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The CLIC system in the Dräger Apollo anesthesia workstation allows a successful pre-use machine checkout without the presence of a carbon dioxide absorbent canister. It also allows the canister to be changed without interrupting controlled ventilation. However, this canister can be easily installed improperly with the CLIC adapter. We report a case in which a patient could not be ventilated by mask after the induction of general anesthesia, resulting in oxygen desaturation before successful ventilation was achieved with a bag valve mask. This case illustrates the importance of a leak test after components of the breathing circuit are changed.

We describe an unusual case of hyperacute hepatic failure following general anesthesia in a patient receiving a simultaneous kidney-pancreas transplant. Despite an aggressive evaluation of structural, immunological, viral, and toxicological causes, a definitive cause could not be elucidated. The patient required a liver transplant and suffered a protracted hospital course. We discuss the potential causes of fulminant hepatic failure and the perioperative anesthesia management of her subsequent liver transplantation. Resumo Descrevemos um caso incomum de insuficiência hepática hiperaguda após a anestesia geral em uma paciente que recebeu um transplante simultâneo de rim-pâncreas. Apesar de uma avaliação agressiva das causas estruturais, imunológicas, virais e toxicológicas, uma causa definitiva não pôde ser identificada. A paciente precisou de um transplante de fígado que resultou em prolongamento da internação hospitalar. Discutimos as potenciais causas da insuficiência hepática fulminante e o manejo da anestesia no período perioperatório de seu subsequente transplante de fígado.

Decompression illness is caused by bubbles that appear in either the bloodstream or in other tissues in the body by ascending too fast from either underwater depth to the surface or from the surface to an altitude such as in high altitude fighter pilots. When ambient pressure increases, such as during diving, so will the pressure of any gas that the person is breathing. This gas will get distributed throughout the body at different speeds, where highly vascularized tissues equilibrate at a faster rate. Bubbles are formed when the ambient pressure is reduced faster than the ability of the blood or tissue to transport the gas which is in solution (usually nitrogen) to the lungs to get exhaled. These bubbles can have various and complex effects on the body, from direct obstruction of blood flow, obstruction of lymph flow, to nerve injury either by direct irritation or through inflammatory mediators. These effects can be mild, resulting in pain or paresthesias, or severe, leading to paralysis and death. One of the most widely used classifications of decompression illness is decompression sickness type 1 (DCS1) with mild pain only or (mild) skin symptoms, decompression sickness type 2 (DCS2) with neurological involvement, and arterial gas embolism (AGE), resulting from pulmonary barotrauma. The primary treatment of decompression illness is recompression in a hyperbaric chamber, which will increase the ambient pressure again, reducing the speed of new bubble formation and reducing existing bubble size as well as creating a large diffusion gradient for the offending gas by breathing 100% oxygen. The appropriate treatment of decompression illness is usually very effective, especially when started early after the injury, leaving either minimal or no residual effects. Most residual effects will improve even further with time as the body is trying to heal, however, some residual effects may be permanent. In addition, a diver may also suffer from barotrauma to air-filled spaces such as ears, sinuses, and the lungs during a dive. After an episode of decompression illness or other diving-related injuries, many divers want to go diving again either for recreation, work, or military service. A thorough understanding of the factors that led to the injury and careful clinical exam will help the diving medicine specialist to decide if additional tests are indicated and to advise the diver of his future risk with a return to diving. Guidelines do exist for military, government, scientific and commercial divers. However, no guidelines have been published in the United States for recreational divers, including dive masters and dive instructors., (Copyright © 2022, StatPearls Publishing LLC.)

Yellow fever is a mosquito-borne viral illness found in tropical and subtropical areas in South America and Africa. Transmission is primarily via Aedes and Haemagogus species of mosquito. It can present with varying clinical features ranging from a self-limited, mild febrile illness to severe hemorrhage and liver disease. The “yellow” comes from jaundice that affects some patients with severe disease. The disease is diagnosed by history travel to an endemic area, exposure to infected mosquitoes, vaccination history, symptoms, and laboratory findings. Most cases are self-limited and resemble many other common viral infections. Of those who develop severe disease mortality can approach 50%. Unlike many other mosquito-transmitted viruses, infected humans are not dead-end hosts and may infect mosquitoes during periods of viremia and spread the virus. There is no specific antiviral therapy, but there is an effective vaccine recommended for travelers to endemic areas. Other than vaccination, prevention of mosquito bites is the best way to avoid contracting the virus., (Copyright © 2022, StatPearls Publishing LLC.)

Laryngeal mask airways (LMA) are single-use or reusable supraglottic airway devices which may be used as a temporary method to maintain an open airway during the administration of anesthesia or as an immediate life-saving measure in a difficult or failed airway as outlined in the difficult airway algorithm published by many societies of anesthesiology worldwide.  Introduced into clinical practice in the 1980s, they were initially used predominantly in the operating room but have become widely used in the intensive care unit, emergency department and field settings.  LMAs are easier to use and more effective than a bag-valve-mask in the hands of basic life support providers and may be used as an alternative to intubation by advanced life support providers. Some models may be used as a conduit to facilitate endotracheal intubation., (Copyright © 2022, StatPearls Publishing LLC.)

End-of-Life discussions or advance care planning (ACP) with family and primary care providers can be challenging, but they are necessary to maintain patient autonomy and reach a well-informed decision.  Studies have shown that less than 30% of survey participants have an advance directive. Most individuals with advance directives share similar characteristics: chronic illness, regular access to healthcare, higher income, higher education, and older age. Racial and ethnic disparities also have accounted for a lower percentage of advance directives, particularly among non-white respondents.  , (Copyright © 2022, StatPearls Publishing LLC.)

Lidocaine is a local anesthetic drug that produces transient loss of sensory, motor, and autonomic function when the drug is injected or applied in proximity to neural tissue. It is the most common local anesthetic and is used in almost all medical specialties. It also is commonly used as an antiarrhythmic agent to depress ventricular arrhythmias. Infusions of lidocaine (and procaine) have been used to supplement general anesthetic techniques, as they are capable of reducing the minimum alveolar concentration of volatile anesthetics by up to 40% as well as providing pain relief in the peri-operative phase. It is in the class of the local amide anesthetics, which, compared to the ester-type local anesthetics, is usually well tolerated with only rare occasions of allergic reactions. Amide local anesthetics are metabolized (N-dealkylation and hydroxylation) by microsomal P-450 enzymes in the liver. Applied either by injection, inhalation, or as a topical agent to provide anesthesia, lidocaine has a good safety margin before reaching toxic blood levels. Since it can be applied in various forms to the same patients, however, care must be taken to keep track of the total dose given to minimize its systemic toxicity. In addition, clinicians should take into account the dose of any other local anesthetics that may have been administered to the same patient, as toxic doses appear to be additive. Lidocaine toxicity not only is determined by the total dose (usually 4.5 mg/kg) but also by the rate of absorption, which is dependent on the blood flow of that tissue. To reduce blood flow to the injection site and therefore the rate of absorption, vasoconstrictors such as epinephrine 1:200000 are frequently used and may increase the toxic dose to 7 mg/kg. Lidocaine toxicity to muscles and peripheral or neuraxial nerves can occur locally at the site of injection. Transient neurologic symptoms (TNS) after high concentration lidocaine spinal anesthetics have been described multiple times and have led to either reducing the concentration of the dose or switching to a different agent. In addition to direct nerve toxicity, systemic toxicity affecting the brain and/or cardiac muscle can lead to sudden and dramatic changes in the patient’s vital signs. Finally, there are the side effects of a relative overdose at the site of injection, which can be quite dramatic. Examples include total spinal anesthesia or subdural injection of the drug that can cause severe hemodynamic compromise such as hypotension or bradycardia up to a cardiac and respiratory arrest., (Copyright © 2022, StatPearls Publishing LLC.)

Pulse oximetry is a non-invasive monitor that measures the oxygen saturation in the blood by shining light at specific wavelengths through tissue (most commonly the fingernail bed). Deoxygenated and oxygenated hemoglobin absorb light at different wavelengths (660 nm and 940 nm respectively), and the absorbed light is processed by a proprietary algorithm in the pulse oximeter to display a saturation value. It is a standard monitor for all anesthesia cases in most developed countries  and also used in emergency departments, hospital wards, and ambulances to assess blood oxygenation in patients with respiratory difficulties or monitor for respiratory depressant effects of pain medications. Since its widespread use in hospitals, the incidence of unrecognized desaturations has decreased significantly . In addition to hospital-grade pulse oximeters, newer and much smaller consumer-grade models are rapidly gaining popularity in the sports, private aviation, mountain climbing, and other recreational activity communities. Because of the size and low cost of these consumer grade models, many patients with chronic respiratory illnesses are purchasing these to titrate either their medications or oxygen flow at home. However, most of those consumer-grade devices have not been evaluated by the Food and Drug Administration to diagnose or treat diseases., (Copyright © 2022, StatPearls Publishing LLC.)

Human limbs are composed of muscle groups divided by fascial membranes into anatomic compartments. When a limb sustains trauma (i.e., crush injury, fractures, repeated injections or infusions, or overuse), swelling and inflammation within a compartment may increase rapidly. Consequently, the acute compartment syndrome (ACS) results when compartment pressures increase to the point that tissue perfusion is compromised., (Copyright © 2022, StatPearls Publishing LLC.)