We report a case of catecholamine-induced acute myocardial stunning that occurred in a six-year-old girl. This was triggered by an accidental noradrenaline injection during general anaesthesia for dental surgery. The clinical course was favourable, although cardiac enzymes and echocardiography were significantly altered. The child was discharged home on the second postoperative day, after complete clinical resolution. We emphasise the need to consider shortening the surgical procedure, and to closely monitor patients following a medication error involving vasopressors even in the absence of symptoms. We highlight the importance of a controlled process for storing, identifying, preparing, and handling medications. The identification of weaknesses in the overall process of drug prescription and administration is of utmost importance.

There is a lack of evidence regarding the optimal intra-operative glycaemic level of patients with ornithine transcarbamylase deficiency to prevent cerebral oedema due to protein catabolism and hyperammonemia. We describe a case of a two-year-old girl with ornithine transcarbamylase deficiency who underwent cardiac surgery requiring cardiopulmonary bypass. A high-dose dextrose infusion to prevent protein catabolism was given throughout surgery, which caused uncontrollable hyperglycaemia unresponsive to high-dose insulin administration. Factors contributing to the hyperglycaemia may have included surgical stress, steroid administration and hypothermia. During invasive surgery, anaesthetists should carefully adjust the rates of dextrose and insulin infusions, guided by close monitoring of blood ammonia, glucose and lactate.

Aromatic L-amino acid decarboxylase deficiency is an autosomal recessive disorder that results in a lack of neurotransmitters including serotonin, dopamine, noradrenaline and adrenaline. It is characterised by developmental delay, severe hypotonia and autonomic disturbance. In patients with this condition, catecholamine deficiency and autonomic dysfunction, resulting in haemodynamic instability under anaesthesia is a primary concern. There is increased sensitivity to exogenous catecholamines and indirect acting agents, such as ephedrine, are ineffective. Hypoglycaemia, difficult airway status and drug interactions such as with monoamine oxidase inhibitors are also of concern, and these patients are at risk of dystonic crises peri-operatively. A 6-year-old boy with aromatic L-amino acid decarboxylase deficiency presented for gastrointestinal endoscopy. Following multidisciplinary discussion, we elected to provide general anaesthesia with a propofol target-controlled infusion, which proceeded without incident. In this report, we describe the precautions taken in this case, and discuss the provision of general anaesthesia for children with rare neurometabolic disorders.

Anaesthesia ReportsVolume 9, Issue 2 e12141 Clinical and Educational Article The fresh gas flow decoupling valve and the potential for leaks in the anaesthetic circle breathing system A. Rey, Corresponding Author A. Rey Consultant arnaud.rey@chuv.ch orcid.org/0000-0003-3878-478X Department of Anaesthesiology, Lausanne University Hospital–CHUV, Lausanne, Switzerland Correspondence to: A. Rey Email: arnaud.rey@chuv.chSearch for more papers by this authorO. Malézieux, O. Malézieux Nurse Department of Anaesthesiology, Lausanne University Hospital–CHUV, Lausanne, SwitzerlandSearch for more papers by this authorA. Potié, A. Potié Consultant orcid.org/0000-0001-5626-3641 Department of Anaesthesiology, Lausanne University Hospital–CHUV, Lausanne, SwitzerlandSearch for more papers by this author A. Rey, Corresponding Author A. Rey Consultant arnaud.rey@chuv.ch orcid.org/0000-0003-3878-478X Department of Anaesthesiology, Lausanne University Hospital–CHUV, Lausanne, Switzerland Correspondence to: A. Rey Email: arnaud.rey@chuv.chSearch for more papers by this authorO. Malézieux, O. Malézieux Nurse Department of Anaesthesiology, Lausanne University Hospital–CHUV, Lausanne, SwitzerlandSearch for more papers by this authorA. Potié, A. Potié Consultant orcid.org/0000-0001-5626-3641 Department of Anaesthesiology, Lausanne University Hospital–CHUV, Lausanne, SwitzerlandSearch for more papers by this author First published: 30 November 2021 https://doi.org/10.1002/anr3.12141Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume9, Issue2July‐December 2021e12141 RelatedInformation

SummaryCOVID‐19 infection immediately after liver transplantation presents a unique and challenging situation. In this report, we present the case of an 11‐year‐old girl who underwent emergency living donor liver transplantation for acute liver failure. After an uneventful intra‐operative course, the patient was transferred to the intensive care unit. On the second postoperative day, the patient developed unexplained severe hypoxia. A polymerase chain reaction test was positive for SARS‐CoV‐2 virus and a hypercoagulable state was indicated by laboratory investigations. Despite therapies such as mechanical ventilation and therapeutic anticoagulation, further clinical deterioration occurred. On the seventh postoperative day, the patient’s pupils were fully dilated bilaterally and unreactive to light, and brain death was later confirmed. This report highlights unique challenges pertaining to oxygenation, coagulation and immunosuppression after liver transplantation in a child with COVID‐19. Hypoxia of unknown origin in the postoperative period should prompt consideration of COVID‐19 as a possible cause.

Epidural catheters are often used in the provision of surgical anaesthesia and analgesia. These catheters need to be removed after a certain period, but difficulties may be encountered during this process. We present a case of difficult epidural catheter removal in an elderly woman who had undergone surgery for reduction and internal fixation of a comminuted intertrochanteric fracture at the left femur under combined spinal epidural anaesthesia. Anaesthesia was satisfactory during the operation; however, initial attempts to remove the catheter at the end of the procedure was met with significant resistance. Normal saline (5ml) was injected through the catheter without difficulty, suggesting that the catheter was likely trapped and compressed but not obstructed. A nickel/titanium memory alloy suture was used as a guidewire to remove the catheter without damaging it. This case was analysed subsequently, and the management of future problematic removals is discussed herein. This article aims to raise awareness of, and to explore techniques for managing difficult epidural catheter removal.