Intraoperative Multipoint Acupuncture for Reducing Postoperative Nausea and Vomiting in High-Risk Children: A Case Series Acupuncture studies have demonstrated varying effects on pediatric postoperative nausea and vomiting (PONV). Unanswered questions include whether the type of therapy, number of points used, or timing of treatments vary the effect of acupuncture. We present a case series of intraoperative multipoint acupuncture treatments for high-risk pediatric patients. Fourteen patients were included, and 19 treatments were provided. Twelve patients (85.7%) had previous PONV. Patients who received intraoperative acupunctur e reported no early phase PONV, and 3 patients (15.8%) reported late-phase PONV. One patient required postoperative antiemetics. Intraoperative multipoint acupuncture may be a safe and efficacious adjunct for PONV in high-risk pediatric patients. Accepted for publication October 4, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Joelle B. Karlik, MD, Department of Anesthesiology and Pain Medicine, Emory University, Egleston Children’s Hospital, 1405 Clifton Dr, Atlanta, GA 30307. Address e-mail to joelle.b.karlik@emory.edu. © 2019 International Anesthesia Research Society

Implementation of a Preoperative Anemia Clinic Utilizing a Minimal Staffing Model We present a process map for the implementation of a program to treat preoperative anemia utilizing 1 existing anesthesiologist in the preoperative evaluation clinic. In the first 7 months postimplementation, 342 patients were screened for anemia, 166 were diagnosed, and 107 were treated. The mean increase in hemoglobin in treated patients was ~2 g/dL (range 0–4.9 g/dL). Two patients’ surgeries were delayed in favor of treatment and 3 surgical patients, who had received 2 complete iron infusions, received an intraoperative transfusion. The total revenue generated for the institution was enough to subsidize the cost of an additional anesthesiologist. Accepted for publication October 3, 2019. Funding: This work was funded by the Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine. The authors declare no conflicts of interest. Address correspondence to Jeanna D. Blitz, MD, Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, 550 1st Ave, New York, NY 10016. Address e-mail to jeanna.viola@nyulangone.org. © 2019 International Anesthesia Research Society

Clevidipine-Induced Extreme Hypoxemia in a Neurosurgical Patient: A Case Report Clevidipine-induced pulmonary shunting is a little-reported adverse effect, manifesting as refractory hypoxemia, which may cause significant patient harm. We present the case of a mechanically ventilated patient admitted to the intensive care unit following a neurosurgical procedure. He was treated postoperatively with clevidipine for blood pressure management, and within 16 hours, he developed profound refractory hypoxemia, requiring increased ventilatory support. A workup for other causes was negative. The hypoxemia recovered within 1 hour of clevidipine discontinuation. Though other calcium channel blockers have been reported to cause pulmonary shunting from vasodilation, this is a novel case report for clevidipine-induced hypoxemia. Accepted for publication October 14, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Jack H. Short, MD, Department of Internal Medicine/Critical Care Medicine, Stanford University School of Medicine, Stanford, CA. Address e-mail to jhshort@stanford.edu. © 2019 International Anesthesia Research Society

Ventilation Failure due to Endotracheal Tube Migration Into a Tracheal Pouch in a Toddler With a Repaired Tracheoesophageal Fistula: A Case Report A tracheal pouch is a rare complication of successful repair of a congenital tracheoesophageal fistula (TEF). An 18-month-old child with a repaired congenital TEF was scheduled for esophageal dilation to treat his esophageal stricture. Migration of the distal end of the endotracheal tube into a previously undetected tracheal pouch caused an abrupt failure to ventilate at the end of surgery. Given our experience, we recommend to screen the trachea of every patient with corrected TEF for a tracheal pouch when they are scheduled for another procedure requiring general anesthesia. Accepted for publication October 16, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Vighnesh Ashok, FRCA, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India. Address e-mail to vighneshmmc@gmail.com. © 2019 International Anesthesia Research Society

Repeated Intercostal Nerve Blocks With Liposomal Bupivacaine for Chronic Chest Pain: A Case Report No abstract available

Paradoxical Critical Hyperkalemia After Acetazolamide for Cerebrovascular Reactivity Study: A Case Report We present the case of a 42-year-old man with moyamoya disease presenting for cerebral revascularization surgery who developed critical hyperkalemia following a single intravenous (iv) dose of 1000 mg of acetazolamide 1 day preoperatively for a cerebrovascular reactivity study. His potassium increased from 5.1 to 6.7 mmol/L. Prompt treatment of this abnormality allowed this patient to undergo surgery the next day uneventfully. A paradoxical, critical increase in potassium can result from a single 1000-mg iv dose of acetazolamide. Accepted for publication October 25, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Mark A. Burbridge, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Palo Alto, CA 94304. Address e-mail to markburb@stanford.edu. © 2019 International Anesthesia Research Society

Another Role for Angiotensin II?: Vasopressin-Refractory Shock After Pheochromocytoma Resection: A Case Report A patient presented with multiple unrelated tumors and was found to have a small but functional adrenal pheochromocytoma. After pheochromocytoma resection, shock developed unresponsive to vasopressin in recommended doses (0.04 U/min infusion plus repeated 1-U boluses) but responded dramatically to an angiotensin II infusion (20 ng/kg/min) with a mean arterial pressure >100 mm Hg. The patient’s blood pressure was maintained for 42 hours postoperatively with an infusion rate that ranged from 2 to 38 ng/kg/min. Because vasopressin may not always be effective for postresection shock in people with pheochromocytomas, angiotensin II may prove to be an effective alternative. Accepted for publication October 21, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Frederick G. Mihm, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Room H3580, 300 Pasteur Dr, Stanford University Medical Center, Stanford, CA 94305. Address e-mail to fmihm@stanford.edu. © 2019 International Anesthesia Research Society

Comment on the Article “Extraluminal Use of a Pediatric Bronchial Blocker With Confirmation by Point-of-Care Ultrasound” No abstract available

Infiltration Between Popliteal Artery and Capsule of the Knee Block to Augment Continuous Femoral Nerve Catheter for Adolescent Anterior Cruciate Ligament Reconstruction: A Case Series Infiltration between popliteal artery and capsule of the knee (IPACK) is a novel technique that can provide additional analgesic relief, although there are no studies to date in the adolescent population. In 3 adolescent patients undergoing anterior cruciate ligament surgery, IPACK block augmented continuous femoral nerve block by providing posterior knee analgesia with no or only minimal opioid needs in the post-anesthesia care unit and did not produce sciatic motor weakness. Accepted for publication October 7, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Kim T. Nguyen, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron, F5-704, Chicago, IL 60611. Address e-mail to kim.nguyen@northwestern.edu. © 2019 International Anesthesia Research Society

Rapid Induction of Buprenorphine/Naloxone for Chronic Pain Using a Microdosing Regimen: A Case Report Buprenorphine is an effective treatment for chronic pain and may reduce opioid-induced hyperalgesia. However, its pharmacological properties make its induction challenging, time-consuming, and can precipitate opioid withdrawal. We present the case of a 66-year-old woman with inadequately controlled postoperative pain despite escalating doses of oxycodone and methadone, who was successfully transitioned to buprenorphine/naloxone using a rapid microinduction technique without precipitating opioid withdrawal. Rapid induction provides an alternative method for transitioning patients from other opioids to buprenorphine/naloxone and facilitates transition of patients with chronic pain to buprenorphine therapy within a shorter window compared to currently existing protocols. Accepted for publication October 15, 2019. Funding: M.N. is supported by Frederick Banting and Charles Best Canada Graduate Scholarships (funding reference number = 157934). The authors declare no conflicts of interest. Address correspondence to Danny S. Lee, MD, Department of Psychiatry, University of British Columbia, Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada. Address e-mail to dannylee@alumni.ubc.ca. © 2019 International Anesthesia Research Society