Providing anesthesia to patients with myotonic dystrophy (DM) can be very challenging due to the multisystemic effects of the disease and extreme sensitivity of these patients to sedatives, opioids, and anesthetic agents. Other factors such as hypothermia, shivering, or mechanical or electric stimulation during surgery can precipitate myotonia which is difficult to abolish and can lead to further complications. Generally, local or regional anesthesia is preferred to avoid the complications associated with general anesthesia in this group. However there are several case reports of successful use of general anesthesia (with or without volatile agents and with or without opioids). These general anesthetic cases led to postoperative admission to the regular floor or ICU. We present a case of a woman with a history of DM who underwent robotic assisted laparoscopic hysterectomy under general anesthesia and was discharged home on the same day.

We report a case of a 41-year-old male with anticipated difficult airway undergoing a repair of a bilateral radial fracture under bilateral sequential brachial plexus block. Anesthesiologists are reluctant to perform bilateral blocks because of the fear of complications like diaphragmatic paralysis, local anesthetic (LA) toxicity, and pneumothorax. We advise that with the correct application of LA pharmacokinetics, careful patient selection and usage of ultrasound, bilateral blocks can be done safely. We used chloroprocaine as an LA in one of the blocks to reduce the dose required for the more toxic LAs. chloroprocaine’s fast metabolism also helped us to prevent the overlapping of peak plasma concentration of different LAs. To our knowledge, this is the first reported case in the literature where chloroprocaine was used for bilateral brachial plexus block.

Peripheral nerve injury following regional or general anesthesia is a relatively uncommon entity but, potentially, a serious complication of anesthesia. Most nerve injuries are related to either regional anesthesia or position-related complications, and they are rarely seen in association with the use of automated blood pressure monitoring. We describe a patient who developed neurological dysfunction of all the three major nerves, median, ulnar, and radial, after general anesthesia. The distribution of sensory motor deficit along with the nerve conduction study demonstrated the location of the anatomical nerve lesions coinciding with the automatic noninvasive blood pressure (NIBP) cuff. No other cause of nerve injury was identified except for the use of the NIBP cuff. In the absence of another identifiable cause, we strongly suspected the NIBP cuff compression as a possible cause for the nerve injuries. In this article, we will discuss the possible risk factors, mechanisms, diagnosis, and prevention of perioperative nerve injury.

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With great interest, we have read the article published by Shrestha et al, where the authors have presented a healthy patient who had prolonged neurological recovery after brachial plexus block for open reduction and internal fixation of left forearm bone fractures. 1 We would like to express our thoughts and concerns regarding the prolonged neurological recovery after brachial plexus block for orthopedic surgery on the forearm. Firstly, although the authors mentioned prolonged neurological recovery possibly being due to local anesthetics, they forgot to mention other possible causes of perioperative nerve injuries, like preexisting peripheral neuropathy, profound hypotension, hypoxemia, hypothermia, morbid obesity or underweight, electrolyte imbalance, diabetes, current tobacco use and procedural risk factors such as the duration of surgery and patient position. 2 We do not know the weight of the patient, and extremes of body habitus can lead to nerve injury, especially if a tourniquet is used. Since the tourniquet was at midarm and was used for close to 2 hours, compression nerve injury from the tourniquet may well be the cause of the prolonged neurological recovery. Bickler et al stated that 45-60 minutes of compression of 250 mmHg over the nerve is required to reversibly block nerve conduction in the segment directly beneath the nerve. 3 Secondly, even though the authors mentioned a nerve conduction study being carried out on the patient, it seems like it was done too early in the course of the disease (day four). While an early conduction study may provide useful information, it can take around 3-4 weeks for the electrophysiological changes of a nerve injury to evolve fully in a nerve conduction study. 4 We wonder whether the authors thought of repeating the nerve conduction study. Thirdly, the conclusion made by the authors that cumulative toxicity from two different local anesthetics may have been a factor seems to be weak as the dose of local anesthetic used for the block was quite low (8 mL of 0.5% bupivacaine and 5 mL of 2% lidocaine). However, a tiny amount of local anesthetic (0.5-1 mL) is sufficient to cause injury if injected into the fascicle, causing direct needle injury and trauma. 5 Peripheral nerve injury due to anesthesia is a very serious complication which can be encountered with both regional and general anesthesia. Two ASA closed-claim

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