Myotonic dystrophy type 1 (DM1) presents significant anesthetic challenges. A 46-year-old woman with DM1 underwent emergent exploratory laparotomy. This case highlights the importance of conservative neuromuscular blocker dosing, quantitative neuromuscular monitoring, clinically-guided timing of sugammadex administration, careful airway planning, and use of opioid-sparing multimodal analgesia in a patient with DM1.

Ataxia with oculomotor apraxia type 2 is a rare autosomal recessive cerebellar ataxia caused by senataxin gene mutations, with minimal published data on anaesthetic management. We report the peri-operative care of a 46-year-old woman with genetically confirmed ataxia with oculomotor apraxia type 2 undergoing laparoscopic cholecystectomy under general anaesthesia. Key challenges included uncertain sensitivity to neuromuscular blocking agents and the potential for respiratory weakness and bulbar dysfunction. Non-technical challenges arose from incomplete recognition and communication of the condition pre-operatively. Anaesthetic strategy prioritised titratable, reversible agents and careful intra-operative monitoring. Rocuronium was administered in reduced dose with quantitative neuromuscular monitoring and fully reversed with sugammadex prior to tracheal extubation. Propofol, sevoflurane and remifentanil target-controlled infusion were used to ensure haemodynamic stability and minimise cumulative opioid exposure. The patient recovered uneventfully with no residual weakness or respiratory impairment. To our knowledge, this is the first published description of general anaesthesia for laparoscopic surgery in a patient with ataxia with oculomotor apraxia type 2. It demonstrates that anaesthesia can be safely delivered to patients with this condition with careful pre-operative planning.

Peribulbar anesthesia is widely used in ophthalmic surgery because it offers a favorable balance between efficacy and safety. However, clinically meaningful variability in block onset, duration, and akinesia quality persists despite technical advances. Pharmacologic adjuvants are commonly added to improve block performance; however, much of the available evidence is extrapolated from peripheral nerve block literature and does not fully account for the unique anatomic and physiologic characteristics of the peribulbar space. This narrative review critically synthesizes current evidence on commonly used pharmacologic adjuvants in peribulbar anesthesia, including dexmedetomidine, magnesium sulfate, fentanyl, and rocuronium, using a peribulbar-specific framework. Evidence is interpreted across key clinical domains relevant to ophthalmic anesthesia practice, including block onset, reliability of akinesia, duration of analgesia, ocular physiology, sedation, hemodynamic stability, and injectate volume considerations. Available data indicate that these adjuvants exert distinct and non-interchangeable effects. Dexmedetomidine provides the most consistent prolongation of block duration and improves reliability with cooperative sedation. Magnesium sulfate offers a hemodynamically stable option with favorable effects on intraocular pressure without sedation. Fentanyl and rocuronium primarily enhance onset and early surgical readiness, with limited impact on block duration. Injectate volume emerges as a critical determinant of ocular safety within the confined orbital space, and pharmacologic adjuvants may improve block quality without necessitating potentially risky increases in volume. Rather than identifying a universally optimal agent, this review supports a goal-directed, peribulbar-specific approach to adjuvant selection that integrates procedural priorities, patient characteristics, ocular safety, and volume constraints to guide individualized, evidence-informed clinical practice.

Neurofibromatosis type 1 (NF1) is an autosomal dominant multisystem disorder that presents significant challenges to the anesthesiologist, particularly in the obstetric setting. The presence of neurofibromas along the airway, potential spinal and intracranial tumors, cardiovascular instability, and altered pharmacological responses collectively complicate anesthetic planning. We report the case of a 42-year-old primigravida at 40 weeks and two days of gestation with previously undiagnosed NF1, admitted for emergency cesarean section under the clinical suspicion of uterine rupture. General examination revealed extensive cutaneous lesions and bilateral breast masses consistent with cutaneous and plexiform neurofibromas. Airway assessment identified a Mallampati grade III classification. Given the strong clinical suspicion of NF1, the absence of prior neuroimaging, and the emergency nature of the procedure, general anesthesia was chosen over neuraxial anesthesia. Rapid sequence induction was performed with propofol and rocuronium, with full difficult airway equipment immediately available. Direct laryngoscopy yielded a Cormack-Lehane grade I view with no glottic lesions identified, and orotracheal intubation was accomplished without difficulty. Anesthesia was maintained with isoflurane in an oxygen/air mixture (fraction of inspired oxygen (FiO2) 0.4). The procedure lasted 45 minutes, hemodynamic stability was maintained throughout without vasopressor support, and a healthy female neonate was delivered with Apgar scores of 9, 10, and 10 at one, five, and 10 minutes. Emergence from anesthesia was smooth and uneventful. This case highlights the importance of systematic clinical recognition of NF1 at admission, thorough airway evaluation, appropriate anesthetic decision-making in the absence of neuroimaging, and the critical role of anticipatory preparation in emergency obstetric scenarios involving undiagnosed multisystem disease.

Rapid sequence induction (RSI) is widely used in patients at risk of pulmonary aspiration but may be associated with haemodynamic instability and intubation difficulties. It remains unclear whether patients with moderately increased risk of aspiration benefit from RSI compared with standard induction including mask ventilation.

Bipolar disorder is a chronic psychiatric illness that presents unique anaesthetic challenges due to potential drug interactions, mood instability, and perioperative complications. Lithium, a mainstay of treatment, has a narrow therapeutic window and can interact with anaesthetic agents, leading to toxicity, arrhythmias, and prolonged neuromuscular blockade. We report the case of a 45-year-old man weighing 72 kg, with a 10-year history of bipolar I disorder, managed on lithium 400 mg twice daily and olanzapine 10 mg at night, who presented for elective laparoscopic cholecystectomy. Medication adherence was poor, and no preoperative psychiatric review was conducted due to limited access to liaison psychiatry services. Lithium was held for 24 hours preoperatively based on the Royal College of Psychiatrists' guidelines, while olanzapine was continued. Preoperative laboratory findings revealed low lithium levels, deranged urea and electrolytes (U&Es), leucocytosis with neutrophilia, and normal haemoglobin. General anaesthesia was induced with propofol 2.5 mg/kg and rocuronium 0.6 mg/kg and maintained with sevoflurane in oxygen/air. Fentanyl 1 mcg/kg and morphine 0.1 mg/kg were used for analgesia. Intraoperatively, the patient developed haemodynamic instability and supraventricular tachycardia. Emergence was complicated by agitation. Postoperatively, he experienced nausea, vomiting, and delirium, with mood disturbance requiring psychiatric review. He was discharged on postoperative day five. This case highlights the critical importance of preoperative psychiatric assessment, lithium level monitoring, and electrolyte optimisation in bipolar patients presenting for surgery. Multidisciplinary collaboration between anaesthetists, psychiatrists, and surgeons is essential to mitigate risks and optimise outcomes.

Patients with compromised immune systems, particularly those living with human immunodeficiency virus (HIV) infection and HIV-related lymphoma, pose multiple challenges for anesthesiologists because of hematologic abnormalities, critically low platelet counts, and potential drug-drug interactions. This report describes a 55-year-old male patient with HIV and Burkitt-type non-Hodgkin lymphoma (NHL) who presented with splenomegaly and severe platelet sequestration. Preoperative hematologic optimization was achieved with two platelet apheresis sessions and tranexamic acid for antifibrinolytic prophylaxis. The patient underwent an elective splenectomy under balanced general anesthesia. Propofol, fentanyl, and rocuronium were used for anesthetic induction, and tracheal intubation was successfully performed using videolaryngoscopy without complications. Following surgery, transversus abdominis plane (TAP) blocks and rectus sheath blocks were performed using ropivacaine, providing adequate analgesia without the need for postoperative opioids. The patient remained hemodynamically stable throughout the procedure, with an uneventful anesthetic recovery and no bleeding or infectious complications. He was discharged on postoperative day 3, with a platelet count of 80,000/µL. Optimal perioperative management of HIV-positive patients with severe thrombocytopenia is essential for safe anesthetic care. Appropriate blood product utilization and regional analgesia techniques may further improve outcomes. Multidisciplinary management is crucial for minimizing perioperative risks and enhancing patient outcomes.