Context: Post Caesarean pain is described as moderate to severe. Although advances in the new analgesics techniques, no current standard exists for optimizing and managing. Taking into consideration of acute post Caesarean pain, this novel technique of surgically assisted anterior abdominal field block at linea semilunaris have proved considerable analgesic potential along with multimodal analgesia. Aims: Although advances have been made in the understanding of the pathophysiology and in the development of new analgesics, patients still suffer from moderate-to-severe post-Cesarean pain. Taking into consideration the consequences of pain, this anterior approach to abdominal field block technique was performed to minimize acute pain experienced during post-Cesarean section. Settings and Design: Prospective observational study design. Materials and Methods: In the present study, a total of 120 parturients undergoing cesarean section (CS), after closure of uterine incision were included. We intraoperatively, under all asepsis, performed surgically assisted abdominal field block at linea semilunaris, by bilaterally injecting 20 mL 0.25% bupivacaine on each side, in addition to standard analgesic 100 mg diclofenac suppository. Each patient was assessed at 0, 4, 8, 12, and 24 h after surgery, by an independent observer for pain using NRS 0–10 and the time of the first demand for analgesic diclofenac paracetamol and its side effects. Statistical Analysis Used: The entire data is statistically analyzed using Statistical Package for Social Sciences (SPSS ver. 21.0, IBM Corporation, USA) for MS Windows. The categorical variables were compared using Wilcoxon's signed-rank test. Results: Of the total 120 patients, it is worth noting that none of the patients had severe or worst pain. The percentage of patients who did not require analgesia were (96.7%) at 4 h, (81.7%) at 8 h, (77.5%) at 12 h, and (90.8%) at 24 h. The mean analgesic consumption of paracetamol diclofenac on 4, 8, 12, 16, and 24 h after CS was significantly less. No patient required opioid supplementation. Patient satisfaction was high and was early ambulated. Conclusions: There is considerable potential for anterior approach abdominal field block, (linea semilunaris block) to comprise an effective component of a multimodal regimen for post-Cesarean section analgesia and is easy to perform within limited resources.

Background: Intraoperative hypotension is frequently encountered during surgery and it can be associated with adverse outcomes. Blood pressure monitoring is critical during surgery, but there are no universally agreed upon standards for interpreting values of hypotension and no consensus regarding interventions. Material and Methods: We performed a retrospective chart review of pediatric patients who underwent idiopathic scoliosis surgery by a single surgeon. We used the arterial line for all measures. Intraoperative hypotension was defined as 20% decrease of the baseline systolic blood pressure (SBP), 30% decrease of baseline SBP, or mean arterial pressure less than 60 mmHg. Use of vasopressor agents was also recorded and correlated with blood pressure definitions. Results: Seventy idiopathic scoliosis patients were retrospectively evaluated. There was a significant correlation between the three measures of hypotension. Sixty percent of the patients received vasopressors. There was a significant correlation between a drop of mean arterial pressure to less than 60 mmHg and the use of the ephedrine. We did not find any changes on neuromonitoring measures during the case and there were no intraoperative or one-month postoperative complications. Conclusions: Blood pressure is only one of the measures anesthesiologists look to for good perfusion during surgery. Pediatric anesthesiologists and orthopedics agree in trying tight blood pressure control during surgery to decrease blood loss, but what the exact definition of that blood pressure number is, is still unclear. We propose that using mean arterial pressure less than 60 mmHg is perhaps a better definition. We provide recommendations for future studies.

Background/Aim: The expectation of undergoing general anesthesia triggers fear in many individuals, and such anxiety can even exceed anxiety about surgery. The only opportunity patients usually have to express their concerns and ask questions is during a preoperative visits to their anesthesiologist. Therefore, a good anesthesiologist-patient relationship is important to reduce patients' anxiety. Achieving this end requires information on patients' attitudes and concerns regarding anesthesia. This study aimed to assess patients' knowledge, attitudes, and concerns about preoperative assessment and fear associated with anesthesia at University Hospital, Jeddah, Saudi Arabia. Methods: This cross-sectional study used a self-administered questionnaire distributed to 399 outpatients. Data were collected on patient's characteristics, perceptions about anesthesiologists, preferences for anesthetic management, and preoperative concerns regarding anesthesia. Results: Most patients thought that anesthesiologists spent only 3 years in medical school and 2 years in a residency program. Survey participants had several misconceptions about anesthesiologists' role, but it did not affect ratings of their importance. Although, the confidence of patients in anesthesiologists was high, it was significantly lower than their confidence in surgeons. The most common concern expressed by the patients was based on whether anesthesiologists had sufficient experience and qualifications. Conclusions: Discussing anesthetic forms preoperatively can help decrease patients' anxiety. More efforts should be made preoperatively to address patients' high level of fear about rare side effects and discuss common side effects they tend to ignore. Preoperative preparation must allow the anesthesiologists enough time to reassure patients about their concerns, as they obtain patients' informed consent.

Introduction: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, an autoimmune disorder resulting from antibodies directed against the NMDA (glutamate) receptor, is the second most frequent cause of immune-mediated encephalitis. To date, the information related to the anesthetic care of children with this disorder is limited to anecdotal reports. Methods: We reviewed the anesthetic care of six patients with anti-NMDA receptor encephalitis who underwent 21 procedures at our institution from 2014 through 2019. Results: The study cohort included six patients, ranging in age from 2 to 18 years, who required anesthetic care during 21 procedures. Airway management included a laryngeal mask airway (n = 8), endotracheal intubation (n = 12), and native airway with spontaneous ventilation (n = 1). Intravenous (IV) induction with propofol was used in 17 procedures for five patients, including three that required rapid sequence intubation using rocuronium or succinylcholine. Inhalation induction with sevoflurane in nitrous oxide (N₂O)/oxygen (O₂) was chosen for two procedures in two patients. A combination of both induction techniques was used for two patients in two procedures. Maintenance anesthesia was accomplished with a volatile agent, predominantly sevoflurane, for 18 of the 21 procedures; propofol infusion for one procedure; and single dose of propofol was used for two short procedures. N₂O was not used for maintenance anesthesia in any of the encounters. None of the patients exhibited adverse events, including hemodynamic instability, thermoregulatory problems, or respiratory events perioperatively. Postoperatively, there was no observed deterioration in clinical status attributed to anesthetic care. Discussion: Multisystem involvement in anti-NMDA receptor encephalitis includes memory loss, behavior irregularity, psychosis, arrhythmias, blood pressure (BP) instability, and hypoventilation. In our study cohort, we noted no intraoperative issues and deterioration in clinical status following the use of volatile anesthetic agents, opioids, dexmedetomidine, and propofol for general anesthesia (GA) or sedation. As ketamine, xenon, and N₂O mediate their anesthetic effects, primarily, through antagonism of NMDA receptors, theoretical concerns suggest that they should be avoided.

Background: Emergence delirium (ED) has been reported among children at a postoperative setting, which delays their recovery and exposes them to traumas. The aim of this study was to determine the prevalence of ED and its associated factors among children who underwent surgeries at a major tertiary healthcare facility in Saudi Arabia. Materials and Methods: Between March and August 2018, a retrospective cohort study was conducted based on a review of 413 medical charts of children (<14 years) who underwent an elective/nonemergency surgery and then were admitted to a Post Anesthesia Care Unit. Patient and surgery-related characteristics were analyzed as potential factors associated with ED. The anxiety level was assessed preoperatively using the Modified Yale Preoperative Anxiety Scale (four domains), while the ED was detected after surgery using the Watcha scale (child is agitated and thrashing around). Results: The leading surgery category was ear, nose, and throat surgeries [184 (44.6%)] and dental surgeries [109 (26.4%)]. Almost one-third received only general anesthesia (31.2%), while 271 (68.8%) received an additional regional block/skin infiltrate. The anxiety domains preop showed that the percentage mean score ± standard deviation of expression of emotions was 37.1 ± 21.6, apparent arousal 33.7 ± 20.4, activeness 30.1 ± 13.5, and vocalization 26.9 ± 20.3. The prevalence of ED among children who underwent surgeries during the 6-month period was 23 (6.6%). Almost 18.8% of those who received opioid analgesics (fentanyl alone) developed ED, while 12% of those who received both opioid and nonopioid analgesics (fentanyl/paracetamol) developed ED. ED was significantly associated with longer recovery duration 69.5 + 27.1 min, P = 0.007. Binary logistics regression analysis showed that participants who did not receive Precedex were adj. odds ratio = 10.3 (2.4–48.9) times more likely to develop ED, compared with those who received it, adj. P = 0.003. Lower preoperative scores of expression of emotions and higher scores of apparent arousal were significantly associated with ED, adj. P = 0.035 and adj. P = 0.023, respectively. Conclusion: ED appears to be inevitable in postoperative settings. It is crucial to address any preoperative anxiety assessment as it is associated with ED. Anxiety remains a modifiable factor that can be managed, as well as to the administration of Precedex and adjunct analgesic treatments.

Background: Unlike the typical tetralogy of fallot (TOF), the presence of pulmonary atresia and major aortopulmonary collaterals is recognized as a rare but severe variant of TOF. The objective was to describe the perioperative anesthetic management of pediatric patients who underwent unifocalization procedure and to describe their postoperative morbidity and mortality. Methods: A retrospective observational study was conducted among pediatric patients who underwent unifocalization procedure at Prince Sultan Cardiac Center (PSCC) between October 2017 and October 2018. Unifocalization procedures were performed in a two-staged approach. Anesthetic management of both stages had similar concerns and challenges but with few peculiar issues. These included preoperative assessment, intraoperative management, vascular access, positioning, ventilation, optimizing hemodynamics, cardiopulmonary bypass monitoring, and postoperative management. Results: A total of 19 unifocalization procedures were included. The average age was one year and 52.6% were females. Two patients (10.5%) arrived in theater already with intubated ventilation. Continuous mandatory ventilation was used in 11 (57.9%) patients while one-lung ventilation was used in the rest of patients. Approximately, 30% of patients encountered a stormy postoperative course, 52.6% underwent cardiopulmonary bypass with or without cross-clamping of the aorta, and 10.5% had reperfusion injury. Conclusions: Despite the major challenges of unifocalization, significantly low rates of morbidity and mortality were observed in our patients. A thorough familiarity of different airway and ventilation issues, besides meticulous hemodynamic and anesthetic management, is of paramount importance. The maintenance of hemodynamic stability, hemostasis, and proper ventilation is critical for the success of the operation.

Introduction: Bariatric surgery is an efficient and safe method of weight reduction among patients who have morbid obesity which cannot be treated by the conservative approach. Safety and feasibility of bariatric surgery among high-risk patients are understudied. Therefore, we aimed to report the patient-level characteristics and outcome among high-risk obese patients undergoing laparoscopic sleeve gastrectomy surgery in Saudi Arabia. Methods: A retrospective analysis was performed among 13 morbidly obese (BMI >39 kg/m²) patients with high-risk cardiac disease, who were referred to Upper Gastro-Intestinal Surgery Clinic at King Khalid University Hospital, which is a center of excellence in bariatric surgery, for consideration for weight loss surgery. Retrospective data on preoperative weight, height, and BMI, operative details, perioperative complications, length of stay, and information on comorbidities and endocrinal disease were collected for analysis and reporting. Results: A total of 13 patients were included in the analysis. Of the total, 61.5% were males with a mean age 40.38 (SD: 16.28) and a mean BMI 51.87 (SD: 7.69). The mean duration of surgery was 33.30 min (SD: 31.01), while the mean duration of anesthesia was 83.61 min (SD: 34.73). The mean length of stay was 6.76 days (SD: 3.89). Three patients required postoperative HDU admission with a mean length of stay of 1 day, while 5 patients required postoperative ICU admission with a length of stay ranging from 1 to 3 days. Within 30 days after discharge, only 1 patient required ER visit and none of the patients reported any postoperative morbidity and mortality. Conclusion: Through this study, we can conclude that laparoscopic sleeve gastrectomy surgery can be considered a safe procedure. However, further studies with a large sample size and a more robust methodology are needed to build upon the findings of this study.

Background: The erector spinae plane block is a newer technique of analgesia to the chest wall. Objective: The study was carried out to establish the efficacy and safety of this block in patients undergoing total mastectomy and axillary clearance. Design: Prospective randomized controlled study. Setting: Single tertiary care center, the study was conducted over a period of 1 year. Patients: 65 patients were included; final analysis was done for 60 female patients undergoing total mastectomy and axillary clearance under general anesthesia were randomly allocated to two groups. Intervention: Group B (block group) received ultrasound-guided erector spinae plane block at T5 level with ropivacaine (0.5%, 0.4 mL/kg) while the control group did not receive any intervention. Postoperatively, patients in both groups received morphine via intravenous patient-controlled analgesia device. Patients were followed up for 24 h postoperatively. Main Outcome Measures: The 24-hour morphine consumption was considered as the primary outcome and secondary outcomes included time to first rescue analgesia, pain scores at 0, ½, 1, 2, 4, 6, 8, 12, and 24 h and characteristics and complications associated with block procedure. Results: The 24-hour morphine consumption was 42% lower in block group compared to control group [mean (SD), 2.9 (2.5) mg vs 5.0 (2.1) mg in group B and group C, respectively, P = 0.01]. The postoperative pain score was lower in group B vs group C at 0, 1/2, 1, 2, 4, 6, 12, and 24 h (P < 0.05). 26 patients in group C against 14 in group B used rescue analgesia within 1 h of surgery (P = 0.01). Conclusion: Erector spinae block may prove to be a safe and reliable technique of analgesia for breast surgery. Further studies comparing this technique with other regional techniques are required to identify the most appropriate technique.

Objectives: Septic shock, defined as sepsis with hypotension not responding to fluid resuscitation or requiring vasopressor support, results in the worst outcomes in sepsis patients. This subtype of the patient is often difficult to detect. The shock index (SI) has demonstrated the potential for predicting hemodynamic compromise and collapse and predicting patient outcomes in multiple medical and surgical settings. In our study, we assessed the utility of the SI as a hemodynamic screening tool to identify patients likely to fail to respond to fluids and ultimately to be diagnosed with septic shock. Methodology: A single-center cross-sectional analysis of patients presenting with hypotension and septicemia over 1 year. The study was conducted using the electronic medical records of the emergency department patients presenting to King Saud University Medical City. The charts were reviewed from 2 May 2015 to 24 April 2016 using the local medical registry. The study was approved by the hospital institutional review board (IRB). Data extraction was performed using a standardized form. Results: The area under the curve was 0.77 (P < 0.001) for the prediction of hemodynamic collapse. An initial SI ≥0.875 had a sensitivity of 81% and a specificity of 72% for the identification of patients in whom fluid resuscitation would fail. Conclusions: Based on our findings, we found that the SI was a reliable screening tool for the identification of hypotensive patients with sepsis who would ultimately be diagnosed with septic shock.

Context: Induction of general anesthesia and mandatory low-ambient temperature in the magnetic resonance imaging (MRI) suite renders the pediatric patient prone to fall in core temperature. Previously done studies have shown mixed results with core temperature showing both rise and fall. Aims: The aim of this study is to evaluate which effect, hypothermia or hyperthermia, predominates in children anesthetized for MRI. Is the change in temperature the same across age groups and for different MRI scanners?. Settings and Design: Prospective, observational study in a tertiary care teaching hospital. Subjects and Methods: Two hundred and fifty children of age between 1 month and 16 years scheduled for MRI under propofol-based total intravenous anesthesia (TIVA) were recruited. A baseline core temperature (pre-scan) was recorded with the pediatric nasopharyngeal temperature probe after induction of anesthesia and also after the scan in the recovery room. Results: The study shows that there is a significant fall in temperature of 1.022°C (CI = 0.964, 1.081) following MRI (P < 0.001) but the difference across different age groups and type of MRI scanner used are not significant. There is a significant correlation between duration in the MRI room and a decrease in temperature (P value = 0.003). Using simple linear regression analysis, it is found that if there is a 1-min increase in the duration of MRI, there is a decrease of 0.006°C in temperature. Conclusion: Vigilant temperature preservation strategies have to be maintained during the time the anesthetized child is present in the MRI suite. MRI compatible active warming devices are warranted especially in high turnover centers.

Background and Objective: Postburn contracture (PBC) of the neck is commonly seen after acute burn in the face and neck region. Managing the airway is a challenge due to functional and anatomical deformities. We compared the ease of intubation using video and direct laryngoscopes. Material and Methods: Eighty patients, 18–60 years of age with ASA physical status I/II with Onah's types 1 and 2 contracture of the neck were randomized in this study. Group DL were intubated by direct laryngoscopy (DL) using Macintosh blade and Group VL by video laryngoscopy (VL) using King Vision. The outcome measures were ease of intubation (EOI), Cormack-Lehane (CL) grading, and associated complications if any. Results: EOI score was significantly lower in group VL (0.42 ± 0.84) as compared to group DL (0.85 ± 1.21) (P = 0.048) as was the use of external maneuvers (group VL: 17.5%; group DL: 42.5%; P = 0.015), and the use of stylet (group VL: 0%; group DL: 20%, P = 0.005). CL grading improved significantly in group VL (P < 0.001). Occurrence of complications was negligible in both the groups. A single failure in group DL needed rescue intubation. Conclusion: Intubation with a video laryngoscope was easier than with DL in patients with mild-to-moderate contracture neck with mouth opening >3 cm and MPG I/II.

Scientific conferences, once deemed essential in scholars' lives, are now converting into a high-profit business. These predatory conferences are often organized by some profit-making predatory publishers or manufacturing companies for marketing their product or luring young researchers and scientists to submit their research manuscripts to these so-called predatory journals. Various tactics are used by these conferences to extract money from the researchers and students such as organizing conferences at attractive tourist places with multidisciplinary scope, invitation to submit a research paper to be published at the earliest or to become part of an editorial board/editor-in-chief. It should be realized that these predatory conferences do not provide any benefit to registering individuals for the development of science. The only remedy to expose and stop the business of all such predatory conference organizers is by creating awareness among young scholars and researchers, regarding these predatory conferences and the demerits of attending them, through the established medical and dental institutions, along with specialized associations and societies. A zero-tolerance policy should be created to ban such conferences with a refusal to provide promotion or funding to scholars or researchers attending these conferences. Hence, this narrative review aims to create awareness regarding these predatory conferences, the tactics used by them to trap researchers and ways which young researchers and academic scholars can use to delineate them from legitimate ones.

Persistent left superior vena cava (PLSVC) is a rare and asymptomatic congenital cardiovascular anomaly. Being asymptomatic, PLSVC was usually discovered while performing interventions (such as insertion of central lines, Swan-Ganz catheters, or placing pacemakers) through the left internal jugular vein or left subclavian veins. Commonly, PLSVC is detected not only as an isolated congenital anomaly, but also it can be associated with many other cardiac anomalies. Also, presence of a dilated coronary sinus on echocardiography should raise the suspicion of PLSVC. The diagnosis should be confirmed by contrast venography or computed tomography angiography. The present case is a female patient, 29 year old, who was undergoing elective excision of a right atrial mass, with closure of patent foramen ovale, and she had end-stage renal failure on regular hemodialysis three times weekly through a permicath inserted in the right subclavian vein.

Extravasation is an inadvertent injection or leakage of fluid and drugs in the extravascular or subcutaneous space. The extravasation by massive transfused blood results in the elevation of intra-compartmental pressures. Severely increased pressure may lead to acute compartment syndrome (ACS). A 50-year-old man underwent craniectomy for traumatic subdural hemorrhage of the brain. During intraoperative periods, the blood components were transfused by rapid transfusion device and manual pressurized pumping through the central and peripheral lines because of hemorrhagic hypovolemic shock. Approximately 30 minutes after transfusion, we found a hardened right low leg that was obscured by the surgical drape. Immediately, fasciotomy was performed to release all four compartments. The early recognition and treatment of ACS were important factors contributing to anatomical structure salvage and preservation of function. Anesthesia providers should check the site of the insertion of the intravenous catheter, especially while pressurized massive transfusion via the peripheral intravenous catheter.

Sternal fractures are high velocity injuries which is associated with thoracic or lumbar vertebral fractures. Severe pain associated with sternal fractures can lead to impaired ventilation, low partial pressure of arterial oxygen, need of non-invasive or invasive ventilation with an endotracheal tube thereby leading to significant morbidity. In a series of three patients with manubrium sternal dislocation, we administered continuous bilateral parasternal blocks and initiated infusion of local anesthetics for different periods of time in all patients. The high pain scores drastically decreased followed by improved spontaneous ventilation. There was improvement in partial pressure of oxygen in arterial blood gas. None of the patient required a non-invasive or invasive ventilation. The spread of local anesthetic using injection of radio-opaque contrast through bilaterally placed parasternal catheters was followed by a computed tomography scan. This was done after obtaining informed consent from patient and waiver for scan. To the best of our knowledge, this is first report of successful pain management in patients who sustained manubrium – sternal dislocations using bilateral continuous catheters for a prolonged period.

Subarachnoid block is commonly used for caesarean deliveries, by virtue of its simplicity in terms of performance and safety for the parturients when compared with general anesthesia. The landmark technique involves palpating the interspinous space at the level of Tuffier's line to ensure the interspace level and direct the spinal needle through optimally selected puncture site for performing the subarachnoid block. However, spinal block is sometimes not easy to perform in obese parturients primarily because of poorly palpable surface landmarks and challenges related to positioning for the block. Recently, ultrasound (USG) is being used for facilitating central neuraxial block, using low-frequency curvilinear probe with encouraging results. We report a case of a 28-year-old, 95-kg parturient, with body mass index of 39.1 kg/m2 scheduled for elective lower segment caesarean section under subarachnoid block, the indication being previous caesarean section. As the landmarks were not appreciable on palpation, we performed USG-assisted preprocedural landmark-based subarachnoid block successfully.

The epidural block is an anesthetic procedure that can have possible complications upon insertion or removal. Epidural catheter retention is a rare complication; its etiology may come from lateral migration with kinking of the catheter or from involvement with bone, ligamentous, muscular, vascular structures, or nerve roots. Up until today, there is not a standard approach to this complication; however, there are some recommendations for the management of retained epidural catheters. Here, we describe a case report of epidural catheter retention, in which we followed the published recommendations. Although computed tomography scanning may be the best option to visualize the anatomical position of the distal extremity of an epidural catheter, with this case report we intend to reinforce the fundamental contribution of the contrast radiograph in the successful catheter removal. Posteriorly, a protocol for clinical orientation of epidural catheter retention was developed in our institution.

There are several modalities described to manage postoperative pain after a total knee replacement (TKR). Presently the regional anaesthesia techniques used after TKR focus on more peripheral, motor sparing blocks so as to facilitate early ambulation along with good quality pain relief. We describe use of ultrasound guided 3 point genicular nerve block (GNB) for managing postoperative pain successfully after a TKR.

Inadvertent injection of nonepidural drugs into the epidural space is a rare situation, which is under-reported, and can lead to serious complications, such as cardiovascular and respiratory complications, paraplegia, or quadriplegia, and can worsen the patients' outcome from surgery. Succinylcholine administered epidurally leads to the appearance of fasciculation and shortness of breath and can prolong neuromuscular blockade. We report a case of accidental administration of 100 mg of succinylcholine via an epidural catheter as a test dose instead of 2 ml 0.5% bupivacaine in a patient planned for major abdominal surgery. After 2 min, the patient complained of shortness of breath; dysarthria; and fasciculation in the trunk, upper limbs, and face. This was managed with induction to general anesthesia (GA). In the postoperative period, no neurological or cardiovascular complications were observed. There is no adequate drug as an antidote of accidentally given nonepidural drugs via an epidural catheter. Succinylcholine given via epidural catheter has been shown to prolong neuromuscular blockade. Proper labeling and storage of syringes are of utmost importance for avoiding these unpleasant situations.

Respiratory failure is a common complication in patients with myotonic dystrophy (MD) and might be a presenting symptom in the perioperative setting. We report the case of a 59-year-old woman with MD who underwent open cholecystectomy and developed postoperative respiratory failure. Without reintubation, the patient was successfully managed with bilevel positive airway pressure (BiPAP) and was discharged uneventfully. BiPAP may be considered as an alternative for postoperative respiratory failure in patients with MD. Careful observation of patients' postoperative condition and an earlier application of BiPAP are instrumental in avoiding retracheal intubation, which may cause further serious problems in patients with MD.

Anesthesia care during surgical procedures in patients with myasthenia gravis (MG) can be challenging, as these patients have increased sensitivity to neuromuscular blocking agents (NMBAs) and may be at high risk for postoperative weakness and respiratory failure. Even intermediate-acting NMBAs may have a prolonged effect resulting in residual weakness after reversal with acetylcholinesterase inhibitors (neostigmine). Sugammadex (Bridion®, Merck and Co, Whithouse Stations, New Jersey) is a novel pharmacologic agent that reverses neuromuscular blockade by encapsulating rocuronium or vecuronium. We report the perioperative management of a 13-year-old adolescent girl with MG undergoing thymectomy. The use of sugammadex for reversal of neuromuscular blockade is discussed and the previous reports regarding its use in patients with MG are reviewed.

A 51-year-old woman presented with symptomatic GB stone was planned for elective laparoscopic cholecystectomy. She had known osteum secondum type atrial septal defect, moderate pulmonary hypertension, and atrial fibrillation. We report the case of a patient with a large atrial septal defect (65 mm) and hemodynamic instability who underwent laparoscopic cholecystectomy under total intravenous anesthesia with careful hemodynamic monitoring. Thorough surveillance and effort could help to make the surgery successful.

Pulmonary hemorrhage (PH) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been primarily reported in pediatric patients. We report a case of fatal PH during VA-ECMO for cardiogenic shock after myocardial infarction (MI). PH, in this case, was secondary to a triad of aortic insufficiency, left ventricle distension, and severe laminar mitral regurgitation. This case scenario, previously unreported in adults, illustrates the need for the echocardiographic assessment of left-sided heart valves prior to VA-ECMO initiation after MI as well as management considerations for massive PH in this context.

A 39-year-old pregnant patient with acute appendicitis was planned for emergency laparoscopic appendectomy in the second trimester of pregnancy. Preoperative two-dimensional transthoracic echocardiography revealed asymptomatic cor triatriatum sinisiter (CTS), dividing left atrium into two chambers. There was no associated cardiac anomaly, wall motion abnormality, or pulmonary hypertension. We report the case of a pregnant patient with CTS who uneventfully underwent laparoscopic appendectomy without invasive cardiac monitoring using total intravenous anesthesia.