We thank Dr Ormandy for their contribution and congratulate them on their work [1]. Unfortunately, we were limited to five references as per the author guidelines set out by Anaesthesia Reports [2]. We are glad to share the aim of enhancing the pre-assessment of patients with a predicted difficult airway through use of technologies. Clinical applications of three-dimensional (3D) modelling are rapidly evolving, with new materials and printing methods such as those we describe becoming more accessible to clinicians [3]. We agree that combined with modalities such as virtual reality (VR) and video-endoscopy (VE) this is an exciting progressive space within the field of anaesthesia [4, 5]. IA has previously received honoraria as educational grants from Stortz, Ambu, Fisher and Paykel, Flexicare, Verathon Medical and BioMarin.

Ondansetron is a highly selective 5-hydroxytryptamine receptor antagonist and the most commonly used anti-emetic for the prevention of postoperative nausea and vomiting. Ondansetron has a low affinity for dopamine receptors and so extrapyramidal side effects are rare. Here, we present the case of a 14-year-old girl who developed a severe post-operative acute dystonic reaction which included oculogyric crisis. We believe that ondansetron was the most likely cause, although propofol may have been a synergistic or alternative causative agent. The patient had no significant past medical history and had previously undergone two uneventful general anaesthetics which included both ondansetron and propofol. The prolonged duration and severity of the reaction and failure to fully respond to specific treatments resulted in the need for tracheal intubation and transfer to a paediatric intensive care unit. She subsequently recovered uneventfully with no ongoing neurological sequalae. Ondansetron-induced dystonic reactions are rare and unpredictable and can occur in patients who have previously received the drug without complication. They are thought to be caused by an imbalance between inhibitory and excitatory neurotransmitters in the extrapyramidal system. Specific treatments include anticholinergics, antihistamines and benzodiazepines.

A 45-year-old man attended to a warehouse fire involving burning plastic, without wearing full protective equipment. He subsequently presented to hospital with shortness of breath and his trachea was intubated for airway protection due to initial concerns of inhalational injury. However, a post-intubation bronchoscopy was normal. The patient's serum lactate level was normal on admission but was increased when measured 14 h after the initial event and accompanied by a metabolic acidosis. Transdermal cyanide poisoning was suspected given this delayed biochemical presentation and the absence of another apparent cause. A handheld chemical detector detected a high level of toxins on the patient's skin. Clinical improvement was not observed after the first dose of intravenous hydroxocobalamin, which was administered before full body decontamination. After decontamination and the administration of a second dose of hydroxocobalamin, the patient's acid-base status rapidly improved and serum lactate level returned to normal. Clinicians should have a high index of suspicion for transdermal cyanide poisoning in patients presenting after exposure to a fire.

Performing sciatic nerve and adductor canal blocks with a single-needle puncture in the supine position has the potential to increase patient comfort and reduce procedural time. We performed this technique to facilitate urgent surgery for a patient at high risk of complications from general anaesthesia, in whom central neuraxial blockade was contraindicated. A 52-year-old female with a background medical history of diabetes mellitus and ischaemic cardiomyopathy (ejection fraction 40%) was scheduled for urgent right ankle wound debridement and application of antibiotic beads and negative pressure dressings. She was initially admitted to hospital for management of necrotising fasciitis of the right leg and had undergone several soft tissue debridement procedures during her admission. Closure of the affected area had been attempted with a free flap procedure, but this had failed due to tissue breakdown. The patient was receiving prophylactic doses of subcutaneous low molecular weight heparin (LMWH) due to prolonged bed rest. On the night proceeding surgery, the patient's clinical condition deteriorated. Clinical examination revealed bilateral chest crepitations and pedal oedema. A chest radiograph was consistent with pulmonary oedema. The patient was treated with furosemide 40 mg intravenously. The surgical team wished to proceed urgently due to the high risk to the patient of developing osteomyelitis should the debridement be delayed. Following multidisciplinary discussion, we agreed to facilitate early surgery, within 12 h of the patient's last dose of LWMH. As the patient displayed signs of worsening cardiac failure, proceeding with general anaesthesia was judged to confer a high risk of peri-operative cardiovascular complications. Spinal anaesthesia was contraindicated due to the administration of prophylactic LMWH 6 h pre-operatively [1]. Given the urgency of this procedure and the patient's precarious clinical status, superficial peripheral nerve block was the anaesthetic technique of choice due to the relatively lower risks associated with bleeding compared with central neuraxial blockade. A superficial nerve block has a lower risk of clinically significant consequences of bleeding and is performed at a location where management of bleeding complication is relatively straightforward [1]. The patient consented to this technique. Pre-operatively, examination of the patient's right leg revealed no sensory or motor deficit. Standard anaesthesia monitoring was established, and the patient remained in the supine position throughout block administration. Her leg was positioned with the hip externally rotated and knee flexed (Fig. 1a). A target-controlled infusion of propofol (plasma target concentration 1.5 μg.ml−1) was commenced to provide sedation, titrated to maintain purposeful response to verbal instructions. A curvilinear ultrasound probe (Sonosite X-Porte, Fujifulm Sonosite, Inc., Bothell, WA, USA) was used to guide nerve blockade. The probe was placed on the mid medial right thigh to obtain the ultrasound image of both the sciatic nerve and adductor canal (Fig. 1b,c). Three millilitres of 1% lignocaine were injected subcutaneously prior to the insertion of a 100 mm echogenic needle (SonoPlex, Pajunk, Geisingen, Germany) under real-time ultrasound imaging using an in-plane technique. After confirming the position of the needle tip on both ultrasound images, 20 ml of 0.4% ropivacaine and 15 ml of 0.8% lignocaine was deposited around the sciatic nerve (Fig. 1d), and into the adductor canal (Fig. 1e). The surgical procedure was performed uneventfully. The patient did not require any further analgesia intra- or postoperatively. She regained full sensory and motor function of her right lower limb approximately 10 h after completion of both blocks, and there were no block-related complications. When reviewed postoperatively, the patient reported that she was highly satisfied with the anaesthesia performed. Pre-operatively she had been concerned that changing position to allow the nerve blocks to be performed might have been uncomfortable. Additionally, having one needle puncture was preferable to multiple punctures due to a phobia of needles. This approach is useful for patients who have problems changing their position due to pain or physical limitations. Our experience is that this is an effective and efficient technique, both for analgesia and as the sole anaesthetic technique for below-knee surgery. It reduces the time needed, number of needle punctures and staffing requirements to achieve sensory blockade for surgery below the knee. This article was published with the written consent of the patient. No external funding and no competing interests declared.

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A parturient with VACTERL association (vertebral defects, anal atresia, cardiac defects, trachea-oesophageal fistula, renal abnormalities and limb abnormalities) was listed for an elective caesarean section. She had a short neck with reduced cervical extension and flexion. Magnetic resonance imaging of her whole spine was performed which showed failure of cervical spine segmentation and cervical stenosis. Neuraxial blockade could have resulted in unpredictable spread of local anaesthetic due to the low volume of the spinal canal, and could have caused myelopathic changes within the spinal cord due to cerebrospinal fluid pressure changes. A general anaesthetic using a rapid sequence induction was also predicted to be challenging due to her fixed, unstable neck and severe cervical spine stenosis. After a multidisciplinary discussion Including neurosurgeons, we planned for awake tracheal intubation followed by general anaesthesia. However, before the date of her planned delivery, she required an urgent caesarean section due to severe preeclampsia. This was performed under general anaesthesia following uncomplicated awake tracheal intubation.

We present the case of a 41-year-old man with Rapp-Hodgkin syndrome who underwent nasal septum deviation surgery under general anaesthesia. This syndrome is rare, with approximately 70 cases reported worldwide. It is one of a group of ectodermal dysplasia syndromes and results from the aberrant development of ectoderm during fetal development. Some of the clinical features may affect anaesthetic management. The most important considerations are potentially difficult airway management, the need for meticulous temperature control, and the importance of skin protection. This case was uneventful, but as there are few case reports on the management of patients with ectodermal dysplasia syndromes undergoing anaesthesia this report contributes useful knowledge. The pathogenesis and clinical features of Rapp-Hodgkin syndrome and the anaesthetic management for this patient are described.

In this case report, we present a rare case of life-threatening gastrointestinal haemorrhage associated with deranged coagulation due to supratherapeutic levels of dabigatran. Dabigatran is a potent, synthetic, reversible non-peptide thrombin inhibitor which is increasingly used for stroke prevention in patients with non-valvular atrial fibrillation. It is generally accepted that dabigatran dosing does not require titration or the monitoring of plasma levels due to its predictable pharmacokinetics and pharmacodynamics. However, this case report challenges this viewpoint while identifying an important knowledge gap in relation to the effect of altered gastrointestinal motility on the absorption of direct oral anticoagulants. Furthermore, it demonstrates the successful use of high-dose idarucizumab in a critical care setting. Idarucizumab is a monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.