Anesthesia-Analgesia

Antiphospholipid Syndrome During Septic Shock: Hyper- or Hypocoagulability?: A Case Report We report the clinical case of a septic patient with antiphospholipid syndrome who developed ischemia in all 4 limbs, despite a normal systemic blood pressure. Prolonged coagulation times suggested a hemorrhagic diathesis, requiring transfusion of fresh-frozen plasma and discontinuation of heparin infusion. In contrast, the study of the viscoelastic properties of the clot by thromboelastography suggested an uncontrolled activation of the coagulation cascade. This observation led to the reintroduction of heparin with improvement in the patient’s laboratory findings. Anesthesiologists should consider thromboelastography to correct coagulopathies in patients with septic shock in the presence of antiphospholipid antibodies. Accepted for publication May 20, 2019. Funding: This work was supported by institutional funds. Conflicts of Interest: See Disclosures at the end of the article. Address correspondence to Emanuele Rezoagli, MD, Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, 20900 Monza, Italy. Address e-mail to emanuele.rezoagli@gmail.com. © 2019 International Anesthesia Research Society

Pancreaticoduodenectomy (Whipple Procedure) in a Toddler: An Anesthesia Case Report Pancreaticoduodenectomy (Whipple procedure) is performed rarely in pediatric patients. We present our anesthetic management of an 18-month-old girl who underwent a Whipple procedure for a mass in the head of the pancreas that was causing obstructive cholangiopathy. We explore the differences between pediatric and adult patients presenting for Whipple procedure, with a focus on pediatric anesthetic management. Key considerations include blood and fluid management, perioperative analgesia, and postoperative care. Accepted for publication May 23, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Erik B. Smith, MD, JD, MS, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans St, Bloomberg 6321, Baltimore, MD 21287. Address e-mail to erik@jhmi.edu. © 2019 International Anesthesia Research Society

Prolapse of Aortic Right Coronary Cusp Causing Right Ventricular Outflow Tract Obstruction in a Child With Large Ventricular Septal Defect No abstract available

Delayed Neuromuscular Blockade Reversal With Sugammadex After Vecuronium, Desflurane, and Magnesium Administration: A Case Report A variety of factors are known to prolong neuromuscular blockade, including several medications commonly used in anesthetic practice. We present a patient who underwent general anesthesia using desflurane, vecuronium, and magnesium infusion with delayed neuromuscular blockade reversal after sugammadex administration. A higher than anticipated total dose of sugammadex was required for adequate reversal, and quantitative neuromuscular monitoring was essential to ensuring complete neuromuscular recovery before extubation in this case. Accepted for publication May 23, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Stuart Grant, MBChB, Department of Anesthesiology, Duke University Medical Center, DUMC Box 3094, Durham, NC 27710. Address e-mail to stuartgrant1@me.com. © 2019 International Anesthesia Research Society

Decreasing Frontal Electroencephalogram Alpha Power and Increasing Sensitivity to Volatile Anesthetics Over 3 Surgeries Within 7 Months: A Case Report Depth of anesthesia (DoA) monitors are widely used during general anesthesia to guide individualized dosing of hypnotics. Other than age and specific drugs, there are few reports on which comorbidities may influence the brain and the resultant electroencephalogram (EEG) of patients undergoing general anesthesia. We present a case of a patient undergoing 3 cardiac operations within 7 months with severe illness and comorbidity, leading to pronounced physical frailty and significant changes of frontal alpha power in the EEG and increased sensitivity to volatile anesthetics. These findings may have important clinical implications and should trigger further investigations on this topic. Accepted for publication May 1, 2019. Funding: This work received funding from Bangerter-Rhyner Foundation Grant and Clinical Trials Unit grant of the University Hospital of Bern, Inselspital, Bern, Switzerland. The authors declare no conflicts of interest. Clinical trial number: ClinicalTrials.gov; Identifier: NCT02976584. Address correspondence to, Heiko A. Kaiser, MD, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland., Address e-mail to heiko.kaiser@insel.ch. © 2019 International Anesthesia Research Society

Postpartum Thyroid Storm in Poorly Controlled Graves’ Disease: A Case Report Hyperthyroidism during pregnancy is a relatively rare event, but poor control of hyperthyroidism during pregnancy is associated with a host of issues. These include intrauterine fetal demise, hypertensive disorders of pregnancy, preterm delivery, low birth weight, intrauterine growth restriction, and maternal congestive heart failure. One of the most feared sequelae of hyperthyroidism is thyroid storm, which has a mortality rate >10%. Patients who develop thyroid storm present several challenges to anesthesiologists including hemodynamic instability and medication management. Here, we present the anesthetic management for a parturient whose delivery was complicated by signs and symptoms consistent with thyroid storm. Accepted for publication May 23, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Jack M. Peace, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron F5-704, Chicago, IL 60611. Address e-mail to jack.peace@northwestern.edu. © 2019 International Anesthesia Research Society

Analgesic Rescue With Opioid-Only Thoracic Epidural After Surgical Infiltration of Liposomal Bupivacaine: A Case Report We present the case of a 51-year-old man with a history of recurrent lung cancer after left upper lobectomy who presented for an elective completion pneumonectomy via a bilateral anterior thoracotomy incision. At the completion of surgery, bilateral multilevel intercostal infiltration was performed with liposomal bupivacaine. Due to poorly controlled postoperative pain after extubation, a thoracic epidural was placed in the intensive care unit. An opioid-only infusion was started and transitioned to a local anesthetic–based infusion on postoperative day 2. This case report represents a novel stepwise approach of thoracic epidural management after surgical infiltration of liposomal bupivacaine. Accepted for publication May 16, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Matthew W. Swisher, MD, Department of Anesthesiology, University of California San Diego, 9500 Gilman Dr MC 0898, La Jolla, CA 92093. Address e-mail to mwswisher@ucsd.edu. © 2019 International Anesthesia Research Society

Lung Isolation for Whole Lung Lavage in a Pediatric Patient With Atypical Airway Anatomy due to Short Stature: A Case Report This case demonstrates the airway management of a pediatric patient with short stature due to STAT5b deficiency, a rare genetic immunodeficiency associated with lung disease and endocrinopathy. The patient had recurrent pulmonary infections and pulmonary alveolar proteinosis (PAP) for which whole lung lavage (WLL) was recommended. Due to short stature and overall body habitus, the patient’s airway would not accommodate a traditional double-lumen tube (DLT). Therefore, we placed 2 single-lumen breathing tubes: 1 endobronchial and 1 endotracheal, to mimic a DLT and facilitate WLL, demonstrating a viable option for lung isolation in the absence of purpose-built equipment. Accepted for publication April 30, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Susan E. Eklund, MD, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Bader 3, Boston, MA 02115. Address e-mail to susan.eklund@childrens.harvard.edu. © 2019 International Anesthesia Research Society

Comparison of Twitter Use of the American Society of Anesthesiologists and the American Association of Nurse Anesthetists Twitter has become a powerful tool for dissemination of information. The objective of this study was to evaluate Twitter usage of the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA). All tweets from ASA (“@ASALifeline”) and AANA (“@aanawebupdates”) were collected over a 1-year time period. The content of each tweet was categorized using a rubric. ASA generated more original tweets than AANA. Twitter use was highest in October for ASA and September for AANA. Both societies are actively using Twitter. Future work should evaluate the impact of societal Twitter use. Accepted for publication May 7, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Elizabeth M. S. Lange, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron St, F5-704, Chicago, IL 60611. Address e-mail to elizabeth.lange@northwestern.edu. © 2019 International Anesthesia Research Society

Having a Conscious Patient During Cardiopulmonary Resuscitation: Is It Not Time to Consider Sedation Protocol?: A Case Report A middle-aged man with acute inferior wall myocardial infarction was admitted in cardiac arrest and in an unresponsive state to the hospital. Cardiopulmonary resuscitation (CPR) was initiated. Patient showed signs of consciousness throughout the CPR. The impact of awareness during CPR on the neuropsychological status of a patient with a favorable neurological outcome is yet to be studied on a large scale. Sedation protocol without compromising hemodynamic status may prove a fair choice in such cases. Accepted for publication April 9, 2019. Funding: None. The author declares no conflicts of interest. Address correspondence to Vasanth Sukumar, DA, DNB, Royal Care Super Specialty Hospitals, Neelambur, Coimbatore 641062, Tamil Nadu, India. Address e-mail to vasnt.dr@gmail.com. © 2019 International Anesthesia Research Society