Helmet CPAP as a Bridge From a Rapid Response Activation for Hypoxia Through Awake Tracheostomy in the Operating Room in a Patient With a Difficult Airway: A Case Report Continuous positive airway pressure (CPAP) has been used in multiple clinical settings with increasing frequency. However, its use in improving blood oxygenation for difficult airways has never been a specific consideration. Here, we present a rapid response team (RRT) intervention in a patient with severe hypoxia requiring emergent surgical tracheostomy. To restore an adequate level of blood oxygen saturation, helmet CPAP was used during transportation and surgical tracheostomy. In selected cases involving difficult airways, helmet CPAP may have some advantages. Additional studies are warranted to assess the benefits of introducing this device to RRT equipment. Accepted for publication August 14, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Matteo Nocci, MD, Departments of Emergency and Urgency, Unit of Intensive and Critical Care Medicine, University Hospital of Siena, Siena, Italy. Address e-mail to matteo.nocci@gmail.com. © 2019 International Anesthesia Research Society

Catastrophic Intracardiac Thrombosis During Emergency Repair of an Expanding Aortic Pseudoaneurysm: A Case Report Catastrophic thrombosis is a rare but frequently fatal event following complex cardiac surgery. It is most often encountered following separation from cardiopulmonary bypass (CPB) and reversal of heparin anticoagulation, and somewhat paradoxically, at the time when bleeding from post-CPB coagulopathy is being treated. We report the case of a 41-year-old female taken to the operating room for repair of an expanding ascending aortic pseudoaneurysm. Following a prolonged operation, she developed intracardiac thrombus during transfusion of hemostatic blood products and procoagulant agents. Potential contributing factors are discussed. Accepted for publication July 18, 2019. The authors declare no conflicts of interest. Funding: R.M.S. has received research funding from Grifols. Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website (www.cases-anesthesia-analgesia.org). Address correspondence to Ratna Vadlamudi, MD, FASE, Department of Anesthesiology, Emory University School of Medicine, Emory University Hospital, C220, 1364 Clifton Rd, NE, Atlanta, GA 30322. Address e-mail to rvadlam@emory.edu. © 2019 International Anesthesia Research Society

Undiagnosed Systemic Mastocytosis Presenting as Postoperative Distributive Shock: A Case Report Systemic mastocytosis (SM) is a rare clinical condition resulting from a clonal proliferation of abnormal mast cells. The clinical presentation may vary from mild cutaneous manifestations to aggressive systemic symptoms including intermittent episodes of anaphylaxis. We present a case of a 69-year-old male with abrupt and recurrent episodes of anaphylaxis with refractory distributive shock following cardiac surgery with cardiopulmonary bypass. Following a complex postoperative course, a bone marrow biopsy ultimately confirmed the diagnosis. Although rare, SM should be considered in the differential diagnosis of postoperative patients with unexplained and recurrent episodes of distributive shock. Accepted for publication August 12, 2019. Funding: Supported by Clinical and Translational Science Award (CTSA) grant No. KL2 TR002379 to Dr Warner from the National Center for Advancing Translational Science (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health (NIH). The authors declare no conflicts of interest. Address correspondence to Matthew A. Warner, MD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. Address e-mail to warner.matthew@mayo.edu. © 2019 International Anesthesia Research Society

The Ventrain Device: A Future Role in Difficult Airway Algorithms? The Ventrain is a small, manually operated, single-use, inspiratory flow-adjustable ventilation device that generates positive pressure during inspiration and, through a Bernoulli effect within the device, active suction during expiration. It was designed to provide emergency ventilation during airway obstruction via narrow-bore cannulae. The device has been used successfully in elective procedures lasting >1 hour. It remains to be seen if its theoretical advantages in “can’t intubate, can’t oxygenate” (CICO) scenarios translate to reliable clinical benefit and allow inclusion in future airway algorithms. We advocate for regular simulation training and the detailed reporting of clinical experience with this encouraging new tool. Accepted for publication July 30, 2019. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website (www.cases-anesthesia-analgesia.org). Address correspondence to Stuart Morrison, MBChB, FFARCSI, Department of Anesthesiology, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium. Address e-mail to stuart.morrison@uza.be. © 2019 International Anesthesia Research Society

Paravertebral Block for a Patient With Achalasia Undergoing a Peroral Endoscopic Myotomy Procedure: A Case Report In 2016, the American Medical Association officially dismissed pain as a vital sign quoting the opioid epidemic as a major reason. Clinically, pain remains very relevant and we present the case of a patient with achalasia treated via peroral endoscopic myotomy procedure (POEM). Given that similar patients previously failed traditional pain management modalities, regional anesthesia was used in this patient’s pain management. The positive outcomes yielded from this technique convinced our gastroenterological colleagues to request regional anesthesia for future patients, altering their approach to pain management. Accepted for publication August 6, 2019. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website (www.cases-anesthesia-analgesia.org). Address correspondence to David A. Gutman, MD, Department of Anesthesia, Medical University of South Carolina, 167 Ashley Ave, Suite 301, Charleston, SC 29425. Address e-mail to gutman@musc.edu. © 2019 International Anesthesia Research Society

Pulmonary Hypertensive Crisis During General Anesthesia in a 3-Year-Old Autistic Boy With Undiagnosed Scurvy, Undergoing Cardiac Catheterization: A Case Report Pulmonary hypertension in children is commonly caused by underlying cardiac and pulmonary disease. Within the past 10 years, scurvy has been identified as a cause for pulmonary hypertension. We describe the case of a 3-year-old autistic boy with undiagnosed scurvy who was scheduled for cardiac catheterization. Immediately after induction, the patient became hemodynamically unstable, which worsened with administration of nitrous oxide. Cardiac catheterization revealed pulmonary hypertension, which dramatically improved with administration of vitamin C. Anesthesiologists should be aware that scurvy is more common than previously thought, even in developed countries and can cause unexpected circulatory collapse from pulmonary hypertensive crisis. Accepted for publication August 2, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Taiki Kojima, MD, Department of Anesthesiology, Aichi Children’s Health and Medical Center, 7–426 Morioka-cho, Obu-shi, Aichi 474–8710, Japan. Address e-mail to daiki_kojima@sk00106.achmc.pref.aichi.jp. © 2019 International Anesthesia Research Society

Atrioesophageal Fistula After Radiofrequency Ablation Presenting With Status Epilepticus: A Case Report Radiofrequency (RF) ablation for atrial fibrillation is commonly performed. Atrioesophageal fistulas are an uncommon complication of RF ablation and can present with status epilepticus due to an extensive vascular air embolus. Initial treatment may require a high level of suspicion of this rare occurrence to help prevent further injury and increase the likelihood of a meaningful recovery. Accepted for publication July 31, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Vinh K. Pham, MD, Department of Anesthesiology, University of Kansas School of Medicine - Wichita, 929 N St Francis, Room 8074, Wichita, KS 67214. Address e-mail to vpham2@kumc.edu. © 2019 International Anesthesia Research Society

A Safe Method for Performing an Epidural Blood Patch in a Pediatric Patient Requiring Deep Sedation for Epidural Catheter Placement: A Case Report A 17-year-old boy developed postdural puncture headache after several lumbar punctures (LPs) for intrathecal chemotherapy. The pediatric anesthesiology service was consulted for an epidural blood patch (EBP). Sedation was required for the LPs, which made performing an EBP problematic because of the need for the patient to be conscious and able to report symptoms during injection of blood. An epidural catheter was placed after the next LP while the patient was sedated. After he woke up, blood was injected through the catheter and the headache resolved. This technique can be used in pediatric patients requiring deep sedation for an EBP. Accepted for publication July 31, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Christopher L. Heine, MD, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Ave, Suite 301, Charleston, SC 29425. Address e-mail to heinec@musc.edu. © 2019 International Anesthesia Research Society

Anesthesia in the Form of Audiovisual Distraction for a Child Requiring Surgery With End-Stage Cardiomyopathy: A Case Report Anesthetizing children with extreme cardiopulmonary illness can be especially challenging. In adults, a host of alternatives to general anesthesia for the labile patient are available, However, in children, these techniques may be challenging due to a lack of patient cooperation. Distraction techniques have been successfully used to reduce procedural pain. The patient whose case is reported here required surgery for inguinal hernia repair after repeated bowel incarceration. Due to severe end-stage cardiomyopathy, the risk of general anesthesia was deemed excessive. Distraction was used to usher the patient through an awake caudal block for avoidance of general anesthesia. Accepted for publication July 19, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Adam C. Adler, MD, MS, FAAP, FASE, Texas Children’s Hospital, Baylor College of Medicine, 6621 Fannin St, Suite #A3300, Houston, TX 77030. Address e-mail to adam.adler@bcm.edu. © 2019 International Anesthesia Research Society

Bilateral Cavernous Sinus Syndrome, Pituitary Macroadenoma, and Postoperative Loss of Vision: A Case Report Postoperative vision loss is a rare complication. When visual loss does occur, it is rarely associated with ophthalmoplegia. We report a case of postoperative bilateral visual field deficits with concomitant complete bilateral ophthalmoplegia in a patient with a known pituitary macroadenoma after surgical excision of a small cell carcinoma of the bladder. Emergency postoperative imaging showed that the macroadenoma had increased in size and was associated with new right optic nerve edema. The patient underwent urgent excision of the macroadenoma 5 days after the onset of symptoms. Visual field deficits and associated ophthalmoplegia had completely resolved at 3-month follow-up. Accepted for publication July 19, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Thomas M. Stewart, MD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55902. Address e-mail to stewart.thomas1@mayo.edu. © 2019 International Anesthesia Research Society