A 62-year-old female with rheumatoid arthritis (RA), weighing 65 kg and off disease-modifying medications for one year, underwent the following procedures for avascular necrosis of the talus with ankle subluxation, subtalar involvement, and cavus deformity:

• Tibiotalocalcaneal nailing
• Tibialis posterior release
• Peroneus longus to brevis tendon transfer
• First metatarsal closing wedge osteotomy

The total surgical duration was 3 hours, with a tourniquet applied for 75 minutes.

Induction was achieved with fentanyl 200 micrograms, propofol 150 mg, and atracurium 40 mg. Maintenance was likely with sevoflurane at MAC 1.2, and the BIS remained between 40 and 48 throughout the procedure. Neuromuscular blockade was maintained with an atracurium infusion of 10 mg/hr.

Adjuncts included dexamethasone 8 mg, dexmedetomidine 30 micrograms, magnesium sulfate 1 g, paracetamol 1 g, and diclofenac 100 mg (suppository). At the end of the case, morphine 5 mg intramuscularly was administered, and neuromuscular reversal was given more than 25 minutes after the last atracurium dose.

The tourniquet was inflated to 300 mmHg, with a baseline blood pressure of 110/70 mmHg. During tourniquet time, blood pressure rose to greater than 180/100 mmHg and returned to baseline immediately after deflation.

Tourniquet-induced hypertension (TIH) is a well-recognised phenomenon, attributed to central sensitisation driven by ischemic nociceptive input from the tourniqueted limb. Even with adequate anesthetic depth, nociceptive afferents below the cuff continue to discharge, activating the spinal cord and sympathetic outflow.

C-fibres release glutamate, substance P, and CGRP at the dorsal horn, leading to NMDA receptor upregulation and a “wind-up” phenomenon. Activation of spinoreticular and spinothalamic tracts amplifies sympathetic activity, increasing systemic vascular resistance and blood pressure.

On a molecular level, glutamate activates NMDA receptors, increasing intracellular calcium. This in turn activates protein kinase C and nitric oxide synthase, propagating central sensitisation. In this patient, dexmedetomidine and magnesium, both modulators of NMDA-mediated pathways, were administered and likely attenuated but did not abolish the hypertensive response.

A key clinical clue is that hypertensive surges resolve rapidly upon tourniquet deflation, as observed here.

Management strategies include NMDA antagonists such as ketamine, alpha-2 agonists such as dexmedetomidine, magnesium sulfate, regional nerve blocks to interrupt afferent transmission, and minimising tourniquet time and pressure.

References

Estebe JP, Davies JM, Richebe P. The pneumatic tourniquet: mechanical, ischemia-reperfusion and systemic effects. Eur J Anaesthesiol. 2011;28(6):404–11.

Rivat C, Richebé P, et al. Pain and anesthesia-induced plasticity of sensory and nociceptive pathways. Prog Brain Res. 2009;175:275–91.

In patients with chronic pain syndromes such as rheumatoid arthritis or longstanding deformities, persistent nociceptive input can drive sympathetic surges even under general anesthesia. In this case, after the initial induction bolus, no continuous opioid infusion such as remifentanil was used. Although the BIS reflected adequate unconsciousness, nociception proceeded unchecked.

At the dorsal horn, glutamate and substance P from C and Aδ fibres activated neurons, but without sustained mu-opioid receptor activation, ascending signals were insufficiently suppressed. This mismatch...

Imagine a patient waking up from a lengthy spine surgery, only to reveal an unexpected complication: one side of their face swollen, the underlying muscle silently damaged. This was the reality for a 50-year-old obese male (BMI 35) who underwent an 8-hour neurofibroma resection in the prone position. Diagnosed with masseter muscle necrosis, this case underscores a rare but serious risk of prolonged surgery. While not directly caused by anesthesia, anesthesiologists play a pivotal role in its prevention and early detection.

This article explores the pathophysiology, differentiates it from anesthetic complications, and outlines the anesthesiologist’s role in managing such cases.

Reference

Chowdhry M, Hazani R, Collis G, Wilhelmi BJ. Masseter muscle hypertrophy and other mimickers of parotid gland enlargement: diagnosis and treatment. Ann Plast Surg. 2010;65(5):456–460. doi:10.1097/SAP.0b013e3181d87bd1

The masseter muscle, positioned adjacent to a surgical headrest in the prone position, is vulnerable during prolonged procedures. In obese patients, sustained pressure can exceed the tissue perfusion threshold (~32 mmHg). Once this occurs, blood flow halts and ischemia begins.

At the cellular level, hypoxia forces cells into anaerobic glycolysis, depleting ATP stores and impairing sodium–potassium pump activity. This results in calcium overload, uncontrolled enzyme activation, and myocyte necrosis. Venous congestion further amplifies acidosis and inflammatory responses.

The cascade typically develops silently during surgery, only to manifest postoperatively as facial swelling.

Reference

Gefen A. The biomechanics of sitting-acquired pressure ulcers in patients with spinal cord injury or lesions. Int Wound J. 2011;8(6):611–618. doi:10.1111/j.1742-481X.2011.00838.x

The use of succinylcholine (75 mg) in this case raised concern for malignant hyperthermia (MH). However, the absence of hypercarbia, rigidity, and hyperthermia excluded MH. Similarly, there was no laboratory evidence of rhabdomyolysis, such as elevated creatine kinase or potassium.

The clinical picture pointed instead to mechanical ischemia from prolonged facial compression. This differentiation is crucial for anesthesiologists: while drugs may raise suspicion, the true etiology here was positional and mechanical rather than pharmacological.

Reference

Larach MG, Gronert GA, Allen GC, Brandom BW, Lehman EB. Clinical presentation, treatment, and complications of malignant hyperthermia in North America from 1987 to 2006. Anesth Analg. 2010;110(2):498–507. doi:10.1213/ANE.0b013e3181c6b9b2

Although anesthesiologists do not directly cause masseter necrosis, they are frontline defenders against it. Preventive measures include:

• Pressure redistribution: Use of gel pads or specialized face pillows to distribute weight evenly.
• Vigilant monitoring: Frequent checks of head and facial position to prevent sustained compression.
• Intermittent offloading: Periodic repositioning to restore perfusion.
• Hemodynamic stability: Maintaining mean arterial pressure above 65 mmHg to optimize tissue oxygenation.

These measures are particularly important in obese patients and long-duration surgeries, where the risk is greatest.

Reference

Stark ME, Lehmann LW, McCusker SB. Ischemic myopathy: a rare complication of prolonged surgery in the prone position. J Clin Anesth. 1994;6(6):473–475....

• Age/Sex: 42-year-old female
• History: Sustained trauma from a road traffic accident
• Comorbidities: None reported
• Condition: Complex radial head fracture requiring excision or fixation

• Mechanism of injury:
• Time and type of accident
• Presence of associated injuries such as head trauma, loss of consciousness, cervical or back pain
• Upper limb symptoms:
• Numbness, paresthesia, or motor weakness
• Pain management:
• Current analgesic medications used
• Pregnancy status:
• Mandatory screening in women of reproductive age
• Past anesthetic history:
• Previous adverse reactions to anesthesia or difficulties with airway management
• Bleeding history:
• Any known bleeding disorders or use of anticoagulants
• Polytrauma assessment:
• Screening for other injuries commonly associated with road traffic accidents

Reference:

American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522-538. doi:10.1097/ALN.0b013e31823c1067

• Laboratory: Complete blood count, renal and liver function tests, electrolytes, coagulation profile
• Urine: Urine pregnancy test
• Cardiac: Electrocardiogram (recommended for age >40)
• Imaging:
• X-ray/CT scan of elbow and forearm
• Chest X-ray or CT if blunt chest injury suspected
• Cervical spine screening where indicated

Reference:

American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522-538. doi:10.1097/ALN.0b013e31823c1067

• Primary technique: General anesthesia as per surgical request
• Regional anesthesia (brachial plexus block): Avoided because:
• Postoperative neurologic evaluation is required to detect surgical nerve injury
• Regional block may mask early signs of compartment syndrome
• Complex surgical dissection expected in close proximity to neural structures

Reference:

American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation. Anesthesiology. 2012;116(3):522-538.

• Supine with the operated arm supported across the chest using a padded bolster or arm board
• Key considerations:
• Neutral shoulder alignment; avoid excessive abduction or stretch
• Adequate padding under the elbow, wrist, and hand
• Secure all lines to ensure continuous airway access and monitor visibility
• Avoid chest compression that could impair ventilation

Reference:

American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory. Anesthesiology. 2018;128(4):657-668. doi:10.1097/ALN.0000000000002025

• Minimize exposure with pulse mode, beam collimation, and reduced fluoroscopy time
• Staff protection with lead aprons and thyroid...

A 37-year-old female presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea. Diagnostic imaging with CT cisternography revealed a 7 × 2.5 mm bony defect in the cribriform plate, consistent with an anterior skull base leak. There was no history of recent trauma, although the patient reported a road traffic accident 17 years prior. On preoperative assessment, dark red nail polish was noted, which may interfere with pulse oximetry readings. An alternative site for oxygen saturation monitoring was considered.

Anesthesia was induced with intravenous glycopyrrolate 0.2 mg, midazolam 1 mg, fentanyl 100 micrograms, propofol 150 mg, and atracurium 40 mg. Airway control was secured with a size 7.0 mm endotracheal tube. Anesthesia was maintained with inhalational agents and continuous atracurium infusion at 10 mg/hour.

Additional intraoperative medications included:

• Dexamethasone (Dexona) 8 mg IV
• Dexmedetomidine 30 micrograms IV
• Magnesium sulfate 1 gram IV
• Paracetamol 1 gram IV
• Diclofenac 100 mg rectal suppository

After surgery, neuromuscular blockade was reversed. The endotracheal tube was gently exchanged for an i-gel supraglottic airway to facilitate smooth emergence. Morphine 5 mg was administered intramuscularly for postoperative analgesia.

• CSF rhinorrhea signifies communication between the subarachnoid space and nasal cavity, increasing the risk of ascending meningitis.
• Cribriform plate defects raise the possibility of air embolism, pneumocephalus, and intracranial infections.
• Spontaneous CSF leaks, particularly in middle-aged females, may indicate underlying idiopathic intracranial hypertension (IIH).

References:

Prosser JD, Vender JR, Solares CA. Traumatic cerebrospinal fluid leaks. Otolaryngol Clin North Am. 2011;44(4):857-873. doi:10.1016/j.otc.2011.05.003

Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope.2004;114(2):255-265. doi:10.1097/00005537-200402000-00016

• Avoidance of increased intracranial pressure or nasal pressures during positioning and airway handling.
• Positive pressure ventilation, coughing, or bucking can disrupt surgical repair.
• Goals include a bloodless surgical field, smooth hemodynamics, and protection of the repair during emergence.

Reference:

Fathi AR, Eshtehardi H, Mehdizade A. Cerebrospinal fluid rhinorrhea: diagnosis and management. Med J Islam Repub Iran. 2014;28:69.

• Rule out active infection or elevated ICP.
• Preoperative imaging (CT cisternography) maps the skull base defect.
• Adjust monitoring due to dark red nail polish (use alternate pulse oximeter sites).

Reference:

Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000;110(7):1166-1172. doi:10.1097/00005537-200007000-00023

• Glycopyrrolate 0.2 mg for antisialagogue effect and heart rate control.
• Midazolam 1 mg for anxiolysis and amnesia.
• Fentanyl 100 mcg to blunt airway reflexes.
• Propofol 150 mg for smooth induction and ICP reduction.
• Atracurium 40 mg for neuromuscular relaxation.

Reference:

Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology. 6th ed. McGraw Hill; 2018. Chapter 20, Anesthesia...

A 6-year-old male with recent-onset squint (strabismus) was scheduled for an MRI brain with contrast under anesthesia. Although the procedure may appear routine, the sudden appearance of a squint raises concern for raised intracranial pressure (ICP) or an intracranial mass lesion. This makes the anesthetic plan especially important, as it must prioritize both neurological stability and safe sedation.

A new-onset squint in a child is not a trivial finding. It can indicate significant underlying neurological disease. In particular, the sixth cranial nerve (abducens) is vulnerable because of its long intracranial course. When stretched by raised ICP, the nerve’s function is compromised, often resulting in esotropia (inward deviation of the eye). This clinical sign prompts further investigation to exclude conditions such as space-occupying lesions, hydrocephalus, or post-viral neuropathy.

Anesthetic relevance: Raised ICP alters both drug selection and airway management. Sedatives or airway maneuvers that increase intracranial pressure, such as coughing, straining, or hypoventilation, must be avoided.

References:

• Ropper AH, Samuels MA, Klein JP. Adams and Victor's Principles of Neurology. 11th ed. New York: McGraw-Hill; 2019.
• Yano H, Hirano T, Matsui T, Yamaura A. Abducens nerve palsy and increased intracranial pressure. Neurosurgery. 1984;15(6):935–8.

The preoperative assessment should focus on:

• Identifying symptoms of raised ICP, such as headache or vomiting
• Reviewing seizure history or signs of developmental delay
• Ensuring appropriate fasting status and hydration

In this case, the child had fasted for six hours but had refused intravenous fluids, increasing the risk of dehydration or hypoglycemia.

Relevance: Early recognition of neurological symptoms influences the choice of anesthetic drugs and ventilation strategy. Avoiding events that can worsen ICP is critical.

References:

• Litman RS, Kost-Byerly S, Berkowitz ID. Chapter 32: Preoperative evaluation of pediatric patients. In: Cote CJ, Lerman J, Anderson BJ, editors. A Practice of Anesthesia for Infants and Children. 6th ed. Philadelphia: Elsevier; 2019. p. 808–21.
• Engelhardt T, Weiss M. A child with a full stomach. Curr Opin Anaesthesiol. 2012;25(3):342–7.

Induction agents:

• Glycopyrrolate 0.05 mg IV: reduces secretions and prevents bradycardia.
• Midazolam 0.5 mg IV: provides anxiolysis and sedation.
• Fentanyl 40 micrograms IV: offers analgesia and blunts the stress response.
• Propofol 10 mg IV: ensures a smooth induction, decreases cerebral metabolic rate, and lowers ICP.

Maintenance:

• Dexmedetomidine 10 micrograms diluted in 50 mL IV fluid, providing light sedation while maintaining spontaneous ventilation.
• Propofol 5 mg IV at 20 and 40 minutes, administered as needed for movement suppression or contrast injection.

Airway:

• A face mask with spontaneous ventilation was used, avoiding airway instrumentation and reducing the risk of ICP surges.

Rationale:

This combination ensures adequate sedation and analgesia while maintaining spontaneous breathing.

• Rezūm is a short, minimally invasive procedure for BPH that avoids major risks of TURP (fluid overload, TUR syndrome, bleeding).
• In elderly, anticoagulated patients with AF and comorbidities, neuraxial anesthesia may be contraindicated; short general anesthesia with spontaneous ventilation is a safe alternative.
• Careful titration of propofol and sevoflurane with adjuncts (fentanyl, dexmedetomidine, glycopyrrolate) minimizes hemodynamic swings and movement.
• Lithotomy positioning, risk of patient movement, and the surgical learning curve demand vigilance from the anesthesia team.
• Anticoagulation resumption and catheter care remain essential parts of postoperative planning.

References

1. McVary KT, Roehrborn CG, et al. Rezūm water vapor thermal therapy for lower urinary tract symptoms secondary to BPH: 2-year results. J Urol. 2019;202(3):601-609.
2. Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Roehrborn C. Rezūm water vapor thermal therapy: 4-year results and safety profile. Urology. 2021;147:154-161.

Patient: An 89-year-old male with recurrent UTIs and indwelling catheter due to obstructive BPH was scheduled for Rezūm therapy.

Comorbidities:

• Chronic atrial fibrillation on apixaban 5 mg, stopped 48 h prior.
• Recovered from left frontoparietal acute infarct.
• Hypertension on nebivolol 2.5 mg BD, sacubitril-valsartan 50 mg OD, rosuvastatin 10 mg HS.
• ECHO: Bilateral atrial enlargement, EF 55%, pulmonary artery pressure 44 mmHg.
• Renal function: Creatinine 1.6 mg/dL.
• Vitals: HR 88/min (irregular), BP 140/90 mmHg.

References

3. Yates J, Barham CP, Perry M. Perioperative risk assessment in the elderly patient. Anaesthesia. 2020;75(S1):e83-e92.

4. Weitz JI, Pollack CV. Practical management of anticoagulation in patients with atrial fibrillation. Circulation. 2017;135(7):648-651.

• High-risk profile due to advanced age, anticoagulation, AF with pulmonary hypertension, and prior stroke.
• Spinal anesthesia avoided because apixaban was stopped only 48 h earlier and renal clearance was impaired.
• Planned for short GA with spontaneous breathing to maintain safety, hemodynamic stability, and airway control.

References

5. Narouze SN, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (ASRA guidelines). Reg Anesth Pain Med. 2018;43(3):225–262.

6. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation. Eur Heart J. 2016;37(38):2893-2962.

• Premedication/Induction:
• Fentanyl 100 mcg IV
• Glycopyrrolate 0.2 mg IV
• Dexmedetomidine 25 mcg IV over 15 min
• Propofol 40 mg IV
• Airway: Mask ventilation with oxygen and air.
• Maintenance: Sevoflurane in oxygen-air mixture, spontaneous breathing.
• Duration: 10 minutes.
• Course: Hemodynamically stable, no adverse airway or cardiovascular events.

References

7. Weerink MAS, Struys MMRF, Hannivoort LN, et al. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017;56(8):893–913.

8. Miller RD, Eriksson LI, Fleisher LA,...