Background/Objectives: An 8-kg, 16-month-old child was brought to the emergency department of a regional community hospital with shallow respirations. Due to her pallor and the diluted appearance of the first blood sample, the emergency physician suspected sepsis associated with severe anemia. Her first laboratory results revealed a hemoglobin of 1.7 g/dL. Subsequent laboratory data revealed positive fibrin split products and hypofibrinogenemia with reticulocytosis. Because this regional community hospital did not have a pediatric intensivist, the emergency physician instead consulted a neonatal intensivist for guidance. Methods: A femoral intraosseous line was placed to allow aggressive massive transfusion. After consultation with the neonatal intensivist, packed red blood cells were transfused at a rate of 30 mL/kg/h. After transfusion, the patient became agitated and required repeated paralytic, sedative, and analgesic boluses of succinylcholine, ketamine, midazolam, dexmedetomidine, and fentanyl, with fentanyl and dexmedetomidine drips. The patient arrived at a tertiary care center 13 h after admission. Results: At the tertiary care center, the patient was weaned off the drips and was theorized to have secondary autoimmune hemolytic anemia due to sepsis after positive direct and indirect Coombs test. She was treated with a course of antibiotics, including cefepime and vancomycin, without steroids or immunotherapy. Five months later, her hemoglobin had returned to 12.1 g/dL, and she tested negative on direct and indirect Coombs test. Conclusions: This case highlights the importance of collaboration between and within departments to successfully manage pediatric hemostatic resuscitation.

Intraoperative neuromonitoring (IONM) is widely used during minimally invasive spine procedures, including trans-Kambin oblique lateral lumbar interbody fusion, to reduce the risk of neural injury. We present a unique case in which prolonged neuromuscular paralysis following succinylcholine induction resulted in the absence of effective neuromonitoring. After careful multidisciplinary consideration of case cancellation and a detailed risk-benefit assessment, the procedure was completed because it involved a single level without complicating anatomical factors. The patient experienced an excellent clinical outcome with no postoperative neurological deficit. This case highlights important anesthetic considerations, potential pharmacogenetic variability, and nuanced intraoperative decision-making when neuromonitoring becomes unexpectedly unavailable.

This review explores the therapeutic potential of the stable gastric pentadecapeptide BPC 157 in addressing electrolyte imbalances, specifically hyperkalemia, hypokalemia, hypermagnesemia, and hyperlithiemia. In hyperkalemia, BPC 157 demonstrated a comprehensive counteractive effect against KCl overdose (intraperitoneally, intragastrically, and in vitro), effectively mitigating symptoms such as muscular weakness, hypertension, sphincter dysfunction, arrhythmias, and lethality. It also counteracted the adverse effects of succinylcholine and magnesium overdose, including systemic muscle paralysis, arrhythmias, and hyperkalemia. In hypokalemia, BPC 157 (administered prophylactically or therapeutically, intraperitoneally or intragastrically) prevented fatal outcomes and addressed furosemide-induced hypokalemia, ECG changes, AV conduction block, ventricular arrhythmias, and skeletal muscle myoclonus. Following magnesium overdose, BPC 157 alleviated muscle weakness, brain lesions, and hyperkalemiainduced complications. In vitro studies (HEK293 cells) revealed the ability of BPC 157 to counteract hyperkalemia- and hypermagnesemia-induced depolarization and hypokalemia-induced hyperpolarization. In lithium intoxication, BPC 157 promoted collateral pathway activation, resolved vascular and multiorgan failure, and counteracted advanced Virchow triad conditions and occlusion-like syndromes. Collectively, these findings underscore the therapeutic promise of BPC 157 in managing electrolyte imbalances and warrant further investigation.

Malignant hyperthermia, a pharmacogenetic disorder of skeletal muscle, is a potentially fatal reaction triggered by exposure to volatile anesthetics or succinylcholine. Genetic testing of the three known involved genes (RYR1, CACNA1S, and STAC3) has become the first line of testing for malignant hyperthermia susceptibility. However, genetic testing has sensitivity of only up to 70%. Contracture testing may be used to rule out the disorder for some individuals. This study outlines a stepwise approach, using clinical history and assessment as well as interpretation of genetic variants to balance risks and benefits for individuals at risk of this disorder. This work has received an Affirmation of Value designation from the American Society of Anesthesiologists (Schaumburg, Illinois) and endorsement from the Canadian Anesthesiologists' Society (Toronto, Canada).

Becker muscular dystrophy (BMD) is a genetic disorder caused by partial deficiency of dystrophin, leading to progressive skeletal muscle weakness and cardiac failure. Up to one-third of affected individuals develop dilated cardiomyopathy, eventually requiring heart transplantation at a young age. Although BMD is not directly linked to malignant hyperthermia (MH), patients may experience severe MH-like reactions, particularly when exposed to succinylcholine or volatile anesthetics. Therefore, total intravenous anesthesia (TIVA) is often preferred in this population, despite the cardioprotective benefits of volatile agents through myocardial preconditioning. We report the case of a teenager with BMD and advanced cardiomyopathy who successfully underwent heart transplantation under TIVA. Anesthesia was maintained with target-controlled infusion (TCI) of propofol and remifentanil. Additional boluses of ketamine and midazolam were administered to maintain a bispectral index (BIS) between 40 and 60. Postoperatively, the patient was admitted to the intensive care unit receiving low-dose infusions of dobutamine, sodium nitroprusside, and inhaled nitric oxide, and was safely extubated 3 h later. This case highlights the feasibility and safety of TIVA in patients with BMD undergoing major cardiac surgery.

Rapid sequence intubation (RSI) remains a cornerstone of airway management in critically ill patients, aiming to optimize oxygenation and ventilation, reduce the risk of secondary brain injury, and prevent gastric aspiration. Originally designed to minimize the interval between loss of airway reflexes and airway protection, while also limiting hemodynamic complications, RSI is now widely used in the operating room, intensive care unit, and emergency department. While aspiration prevention has historically been a central rationale for RSI, emerging evidence suggests that RSI may not significantly reduce this risk and may, in fact, be associated with increased rates of hypoxemia and hemodynamic instability. Pharmacological approaches, airway management techniques, and team-based preparation must be tailored to mitigate these complications. Contemporary RSI involves thorough preintubation assessment, preparation, and teamwork, emphasizing first-pass intubation success, patient positioning, apneic oxygenation, and gentle ventilation when appropriate. Several interventions have shown a clinically significant reduction of adverse events, such as the use of a video laryngoscope, apneic bag mask ventilation, or non-invasive ventilation for pre-oxygenation. The main recommended medications include a sedative (etomidate or ketamine are favored over propofol in hemodynamically unstable patients) and a paralytic (rocuronium or succinylcholine). Human factors, team-based preparation, and first-pass success remain key determinants of RSI outcomes. This narrative review synthesizes current evidence on RSI, highlighting pharmacological strategies, airway management techniques, and human factors, reflecting a shift from rigid protocols toward a more flexible, patient- and team-centered approach that balances aspiration risk with the prevention of desaturation and hypotension.