Background: This case report highlights an occurrence of bilateral diaphragm paralysis following surgical drainage for deep neck infection. Case: A 56-year-old male underwent surgical drainage and tracheostomy for a deep neck infection. Before the second surgical drainage, he exhibited tachypnea (>30 bpm), although his general condition was not significantly compromised. Following a successful drainage procedure, he was transferred to the intensive care unit and placed on mechanical ventilation. Despite attempts at spontaneous breathing trials (SBT), he failed each trial, leading to a deterioration in his general condition. Subsequently, he was diagnosed with diaphragm paralysis. Conclusion: The clinical manifestations of bilateral diaphragm paralysis closely resemble the common symptoms of sepsis. Therefore, it is crucial to recognize that surgical interventions for deep neck infections may pose a risk of developing diaphragm paralysis, likely associated with phrenic nerve palsy.

Background: Down syndrome is one of the common congenital chromosomal disorders. Renal complications in Down syndrome patients are rare but is increasing in number due to increased survival. Anaesthesia in such patients is challenging due to intellectual disability, anatomical complications and multiple comorbidities. Case: This case report describes the pre-operative evaluation and anaesthetic management of a 19 -year-old male patient with Down syndrome with hypothyroidism with Chronic Kidney Disease stage 4 who underwent open reduction internal fixation with plating for bilateral subtrochanteric fracture under general anaesthesia. It was a complicated surgery for both surgeon and anaesthetist because the patient was anaemic with significant anticipated blood loss along with fluid restriction during the perioperative period. We had major challenges like patient positioning, significant blood loss, hypotension, and early fluid overload. But an extensive preoperative evaluation, optimization prior and proper coordination we overcame the challenges. Conclusion: Major orthopaedic surgeries in patients like Down syndrome with chronic kidney disease create a major anaesthetic challenge due to expected significant blood loss, chances of fluid overload, multiple comorbidities and intellectual disability. Thorough preoperative evaluation, intraoperative monitoring as well as postoperative period is important as several complications are envisaged. So a closed group management with orthopaedic surgeon, nephrologist, anaesthesiologist, endocrinologist, nursing team is required to handle such complicated cases.

Background: Breast cancer mostly affects patients older than 65 years old. Geriatric patients may have comorbidities so the selection of anaesthesia for breast cancer surgery is challenging. In the past decade, thoracic spinal anaesthesia as regional anaesthesia was feasibly performed for laparoscopic cholecystectomy and minor breast surgery. This article aims to evaluate thoracal spinal anaesthesia for Modified Radical Mastectomy (MRM) in our hospital settings. Case: Three cases of Thoracal Spinal Anaesthesia were carried out for MRM surgery after neoadjuvant chemotherapy treatment. This procedure consists of removal of breast tissue and the ipsilateral axillary contents. The comorbidities include hypertension, cardiomegaly, and mild anaemia. There was no conversion to general anaesthesia during surgery until completion. Duration for surgery less than 120 minutes. No significant hemodynamic instability and complaint were found during intra and postoperative. Conclusion: From these cases, thoracal spinal anaesthesia was acceptable as regional anaesthesia for MRM in geriatric patient.

Background: Double outlet right ventricle (DORV) is a rare cardiac condition in which the heart demonstrates single ventricle physiology. Pregnancy complicates cyanotic heart disease as the decrease in systemic vascular resistance (SVR) worsens the right-to-left shunt. The effect worsens by neuraxial anesthesia for cesarean delivery. Anesthesia for these patients needs understanding for the physiology of DORV in order to maintain stable hemodynamics. Heart defect still become non obstetric main factor causing morbidity and mortality in pregnant woman. Case: We present three case of parturients with DORV scheduled for cesarean section. Elective caesarean section was scheduled using spinal anesthesia hyperbaric bupivacain combined with fentanyl. Hemodynamic during operation was stable. Conclusion: Low dose spinal anesthesia performed in this patient did not cause hypotension and minimal hemodynamic changes because the intensity of the sympathetic block was lower.

Background: Occipital neuralgia defined as a pain such as being stabbed in the skin according to the dermatomes of the greater occipital nerves (GON) and lesser occipital nerves (LON). Case: An 80-year-old male patient diagnosed with occipital neuralgia. Previously, patients were diagnosed with lung cancer six months ago and planned for follow-up chemotherapy. Patient already receive medications including paracetamol, Non-steroidal anti-inflammatory drugs (NSAIDs), minor tranquilizers, and antidepressants, but the pain still exist. Patient then scheduled to receive blocks of GON and LON-ultrasound-guided using plain lidocaine 2% and steroids dexamethasone 10 mg. Fifteen days later, patient receive perineural deep injection along with prolo-hydrodissection in GON and LON using dextrose 15% and local anesthesia lidocaine plain 2% with a volume of 3 cc each nerve. The intervention give a positive outcomes, pain is reduced with NRS rest 0-1, NRS motion 2-3, hearing improves, and the noise in the ear disappears. The patient can sleep using a pillow. Conclusion: Block GON and LON, perineural deep injection along with prolo-hydrodissection provides a positive outcome for occipital neuralgia pain management. This case showed an opportunity for pain specialist to develop pain intervention based on prolotherapy.

Background: Esophageal atresia is a congenital disorder in which there is no esophagus because the proximal and distal esophagus is not connected. Babies with esophageal atresia can show several symptoms: foamy mouth, cyanosis, coughing and tightness, flatulence, oliguria, or worse, pneumonia symptoms. Accompanying anomalies occur in greater than 50% of neonates with esophageal atresia. Esophageal atresia is identified by ultrasound at 18 weeks of gestation, ultrasound, and Magnetic resonance imaging (MRI) of the fetal neck, or examination of a nasogastric tube in the neck of a newborn. The management of esophageal atresia is challenging. The main choice remains the surgical procedure, which usually involves making a stoma on the proximal esophagus and gastrostomy. However, surgery has risky complications. Case: In this case, it was reported that a 22-day-old baby with tracheoesophageal fistula (TEF) type C with Ventricular Septum Defect and Atrial Septum Defect and Double Outlet Right Ventricle (DORV) underwent esophagostomy surgery with general anesthesia. Conclusion: Anesthesia management with general anesthesia, intubation using intravenous ketamine 3 mg, fentanyl 3µg, atracurium 1.5 mg gives stability for esophagostomy in a patient with a double outlet right ventricle.