Short Case Report: Connecting the dots before anaesthesia

  • Issue 60

Mohamed Mahmoud | Cincinnati Children’s Hospital Medical Center, USA

Editor’s note: We are pleased to publish a new series: “Short case reports”, dedicated to those readers who would like to share with all of us their clinical experience related to an unusual case.

Most people think of their anaesthesiologist only as the “doctor behind the mask” who keeps the patient unconscious and pain-free during an operation and who wakes them up when the operation is complete. Beyond this simple description of our job, we are the last line of defense for avoiding potential major complications. By applying our knowledge of medicine from medical school and residency training, we fulfill our primary role of providing overall plan of action for safe anaesthesia. We report this case to emphasise that our role definitely extends beyond administering anaesthesia; we can be the driving force to make a difference in the outcome for our patients by thinking outside the box.
Case description:
A 3-year-old previously healthy boy presented for magnetic resonance image (MRI) of the head and neck under anaesthesia to evaluate a left cheek mass. During the previous three weeks, his mother reported that he has not been acting like himself with decreased activity and appetite, several episodes of emesis and loose stools, as well as fever. He seemed to be improving until his mother noticed limping with walking and a mass on his left cheek. He was evaluated by his paediatrician and sent to the emergency department for further workup where an ultrasound showed a lesion consistent with a possible vascular or lymphatic malformation. The patient was discharged home and outpatient MRI imaging was scheduled. On the day of imaging, we were concerned about the history of cheek mass, decreased appetite and recent limping. Although the physical exam was normal, malignancy was high on our differential diagnosis. We ordered a chest x ray to rule out a mediastinal mass. A large paraspinal mass was obvious on the radiograph. The plan of action was changed and a CT scan showed a left adrenal mass, paraspinal masses, a few prominent left axillary lymph nodes, right hepatic lobe lesions with hepatomegaly and masses on both femurs. Further work up confirmed the diagnosis of metastatic neuroblastoma.

Despite the increasing complexity and volume of patients, anaesthesia providers generally meet the patients only minutes before the scheduled (or unscheduled) procedure. We assess the situation quickly and accurately to ensure safety and optimal effectiveness. Without connecting the dots during assessment, we can easily miss an important diagnosis. Thoughtful preanaesthetic evaluation is critical not only to safe anaesthesia care, but also to promoting the overall health of our patients.

1Assocciate Professor
Department of Anesthesiology
Cincinnati Children’s Hospital Medical Center,

Cincinnati, USA.

Disclosure: No financial support other than departmental salary support for the authors

Corresponding Author and Address Mohamed Mahmoud, MD
Associate Professor in Clinical Anesthesia and Pediatrics
Cincinnati Children’s Hospital Medical Center
3333 Burnet Avenue, MLC 2001
Cincinnati, OH 45229

Phone: 513-636-4408
Fax: 513-636-7337


The anaesthesiologist: a strategic role in modern medicine
The case report describes how the the anaesthesiologist, particularly paediatric anesthesiologist, is one of the most complete and prepared professionals in the field of medicine. Anaesthesiologists have a wide range of knowledge about medications, internal medicine, haemodynamic and respiratory parameters and responses to the stress and surgery. Few people realise that anaesthesiologists’ primary role in the operating room is not only to protect and regulate the patient’s critical life functions but these medical specialists are the doctors who have the ability to recognise even the smallest changes in the physiology and lead them to a diagnosis of pathology.

Dario Galante, MD

University Department of Anesthesia and Intensive Care

University Hospital “Ospedali Riuniti” of Foggia, Italy