Total Hip Replacement in a Patient With a Fontan Circulation: A Case Report Anesthetic management of the adult patient with a Fontan circulation is complex and requires understanding of the specific physiology of the individual patient. Long-term survival in this cohort has increased to the point where patients are presenting for noncardiac surgery related to degenerative diseases of aging. We describe the perioperative management of a patient with a Fontan circulation undergoing total hip arthroplasty using combined spinal–epidural anesthesia and discuss the issues requiring special consideration for this surgical procedure in this group of patients. Accepted for publication June 9, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Address correspondence to Nicholas D. Black, MBBCh, BAO (Hons), Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St, Toronto, ON, Canada. Address e-mail to nicholasdavidblack@hotmail.com. © 2019 International Anesthesia Research Society

Retained Perineural Catheter: A Sentinel Case Report We report the rare complication of a retained peripheral nerve block catheter (PNBC). A 45-year-old man with intractable postamputation phantom limb pain was treated with continuous infusions via femoral and sciatic peripheral nerve catheters. The catheters were removed by an emergency department physician 2 days after placement. Five months later, the patient presented with a discharging sinus from the sciatic nerve catheter site. Magnetic resonance imaging (MRI) was inconclusive. Surgical exploration showed 15 cm of retained peripheral nerve catheter, which was removed. Accepted for publication June 12, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Alparslan Turan, MD, Outcomes Research Department, Cleveland Clinic, Cleveland, OH 44195. Address e-mail to turana@ccf.org. © 2019 International Anesthesia Research Society

Intravenous Ketamine as an Adjunct for Pachyonychia Congenita–Associated Pain: A Case Report Pachyonychia congenita (PC) is a rare, inherited disorder of keratin filaments characterized by palmoplantar hyperkeratosis, keratoderma, and extreme pain. Management is largely symptomatic and typically involves multimodal pain control strategies. Here, we report the treatment of one 21-year-old man’s refractory neuropathic PC pain with a 4-day inpatient ketamine infusion. Within 1 night of beginning treatment, his pain diminished to a 0/10 without any adverse effects, with effects lasting 2 weeks. No reported PC pain regimens have made use of intravenous ketamine; thus, we suggest recurrent ketamine infusions as an additional option in the multimodal pain regimen for patients with PC. Accepted for publication June 17, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Xiang Qian, MD, PhD, Stanford University School of Medicine, Pain Management Center, 450 Broadway St, Pavilion A, 1st Floor MC5340, Redwood City, CA 94063. Address e-mail to xqian@stanford.edu. © 2019 International Anesthesia Research Society

A Case Report of Surgical Entrapment and Catheter Embolization: A Rare Complication of Peripherally Inserted Central Catheters Peripherally inserted central catheters (PICCs) are a feasible alternative to conventional central venous access. PICCs are often used perioperatively for central venous pressure monitoring and administration of vasoactive drugs especially in cancer patients. Catheter breakage and embolization are rare but potentially fatal complications, and most of the reported literature pertains to pediatric patients after medium- to long-term use. In this report, we describe a rare scenario of catheter breakage, entrapment, and embolization in a patient caused by inadvertent surgical clip and suture placement. Accepted for publication May 30, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Seema Mishra, MD, Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi 110029, New Delhi. Address e-mail to seemamishra2003@gmail.com. © 2019 International Anesthesia Research Society

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