We describe an incident of methylene blue extravasation into the hand and forearm of a patient undergoing parathyroidectomy. We discuss the management of this patient, how this compares to other cases in the literature and highlight an ongoing need for national guidance.
We present a case series describing a novel approach to the lumbar plexus, which we have named the psoas sheath block. In this technique, we deposited local anaesthetic into the potential space between the psoas major muscle and its surrounding fascia, in a manner similar to the rectus sheath block. We hypothesised this anatomical plane would facilitate the spread of local anaesthetic to the branches of the lumbar plexus, specifically the femoral, obturator and lateral femoral cutaneous nerves, as they traverse the body of the psoas major muscle on their course to innervate the hip and anterior thigh. In this report, we outline the technique and describe its application in six consecutive patients undergoing hip surgery.
Intra-operative airway injuries in robotic thoracic surgery pose unique challenges for the anaesthetist and surgeon. Close communication between the anaesthetic and surgical team is vital in providing adequate one-lung ventilation and a successful operation. We describe a case of intra-operative iatrogenic surgical bronchial tear and subsequent bronchial cuff rupture, requiring immediate specialist anaesthetic management. Management priorities include providing safe oxygenation, ventilation and subsequent lung isolation to allow completion of lung resection.
Progressive supranuclear palsy is a neurodegenerative disease of unknown aetiology; few reports address its anaesthetic management. Remimazolam, a recently approved short-acting benzodiazepine, was used in combination with remifentanil for total intravenous anaesthesia during open cholecystectomy in a patient with progressive supranuclear palsy. Due to its cardiovascular stable profile and rapid reversibility with flumazenil, remimazolam may serve as a viable option for general anaesthesia in patients with this condition.
Methaemoglobinaemia is a rare but serious condition which can arise due to the administration of local anaesthetic agents. A 36-year-old woman with metastatic oesophageal adenocarcinoma experienced a rapid onset of methaemoglobinaemia following airway topicalisation with lidocaine and benzocaine sprays for bronchoscopy. The patient was treated with supplementary oxygen, non-invasive respiratory support, methylene blue and ascorbic acid. Early diagnosis and timely treatment of methaemoglobinaemia can result in rapid clinical improvement and prevent long-term complications.
A 7-year-old boy with juvenile pilocytic astrocytoma experienced sudden haemodynamic collapse after significant venous bleeding and the application of absorbable haemostatic gelatin sponge. Following successful resuscitation, intra-operative transthoracic echocardiography revealed acute right ventricular failure. Subsequent computed tomography angiography confirmed the diagnosis of a massive pulmonary embolism. Extracorporeal membrane oxygenation was initiated and catheter thrombectomy was performed. The patient had a rapid and complete recovery. This case underscores the importance of vigilance and multidisciplinary teamwork in the management of rare but life-threatening complications.
Glucagon-like peptide-1 receptor agonists slow gastric emptying and may increase aspiration risk. Recent guidelines suggest using prokinetic agents pre-operatively, but no studies have assessed the efficacy of erythromycin for this purpose. We present a 53-year-old man (weight 110 kg) taking liraglutide and undergoing elective knee arthroscopy. Despite 19 h of fasting and withholding liraglutide, gastric ultrasound revealed a grade 3 antrum with solid content. Intravenous erythromycin 300 mg was administered, causing transient gastrointestinal symptoms. A repeat ultrasound 15 min later showed reduced solid content, although the antrum was not convincingly empty. As the patient declined neuraxial anaesthesia without sedation, a modified rapid sequence induction was performed. An ultrasound scan at the completion of surgery confirmed an empty stomach, and recovery was uneventful. This is the first documented case using gastric ultrasound to assess the effect of erythromycin on a patient taking a glucagon-like peptide-1 receptor agonist. While erythromycin achieved its desired effect within 100 min, the optimal timing for prokinetic administration and subsequent ultrasound assessment remains uncertain. Gastric ultrasound may refine risk stratification and guide prokinetic use for these patients. Further research is needed to determine optimal erythromycin dosing, time to desired effect and side effects to optimise peri-operative management.
Blood transfusion is one of the causes of anaphylaxis during general anaesthesia. In most cases, adrenaline administration quickly alleviates circulatory failure and its continuous administration for days is very rare. We present the case of a 79-year-old man who experienced prolonged anaphylactic circulatory failure with increased histamine and tryptase concentrations following laparoscopic total gastrectomy, during which he received a blood transfusion. He developed hypotension soon after the initiation of blood transfusion during surgery. We immediately administered intravenous adrenaline, followed by a continuous adrenaline infusion to stabilise the circulation. Circulatory failure recurred and itchy wheals appeared when the adrenaline dose was reduced necessitating continuous adrenaline administration for > 24 h. The histamine and tryptase serum concentrations increased when the adrenaline dose was reduced. The timing of anaphylaxis onset and skin test results excluded rocuronium, cefazolin, ropivacaine and propofol as causes of the anaphylaxis. Therefore, the blood transfusion was the most likely cause. For anaphylaxis due to common causes, boluses of adrenaline often restore the circulation shortly after onset. However, transfusion-induced anaphylaxis, as in this case, can require prolonged infusion of adrenaline because of the lack of allergen clearance. For such cases, careful follow-up is very important.
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