Ultrasound-Guided Intermediate Cervical Plexus Block With Depot Steroids in the Management of Refractory Neck Pain Secondary to Cervicothoracic Myofascial Pain Syndrome: A Case Series Persistent cervicothoracic myofascial pain is a common condition that causes loss of function and can result in significant health care costs. The underlying cause is tender trigger points that result in impaired muscle function. Standard treatment includes physiotherapy, medications, acupuncture, and trigger point injections. Patients who fail to respond have very limited treatment options. The authors present a novel treatment in 2 patients presenting with severe unilateral cervicothoracic myofascial neck pain that failed to respond to standard treatment. The novel treatment, ultrasound-guided intermediate cervical plexus block with depot steroids, produced significant and durable pain relief in the 2 patients. Accepted for publication August 22, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Gopinath Niraj, FFPMRCA, Department of Pain Medicine, University Hospitals of Leicester NHS Trust, Gwendolen Rd, LE5 4PW, United Kingdom. Address e-mail to niraj.g@nihr.ac.uk. © 2019 International Anesthesia Research Society

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Elective Laryngeal Surgery During Pregnancy: A Case Report Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) maintains oxygenation and blunts the partial pressure of carbon dioxide (PaCO2) rise in nonpregnant subjects during apnea. Physiologic changes of pregnancy may attenuate the utility of THRIVE. We present a nulliparous patient at 31 weeks’ gestation undergoing tracheal dilation requiring general anesthesia without intubation utilizing THRIVE. Our data confirms prior reports in nonpregnant patients showing markedly extended time to desaturation. However, PaCO2 rise more closely mirrors classic apneic oxygenation in nonobstetric patients. The PaCO2 elevation and subsequent acidosis may limit the utility of THRIVE for prolonged apnea in pregnant surgical patients. Accepted for publication August 20, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Brendan Carvalho, MBBCh, FRCA, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305. Address e-mail to bcarvalho@stanford.edu. © 2019 International Anesthesia Research Society

Gastric Ultrasound Imaging to Direct Perioperative Care in Pediatric Patients: A Case Report of 2 Cases Pulmonary aspiration of gastric contents carries significant risk in children in the perioperative period. Ultrasound imaging of the gastric antrum has been validated to predict gastric content and volume in both pediatric and adult patients, and yet clinical applications in pediatric patients are sparse. We report 2 cases of children presenting for elective surgery with uncertain volume of gastric contents. Bedside gastric imaging successfully identified “full stomachs,” and the information was used to direct care. Accepted for publication August 21, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Karen R. Boretsky, MD, 300 Longwood Ave, Boston, MA 02115. Address e-mail to karen.boretsky@childrens.harvard.edu. © 2019 International Anesthesia Research Society

Self-Limited Spinal Subarachnoid Hemorrhage After Lumbar Spinal Drain Removal While on Clopidogrel: A Case Report Spinal subarachnoid hemorrhage (SSH) is a rare yet potentially devastating complication of neuraxial procedures. We present a case of SSH after inadvertent lumbar spinal drain removal while on clopidogrel. The contrast between the patient’s mild clinical symptoms compared to his impressive magnetic resonance imaging (MRI) highlights the variable presentations that can be seen with spinal and epidural hematomas. Despite sophisticated electronic warnings systems available to improve patient safety, better efforts are needed to improve interprofessional communication with providers taking care of patients with indwelling neuraxial catheters. Accepted for publication August 26, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Dalia H. Elmofty, MD, Department of Anesthesiology, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637. Address e-mail to delmofty@dacc.uchicago.edu. © 2019 International Anesthesia Research Society

Absence of Adverse Neurological Outcomes in a Non-Neurologically Injured Polytrauma Patient Despite Extreme and Prolonged Treatment-Resistant Hypotension: A Case Report Temporary hypotension after severe trauma might help achieve hemostasis and increase the chances of survival. However, excessive hypotension can lead to adverse neurological sequelae or be fatal. The relationship between the degree of hypotension and neurological prognosis after trauma is not fully understood. Our report describes a patient with severe trauma who survived with a favorable neurological outcome despite extreme and prolonged treatment-resistant hypotension. Accepted for publication August 20, 2019. Funding: None. The authors declare no conflicts of interest. The Ethics Committee at Kitami Red Cross Hospital approved this study. Address correspondence to Wataru Sakai, MD, Department of Anesthesiology, Sapporo Medical University School of Medicine, W 16, S 1, Chuo-ku, Sapporo, Hokkaido 060-8556, Japan. Address e-mail to sakaiwataru1128@gmail.com. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 International Anesthesia Research Society

Unilateral Lung Recruitment Maneuver for Massive Atelectasis in a Child With Glenn Circulation: A Case Report A 9-year-old girl with Glenn circulation suffered from massive atelectasis of the left lung caused by bleeding during cardiac catheterization. The atelectasis resulted in frequent hypoxia leading to oxygen saturation (SpO2) of 40%–50%. In the intensive care unit, we performed a unilateral lung recruitment maneuver (ULRM) for 2 days. The ULRM involved placement of a bronchial blocker in the right main bronchus and application of continuous positive airway pressure to the left lung without hemodynamic deterioration. Eventually, SpO2 improved to 80%–85%. ULRM can be a treatment option for unilateral atelectasis in a child with Glenn circulation. Accepted for publication August 22, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Tomoyuki Kanazawa, MD, PhD, Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama-city, Okayama, Japan 7008558. Address e-mail to tyskanazawa@gmail.com. © 2019 International Anesthesia Research Society

Spontaneous Resolution of Gravid Uterine Incarceration With Spinal Anesthesia: A Case Report Incarceration of the gravid uterus may pose significant risks to both maternal and fetal health. Anesthetic management for these patients is variable, and the ideal anesthetic technique is unknown. The patient presented to the labor and delivery unit with pelvic pain and urinary retention in the setting of a gravid incarcerated uterus. Previous attempts at manual reduction in the outpatient setting were unsuccessful. A combined spinal-epidural anesthetic was administered, followed by spontaneous resolution of the incarcerated uterus. In addition to providing analgesia, neuraxial blockade may occasionally be an adequate therapeutic technique for reduction of a gravid incarcerated uterus. Accepted for publication August 26, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Matthew G. Hire, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E. Huron St, F5-704, Chicago, IL 60611. Address e-mail to matthew-hire@northwestern.edu. © 2019 International Anesthesia Research Society

Black Seed Oil and Perioperative Serotonin Syndrome: A Case Report Perioperative serotonin syndrome has been associated with a number of medications and herbal supplements. We report a patient who developed serotonin syndrome immediately after an endoscopic procedure in which the preoperative use of black seed oil appears to have played a role in stimulating the syndrome. Black seed oil has not been previously reported in association with perioperative serotonin syndrome. Anesthesia professionals should be aware that patients taking black seed oil supplements may develop serotonin syndrome postoperatively. Accepted for publication August 20, 2019. Funding: None The authors declare no conflicts of interest. Address correspondence to Mary E. Warner, MD, Department of Anesthesiology, Mayo Clinic, 1-145 Charlton Bldg, 200 First St SW, Rochester, MN 55905. Address e-mail to warner.mary@mayo.edu. © 2019 International Anesthesia Research Society

Epicardial Echocardiography as Rescue Modality for Detection of Dynamic Right Ventricular Outflow Tract Obstruction in Post Pulmonary Valve Stenosis Repair No abstract available

Role of Ultrasound in Emergency Front of Neck Access: A Case Report and Review of Literature Emergency front of neck access (eFONA) is a lifesaving procedure in a cannot intubate cannot oxygenate (CICO) situation. We report a case of a patient who presented to the emergency department (ED) in extremis with a difficult airway. A history of multiple neck surgeries and permanent tracheostomy from birth until the age of 17 years complicated his airway management. Altered neck anatomy led to failed intubation and oxygenation. EFONA was established with the use of rapid ultrasound imaging and using the scalpel-bougie-tube technique. We present a review of literature relating to the use of ultrasound during emergency airway management. Accepted for publication August 7, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Umair Ansari, FCAI, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom. Address e-mail to umair.ansari@uhcw.nhs.uk. © 2019 International Anesthesia Research Society