Pediatric malignant hyperthermia: recognizing early warning signs – a case report

Anaesthesia Pain & Intensive Care · 2025-07-17 · 1 citations

Malignant hyperthermia (MH) is a rare, life-threatening pharmacogenetic disorder triggered by exposure to volatile anesthetics and succinylcholine. It results from mutations in the RYR1 gene, leading to excessive intracellular calcium release, hypermetabolism, and potential multiorgan dysfunction. Prompt recognition and treatment are essential to reduce morbidity and mortality. We report the case of an 11-year-old female undergoing pancreaticoduodenectomy who developed intraoperative MH following sevoflurane exposure. Early signs included rising end-tidal CO₂ (EtCO₂) despite increased ventilation, followed by tachycardia and metabolic acidosis, with a peak temperature of 37.1°C. MH was suspected approximately two hours after induction, leading to immediate discontinuation of sevoflurane, transition to total intravenous anesthesia, and administration dantrolene. The patient's vital signs stabilized, and the surgery was completed without further complications. This case underscores the importance of early MH recognition, especially in pediatric patients, who may present with subtle or atypical symptoms. The MH Clinical Grading Score, designed for adults, may not reliably predict MH likelihood in children, necessitating a high index of suspicion. Given the variable presentation of MH in pediatric patients, anesthesiologists must be vigilant in monitoring intraoperative changes. Timely intervention and adherence to MH crisis protocols significantly improve outcomes. Further research is needed to optimize pediatric-specific MH diagnostic criteria and management strategies. Abbreviations: MH: Malignant Hyperthermia, EtCO2: End Tidal Carbon Dioxide, RYR1: Ryanodine Receptor Gene Keywords: Malignant Hyperthermia; Anesthesia; Pediatric Anesthesia; General Anesthesia; Dantrolene; RYR1 gene Citation: Shah S, Dhoon T, Choi Y, Wang G, Rajan G. Pediatric malignant hyperthermia: recognizing early warning signs – a case report. Anaesth. pain intensive care 2025;29(4):446-452. DOI: 10.35975/apic.v29i4.2835 Received: May 09, 2024; Revised: October 26, 2024; Accepted: January 01, 2025

Intractable Neuromuscular Blockade Resistant to Sugammadex Rescue Administration: A Case Report

Cureus · 2025-09-03

We describe the failure of sugammadex when used as a rescue agent, after neuromuscular blockade with rocuronium was insufficiently reversed with neostigmine and glycopyrrolate. Despite repeated doses, this patient needed to be reintubated and sedated until spontaneous recovery was observed over the next few hours. With the increasing preference to utilize sugammadex in the perioperative setting, we are starting to notice a significant number of patients displaying residual paralysis despite sugammadex administration as a solo or rescue agent at our institution. We believe that more attention is needed to examine the factors that contribute to insufficient neuromuscular blockade reversal in these settings.

Managing Recurrent Carbon Dioxide Embolism During Laparoscopic Hepatectomy With Transesophageal Echocardiography Guidance: A Case Report

A&A Practice · 2025-01-01

Carbon dioxide gas emboli is a potentially fatal complication that occurs more frequently during laparoscopic hepatectomy compared to other laparoscopic surgeries. The patient featured in this report had massive gas embolism confirmed by intraoperative transesophageal echocardiography (TEE) that were associated with episodes of severe hypoxemia, hemodynamic instability, and right ventricular failure requiring conversion to open hepatectomy. Abrupt abdominal decompression resulted in massive hemorrhage from a previously undetected defect in the middle hepatic vein. The report demonstrates the successful management of gas embolism during laparoscopic hepatectomy even with a significant delay in vascular repair and highlights the critical role of TEE.

Barotrauma following liquid nitrogen spray cryotherapy for airway recanalization

Anaesthesia Pain & Intensive Care · 2025-11-26

Spray cryotherapy (SCT) using the truFreeze® system (Steris, Mentor, Ohio, USA) is a minimally invasive technique that is becoming increasingly common for airway stenosis management. Although generally considered safe, rare but serious, high-morbidity complications such as barotrauma can occur. We report the case of a 49-year-old female with a history of tracheal and subglottic stenosis who developed a pneumothorax during airway recanalization with truFreeze® cryotherapy. This complication occurred despite the use of standard safety protocols and safeguards, including passive venting. Shortly after the initiation of the cryotherapy, significant abdominal distention was detected, prompting immediate cessation of the procedure. Subsequently, the patient developed transient hypoxemia, and imaging confirmed a left-sided pneumothorax with mediastinal shift. A chest tube was inserted with near-complete resolution of the pneumothorax and associated symptoms. The patient was then discharged in stable condition. This case demonstrates the necessity of intraoperative vigilance and preparation for high-risk complications when using the truFreeze® system. As its usage becomes more widespread, clinicians must have preplanned interventions for barotrauma in order to increase early recognition, timely management, and improved patient outcomes. Abbreviations: ED: Emergency department, LMA: laryngeal mask airway, PSI: pounds per square inch, SCT: Spray cryotherapy Keywords: Spray Cryotherapy, Airway Stenosis, Barotrauma, Pneumothorax, Tracheal Recanalization Citation: Martin-Orr N, Choy J, Rajan G. Barotrauma following liquid nitrogen spray cryotherapy for airway recanalization. Anaesth. pain intensive care 2025;29(8):1044-1046. DOI: 10.35975/apic.v29i8.3033 Received: June 20, 2025; Revised: August 03, 2025; Accepted: August 28, 2025

Managing carbon dioxide embolism in hepatobiliary laparoscopic surgery: a case report

Anaesthesia Pain & Intensive Care · 2025-04-03

Laparoscopic surgery has become a cornerstone of modern medicine, emerging as one of the most frequently performed procedures in the most of the world. It serves as a minimally invasive technique used for a range of diagnostic and therapeutic interventions, including cholecystectomy, hysterectomy, and tissue biopsies. It needs insufflation of the carbon dioxide (CO2) peritoneal cavity to offer space in the abdominal cavity. Veress needle technique being one of the most commonly used, which may injure abdominal contents and blood vessels. This case report is about the inadvertent intrahepatic entry of the Veress needle. Keywords: Cholecystectomy; Laparoscopic surgery; Veress needle Citation: Jiang M, Rajan GR. Managing carbon dioxide embolism in hepatobiliary laparoscopic surgery: a case report. Anaesth. pain intensive care 2025;29(2):345-349. DOI: 10.35975/apic.v29i2.2727

Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome

Anaesthesia Pain & Intensive Care · 2024-10-08

Aortic dissection is a life-threatening condition that can result in rupture, massive hemorrhage, and death. Parturients with Marfan syndrome are at increased risk of aortic dissection due to connective tissue dysfunction and physiologic changes secondary to pregnancy. Aortic dissection typically manifests during the intrapartum period, rather than the postpartum course. This article discusses a case of a parturient with Marfan syndrome who suffered a massive thoracic aortic dissection in the subacute postpartum period after an uncomplicated vaginal delivery. Abbreviations: CT - computerized tomography; AD - Aortic dissection; MFS - Marfan syndrome; PPD - postpartum day; TEVAR - thoracic endovascular aortic repair; TTE - transthoracic echocardiogram; VAVD - vacuum assisted vaginal delivery; VD - vaginal delivery Keywords: Marfan Syndrome; Pregnancy; Aortic Dissection; Neuraxial Anesthesia Citation: Dhoon T, Crain NA, Rahimian R, Rajan GR. Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome. Anaesth. pain intensive care 2024;28(5):964−968; DOI: 10.35975/apic.v28i5.2564 Received: May 09, 2024; Reviewed: August 15, 2024; Accepted: August 15, 2024

Video laryngoscopy: a double-edged sword

Anaesthesia Pain & Intensive Care · 2023 · 1 citations

• Computer Science
• Medicine
• Computer Science

Endotracheal intubation revolutionized anesthesia and allowed prolonged surgical procedures to be performed. It also made positive pressure ventilation possible in patients in respiratory insufficiency and being managed in intensive care units. But successful intubation required the development of laryngoscopes. A variety of blades were developed to be used in different sets of patients. A laryngoscope came to be known as a symbol of the specialty of anesthesiology. But it was not always safe, nor successful, necessitating more sophisticated instruments. Video laryngoscopes were introduced with a sigh of relief for the anesthesiologists in difficult airway cases. Many variations of video laryngoscopes with slight differences have been marketed. But cases of video laryngoscope related injuries have been reported. This paper gives an over-view of the possible mechanism and preventive measures.
 Abbreviations: DL - Direct laryngoscopy; ETT – Endotracheal intubation; IDL - indirect laryngoscopy; VL - Video laryngoscopy; 
 Key words: Airway management; Instrumentation; Intubation, endotracheal; Laryngoscope; Laryngoscopy
 Citation: Dhoon TQ, Wilson L, Rajan GRC. Video laryngoscopy: a double-edged sword. Anaesth. pain intensive care 2023;27(3):413−416; DOI: 10.35975/apic.v27i3.2219
 Received: March 30, 2023; Reviewed: April 11, 2023; Accepted: April 15, 2023

Incision Precision of a Novel Wire-Guided Scalpel During Central Venous Catheter Placement: A Randomized Observational Trial

Journal of Cardiothoracic and Vascular Anesthesia · 2023-03-03 · 2 citations

OBJECTIVE: To determine whether the wire-guided scalpel (GuideBlade) improves incision precision, reduces the need to revise dermatotomy incision, improves the first-time success rate of a central venous catheter (CVC) placement, and decreases CVC-related complications. DESIGN: A randomized 2-arm observational trial. SETTING: At University of California Irvine Medical Center. PARTICIPANTS: Patients (n = 63) undergoing surgery requiring placement of a CVC as part of the standard of care recruited from August 1, 2021, to December 31, 2021. INTERVENTIONS: After randomization, either the GuideBlade (intervention) or the standard #11 scalpel (control) was used during CVC placement before surgery. MEASUREMENTS AND MAIN RESULTS: The number of dermatotomy attempts was higher using the GuideBlade (1.6 ± 1.0) compared to the standard #11 scalpel (1.4 ± 0.6); however, the difference did not reach statistical significance (p = 0.19). Similarly, the number of dilation attempts demonstrated no significant difference between the GuideBlade (1.2 ± 0.4) and the standard scalpel (1.1 ± 0.4; p = 0.65). No CVC-related infections or complications were documented. CONCLUSIONS: No superiority was observed with using the GuideBlade compared to the standard scalpel during central line insertion by novice users. User unfamiliarity and inadequate training may have contributed to this finding, highlighting the importance of proper technique and user experience.

Heart Rate Variation is The Clinical Sign Associated with The Deepest Plane of Anesthesia During Induction: The Novel Finding and Its Clinical Implications

Anaesthesia Pain & Intensive Care · 2023-04-02 · 1 citations

Background: Premature airway manipulation during induction can lead to adverse patient outcomes. However, there is currently no standardized clinical sign to assess adequate anesthesia depth during induction. With the goal of increasing patient safety during induction, we aim to correlate different clinical signs during induction with the depth of anesthesia using the bispectral index (BIS) monitor and determine the physical metrics corresponding to the deepest plane of anesthesia. Methodology: This prospective study enrolled 41 subjects scheduled for surgery requiring propofol for induction. A BIS monitor was used for standardized monitoring of anesthesia depth during the induction process. We documented the BIS value and occurrence time of the observed physical metrics: (1) loss of eyelash reflex, (2) loss of response to verbal stimuli, (3) loss of muscle tone, (4) loss of end tidal carbon dioxide (EtCO2) or apnea, and (5) transient heart rate variations. Results: Apnea, change in heart rate from baseline, and heart rate return to baseline are signs during induction associated with both lower BIS values and later occurrence when compared to other clinical signs such as loss of eyelash reflex, verbal response, and muscle tone (P < 0.001). Conclusion: Physical signs such as loss of eyelash reflex, verbal response, and muscle tone during induction are associated to lighter planes of anesthesia. A safer and deeper plane of anesthesia occurs later. Relying on these physical signs for assessment of laryngeal mask airway insertion may increase the risk of stimulating the patient’s airway prematurely, which can lead to adverse patient outcomes. Abbreviations: EtCO2 - End tidal carbon dioxide; BIS - Bispectral index; EEG - electroencephalogram; EKG - electrocardiogram Key words: Depth of Anesthesia; Patient Safety; Heart rate variation; Induction Citation: Chiang TH, Strutner S, Moheban A, Rinehart J, Rajan GR. Heart rate variation is the clinical sign associated with the deepest plane of anesthesia during induction: the novel finding and its clinical implications. Anaesth. pain intensive care 2023;27(2):243−249. DOI: 10.35975/apic.v27i2.1930 Received: October 13, 2022; Reviewed: March 29, 2023; Accepted: March 31, 2023

Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta‐analysis

Head & Neck · 2023 · 17 citations

• Medicine
• Surgery
• Anesthesia

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.