Postoperative Analgesia and Cesarean Section under General Anesthesia: Multicenter Study

Background: Neuraxial anesthesia with intrathecal morphine is the reference technique in cesarean section anesthesia for the management of postoperative analgesia. If there is a contraindication to this, general anesthesia is required. The objective of the study was to evaluate the analgesic effectiveness of 4 analgesic techniques performed during cesarean section under general anesthesia in two centers with different anesthetic practices (North Franche Comté Hospital and Omar Bongo Ondimba Army Training Hospital). Method: This is a retrospective and descriptive study over 2 years, from January 1, 2019 to December 31, 2020. It involved evaluating the analgesic effectiveness and tolerance of morphine in the epidural catheter, wound infiltration, intravenous analgesia and Transversus Abdominous Plane block (TAP block) from the post-anesthesia care unit (PACU) until the 4th post-operative day. Results: Of the 354 cesarean sections performed, 84 (11.14%) received general anesthesia. The average age was 32.27 years. Acute fetal distress was the first indication for cesarean section (45.2%), followed by hemorrhagic placenta previa (10.7%) and prolapse of the cord (8.33%). Morphine in the epidural catheter was the most used (47.6%) followed by parietal infiltration (36.9%), intravenous analgesia (13.1%) and TAP block (2.38%). The analgesic effectiveness was comparable between the techniques from postoperative day 0 to day 4. No difference in side effects. Postoperative morphine consumption was significantly reduced (p = 0.011) in the infiltration (9 mg) and TAP block (9mg) groups compared to the epidural catheter (16 mg) and intravenous analgesia (17 mg). No difference in 02 rehabilitation criteria (ambulation, first bowel movement). No difference in the occurrence of chronic pain. Conclusion: In the event of a cesarean section under general anesthesia, there are effective and well-tolerated alternatives to neuraxial anesthesia, particularly regional anesthesia techniques (nerve blocks), particularly in countries with low availability of morphine.

Comparison of efficacy of lung ultrasound and chest X-ray in diagnosing pulmonary edema and pleural effusion in ICU patients: A single centre, prospective, observational study

Background and Aims While chest X-ray (CXR) has been a conventional tool in intensive care units (ICUs) to identify lung pathologies, computed tomography (CT) scan remains the gold standard. Use of lung ultrasound (LUS) in resource-rich ICUs is still under investigation. The present study compares the utility of LUS to that of CXR in identifying pulmonary edema and pleural effusion in ICU patients. In addition, consolidation and pneumothorax were analyzed as secondary outcome measures. Material and Methods This is a prospective, single centric, observational study. Patients admitted in ICU were examined for lung pathologies, using LUS by a trained intensivist;and CXR done within 4 hours of each other. The final diagnosis was ascertained by an independent senior radiologist, based on the complete medical chart including clinical findings and the results of thoracic CT, if available. The results were compared and analyzed. Results Sensitivity, specificity and diagnostic accuracy of LUS was 95%, 94.4%, 94.67% for pleural effusion;and 98.33%, 97.78%, 98.00% for pulmonary edema respectively. Corresponding values with CXR were 48.33%, 76.67%, 65.33% for pleural effusion;and 36.67%, 82.22% and 64.00% for pulmonary edema respectively. Sensitivity, specificity and diagnostic accuracy of LUS was 91.30%, 96.85%, 96.00% for consolidation;and 100.00%, 79.02%, 80.00% for pneumothorax respectively. Corresponding values with CXR were 60.87%, 81.10%, 78.00% for consolidation;and 71.3%, 97.20%, 96.00% for pneumothorax respectively. Conclusion LUS has better diagnostic accuracy in diagnosis of pleural effusion and pulmonary edema when compared with CXR and is thus recommended as an effective alternative for diagnosis of these conditions in acute care settings. Our study recommends that a thoracic CT scan can be avoided in most of such cases.

Propofol with Varied Functions: A Potential Therapeutic Opportunity for Postoperative Nausea, Vomiting and Pruritus—A Narrative Review

Background: Despite the advances in anesthetics and non-pharmacological techniques, the prevalence of postoperative nausea and vomiting in all patients remains high. It is one of the most common distressing symptoms that cause dissatisfaction among patients after anesthesia and surgery. A sub-hypnotic dose of propofol has been shown to reduce morphine-induced postoperative nausea, vomiting, and pruritus. This review article will provide sufficient knowledge on the role of propofol in minimizing opioid-induced postoperative nausea, vomiting, and pruritus by providing detailed information on propofol antiemetic and antipruritic effects, as well as discussions based on empirically available data. Method: We conducted a narrative review of the literature published between 1990 and 2023 from a range of databases;PubMed, BioMed Central, Biosis Previews, Nature, International Pharmaceutical Abstracts, Springer-Link, and Elsevier. Discussion and Conclusion: The literatures reviewed in this study have demonstrated that propofol may have diverse therapeutic effects including antiemetic and antipruritic. The antiemetic effect of propofol may be an effective therapeutic approach for the prevention of postoperative nausea and vomiting. The literature also demonstrated that the use of propofol for sedation during surgery may as well ameliorates opioids induced postoperative pruritus, which may be beneficial to surgical patients. Also, it was demonstrated that prophylactic use of propofol may be an effective way of preventing nausea and vomiting and pruritus during opioid use.

Morbidity and Mortality during Anaesthesia in Patients with versus without Diabetes: Single-Centre Cohort Study

Background and objective: Classically, diabetic subjects are at high risk of anaesthesia compared with general population. However, some recent publications have shown contrasting and sometimes contrary results. The aim of our study was to evaluate morbidity and mortality during and after anaesthesia in patients with versus without diabetes operated on at Monkole Hospital over the last ten years. Methods: Retrospective cohort study including all patients who underwent all-comers surgery excluding cardiac surgery between 2011 and 2021. Each diabetic patient was matched to 2 non-diabetic controls on age and sex. The evaluation criterion was the frequency of occurrence of at least one perioperative complication and/or death up to day 30. A multivariate analysis using a Cox model was used to determine the factors associated with the occurrence of this morbidity and mortality. The model was adjusted for comorbidities, preoperative hyperglycaemia, ASA score, type of anaesthesia and severity of surgery. Results: A total of 351 diabetic patients (mean age 53.3 ± 14.18 years) and 701 non-diabetic patients (mean age 53.52 ± 14.7 years) were included and analysed. Preoperatively, hyperglycaemia (blood glucose > 180 mg/dl) was observed in 24.3% of diabetic patients compared with 1.6% of non-diabetic patients. The incidence of overall perioperative complications was 25.6% in diabetic patients compared with 28.6% in non-diabetic patients (p = 0.27). The risk factors associated with this morbidity were general anaesthesia with oro-tracheal intubation vs loco-regional anaesthesia (OR = 3.06 [95%CI: 1.91 - 4.94];p Conclusion: This study shows that there is not significant increase in perioperative morbidity and mortality in diabetic patients compared with non-diabetic ones of similar severity. These results suggest that diabetes itself (excluding associated comorbidities) has only a minor impact on perioperative morbidity and mortality.

Obstetric Anesthesia Practice Significantly Evolved: A Field for Cesarean Delivery Parturient for the Provision of Safe Anesthesia in Urgent Circumstances

General anesthesia and Obstetric Anesthesia is the gold standard for a cesarean section but there are some cases where general anesthesia is unavoidable. The use of general anesthesia for cesarean delivery has decreased in recent years due to the widespread use of neuraxial techniques. The choice of anesthesia techniques for cesarean delivery depends on several factors, including the patient’s psychology and the attending physician’s experience. It is chosen because of its safety profile and its benefits to the mother and fetus. It may be indicated due to emergency, maternal refusal of regional techniques, or regional contraindications. Major complications include failed intubation, gastric content aspiration, and increased bleeding risk. This study aims to evaluate the impact of a newly launched team on obstetric anesthesia practice.

Intermediate Hip Arthroplasty in Gabon: Blood Loss and Risk Factor for Transfusion

Background: Hip arthroplasty is a surgery with a high risk of bleeding. The main objective of this study was to research risk factors for bleeding and transfusion in patients undergoing hip hemiarthroplasty in Gabon. Method: It was a retrospective, monocentric, descriptive and analytical study carried out from June 2011 to June 2021 at the Omar Bongo Ondimba army training hospital. The variables studied were demographic characteristics, biological variables, transfusion and intraoperative data. The primary outcome was intraoperative transfusion. A univariate and multivariate analysis was conducted to identify the factors associated with the occurrence of a transfusion. Results: Of the 97 patients included, the average age was 74.2 years ± 10, male predominance was 73.2%, the average ASA score was 1.9 ± 0.5, and transfusion incidence was 38.1%. The average number of RBCs transfused was 1.2 ± 0.6. Tranexamic acid was used in 11.3% of patients. The average bleeding was 450 ± 453 ml. Preoperative anemia was predictor of transfusion to be significant. Conclusion: The incidence of transfusion is law compared to total hip arthroplasty. The implementation of a patient blood management protocol is difficult given the urgency of bone repair. However, a better use of tranexamic acid could reduce this transfusion incidence.

A Structured Method of Teaching Epidural Block reduces the incidence of accidental dural puncture in inexperienced trainees.

Background: The rate of accidental dural puncture is particularly high during the period of training, especially in novices. The structured epidural teaching model (SETM) includes three standardized video lessons, the construction of a 3D epidural module by trainees and practical training by using an epidural simulator with and without the CompuFlo™ Epidural instrument. In this study we report the retrospective analysis of the accidental dural puncture rate of inexperienced trainees during their 6 months clinical practice rotation in obstetrics before and after the introduction of the SETM in our Institution. Method: We evaluated the incidence of accidental dural puncture before the introduction of the SETM methodology and afterwards by analyzing our departmental database from February 2019 to January 2023. All epidural blocks were executed by trainees who had never previously performed an epidural block and were about to begin their obstetrics rotation. Results: We analyzed 7415 epidurals: 3703 were performed before the introduction of the SETM methodology (control group) and 3712 afterwards (study group). The incidence of accidental dural puncture was 0.37% for the control group and 0.13% for the study group (p<.05). The probability of making an accidental dural puncture was 64% (OR: 0.36) lower for trainees who had the training than for those who did not. Conclusions: After the introduction of the structured teaching method, we observed a significant reduction of accidental dural puncture during the training period. We hope that our observation will encourage a constructive discussion among experts about the need to use standardized and validated tools as a valuable aid in teaching epidural anesthesia.

Complex Regional Pain Syndrome: Outpatient Pain Management in the Chronic Setting: A Case Report

Background: Complex Regional Pain Syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a neuropathic pain condition that usually develops after an injury to an extremity. CRPS can be a debilitating condition with high levels of pain and reduced function. Aim: This case report aims to discuss the multimodal approach in the management of a patient who presented with ongoing poorly controlled pain secondary to CRPS from an injury that happened years prior. Case Presentation: A 45-year-old female was involved in a motor vehicle accident where her right leg was injured. She underwent several surgeries and developed CRPS that significantly reduced her mobility and quality of life. She presented to the pain clinic years after her initial injury and a multimodal regimen was started for her resulting in significantly improved function. Conclusion: CRPS can be a severely debilitating condition. While early diagnosis and management are important, ongoing management in the outpatient chronic pain setting is important in maintaining a good level of function.

Anesthetic Management of a Patient with Spinal Muscular Atrophy Type III Undergoing Emergent Caesarean Section: A Case Report

In this case report, we describe the anesthetic management for a 36-year-old G2P0010 at 36 weeks gestation with Spinal Muscular Atrophy Type III who underwent an emergent caesarean section due to fetal footling breech position. The patient is a wheelchair-bound quadriplegic with kyphoscoliosis and a lack of cough reflex who required nasal continuous noninvasive ventilatory support (CNVS) for chronic hypercapnic respiratory failure. Surgery was done under general anesthesia due to its emergent nature, and the patient was successfully extubated and transitioned to nasal CNVS in the operating room at the end of the case. Postoperative care was provided in the medical intensive care unit for three days without complication and the patient was discharged home uneventfully.

Abnormal ACT in a Patient with Prekallikrein Deficiency Undergoing Cardiopulmonary Bypass

Prekallikrein deficiency is a disorder that often remains undiagnosed. Prekallikrein activates factor XII, which initiates the intrinsic coagulation pathway. Prekallikrein deficiency results in prolonged Partial Thromboplastin Time and Activated Clotting Time in absence of anticoagulants or active bleeding. This case report describes the anesthesia management of a patient with Prekallikrein deficiency who underwent cardiac surgery with Cardiopulmonary Bypass for correction of a congenital cardiac malformation. We highlight the importance of understanding the different tests available for the diagnosis of coagulation factors deficiency during administration of heparin in the setting of cardiovascular procedures under general anesthesia.

Usefulness of the Surgical Apgar Score to Predict the Occurrence of Major Complications in the Early Post-Operative Period of Major Surgeries: Experience of Two Second-Category Hospitals in Cameroon

Objective: The Surgical Apgar Score (SAS) is a tool for intraoperative stratification of the risk of serious complications in the early postoperative period. It varies from 0 to 10 points divided into three risk categories (0 to 4 high, 5 to 7 moderate, 8 to 10 low). The aim of the study was to evaluate its relevance in predicting the appearance of these complications. Material and methods: This descriptive and analytical study was carried out at the “Laquintinie” Hospital in Douala and at the Central Hospital in Yaounde, Cameroon. The main data were collected on a population of patients over 18 years old and recorded on a survey form. They consisted of variables of main interest and exposure variables. Univariate and multivariate statistical analysis using top-down logistic regression models made it possible to evaluate the association of each variable of main interest and each exposure variable. The association was significant at P Results: Of the 88 patients studied, the SAS was 3 hours. In multivariate, this link persisted only and strongly for the SAS OR (IC) 0.1 (0.1 - 0.2) and p = 000. Conclusion: The study found a specific and powerful link between the SAS score < 4 and the occurrence of complications in the early postoperative period, in favor of its relevance in predicting them.

Neonatal Direct Rigid Laryngoscopy and Bronchoscopy: A Near Miss

Airway management is a skill necessary for healthcare providers who manage patients. Intubation is a skill that both anesthesiologists and intensivists use daily. We present a case of a neonate that developed significant worsening stridor after a successful intubation for a hernia repair. After 4 intubation attempts, with easy visualization of the vocal cords and unsuccessful placement of the endotracheal tube, the patient was emergently brought to the operating room for evaluation.

A Case Report: Emergency Management of a Pregnant Trauma Patient—An Anesthesiologist’s Perspective and Role

Trauma is the leading cause of death for all women of childbearing age. Motor vehicle accidents account for almost two-thirds of all maternal non-obstetric, trauma-related deaths, while falls and domestic violence comprise a large percentage of the rest. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma . The causes are different with different life styles and different socio-economic and cultural background. Pregnant trauma victims tend to be younger, less severely injured, and more likely African American or of Hispanic descent compared with nonpregnant victims of trauma. Drugs and alcohol are a factor in about 20 percent of maternal trauma. With pregnancy comes the challenge and responsibility of caring for two patients at once, the mother and the fetus. In general, providing optimal maternal care is the best strategy to optimize fetal survival. Decision-making including the condition of the mother, gestational age, status of the fetus, and interventions are based on these key factors. Many providers are involved in the care of the pregnant patient: at the trauma scene, in the emergency department, and in the operating room. The anesthesiologist plays a key role in the care and management of the pregnant trauma patient. All anesthesiologists have ample training in obstetric anesthesia during their residency and frequently cover obstetric units in hospitals where pregnant patients are cared for. On the other hand, most nonobstetric physicians have little obstetric exposure and may be uncomfortable caring for the pregnant patient because of unfamiliarity with the physiologic changes of pregnancy or the evaluation of fetal well-being. This is not only a source of stress for other trauma providers, but can put maternal well-being at risk. Non-obstetric physicians may hesitate to order necessary diagnostic and therapeutic interventions for fear of doing the “wrong thing,” all because the patient is pregnant. A multidisciplinary approach to the pregnant trauma patient involving trauma surgeons, obstetricians, anesthesiologists, emergency medicine, and other providers, is critical to deliver optimal care and achieve the best outcomes for both the mother and the baby. In summary, a multidisciplinary approach to provide optimal maternal care will facilitate to achieve the best outcomes for the mother and is also the best strategy for optimizing fetal survival. The following is a case report of a pregnant trauma patient who needed immediate intervention because of massive placental abruption when only a minimal workup was completed because of the urgency of the situation.

A Comparative Study between Landmark Based and Real Time Ultrasound Guided Sub Arachnoid Block

Background: Sub arachnoid block (SAB) performed by traditional landmark palpation technique can be inaccurate. This problem is exacerbated by altered patient anatomy due to obesity and age-related changes. A pre-procedural ultrasound scan of the lumbar spine has been shown to be of benefit in guiding lumbar epidural insertion in obstetric patients. Information on the use of real-time ultrasound (RUS) guided SAB, to date, been limited. This study compared RUS guided SAB to traditional landmark guided technique in patients undergoing spinal anesthesia for different surgical procedures. Methods: This was a prospective, single center, comparative observational study conducted in the department of anesthesiology at our center. 560 patients who underwent spinal anesthesia either by landmark based technique or real-time ultrasound-guided methods. The primary outcome was the first attempt success rate of dural puncture when employing the two methods. Results: Baseline characteristics were similar in the two study groups. The first attempt success rate of dural puncture in landmark guided group was 64.3% compared to 72.6% in the ultrasound guided group. This difference was not statistically significant. The procedure performance time was significantly shorter with landmark palpation compared to use of real-time ultrasound guided method. Conclusion: Use of RUS-guided technique does not significantly improve the first attempt success rate of SAB dural puncture during spinal anesthesia compared to the traditional landmark-guided technique.

A Spiral History of the Development of Ways to Identify the Correct Position of the Injection Needle in Relation to the Peripheral Nerve: A Brief Historical Essay

The first way to identify the needle in relation to the peripheral nerve W. Halsted and R. Hall in 1884 performed the first regional blockade (using direct visualization). However, Vassily von Anrep was a few months earlier described the blockade of the peripheral nerve by anatomical landmarks. In 1912, the blockade of the brachial plexus was first performed using electrical stimulation, but this technique has been widely used only since 1962. The most popular way to identify the needle relative to the nerve at the moment remains US guidance. A promising direction may be optical coherence tomography. But this method is under development. In the last decade, a method for determining the pressure of a local anesthetic has been introduced into practice to determine the position of the needle relative to the nerve.

Acute and Persistent Post-Craniotomy Pain: A Prospective 6-Month Follow-Up Questionnaire Study

Introduction: The incidence of acute pain after craniotomy differs remarkably in previous studies, and the prevalence of persistent pain is not precisely known. We conducted 6-month follow-up surveys on the incidence and intensity of acute and persistent pain after elective craniotomy. Methods: We carried out a prospective cohort study via a series of structured questionnaires to record acute pain intensity preoperatively and postoperatively, and the incidence of persistent pain 3 and 6 months after a craniotomy in a tertiary care center. Patients scheduled for elective craniotomy were interviewed the day before surgery, postoperatively before discharge from the hospital, and 3 and 6 months after surgery. Pain was assessed on a numeric rating scale (0 - 10) at rest and movement, as well as expectations of pain before surgery, efficacy of pain therapy, and satisfaction with pain treatment. The incidence of adverse events, sleep time and interruptions caused by pain, different pain types, and drugs used for pain treatment were also recorded. Results: A total of 152 patients were enrolled in the study and completed the preoperative questionnaire;123 (81%) completed postoperative questionnaire and 108 (72%) completed the 3- and 6-month follow-ups. The average pain score at the time of the postoperative questionnaire was moderate, 4 at rest and 5 upon movement. The percentage of patients experiencing mild pain at rest and upon movement was 52% and 49%, and moderate pain was 15% and 16%, respectively. Severe postoperative pain was detected in 5% and 8% of patients at rest and upon movement, respectively. Three months after surgery, 6% of patients reported mild pain at rest, 3% moderate pain at rest, and 1% severe pain at rest. Persistent mild and moderate pain at rest after 6 months was reported by 3% and 1% of patients, respectively. The most common adverse events were postoperative nausea and vomiting (11%) and abdominal discomfort (8%). During postoperative pain treatment in the intensive care unit or post-anesthesia care unit, 92% of patients received acetaminophen, 88% fentanyl, and 24% oxycodone. During neurosurgical ward care, ibuprofen was used in 61% of patients. Satisfaction with analgesia was high throughout the study period with a median satisfaction score of 9 postoperatively and 10 at 3 and 6 months on the 0 - 10 scale. Conclusion: The findings indicate that most patients experience moderate or mild pain after craniotomy, but patient satisfaction with pain treatment is high. Persistent pain after 3 and 6 months is rare and mild in nature.

Artificial Intelligence-Supported Systems in Anesthesiology and Its Standpoint to Date—A Review

Artificial intelligence (AI) is the technique that enables computers to solve problems and perform tasks that traditionally require human intelligence. The availability of large amounts of medical data from electronic medical records and powerful modern microcomputers enables the development of AI in medicine. AI has proven its applicability in many different medical areas, such as drug discovery, diagnostic radiology and pathology, as well as interventional applications in cardiology and surgery. However, until today, AI is scarcely used in the clinical practice of anesthesiology. Although there has been a significant body of research published on AI applications for anesthesiology in the literature, the number of developed robot systems for commercial use or those ready for clinical trials remains limited. The limitations of AI systems are identified and discussed, which include incorrect medical data formatting, individual patient variability, the lack of ability of current AI systems, anesthesiologist inexperience in AI usage, system unreliability, unexplainable AI conclusions and strict regulations. In order to ensure anesthesiologists’ trust in AI systems and improve their implementation in daily practice, strict quality control of the systems and algorithms should be undertaken. Further, anesthesiology personnel should play an integral role in the development of AI systems before we are able to see more AI integration in clinical anesthesiology.

Effects of Coronavirus Disease 2019 and Frailty on Delirium in the Intensive Care Unit: A Propensity Score Analysis

Purpose: The association between frailty and delirium has emerged as a research topic. Neurological symptoms have been reported among patients with coronavirus disease 2019 (COVID-19), but its effects on delirium remain unclear. This study aimed to compare the incidence of delirium between patients with COVID-19 and those without COVID-19, and to evaluate the impact of COVID-19 and frailty on delirium. Methods: This retrospective study included patients aged ≥ 20 years who were admitted to our intensive care unit (ICU) between January 2020 and February 2022. An inverse probability of treatment weighting using stabilized inverse propensity scores was adopted to minimize bias. After patient demographics were adjusted, the incidence of delirium, assessed using the Confusion Assessment Method for ICU, was compared between patients with COVID-19 and those without COVID-19. The effects of COVID-19 and the Clinical Frailty Scale score on delirium were analyzed by adjusting some covariates, including the sequential organ failure assessment (SOFA) score, using a generalized estimating equation. Results: Among 260 eligible patients, 226 patients were included. The weighted incidence of delirium was 56.9% and 61.9% in patients with and without COVID-19, respectively (p = 0.67). The generalized estimating equation revealed that the odds ratios (95% confidence interval) for COVID-19, the CFS score, and the SOFA score were 1.49 (0.62 - 3.57), 1.46 (1.11 - 1.91), and 1.22 (1.10 - 1.36), respectively. Conclusion: CFS and SOFA scores on ICU admission may be associated with delirium, with no significant difference between patients with COVID-19 and those without COVID-19.

Is It Safe to Perform an Autologous Epidural Blood Patch on Patients with Underlying Spinal Stenosis or Lumbar Disc Disease? Case Report and Literature Review

The most common spinal pathology seen in the obstetric population is lumbar disc herniation. There is currently no literature documenting the safety of performing an epidural blood patch on obstetric patients with underlying spinal pathology. We present a case of a patient with known severe lumbar spinal stenosis with compressive radiculopathy who received a successful epidural blood patch without worsening her underlying neurologic symptoms. Epidural blood patches can be safely performed in this patient population. However, the anesthesiologist should be aware of the risk of potentially worsening preexisting neurological deficits. Thus, we advise caution prior to placing an epidural blood patch on these patients. The risks and benefits of the procedure should be carefully weighed and considered. It is important to have a thorough discussion with the patient regarding the risks of an epidural blood patch prior to performing the procedure.

Perioperative Care of the Adult Patient with Johanson-Blizzard Syndrome

Johanson-Blizzard syndrome (JBS) is a rare genetic disorder characterized by multiple craniofacial abnormalities, intellectual disability, sensorineural hearing loss, pancreatic exocrine insufficiency, and involvement of other organ systems to varying degrees. Patients with JBS may require surgical intervention to address the underlying phenotypic abnormalities. The many craniofacial abnormalities found in patients with JBS are a concern for the anesthesiologist. We present the case of an adult patient with JBS who is undergoing implantation of a leadless pacemaker. Considering the many cardiac and craniofacial abnormalities in these patients, the anesthesiologist should order diagnostic tests such as echocardiography to assess cardiac function, as well as be prepared to perform advanced airway techniques for difficult airways. The anesthetic provider should be aware of the varied phenotypic expression of JBS and should individualize the anesthetic plan to each patient. Prior medical literature on the anesthetic management of these patients is scarce and limited to pediatric patients. This is the first case report addressing anesthetic concerns in an adult patient with JBS.