Local anesthetic-associated cardiac toxicity following caudal epidural blockade is, fortunately, a rare event. Prompt recognition and early treatment is the key to successful resuscitation. Early use of the lipid emulsion Intralipid in bupivacaine-induced cardiac toxicity may lead to a good outcome.

Surgical repair of pectus excavatum can be associated with significant postoperative pain. Various analgesic modalities have been suggested including thoracic epidural analgesia and intravenous patient-controlled analgesia (IV PCA). The current study compares the efficacy and adverse efficacy profile of these 2 analgesic modalities. The charts of 18 adolescents who had undergone pectus excavatum repair were retrospectively reviewed and divided into 2 groups: thoracic epidural analgesia (E) or IV PCA (I). Demographic data included age, weight, sex, and anesthesia/surgical times. Treatment days (defined as the number of days the patients received intravenous or epidural analgesia), time to oral intake, and time to discharge from the hospital were also recorded. Pain scores using a visual analogue scale ranging from 0 (no pain) to 10 (worst imaginable pain) and sedation scores were recorded in the postanesthesia care unit and at 6, 12, 24, 36, 48, and 60 hours postoperatively. The charts were also reviewed for side effects including nausea and/or vomiting, pruritus, oxygen desaturation, and respiratory depression. The study cohort included 18 patients divided equally into group E (epidural analgesia) (n = 9) and group I (IV PCA). There were no statistically significant differences between the 2 groups with regard to demographic data, time to oral intake, and time to hospital discharge. Anesthesia to surgery times were longer in group E compared with group I (43 +/- 11 versus 25 +/- 11 minutes, P = 0.004), but there was no difference in overall surgery and anesthesia times. The number of treatment days (days that the patients received intravenous or epidural medications) was decreased in group E versus group I (2.3 +/- 0.7 versus 3.3 +/- 1.0 days, P = 0.027). There was no difference between the 2 groups in regard to the onset of oral intake or hospital discharge time. Pain scores were initially higher in the postanesthesia care unit in group E versus group I (6.78 +/- 2.17 versus 5.78 +/- 3.77); however, after that point, pain scores were lower in group E than in group I. There was no difference between the 2 groups in regard to sedation scores or adverse effect profile. Epidural analgesia provided better pain control than the intravenous route for the management of patients after pectus excavatum repair. No adverse effects related to epidural analgesia were noted. The only issue identified with thoracic epidural anesthesia was a mean increase of 18 minutes for anesthesia time required for catheter placement before the start of the case.

Patients with impaired ability to understand and communicate can be difficult to manage perioperatively. They frequently require lateral thinking on the part of the anesthesiologists to make the induction process as smooth as possible. We present a case of a severely autistic and violent patient scheduled for dental rehabilitation under general anesthesia. A combination of oral ketamine and midazolam was mixed in the beverage Dr Pepper to mask the taste and the appearance of the drugs. The unique flavor of Dr Pepper is well suited to increase the palatibility and the acceptability of medications in children and patients with developmental delay.