We present a case of inadvertent spread of local anaesthetic from combined pectoralis (PECS) 1 and 2 fascial plane blocks that resulted in an incomplete brachial plexus block. An otherwise healthy 42-year-old woman with a body mass index of 23.3 kg.m−2 presented for unilateral mastectomy with immediate prosthetic reconstruction for breast cancer. No axillary dissection was performed. Because of service requirements, the blocks were performed at the conclusion of surgery. This may have resulted in greater cranial spread of the local anaesthetic due to surgical dissection along musculature and placement of the breast implant. Following emergence from general anaesthesia, the patient experienced numbness over the ipsilateral medial forearm extending to the little finger. Further examination with a finger-nose test revealed reduced coordination and joint proprioception of the ipsilateral arm. There was no detectable gross motor weakness. She was reviewed the following day (23 h after the blocks) by which time her symptoms had subsided entirely. We believe that this is the first documented brachial plexus block after injection of local anaesthetic into the pectoralis 1 and 2 fascial planes.
{"title":"Brachial plexus blockade arising from a combined pectoralis (PECS) 1 and 2 block","authors":"J. D. Mathers, A. Engum, G. Galleberg","doi":"10.1002/anr3.12251","DOIUrl":"10.1002/anr3.12251","url":null,"abstract":"<p>We present a case of inadvertent spread of local anaesthetic from combined pectoralis (PECS) 1 and 2 fascial plane blocks that resulted in an incomplete brachial plexus block. An otherwise healthy 42-year-old woman with a body mass index of 23.3 kg.m<sup>−2</sup> presented for unilateral mastectomy with immediate prosthetic reconstruction for breast cancer. No axillary dissection was performed. Because of service requirements, the blocks were performed at the conclusion of surgery. This may have resulted in greater cranial spread of the local anaesthetic due to surgical dissection along musculature and placement of the breast implant. Following emergence from general anaesthesia, the patient experienced numbness over the ipsilateral medial forearm extending to the little finger. Further examination with a finger-nose test revealed reduced coordination and joint proprioception of the ipsilateral arm. There was no detectable gross motor weakness. She was reviewed the following day (23 h after the blocks) by which time her symptoms had subsided entirely. We believe that this is the first documented brachial plexus block after injection of local anaesthetic into the pectoralis 1 and 2 fascial planes.</p>","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10625990/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71489532","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Myoclonus is a known side effect of propofol and can interfere with surgery and possibly precipitate patient injury. Here, we report a 23-year-old patient undergoing an L5 osteoblastoma resection with a predominantly propofol-based anaesthetic who developed intra-operative myoclonus. Other adjuncts included ketamine, lidocaine and fentanyl infusions. The myoclonus did not improve after deepening the anaesthetic with propofol, opioid boluses or discontinuation of the lidocaine infusion. The myoclonus ceased after reducing the propofol infusion and increasing the ketamine and opioid infusions. The remainder of the intra-operative course was uneventful. This report details our intra-operative management of propofol-induced cortical reflex myoclonus and discusses our institution's experience with treating this phenomenon.
{"title":"Propofol-induced myoclonus during maintenance of anaesthesia","authors":"S. Chao, R. Khan, J. Lieberman, M. Buren","doi":"10.1002/anr3.12253","DOIUrl":"10.1002/anr3.12253","url":null,"abstract":"<p>Myoclonus is a known side effect of propofol and can interfere with surgery and possibly precipitate patient injury. Here, we report a 23-year-old patient undergoing an L5 osteoblastoma resection with a predominantly propofol-based anaesthetic who developed intra-operative myoclonus. Other adjuncts included ketamine, lidocaine and fentanyl infusions. The myoclonus did not improve after deepening the anaesthetic with propofol, opioid boluses or discontinuation of the lidocaine infusion. The myoclonus ceased after reducing the propofol infusion and increasing the ketamine and opioid infusions. The remainder of the intra-operative course was uneventful. This report details our intra-operative management of propofol-induced cortical reflex myoclonus and discusses our institution's experience with treating this phenomenon.</p>","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10626004/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71489535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Is it time for the ‘OOPS’ to ‘EXIT’?","authors":"E. Powell, Y. Metodiev","doi":"10.1002/anr3.12259","DOIUrl":"10.1002/anr3.12259","url":null,"abstract":"","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71489534","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
V. Katerenchuk, A. Calçada, A. C. Batista, L. Cordeiro
<p>Numerous sources of interference with Bispectral Index™ (BIS) values have been reported, including electrocautery, forced-air-warming devices, and pacemakers [<span>1-3</span>], electrical artefact can be misinterpreted by the BIS algorithm, resulting in misleading values [<span>1</span>].</p><p>Quantitative neuromuscular monitoring at the corrugator supercilii muscle is of particular utility when a patient's arms are not accessible due to surgical positioning. However, this site, involving electrodes applied to the patient's forehead, might impair BIS interpretation. We observed these changes during a steady state of general anaesthesia with a BIS Vista sensor (Covidien, Dublin, Ireland) placed on the left forehead of a patient undergoing laparoscopic abdominal surgery.</p><p>After achieving a constant effect-site concentration of propofol and an appropriate depth of anaesthesia according to BIS monitoring, and assuring neuromuscular blockade with a bolus of rocuronium, we set up a train of four (TOF) acceleromyography monitor (ToFscan®, Dräger Medical, Lübeck, Germany) with a stimulating current set at 30 mA and stimulating electrodes placed over the facial nerve, as shown in Figure 1.</p><p>Within 1 min of placing the TOF electrodes (without obtaining measurements, just with the monitor turned on), a sustained increase of between 5 and 15 points in the BIS value was observed. There were no other indications of a variation in anaesthetic depth, and there were no expected surgically induced variations in anaesthetic requirements. The BIS monitor displayed optimal signal quality (full bars), but the electromyogram (EMG) signal indicator increased slightly. Switching off the TOF monitor (maintaining connector cables applied), caused a reduction to the previously observed BIS values within 2 min.</p><p>This unexpected increase in BIS value may be explained by the fact that TOF electrode connector cables, simply attached with the monitor turned on, are a source of electrical noise [<span>1, 3, 4</span>]. When asked about potential interference, the manufacturer of ToFscan suggested that a probable explanation is related to frequent and periodic (every few seconds) impedance checks. Additionally, in accordance with our observations, they reported that this interference is not present when the stimulating electrodes are placed over the ulnar nerve and is no greater than that of an electric scalpel. With that in mind, using a standard digital multimeter, we measured the voltage between the two TOF electrodes and verified repeating brief rises to a maximum of 27 mV (a typical adult human electroencephalogram signal is up to 200 μV), which supports the previous explanation.</p><p>When BIS values are exceedingly high and inconsistent with clinical assessment, one should carefully confirm that no sources of interference are present. Subtle changes may go unnoticed by the BIS signal quality indicator [<span>1</span>]. Although variation in-between the bo
{"title":"Falsely increased Bispectral Index™ due to neuromuscular transmission monitoring","authors":"V. Katerenchuk, A. Calçada, A. C. Batista, L. Cordeiro","doi":"10.1002/anr3.12256","DOIUrl":"10.1002/anr3.12256","url":null,"abstract":"<p>Numerous sources of interference with Bispectral Index™ (BIS) values have been reported, including electrocautery, forced-air-warming devices, and pacemakers [<span>1-3</span>], electrical artefact can be misinterpreted by the BIS algorithm, resulting in misleading values [<span>1</span>].</p><p>Quantitative neuromuscular monitoring at the corrugator supercilii muscle is of particular utility when a patient's arms are not accessible due to surgical positioning. However, this site, involving electrodes applied to the patient's forehead, might impair BIS interpretation. We observed these changes during a steady state of general anaesthesia with a BIS Vista sensor (Covidien, Dublin, Ireland) placed on the left forehead of a patient undergoing laparoscopic abdominal surgery.</p><p>After achieving a constant effect-site concentration of propofol and an appropriate depth of anaesthesia according to BIS monitoring, and assuring neuromuscular blockade with a bolus of rocuronium, we set up a train of four (TOF) acceleromyography monitor (ToFscan®, Dräger Medical, Lübeck, Germany) with a stimulating current set at 30 mA and stimulating electrodes placed over the facial nerve, as shown in Figure 1.</p><p>Within 1 min of placing the TOF electrodes (without obtaining measurements, just with the monitor turned on), a sustained increase of between 5 and 15 points in the BIS value was observed. There were no other indications of a variation in anaesthetic depth, and there were no expected surgically induced variations in anaesthetic requirements. The BIS monitor displayed optimal signal quality (full bars), but the electromyogram (EMG) signal indicator increased slightly. Switching off the TOF monitor (maintaining connector cables applied), caused a reduction to the previously observed BIS values within 2 min.</p><p>This unexpected increase in BIS value may be explained by the fact that TOF electrode connector cables, simply attached with the monitor turned on, are a source of electrical noise [<span>1, 3, 4</span>]. When asked about potential interference, the manufacturer of ToFscan suggested that a probable explanation is related to frequent and periodic (every few seconds) impedance checks. Additionally, in accordance with our observations, they reported that this interference is not present when the stimulating electrodes are placed over the ulnar nerve and is no greater than that of an electric scalpel. With that in mind, using a standard digital multimeter, we measured the voltage between the two TOF electrodes and verified repeating brief rises to a maximum of 27 mV (a typical adult human electroencephalogram signal is up to 200 μV), which supports the previous explanation.</p><p>When BIS values are exceedingly high and inconsistent with clinical assessment, one should carefully confirm that no sources of interference are present. Subtle changes may go unnoticed by the BIS signal quality indicator [<span>1</span>]. Although variation in-between the bo","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10609538/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71415536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Congenital epulides, rare benign gum tumours which present at birth, pose challenges for neonatal anaesthesia due to potential airway obstruction and surgical requirements. This case report discusses successful anaesthesia for a newborn with these tumours. An oversized facemask enabled an adequate seal, and videolaryngoscopy provided good airway visualisation for orotracheal intubation. Close collaboration between anaesthesia, surgical and nursing teams resulted in safe anaesthesia and surgical removal of the epulides and an uneventful recovery.
{"title":"Anaesthetic management of a neonate with multiple congenital epulides","authors":"C. Downes, C. Moores","doi":"10.1002/anr3.12255","DOIUrl":"10.1002/anr3.12255","url":null,"abstract":"<p>Congenital epulides, rare benign gum tumours which present at birth, pose challenges for neonatal anaesthesia due to potential airway obstruction and surgical requirements. This case report discusses successful anaesthesia for a newborn with these tumours. An oversized facemask enabled an adequate seal, and videolaryngoscopy provided good airway visualisation for orotracheal intubation. Close collaboration between anaesthesia, surgical and nursing teams resulted in safe anaesthesia and surgical removal of the epulides and an uneventful recovery.</p>","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10608796/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71415535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
G. P. Deepak, S. Juneja, A. Wadehra, K. Sandhu, B. S. Walia
{"title":"Pinch purpura; an acute presentation of systemic amyloidosis under general anaesthesia","authors":"G. P. Deepak, S. Juneja, A. Wadehra, K. Sandhu, B. S. Walia","doi":"10.1002/anr3.12252","DOIUrl":"10.1002/anr3.12252","url":null,"abstract":"","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1002/anr3.12252","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49694402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Comment on ‘Utilising 3D printing in assessment of anticipated difficult airways’: a response","authors":"H. A. Iliff, I. Ahmad, C. Woodford","doi":"10.1002/anr3.12257","DOIUrl":"10.1002/anr3.12257","url":null,"abstract":"","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1002/anr3.12257","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49685575","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Posterior reversible encephalopathy syndrome is a rare and serious condition that presents with acute neurological symptoms with characteristic changes on imaging. It can lead to substantial morbidity and mortality, but can be reversible if recognised and treated. Here, we report a case of posterior reversible encephalopathy syndrome in a child post-splenectomy under general anaesthesia with spinal anaesthesia. As far as we are aware, this condition has not previously been described in relation to spinal anaesthesia in the paediatric population. This case demonstrates the importance of recognising blood pressure changes in children, which can be challenging due to age-, sex- and height-related centiles for blood pressure measurements. Posterior reversible encephalopathy syndrome should be considered as a differential diagnosis for headache in a patient that has had a spinal anaesthesia.
{"title":"Posterior reversible encephalopathy syndrome in a child, following splenectomy under combined general and spinal anaesthesia","authors":"L. Gallop, N. McNeillis","doi":"10.1002/anr3.12245","DOIUrl":"10.1002/anr3.12245","url":null,"abstract":"<p>Posterior reversible encephalopathy syndrome is a rare and serious condition that presents with acute neurological symptoms with characteristic changes on imaging. It can lead to substantial morbidity and mortality, but can be reversible if recognised and treated. Here, we report a case of posterior reversible encephalopathy syndrome in a child post-splenectomy under general anaesthesia with spinal anaesthesia. As far as we are aware, this condition has not previously been described in relation to spinal anaesthesia in the paediatric population. This case demonstrates the importance of recognising blood pressure changes in children, which can be challenging due to age-, sex- and height-related centiles for blood pressure measurements. Posterior reversible encephalopathy syndrome should be considered as a differential diagnosis for headache in a patient that has had a spinal anaesthesia.</p>","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41141505","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
P. Martín-Serrano, E. Sarrió-Badenes, M. Durá-Aranda, L. Molero-Sala
Relapsing polychondritis is a rare disease that affects cartilaginous structures throughout the body. Progressive destruction of the laryngeal structures and the tracheobronchial tree occurs in 50% of patients, potentially leading to loss of patency and collapse of the airway. Respiratory involvement in relapsing polychondritis includes airway stenosis, tracheomalacia and recurrent lung infections due to chronic inflammation caused by the destruction of upper and lower airway cartilage. Pregnancy and preeclampsia can worsen pharyngolaryngeal oedema, while treatment with magnesium sulphate can affect neuromuscular function, exacerbating the degree of airway collapse in the most serious cases of relapsing polychondritis, possibly altering obstetric outcomes. Here, we present the management of a pregnant woman with relapsing polychondritis who presented with features of severe preeclampsia at 29 weeks and 6 days gestation. We believe that this is the first published case of the combination of the two disorders, complicated by acute respiratory failure after treatment with magnesium sulphate.
{"title":"Management of preeclampsia with severe features in a patient with relapsing polychondritis affecting the tracheobronchial tree","authors":"P. Martín-Serrano, E. Sarrió-Badenes, M. Durá-Aranda, L. Molero-Sala","doi":"10.1002/anr3.12249","DOIUrl":"10.1002/anr3.12249","url":null,"abstract":"<div>\u0000 \u0000 <p>Relapsing polychondritis is a rare disease that affects cartilaginous structures throughout the body. Progressive destruction of the laryngeal structures and the tracheobronchial tree occurs in 50% of patients, potentially leading to loss of patency and collapse of the airway. Respiratory involvement in relapsing polychondritis includes airway stenosis, tracheomalacia and recurrent lung infections due to chronic inflammation caused by the destruction of upper and lower airway cartilage. Pregnancy and preeclampsia can worsen pharyngolaryngeal oedema, while treatment with magnesium sulphate can affect neuromuscular function, exacerbating the degree of airway collapse in the most serious cases of relapsing polychondritis, possibly altering obstetric outcomes. Here, we present the management of a pregnant woman with relapsing polychondritis who presented with features of severe preeclampsia at 29 weeks and 6 days gestation. We believe that this is the first published case of the combination of the two disorders, complicated by acute respiratory failure after treatment with magnesium sulphate.</p>\u0000 </div>","PeriodicalId":72186,"journal":{"name":"Anaesthesia reports","volume":"11 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1002/anr3.12249","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41173862","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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