Objectives: Spontaneous splenorenal shunts cause significant vascular steal from the liver. There is no accepted algorithm for treating spontaneous splenorenal shunts before, during, or after liver transplant, and evidence for efficacy of treatments remains limited. Materials and Methods: We reviewed the literature, and our institution's experience regarding spontaneous splenorenal shunts, including a case series of 6 patients with spontaneous splenorenal shunts undergoing transjugular intrahepatic portosystemic shunts, a case of intraoperative ligation of a large spontaneous splenorenal shunts during transplant, and 1 patient requiring multiple endovascular interventions to embolize recurrent spontaneous splenorenal shunts after orthotopic liver transplant.

Introduction: Induction of anesthesia relies on multiple factors including appropriate monitoring, administration, and dosing of induction agents. In morbidly obese patients, placement and maintenance of intravenous lines may be difficult and accidental subcutaneous infiltration of medications may be challenging to identify. The treatment of accidental subcutaneous administration of neuromuscular blocking agents may be complex as the absorption and subsequent elimination is altered and not well known, and the inadvertent prolonged dosing could lead to catastrophic complications. Case Report: We present a case report of the successful management of the accidental subcutaneous administration of rocuronium in a morbidly obese, 65-year-old Caucasian female with multiple comorbidities undergoing an elective endovascular procedure. The perioperative management of the patient is discussed, and a review of the literature is provided. Conclusion: Relatively little information is available regarding the absorption of medications outside of the typical route of administration. The accidental subcutaneous infiltration of neuromuscular blockers could lead to airway compromise or prolonged blockade due to the unknown onset, peak effect, and duration of action. Open discussion among the many treatment team members after identification of accidental misadministration of medications is critical and clinical acumen is paramount to ensure optimal patient outcomes. Since intravenous line infiltration and subsequent subcutaneous extravasation are not a rare intraoperative event, more research into the effects of neuromuscular blocking agents is needed to aid clinical outcomes. Keywords: Anesthesia, critical care, drug administration routes, extravasation, neuromuscular blocker.

This analysis demonstrated that early EVAR for AAAs <5.5 cm is not likely to be cost-effective compared with elective repair at 5.5 cm. However, EVAR for small AAAs may become cost-effective when differences in quality of life and mortality are considered.

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