We report a case of acute intraoperative tympanic membrane (TM) rupture in a patient anesthetized with desflurane without N2O. The patient was undergoing endoscopic retrograde cholangiopancreatography (ERCP) to treat ascending cholangitis. TM rupture is known to occur with N2O but has not been reported in the literature with the use of inhaled volatile anesthetics without N2O. We suspect that several factors contributed to this complication, including prone positioning, a remote history of ear trauma, and the selection of desflurane as the maintenance anesthetic as opposed to a vapor with a higher blood-gas partition coefficient.

Volatile anesthetics have been described as a rescue therapy for patients with refractory status asthmaticus (SA), and the use of isoflurane for this indication has been reported since the 1980s. Much of the literature reports good outcomes when inhaled isoflurane is used as a rescue therapy for patients for refractory SA. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a mode of mechanical circulatory support that is usually employed as a potentially lifesaving intervention in patients who have high risk of mortality, primarily for underlying pulmonary pathology. VV ECMO is usually only considered in cases where patients gas exchange cannot be satisfactorily maintained by conventional therapy and mechanical ventilation strategies. We report the novel use of isoflurane delivered systemically as treatment for severe refractory SA in a patient on VV ECMO. A 51-year-old male with a history of asthma was transferred from another institution for management of severe SA. He was intubated at the referring hospital after failing non-invasive ventilation. Initial arterial blood gas (ABG) showed pH 7.21, partial pressure of carbon dioxide (PCO2) >95 mmHg, and partial pressure of oxygen (PaO2) 60 mmHg. VV ECMO was initiated on hospital day (HD) 1 due to refractory respiratory acidosis. After ECMO initiation, acid-base status improved, however, severe bronchospasm persisted and intrinsic positive end expiratory pressure (PEEP) was measured at 18 cm H2O. Systemic paralysis was employed, respiratory rate (RR) was reduced to 4 breaths per minute. This degree of bronchospasm did not allow for ECMO weaning. On HD 5, the patient received systemic isoflurane via the ECMO circuit for 20 h. The following morning, intrinsic PEEP was 4 cm H2O, and wheezing improved. He was decannulated from VV ECMO on HD 10 and extubated on HD 17. Inhaled isoflurane therapy in patients on VV ECMO for refractory SA has shown good results, but requires delivery of the medication via anesthesia ventilators. Our case highlights an effective alternative, systemic delivery of anesthetic via the ECMO circuit, as it is often difficult and dangerous to transport these patients to the operating room (OR) or have an intensive care unit (ICU) room adjusted to accommodate an anesthesia ventilator.

Malignant hyperthermia (MH) is a hypermetabolic disorder that can occur in genetically susceptible individuals exposed to halogenated anesthetics and succinylcholine. Spinal cord injury (SCI) above the sixth thoracic vertebra is associated with dysfunction of the sympathetic/parasympathetic nervous pathways, including thermoregulatory dysfunction, presenting as hypothermia in cold environments because of vasodilation and heat loss. This effect could mitigate or obscure an MH episode. Here, we describe development of a fatal MH crisis in a patient with SCI.
A 27-yr-old male patient with an SCI after fracture of the sixth cervical vertebra was admitted for spinal arthrodesis. Anesthetic medications included remifentanil, propofol, succinylcholine, rocuronium, and isoflurane. After the start of the surgery, muscular contractures resembling myoclonus were noted, which resolved with pancuronium administration. Four hours after the start of anesthesia, the patient presented with hyperthermia, hypercarbia, hypotension, muscle rigidity, arrhythmia, and cardiogenic shock, with metabolic/respiratory acidosis. Malignant hyperthermia was suspected and the treatment was started, but he developed cardiopulmonary arrest and died an hour and a half after the first cardiac arrest. Both parents were investigated and were found to have normal creatine kinase levels and positive in vitro contracture tests. His mother carried a variant in the ryanodine receptor type 1 (RYR1) gene (c.14918C>T), which is associated with MH.
Spinal cord injury-induced thermoregulatory dysfunction may obscure the early diagnosis of MH and lead to fatal outcome.
RéSUMé: OBJECTIF: L’hyperthermie maligne est un trouble hypermétabolique qui peut survenir chez les personnes génétiquement susceptibles exposées à des anesthésiques volatils et à la succinylcholine. Les lésions médullaires situées au-dessus de la sixième vertèbre thoracique sont associées à un dysfonctionnement des voies nerveuses sympathiques / parasympathiques, y compris un trouble de la thermorégulation, et se présentent sous forme d’hypothermie dans des environnements froids en raison de la vasodilatation et de la perte de chaleur. Cet effet pourrait atténuer ou occulter un épisode d’hyperthermie maligne. Nous décrivons ici l’apparition d’une crise mortelle d’hyperthermie maligne chez un patient atteint de lésion médullaire. CARACTéRISTIQUES CLINIQUES: Un patient de 27 ans atteint d’une lésion médullaire après une fracture de la sixième vertèbre cervicale a été admis pour une arthrodèse rachidienne. Les médicaments anesthésiques comprenaient du rémifentanil, du propofol, de la succinylcholine, du rocuronium et de l’isoflurane. Après le début de la chirurgie, des contractures musculaires ressemblant à une myoclonie ont été notées, lesquelles se sont résolues avec l’administration de pancuronium. Quatre heures après l’induction d’anesthésie, le patient a présenté une hyperthermie, une hypercarbie, une hypotension, une rigidité musculaire, une arythmie et un choc cardiogénique, avec acidose métabolique / respiratoire. Une hyperthermie maligne a été suspectée et le traitement a été amorcé, mais le patient a subi un arrêt cardiorespiratoire et est décédé une heure et demie après le premier arrêt cardiaque. Les deux parents ont passés des tests et se sont avérés avoir des taux normaux de créatine kinase et des tests de contracture in vitro positifs. La mère du patient était porteuse d’un variant du gène récepteur de ryanodine de type 1 (RYR1) (c.14918C>T), lequel est associé à l’hyperthermie maligne. CONCLUSION: Un trouble de la thermorégulation induit par une lésion médullaire peut masquer un diagnostic précoce d’hyperthermie maligne et entraîner une issue fatale.

This article reports the case of a 29-year-old female Jehovah\'s Witness with severe anemia after intrauterine fetal death in the 25th week of gestation, complicated by vaginal bleeding, acute renal failure and hemolysis. Due to her religious beliefs the patient categorically refused blood transfusions. Despite adhering to the recommendations for patient blood management, the hemoglobin (Hb) level gradually decreased to 1.9 g/dl on day 10, when she fainted and had to be sedated and invasively ventilated. Inhalative isoflurane was chosen for sedation because of its potential organ-protective effects and because it provides deep sedation with reduced oxygen requirements, while enabling rapid neurological examination during the sedation windows as well as regular and calm spontaneous breathing. Posthypoxic encephalopathy was demonstrated clinically and electroencephalographically by seizure activity during the sedation windows. Anticonvulsive treatment was started. At a hemoglobin of 1.8 g/dl, she received 2 units of polymerized bovine hemoglobin (Hemopure®, Hemoglogin Oxygen Therapeutics LLC, Souderton, PA, USA), repeated several times on subsequent days because of its short half-life. Considerable methemoglobinemia was noted. After subtracting methemoglobin, the hemoglobin rose by 0.4-0.8 g/dl after each 2 units, initially increasing the oxygen binding capacity of the blood by 33%. After a full neurological recovery and weaning from the ventilator but still on hemodialysis, the patient was transferred to another hospital after 38 days.If allogeneic blood transfusion is not an option, administration of polymerized bovine hemoglobin can temporarily increase the oxygen transport capacity as a last resort treatment. Reduction of oxygen requirements by deep inhaled sedation with isoflurane also seems beneficial and provides advantages.
UNASSIGNED: Eine 29-jährige Zeugin Jehovas erlitt nach intrauterinem Fruchttod in der 25. Schwangerschaftswoche ein akutes Nierenversagen und eine schwere Anämie, bedingt durch Blutverlust und Hämolyse, erlitt. Wegen ihrer religiösen Überzeugung lehnte die Patientin Bluttransfusionen kategorisch ab. Trotz Umsetzung aller Empfehlungen des Patient Blood Management fiel der Hämoglobin(Hb)-Wert kontinuierlich. Am Tag 10 wurde sie bei Hb 1,9 g/dl plötzlich bewusstlos und musste intubiert und beatmet werden. Wegen organprotektiver Effekte und der guten Steuerbarkeit wurde sie inhalativ mit Isofluran sediert. Isofluran ermöglichte jeweils eine rasche neurologische Beurteilbarkeit in Sedierungsfenstern sowie eine regelmäßige, ruhige Spontanatmung bei tiefer Sedierung mit reduziertem Sauerstoffverbrauch. Als Ausdruck einer posthypoxischen Enzephalopathie zeigte sie in den Sedierungsfenstern Krampfanfälle, die im EEG bestätigt und antikonvulsiv behandelt wurden. Bei Hb 1,8 g/dl erhielt sie 2 Infusionsbeutel mit polymerisiertem bovinem Hämoglobin (Hemopure®, Fa. Hemoglobin Oxygen Therapeutics LLC, Souderton, PA, USA), wegen der kurzen Halbwertszeit mehrmals wiederholt an den Folgetagen. Eine beachtliche Methämoglobinämie wurde festgestellt. Auch nach Abzug des Met-Hb zeigten sich Hb-Anstiege um 0,4–0,8 g/dl nach den Gaben. Die Sauerstoffbindungskapazität des Blutes konnte damit initial um 33 % gesteigert werden. Es kam zu einer vollständigen neurologischen Erholung, und die Patientin wurde schließlich vom Respirator entwöhnt, jedoch weiterhin dialysepflichtig nach 38 Tagen in eine andere Klink verlegt.Wenn die Gabe von Fremdblut keine Option darstellt, kann durch Gabe von polymerisiertem bovinem Hämoglobin als Ultima-Ratio-Therapie die Sauerstofftransportkapazität vorübergehend erhöht werden. Eine inhalative Sedierung mit Isofluran zur Senkung des Sauerstoffverbrauchs erscheint gleichermaßen vorteilhaft.

Bartter syndrome is a rare disorder characterized by reduced sodium chloride transport in the distal nephrons of the kidney. Its clinical features are renal salt wasting, hypokalemic metabolic alkalosis, elevated renin and aldosterone levels with normal or low blood pressure, polyuria, hypercalciuria and malnutrition. The pathophysiologic and biochemical changes in these patients should be kept in mind when considering anaesthetic management. This case report describes our management in a nineteen months old, 3.6 kg weight male child with Bartter\'s syndrome who underwent elective repair of hiatal hernia and gastrostomy.

A 2-day-old filly was referred to the hospital with abdominal pain and constipation. The foal presented tachycardia, tachypnea, hypoxemia, hyperlactatemia, and abdominal distension. Meconium impaction was diagnosed, and the filly underwent abdominal surgery. Diazepam and butorphanol were administered for anesthesia premedication, but sedative effects were mild. Xylazine was used to enhance sedation and ketamine was subsequently administered for induction. The foal showed swallow reflex and head movement when intubation was attempted. Consequently, isoflurane on oxygen was provided via an anesthetic face mask. After intubation, the foal was connected to the anesthetic machine and monitored. The electrocardiogram revealed accelerated idioventricular rhythm, characterized by atrioventricular isorhythmic dissociation with monomorphic wide QRS complexes. Lidocaine was administered but the arrhythmia persisted during anesthesia and was spontaneously corrected once the isoflurane was discontinued at the end of the procedure. The foal recovered from anesthesia without complications and no further cardiac events were observed before the patient being discharged. Accelerated idioventricular rhythm likely resulted from administration of isoflurane to a foal presenting hypoxemia, a condition that exacerbates the risk of arrhythmia. Proper management of this abnormal rhythm is crucial as inappropriate treatments may worsen the arrhythmia.

Tricuspid regurgitation (TR) and pulmonary hypertension (PHT) are highly dynamic cardiovascular lesions that may progress rapidly, particularly in the orthotopic liver transplantation (OLT) waitlist population. Severe TR and PHT are associated with poor outcomes in these patients, however it is rare for the two to be newly diagnosed intraoperatively at the time of OLT. Without preoperative information on pulmonary vascular and right heart function, the potential for reversibility of severe TR and PHT is unclear, making the decision to proceed to transplant fraught with difficulty.
We present a case of successful orthotopic liver transplantation (OLT) in a 48 year old female with severe (PHT) (mean pulmonary arterial pressure > 55 mmHg) and severe TR diagnosed post induction of anaesthesia. The degree of TR was associated with systemic venous pressures of > 100 mmHg resulting in massive haemorrhage during surgery and difficulty in distinguishing venous from arterial placement of vascular access devices. Intraoperative transoesophageal echocardiography (TOE) proved crucial in diagnosing functional TR due to tricuspid annular and right ventricular (RV) dilatation, and dynamically monitoring response to treatment. In response to positioning, judicious volatile anaesthesia administration, pulmonary vasodilator therapy and permissive hypovolemia during surgery we noted substantial improvement of the TR and pulmonary arterial pressures, confirming the reversibility of the TR and associated PHT.
TR and PHT are co-dependent, dynamic, load sensitive right heart conditions that are interdependent with chronic liver disease, and may progress rapidly in patients waitlisted for OLT. Use of intraoperative TOE and pulmonary artery catheterisation on the day of surgery will detect previously undiagnosed severe TR and PHT, enable rapid assessment of the cause and the potential for reversibility. These dynamic monitors permit real-time assessment of the response to interventions or events affecting right ventricular (RV) preload and afterload, providing critical information for prognosis and management. Furthermore, we suggest that TR and PHT should be specifically sought when waitlisted OLT patients present with hepatic decompensation.

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.

Cutaneomeningospinal angiomatosis, popularly known as Cobb syndrome, is a rare clinical disorder predominantly presenting with a vascular skin lesion and a spinal angioma at the same dermatomal level. Several case reports and case series have reported on the surgical management of this syndrome, but we failed to find any information about its anesthetic considerations in the Medline database. Our case report describes the perioperative anesthetic management of a 46-year-old man with Cobb syndrome.

Status Asthmaticus is a common reason for Emergency Room visits in children. Most of the asthma flares are successfully managed by use of β agonist and steroids. If these therapies fail to halt the progression of asthma, a number of medical therapies may be used to treat it. However, the data supporting the use of these therapies are conflicting. We present successful use of Extracorporeal Membrane Oxygenation and isoflurane in a child with Refractory Status Asthmaticus.