Brain Tumor, Pheochromocytoma, and Pregnancy: A Case Report of a Cesarean Delivery in a Patient With Von Hippel–Lindau Disease A young woman first diagnosed with von Hippel–Lindau disease (VHL) during pregnancy underwent an uncomplicated cesarean delivery despite having multiple classic VHL tumors, including a large cerebellopontine brain mass and vasoactive pheochromocytoma. Patients with VHL may have multiple tumors of the central nervous system and viscera that greatly impact anesthetic management. This case highlights the anesthetic considerations for a parturient with pheochromocytoma and elevated intracranial pressure, as well as the importance of a multidisciplinary team approach.

Analgesic Rescue With Opioid-Only Thoracic Epidural After Surgical Infiltration of Liposomal Bupivacaine: A Case Report We present the case of a 51-year-old man with a history of recurrent lung cancer after left upper lobectomy who presented for an elective completion pneumonectomy via a bilateral anterior thoracotomy incision. At the completion of surgery, bilateral multilevel intercostal infiltration was performed with liposomal bupivacaine. Due to poorly controlled postoperative pain after extubation, a thoracic epidural was placed in the intensive care unit. An opioid-only infusion was started and transitioned to a local anesthetic–based infusion on postoperative day 2. This case report represents a novel stepwise approach of thoracic epidural management after surgical infiltration of liposomal bupivacaine.

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.

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.

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.

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.

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.

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.

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.

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.