilateral pigmentary retinopathy, and cardiac conduction abnormalities. In this report, we show how a combined spinal epidural anesthesia can be useful for cesarean delivery, as we illustrate in a dual-chamber and VVI implantable defibrillator pacemaker/defibrillator parturient with a KSS and preeclampsia.

Hysteroscopy is becoming fairly common in most centers these days, both as a diagnostic and therapeutic tool especially for short day-care procedures, reducing unnecessary hospital admissions and overuse of resources. However, these procedures are not without complications, and some could be delayed and potentially fatal if a high index of suspicion is not maintained. One such rare yet one with a high mortality among urological patients is the transurethral resection syndrome on which there is a cornucopia of literature in the form of articles and chapters. There are very few highlighting a similar syndrome of sorts called the operative hysteroscopy intravascular absorption syndrome. Here, we describe one such case, and in brief, the anesthetic management options for hysteroscopic procedures to prevent such a complication.

Cerebral arteriovenous malformation (AVM) or aneurysm in pregnancy is a complex situation and there is no definite recommendation regarding mode of anesthesia for patient with this type of intracranial pathology. We present a case series on the anesthetic management in two pregnant patients with either cerebral AVM or aneurysm presenting for elective cesarean section. Our case series highlights the following: (1) team working and collaboration with neurosurgeon and obstetrician to improve patient outcome; (2) crucial role of anesthetic management in reducing perioperative complications; (3) anesthetic management goals so as to minimize the risk of hemorrhage from an AVM or aneurysm.

Ultrasound assessment of gastric contents and volume is gaining popularity in adults and children. At present, a preoperative verbal check is used to determine the fasting status. Due to fear of delay or cancellation of surgery, parents may not disclose noncompliance with fasting guidelines. Pulmonary aspiration of gastric contents is a potential cause of morbidity and mortality. Ultrasound assessment of gastric contents is noninvasive and easy to learn. We present a series of three cases to demonstrate how the use of ultrasound to assess gastric contents in children can provide an objective means for decision-making and impact anesthetic management when preoperative fasting status is uncertain.

Pulmonary endarterectomy (PEA) is considered treatment of choice for chronic thromboembolic pulmonary hypertension. The procedure dramatically improves functional status and provides an excellent immediate improvement and long-term survival, better than lung transplantation. PEA, until recently performed in only a few highly specialized centers, is now spreading worldwide with good results. We report successful anesthetic management of PEA under deep hypothermic circulatory arrest in our institute.

Arteriovenous (AV) malformations of the face are rare presentations. Endovascular coiling is one of the treatment modalities. We report a case of a 65-year-old lady who presented with a large AV malformation of the face located around the nasal bride and alae nasae posted for coiling under general anesthesia. Anesthetic management of the case was a challenge as it was an anticipated difficult airway situation. Furthermore, any pressure on the swelling can lead to rupture and hemorrhage as the skin above swelling was unhealthy. There was difficulty in mask ventilation both with larger- and smaller-sized facial masks including Rendell-Baker-Soucek mask. Supraglottic airway device had to be inserted as a rescue measure. After getting effective ventilation, muscle relaxants were supplemented, and trachea was intubated. While intubating the axis of the laryngoscope had to be maintained on the right side to avoid pressure on the swelling as it could traumatize the malformation. The procedure went on uneventful. The patient was extubated fully awake.

Anesthetic and surgical management of small children is challenging because of technical difficulties and repeated re-explorations for vascular or biliary complications. Preoperative optimization and meticulous intraoperative and postoperative management can achieve the survival rates comparable to older children. In our institution, we have successfully managed living donor liver transplant in four small children ≤8 kg, and with these case reports, we have tried to present anesthetic concerns and management of these cases along with surgical and postoperative details.

Tumors from remnants of the embryonic notochord are called as Chordomas. These are slow growing, yet aggressive tumors. Despite treatment, these, low grade, malignant tumors are very prone to recurrence and 6 years is approximately the median survival time. Though commonly located in the sacrococcygeal or sphenooccipital regions, their incidence in the cervical spine is around 7.5%. Treatment approaches vary from surgical excision to radiotherapy and chemotherapy. Outcome of these tumors depends on the size and location of tumour and the course of treatment delivered. Surgery is the treatment of choice with the goal to remove maximum tumor as possible and thereafter, patients are offered radiotherapy or chemotherapy. Due to the proximity of these tumors to various vital structures such as brain and spinal cord, the management requires the involvement of various subspecialties working in cohesion. We present the anesthetic management of a 32-year-old male patient who presented with recurrence of C2 chordoma postradiotherapy and was a challenge for airway management.

Anaphylaxis during anesthesia is a life-threatening situation that occurs uncommonly. A 60-year-old woman with a history of anaphylaxis during previous anesthesia is scheduled to undergo elective open cholecystectomy. Her skin tests revealed sensitivity to vecuronium and nonsensitivity to injections of midazolam, fentanyl, and propofol. Due to high incidence of cross sensitivity among neuromuscular drugs, it was thought best to avoid general anesthesia. Spinal anesthesia was planned for the patient. The patient refused to give consent for spinal anesthesia, and she had to be taken up for surgery under general anesthesia. The only alternate neuromuscular blocking drug available to us was atracurium, which was tested for sensitivity by intradermal test. Atracurium was found to be not sensitive on intradermal test. We report here the dilemma and the challenges faced during management of general anesthesia in a patient with history of anaphylaxis to vecuronium.

Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Postoperative analgesia is important, particularly in orthopedic surgeries one for pain relief. This review highlights the clinical manifestations in CP and anesthetic considerations in such child presenting for various surgeries.

Anesthetizing an intellectually disabled patient is a challenge due to lack of cognition and communication which makes perioperative evaluation difficult. The presence of associated medical problems and lack of cooperation further complicates the anesthetic technique. An online literature search was performed using keywords anesthesia, intellectually disabled, and mentally retarded and relevant articles were included for review. There is scarcity of literature dealing with intellectually disabled patients. The present review highlights the anesthetic challenges, their relevant evidence-based management, and the role of caretakers in the perioperative period. Proper understanding of the associated problems along with a considerate and unhurried approach are the essentials of anesthetic management of these patients.

Stevens–Johnson syndrome (SJS) is an acute reaction to medications. It is a severe form of erythema multiforme. It is characterized with vesiculobullous eroded lesions of the skin and mucous membrane. Anesthetic management pertains to the drugs that can be used for anesthesia and preventing injury of oropharynx and larynx due to lesions. We report a rare case of SJS with attention deficit hyperkinetic disorder and seizure disorder for circumcision.

Myasthenia gravis (MG) is a rare disorder involving neuromuscular junction. In conjunction with medical therapy, thymectomy is a known modality of treatment of MG and has shown to increase the probability of remission and overall symptomatic improvement. For minimally invasive thymectomy, video-.assisted thoracoscopic surgery has been the preferred surgical approach till recently. The robotic surgical procedure must necessarily bring new challenges to the anesthesiologists to effectively meet the specific requirements of the technique. At present, there is a paucity of literature regarding the anesthetic concerns of robotic assisted thymectomy, patient in question specifically posed a challenge since different maneuvers and techniques had to be tried to obtain optimum surgical conditions with stable ventilatory and hemodynamic parameters. Concerns of patient positioning and hemodynamic monitoring have also been discussed.

Congenital abnormalities of the large airways are uncommon, but may occasionally pose significant difficulties for anesthesiologists. The tracheal bronchus is an anatomical variant in which an accessory bronchus originates directly from the trachea rather than distal to the carina, as a takeoff from the right mainstem bronchus. Anesthesiologists should be aware of this uncommon anomaly, its different variants, and its management in order to successfully establish one lung ventilation (OLV) for surgical isolation. In this article, we report the challenges encountered in establishing OLV in a patient with a previously undiagnosed aberrant right upper lobe bronchus arising directly from the trachea.