Document 1561003

MIDDLE EAST JOURNAL OF ANESTHESIOLOGY
Department of Anesthesiology
American University of Beirut Medical Center
P.O. Box 11-0236. Beirut 1107-2020, Lebanon
Editorial Executive Board
Consultant Editors
Editor-In-Chief:
Ghassan Kanazi
Assem Abdel-Razik
(Egypt)
Executive Editors
Maurice A. Baroody
Bassam Barzangi
(Iraq)
Editors
Chakib Ayoub
Marie Aouad
Sahar Siddik-Sayyid
Izdiyad Bedran
(Jordan)
Dhafir Al-Khudhairi
(Saudi Arabia)
Mohammad Seraj
(Saudi Arabia)
Abdul-Hamid Samarkandi
(Saudi Arabia)
Mohamad Takrouri
(Saudi Arabia)
Emeritus Editor-In-Chief Anis Baraka
Bourhan E. Abed
(Syria)
Honorary Editors
Nicholas Greene
Musa Muallem
Mohamed Salah Ben Ammar
(Tunis)
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Rabi Moukalled
M. Ramez Salem
(USA)
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Alice Demirdjian
[email protected]
Elizabeth A.M. Frost
(USA)
Halim Habr
(USA)
Managing Editor
Founding Editor
Mohamad El-Khatib
[email protected]
Bernard Brandstater
The Middle East Journal of Anesthesiology is a
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“For some must watch, while some must sleep”
(Hamlet-Act. III, Sc. ii)
134
Middle East Journal of Anesthesiology
Vol. 22, No. 2, June 2013
CONTENTS
editorial
“Neostigmine-Resistant Curarization”
Anis Baraka
131
Kemal Tolga Saracoglu, Zeynep Eti, Fevzi Yilmaz Gogus
135
review article
Airtraq Optical Laryngoscope: Advantages And Disadvantages
scientific articles
Post-Operative Cognitive Functions After General Anesthesia With Sevoflurane And
Desflurane In South Asian Elderly
Telugu Seetharam Deepak, Srisha Vadlamani,
K Sunil Kumar, Punith Kempegowda
143
Ultrasound Guided Peritubal Infiltration Of 0.25% Ropivacaine For Postoperative Pain Relief
In Percutaneous Nephrolithotomy
Geeta P. Parikh, Veena R Shah, Kalpana S. Vora,
Beena K. Parikh, Manisha P Modi, Arun Panchal
149
Ketamine Improves Postoperative Pain And Emergence Agitation Following
Adenotonsillectomy In Children. A Randomized Clinical Trial
Mohammad Hossein Eghbal, Shujaulhagh Taregh,
Ayeh Amin, Mohammad Ali Sahmeddini
155
Use Of The Bilateral Bis Monitor As An Indicator Of Cerebral Vasospasm In Icu Patients
Jess W. Brallier, Stacie G. Deiner
161
Effects Of Liberal Vs. Conventional Volume Regimen On Pulmonary Function In Posterior
Scoliosis Surgery
Jennifer Niescery, Nina Huhmann, Burkhard Dasch,
Viola Bullmann, Thomas Peter Weber, Martin Bellgardt, Heike Vogelsang
165
Effect Of Preoperative Licorice Lozenges On Incidence Of Postextubation Cough And Sore
Throat In Smokers Undergoing General Anesthesia And Endotracheal Intubation
Diyva Gupta, Sanjay Agrawal, Jagdish P Sharma
173
Success Of Ultrasound Guided Popliteal Sciatic Nerve Catheters Is Not Influenced By Nerve
Stimulation
Christopher B. Robards, Steven B. Porter,
Ilana Logvinov, Steven R. Clendenen
179
case reports
Monitored Anesthesia Care For A Patient With Advanced Huntington’s Chorea
Taylor White, Steven Neustein
185
Use Of Airway Exchange Catheter For Bronchoscopy Of A Patient With Down’s Syndrome
Ayşe Karcı, Seden Duru, Elvan Öçmen, Volkan Karaçam
129
187
M.E.J. ANESTH 22 (2), 2013
Incidental Finding Of Foreign Bodies During Nasal Intubation In A Mentally Challenged
Patient
Abdul Kader Mahfouz, Mohammad Suleiman Khan
191
Cardiorespiratory Crisis At The End Of Pregnancy: A Case Of Pheochromocytoma
Samir Haddad, Basel Al-Raiy, Azza Madkhali,
Saad Al-Qahtani, Mohammad Al-Sultan, Yaseen Arabi
195
Echocardiography Guided Therapy For Massive Intra-Operative Pulmonary Emboli During
Arterio-Venous Fistula/Graft Thrombectomy
Jahan Porhomayon, Nader D. Nader
203
High Dose Streptokinase For Thrombolysis In The Immediate Postoperative Period: A Case
Report
Rakesh V Sondekoppam, Manjeet Kanwar,
Latha Y S, Banashree Mandal
207
Pathology Quiz: Oncocytic Cyst Of The Ventricular Fold
Hamdan Al, Marie-Therese Homsi, Zaahir Turfe, Fouad Boulos
213
Anesthesia Considerations In Stiff Person Syndrome
Moises A. Sidransky, Neilson V. Tran, Alan David Kaye
217
Role Of Laryngeal Mask Airway In Interventional Bronchoscopy Procedures For Upper
Tracheal Stenosis: Case Series
Lida Fadaizadeh , Mahsa Sadat Hosseini, Shideh Dabir
223
Transglottic Basaloid Squamous Cell Carcinoma Of The Larynx
Abdul-Latif Hamdan, Roger Moukarbel, Ayman Tawil,
Hanna Kaspar, Mohammad Natout
229
letter to the editor
Prevention Of Blood Return Into Intravenous Infusion Tubing
Mahesh Nagappa, Sandeep Kumar Mishra,
Lenin Babu Elakkumanan
233
Radial Nerve Lesion After Malposition And Sedation By Continuous Target Controlled
Infusion Of Propofol For Extracorporeal Shock Wave Lithotripsy
Adriano BS Hobaika, Cristiano HV Horiguchi
235
technical note
High Inspired Carbon Dioxide Levels Due To Misplaced Central Tubing Of The Absorbent
Canister
Nimisha Verma, Pratibha Toal
130
237
EDITORIAL
“NEOSTIGMINE-RESISTANT
CURARIZATION”
The concept of “neostigmine-resistant curarization” was introduced by Hunter 19561.
However, Churchill-Davidson 1959 stated that before the concept of “neostigmine-resistant
curarization” can be accepted, it is first necessary to prove that a neuromuscular block was in fact
present, and second, that neostigmine failed to reverse the blockade2.
Baraka has shown in–vitro using the isolated phrenic nerve-diaphragm preparation, as well
as in the anesthetized human, that neostigmine can only reverse a blocking dose of tubocurarine.
In contrast, an overdose cannot be readily reversed by neostigmine, confirming the statement that
“neostigmine-resistant curarization” really exists3-6. Using the isolated phrenic nerve-diaphragm
preparation of rats, the addition of neostigmine to the perfusion bath of a preparation just blocked
by tubocurarine could reverse completely the neuromuscular block. However, if an overdose of
tubocurarine is added to the perfusion bath, complete neuromuscular block occurred despite the
presence of a reversal dose of neostigmine in the bath. Further additional dose of neostigmine
could not reverse the block6. These results have been confirmed in man by showing that adequate
reversal of neuromuscular block by neostigmine is only achieved against doses of tubocurarine that
are not much greater than the blocking concentrations. Doubling the dose of tubocurarine was only
partially reversed, while tripling the dose could not be reversed irrespective of using additional
doses of neostigmine3-6.
The reversal effect of neostigmine is secondary to its antiacetylcholinesterase activity. The
accumulated acetylcholine does not reverse nondepolarizing neuromuscular block by displacing the
relaxant molecules from the receptors (i.e. pharmacokinetic effect), but probably by its action on the
free endplate cholinergic receptors (i.e. pharmacodynamic action). This has been shown by Waser
1967 in the mouse diaphragm autoradiographs by the use of labeled curarine; the minimum lethal
dose of radiocurarine was mixed with the reversal dose of neostigmine; although neuromuscular
transmission was restored, radioactivity in the endplate was not noticeably diminished7.
In contrast with the pharmacodynamic reversal by neostigmine, the mechanism of reversal of
aminosteroided NMBs such as rocuronium by the ∞-cyclodextrin sugammadex is a pharmacokinetic
process secondary to encapsulation of the steroid relaxant molecule in the central compartment.
This process will decrease the plasma level of the free (unbound) NMB concentration. Due to the
binding of NMB, a concentration gradient develops that moves the relaxant molecules from the
biophase towards the central compartment by diffusion. This causes liberation of the acetylcholine
receptors to which acetylcholine can then bind8,9.
131
M.E.J. ANESTH 22 (2), 2013
132
In non-curarized muscles, the cholinergic
endplate receptors are around 5,000,000, while the
released acetylcholine needs to attach itself to only
500,000 receptors to result in muscle contraction. The
rest of the receptors can be considered according to
Paton and Waud as “safety margin”. Thus, to achieve
neuromuscular block by one ED95 of a nondepolarizing
relaxant about 75%-90% of the receptors (i.e. the safety
margin) need to be occupied, and only 10-25% of the
receptors are free10. An overdose of curare will occupy
the remaining 10-25% of the receptor sites, and hence
the neuromuscular cannot be reversed, irrespective of
the neostigmine dose used.
Normally, the ACh released is rapidly hydrolysed
by the acetylcholinesterase enzyme in less than 1
millisecond. The addition of neostigmine which
inhibits the enzyme will delay the hydrolysis of the
released acetylcholine resulting in an increase of its
concentration and its duration of action. Initially, it
has been thought that reversal of nondepolarising
block by neostigmine is due to displacement of the
curare molecules from the endplate receptors by the
accumulated acetylcholine. However, it has been
shown by Waser using the radioactive curare that
the concentration of curare at the receptors remains
constant following reversal of the neuromuscular
block by neostigmine7. This has been confirmed
by Baraka in-vivo3-5 who showed in man that the
serum concentrations of tubocurarine were not
different whether reversal could be achieved or
not achieved. Thus, the results of Waser in animals,
and by Baraka in man confirm that reversal of
antidepolarizing neuromuscular block by neostigmine
is a pharmacodynamic and not pharmacokinetic
effect. It also confirms that overdose of relaxant which
occupies the endplate receptors explains the so called
“neostigmine-resistant curarization”.
Neostigmine reverses nondepolarising neuromuscular block by inactivating acetylcholinesterase. There
is an optimal dose of neostigmine for reversal. Doses
exceeding 0.05-0.07 mg.kg-1 are unlikely to achieve
any additional effect and may decrease rather than
improve neuromuscular transmission. Neostigmine
may even cause neuromuscular transmission failure
when given in overdose to patients who have already
recovered from neuromuscular block. This can impair
Baraka A.
upper airway dilator volume, genioglossus muscle
function and diaphragmatic function11,12.
Incomplete
recovery
of
neuromuscular
transmission is an important contributing factor in the
development of postoperative respiratory events. In a
prospective blinded study, Berg et al13 have shown that
the incidence of postoperative pulmonary complication
was <5% in patients receiving the intermediate-acting
muscle relaxants such as atracurium and vecuronium,
and in those patients who received pancuronium and
had T-O-F ratios ≥0.7 at the end of surgery. However,
pancuronium when associated with a T-O-F ratio <0.7
resulted in a threefold increase in the probability of
respiratory complications. The authors concluded
that residual curarization caused by a long-acting
neuromuscular blocker is a significant risk factor for
postoperative pulmonary complications.
Monitoring Of Postoperative Residual
Curarizaiton (PORC)
For many years, a train-of-four T-O-F ratio 0.7 was
considered sufficient to exclude PORC14. Clinically,
this level of neuromuscular block is characterized by
the ability to maintain 5 seconds head lift and hand
grip, to protrude the tongue, as well as a return to
normal eye-lid tone and jaw tone, and recovery to an
adequate tidal volume, vital capacity and inspiratory
force. However, in recent years, a T-O-F ratio of 0.7
does not guarantee sufficient neuromuscular recovery,
and today’s general consensus is that to exclude
clinically significant PORC, the T-O-F ratio should be
≥0.9. Even at a T-O-F ratio of ≥0.9 or 1.0 measured at
the adductor pollicis muscle, some subjects still have
impaired pharyngeal or respiratory function15.
Subjective monitoring of neuromuscular block
by visual or tactile evaluation of the response to
nerve stimulation may decrease but does not exclude
the risk of PORC. Objective monitoring by actual
quantification of the T-O-F ratio is ≥0.9. Good practice
based on evidence dictates that objective monitoring
should be the acceptable standard of care whenever
neuromuscular block is used. T-O-F ratio ≤0.9 patients
are more likely to develop postoperative hypoxemia
and to experience symptoms of muscle fatigue than
those whose T-O-F ratio equaled or exceeded this ratio.
NEOSTIGMINE-RESISTANT CURARIZATION
Skeletal muscles such as masseter muscle16
contract not as a single twitch response but as a tetanic
response usually above 10-20 Hz, and not at 2 Hz which
is the frequency of stimulation by the T-O-F. Thus,
a T-O-F ratio of 0.7 or even 0.9 does not guarantee
complete neuromuscular recovery. Therefore, it may be
advisable, before recovery of patient from anesthesia,
to check the recovery of neuromuscular transmission
by the traditional tetanic fade and post-tetanic
facilitation, using tetanic stimulation at high frequency
of 50 Hz applied for 5 seconds. The muscular response
is perceived as a sustained forceful contraction with
no fade when neuromuscular recovery is achieved.
In the presence of residual neuromuscular block,
tetanic fade is observed. Double-burst stimulation
may be a suitable alternative; it consists of two bursts
of stimuli at 50 Hz with an interval of 750 ms. Each
burst consists of 3 impulses. A fading of the second
133
impulse series compared to the first correlates with
an incomplete neuromuscular recovery17. The method
is more sensitive for tactile evaluation of a residual
blockade in comparison with a tactile evaluation of the
fade using TOF stimulation18.
In
conclusion,
“neostigmine-resistant
curarization” does exist. An overdose of the
antidepolarizing neuromuscular blockers, whether
absolute or relative, is the most important contributing
factor. Objective monitoring should be the acceptable
standard whenever neuromuscular blockers are used
during anesthesia. However, clinical evaluation should
remain as the golden standard of care.
Anis Baraka, MD, FRCA (Hon)
Emeritus Professor of AnesthesiologyAmerican
University of Beirut, Lebanon
M.E.J. ANESTH 22 (2), 2013
134
Baraka A.
References
1. Hunter AR: Neostigmine-resistant curarization. Br M J; 1956,
2:919.
2. Churchill-Davison HC: The causes and treatment of prolonged
apnea. Anesthesiology; 1959, 20:535.
3. Baraka A: Irreversible tubocurarine neuromuscular block in the
human. Br J Anaesth; 1967, 39:891-3.
4. Baraka A: Irreversible curarization. Anaesthesia and Intensive
Care; 1977, 5 (no. 3): 244-246.
5. Baraka A: Neostigmine and tubocurarine neuromuscular block. Br
J Anaesth; 1981, 53:1005-1006.
6. Baraka A: Neuromuscular block in different species. Acta Anaesth
Scand; 1972, 16:132-139.
7. Waser PG: Receptor localization by autoradiographic technique.
Ann NY Acad Sci; 1967, 144:737.
8. Bom A, Bradley M, Cameron K, et al: A novel concept of reversing
neuromuscular block: chemical encapsulation of rocuronium
bromide by a cyclodextrin-based synthetic host. Angewandte
Chemie Inernational Edition; 2002, 41:565-70.
9. Booij LHD: Cyclodextrins and the emergence of sugammadex.
Anaesthesia; 2009, 64(supp. 1):31-37.
10.Paton WDM, Waud DR: The margin of safety of neuromuscular
transmission. J Physiol; 1967, 191:59.
11.Kopman AF, Eikermann M: Antagonism of non-depolarizing
neuromuscular block, current practice. Anaesthesia; 2009, 64(supp.
1):22-30.
12.Eikermann M, Fassbender P, Malhotra A, et al: Unwarranted
administration of acetylcholinesterase inhibitions can impair
genioglassus and diaphragm muscle function. Anesthesiology; 2007,
107:621-9.
13.Berg H, Viby-Mogensen J, Raed J, et al: Residual neuromuscular
block is a risk factor for postoperative pulmonary complications.
Acta Anaesthesiologica Scandinavica; 1977, 41:1095-103.
14.Ali HH, Utting JE, Gray C: Stimulus frequency in the detection of
neuromuscular block in humans. Br J Anaesth; 1970, 42:967-78.
15.Claudius C, Garvey LH, Viby-Mogensen J: The undesirable effects
of neuromuscular blocking drugs. Anaesthesia; 2009, 64(supp.
1):10-21.
16.Tamari JW, Tomey GF, Ibrahim ZM, Baraka A, Jabbur SJ,
Bahuth N: Correlative study of the physiologic and morphologic
characteristics of the temporal and masseter muscles of the cat.
Journal of Dental Research; 1973, vol. 52, no. 3:538-543.
17.Engbaek J, Ostergaard D, Viby-Mogensen J: Double burst
stimulation (DBS) a new pattern of nerve stimulation to identify
residual neuromuscular block. British Journal of Anaesthesia; 1989,
62:274-8.
18.Drenk NE, Ueda N, Olssen NV, et al: Manual evaluations of
residual curarization using double burst stimulation: a comparison
with train of four. Anesthesiology; 1989, 70:578-82.
review article
AIRTRAQ OPTICAL LARYNGOSCOPE:
ADVANTAGES AND DISADVANTAGES
Kemal Tolga Saracoglu*, Zeynep Eti**,
and F evzi Y ilmaz G ogus **
Abstract
Difficult or unsuccesful tracheal intubation is one of the important causes for morbidity and
mortality in susceptible patients. Almost 30% of the anesthesia-related deaths are induced by
the complications of difficult airway management and more than 85% of all respiratory related
complications cause brain injury or death. Nowadays, due to the advances in technology, new
videolaryngoscopic devices became available. Airtraq is a novel single-use laryngoscope which
provides glottis display without any deviation in the normal position of the oral, pharyngeal or the
tracheal axes. With the help of the display lens glottis and the surrounding structures are visualised
and under direct view of its tip the tracheal tube is introduced between the vocal cords. In patients
having restricted neck motion or limited mouth opening (provided that it is greater than 3 cm)
Airtraq offers the advantage of a better display. Moreover the video image can be transfered to an
external monitor thus an experienced specialist can provide assistance and an educational course
can be conducted simultaneously. On the other hand the Airtraq videolaryngoscopic devices possess
certain disadvantages including the need of experience and the time demand for the operator to
learn how to use them properly, the rapid deterioration of their display in the presence of a swelling
or a secretion and the fact that they are rather complicated and expensive devices. The Airtraq
device has already documented benefits in the management of difficult airways, however serial
utilization obviously necessitates experience.
Conflict of interest: The authors state no conflict of interest.
Key words: airtraq, airway management, videolaryngoscope.
*
**
Assistant Prof. MD.
Prof. MD.
Affilaition: Department of Anesthesiology, Marmara University School of Medicine, Istanbul, Turkey.
Corresponding author: Kemal Tolga SARACOGLU. Department of Anesthesiology, Marmara University School of
Medicine, Fevzi Cakmak Mah. Ust Kaynarca, Pendik, Istanbul, Turkey. Tel: +905385478620, Fax: +902164144731.
E-mail: [email protected]
135
M.E.J. ANESTH 22 (2), 2013
136
Introduction
Difficult or unsuccesful tracheal intubation is one
of the important causes for morbidity and mortality
in susceptible patients1. Cormack and Lehane
laryngoscopic view grade 3 or 4 difficult intubation
occur in between 0.3-20% of laryngoscopies. Almost
30% of the anesthesia-related deaths are induced by
the complications of difficult airway management and
more than 85% of all respiratory related complications
cause brain injury or death2. The incidence of difficult
intubation is 1.15-3.8%, on the other side the incidence
for failed intubation is 0.13-0.3% in the general
population3. Furthermore failed intubations using
Macintosh laryngoscopes were reported in up to 30%
intubations by paramedics4.
In addition to the operating theatre, the need
for emergent endotracheal intubation is also high in
intensive care unit, emergency intervention room
and emergency ward; thus this subject obviously is
of particular concern to many physicians of various
specialties. Trauma to the airways, esophageal
intubation,
pulmonary
aspiration,
systemic
complications secondary to hypoxia and undesired
hemodynamic changes are some of the unwanted
conditions which could accompany emergent
endotracheal intubation5. Nowadays, due to the
advances in technology, new videolaryngoscopic
devices became available. Optical systems with
adjustable position capability and modified blades
with LED lights, rechargeable batteries, accelerated
the developmental progress of these devices6, which
include Airtraq, Glide scope7, LMA C Trach8, Airway
scope9, Storz V-Mac10, lightwand11, Mc-Grath video
laryngoscope12 or True-view laryngoscope13. These
devices are originally designed to handle difficult
intubation, and with time they become regular for
management of the normal airways, as well.
Airtraq Optical Laringoscope
The standard direct laryngoscopy procedure
requires the proper alignment of the oral, pharyngeal
and laryngeal axes in order to provide the necessary
display of the vocal cords. Airtraq is a novel singleuse laryngoscope which provides glottis display
Saracoglu K. T. et. al
without any deviation in the normal position of the
oral, pharyngeal or the tracheal axes. The Airtraq
blade is composed of two channels running parallel
to each other. The more externally positioned channel
serves as a conduit for the introduction of the tracheal
tube14 (Figure 1). The exaggerated curvature of the
blade and the combination of the lens with the prism
ensure the transmission of the image to the proximal
field. A battery-powered light source is located on the
edge of the blade. The purpose of this configuration
is to enable intubation with minimal movement of the
cervical spine15 (Figure 2). With the help of the display
lens, the glottis and the surrounding structures are
visualised and under direct view of its tip the tracheal
tube is introduced between the vocal cords.
Fig. 1
Fig. 2
AIRTRAQ OPTICAL LARYNGOSCOPE: ADVANTAGES AND DISADVANTAGES
Advantages
In patients having restricted neck motion or
limited mouth opening (provided that it is greater
than 3 cm) Airtraq offers the advantage of a better
display. Moreover the video image can be transfered
to an external monitor thus an experienced specialist
can provide assistance and an educational course
can be conducted simultaneously16. Alignment of
the airway with the eye of the operator is deemed
unnecessary. Compared to Macintosh laryngoscope,
Airtraq requires less operator skills thus it constitutes
an advantage to the emergency service staff and
the ambulance personnel who have limited or no
intubation experience. Nowadays it is a prerequisite
for the medical and paramedical health professionals
to know these instruments as much as possible. Shorter
duration of intubation, fewer complications during
procedure and lower intubation difficulty scores were
reported using Airtraq17.
Macintosh laryngoscope being the gold standart
device for tracheal intubation has been utilized for many
years. Despite all of the developed videolaryngoscopic
devices, it is still the most frequently used intubation
device18. Previous studies have demonstrated that
the learning process of intubation with Macintosh
laryngoscope is quite difficult and necessitates a long
period of time19,20. However Airtraq laryngoscope is
a novel intubation device which has been introduced
to the clinical practice in recent years during the
videolaryngoscopic revolution and its utilization is
rapidly becoming more and more widespread. Airtraq
was previously used in normal and difficult airways to
compare with both Macintosh laryngoscope and other
videolaryngoscopic devices21,22. One of the greatest
advantage of this device is the provision of intubation
conditions with the least amount of cervical spine
movement, due to the lens and prism configuration. In
comparison to Macintosh laryngoscope, the reduction
of the cervical spine mobility to a minimum level
during Airtraq utilization was also demonstrated
fluoroscopically23. It was observed that all of the
Cormack and Lehane grade 4 appearances were
reduced to grade 124. Additionally, Airtraq can shorten
the duration of intubation in difficult airways as well
as normal airways25. It was demonstrated that Airtraq
influenced the hemodynamic changes to a lower
137
extent than Macintosh laryngoscope and thus it was
emphasized that Airtraq could be safely utilized in
patients with coronary artery disease or arrhythmia26.
Airtraq was also succesfully applied in awake
intubation27; before the procedure a lidocaine injection
was performed through the Airtraq channel and thus
succesful intubations were achieved28. Moreover,
Airtraq was also utilized for transesophageal
echocardiography probe placement29, bronchial bloker
placement30 and biluminal tube insertion31.
In one study 40 medical students with no previous
intubation experience have performed intubations easier
with Airtraq compared to Macintosh laryngoscope32;
in another study the dental trauma incidence was found
to be lower with Airtraq16. Arslan et al.25 comparing
Airtraq with Macintosh laryngoscope, concluded that
the duration of intubation was shorter and the severity
of mucosal damage was found to be lower with Airtraq.
Compared to Macintosh laryngoscope, the success rate
of the first intubation attempt in experienced as well
as unexperienced staff was found to be significantly
higher with Airtraq33. In this study the rate of
esophageal intubation was reported to be 65% with
Macintosh blade and 13% with Airtraq. A comparative
study of Airtraq with Lightwand revealed no significant
difference for the hemodynamic changes34. The
disposable nature of the device decreases the risk of a
possible prion contamination and thus the occurence of
Creutzfeld Jacob Disease35.
Savoldelli GL, et al.36 concluded that time
taken to position the endotracheal tube was shorter
for the Airtraq when compared with the McGrath
and Glidescope. The Airtraq had the most favourable
learning curve in this study. In another study which is
conducted in 318 morbidly obese patients, the duration
tracheal intubation has been found shorter with the
Airtraq laryngoscope than with the LMA CTrach37. The
evaluation of ease of intubation in patients immobilised
with cervical collar proved that Airtraq improves the
ease of intubation when compared to laryngoscopy
with Mc Coy blade38. Airtraq aided intubation without
requiring the removal of the collar. Airtraq has also
been shown to reduce the Intubation Difficulty Scale
score and the need for optimization manoeuvres,
improving the Cormack and Lehane glottic view when
compared with the C-MAC®39. In another comparative
M.E.J. ANESTH 22 (2), 2013
138
study of endotracheal intubation with Airtraq versus
Storz videolaryngoscope in children younger than two
years, the Airtraq has been found significantly faster in
all measured procedural elements of intubation40.
Disadvantages
On the other hand Airtraq videolaryngoscopic
devices possess certain disadvantages including
the need of experience and the time demand for the
operator to learn how to use them properly, the rapid
deterioration of their display in the presence of a
swelling or a secretion and the fact that they are rather
complicated and expensive devices16.
The disposability of the device necessitates the
provision of backups, which increases the expenditures
and represents a disadvantage for its utilization.
That’s why it inevitably directs us into the search of a
reusable videolaryngoscope among the equipments for
the management of difficult airways.
In the literature there are previous studies
comparing Airtraq with videolaryngoscopic devices
such as airway scope41 and True-view42, in addition
to the comparative studies of Airtraq with Macintosh
laryngoscope. In a study comparing Airtraq,
Macintosh laryngoscope and airway scope blades the
duration of intubation as well as the success rate of
the intubation attempts were compared in resuscitation
cases which underwent chest compression43. Both of
these parameters were found to be significantly more
favorable for airway scope. One of the reasons for the
increase in duration of intubation with Airtraq is the
fact that during the procedure the eye needs to be fully
approximated to the laryngoscope and even a small
movement of the head can compromise the visibility of
larynx. However with increasing experience on how to
use the device, the proper application of optimisation
maneuvers are learned and the problems can be solved.
Airtraq device also requires some time for setup. Upon activation of Airtraq approximately 30-60
seconds of time is needed to warm-up the lens and
to prevent fogging23. That is a disadvantage of the
Airtraq device during emergency situations. There
are reports of tonsillar injury in children during the
intubation attempts with Airtraq44. Certain factors,
including the blurred vision provided by the Airtraq
Saracoglu K. T. et. al
laryngoscope, the accidental extubation of a patient
upon the retraction of the device following a successful
intubation and the inability to place Airtraq into the
oral cavity of a patient with a rather limited mouth
opening can contribute to the failure of intubation by
even some of the experienced anesthesiologists45.
In a study conducted on morbidly obese patients,
although Airtraq was found to be a faster and safer way
of intubation compared to Macintosh laryngoscope,
the patients were preoperatively warned about the risk
of tissue trauma10.
Airtraq is a device with 1.8 cm thickness and 2.8
cm width46. It is not possible to use it in patients with
restricted mouth opening. Airtraq provides a better
laryngoscopic view but this does not always mean that
the intubation will be easier. Even in cases with excellent
visibility additional manipulations might be necessary
and the duration of intubation could be longer. In fact,
during a case Cormack and Lahen Grade 3 difficult
intubation was detected with Macintosh laryngoscope,
followed by several intubation attempts with Airtraq,
which has yielded an excellent display, and upon the
failure of these attempts a fiberoptic bronchoscope
was introduced through the Airtraq device and the
intubation was completed under its guidance47.
The insertion of Airtraq can damage the
mucosal tissue because of its 2.8 cm width. Moreover
the pressure exerted by the device through the
oropharyngeal region may result in postoperative
emergence of sore throat. Holst et al. [48] reported
a 2 cm long vertical laceration due to the utilization
of Airtraq in oropharyngeal airway areas. The
exaggerated curvature and the large anteroposterior
diamater of the Airtraq blade might lead to difficulties
during its intraoral insertion. Moreover the tip of the
blade does not have a rounded vallecular ending like
the Macintosh blade thus the risk of trauma increases
during the placement of the Airtraq blade behind
the tongue. Ndoko SK et al.49 have reported that the
standard Airtraq insertion technique might cause
bleeding and the reverse maneuver could be utilized
to decease the complication rates in morbidly obese
patients.
Especially for patients with restricted mouth
opening Airtraq is not the best choice in every
circumstances. Compared to Airtraq, the Glidescope,
AIRTRAQ OPTICAL LARYNGOSCOPE: ADVANTAGES AND DISADVANTAGES
Trueview or Storz videolaryngoscope seem to be better
choices for patients having limited mouth opening50.
It should always be kept in mind that a successful
intubation could never be guaranteed for each and
every case despite the good visualisation of glottis
obtained by Airtraq.
139
Conclusion
The Airtraq device has already documented
benefits in the management of difficult airways,
however serial utilization obviously necessitates
experience.
M.E.J. ANESTH 22 (2), 2013
140
Saracoglu K. T. et. al
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M.E.J. ANESTH 22 (2), 2013
scientific articles
POST-OPERATIVE COGNITIVE FUNCTIONS AFTER GENERAL
ANESTHESIA WITH SEVOFLURANE AND DESFLURANE
IN SOUTH ASIAN ELDERLY
Telugu Seetharam Deepak*, Srisha Vadlamani**,
K. Sunil Kumar*** and Punith Kempegowda****
Abstract
Background: The duration of the recovery of cognition after anesthesia and surgery is
multifactorial and is dependent on the type of anesthesia used, the type of surgery, and the patient.
The present study compared the speed of recovery in elderly patients undergoing general anesthesia
with sevoflurane or desflurane and the incidence and duration of cognitive impairment in them.
Methods: The prospective study was conducted at a tertiary care centre in Bangalore
from November 2008 to March 2010. Patients aged above 65 years with American Society of
Anaesthesiology (ASA) physical status I, II, III undergoing surgeries under general anesthesia
lasting from 45 min up to 3 hours were included in the study. The times from discontinuing nitrous
oxide to eye opening, tracheal extubation, obeying commands, and the time to orientation to name
and place were assessed at 30-60 s intervals. At 1, 3, 6 h after the end of anesthesia, the patient’s
cognitive functions were assessed by asking them to repeat the Mini Mental Score Examination.
Statistical analysis used: Student t-test, Chi-square test
Results: The time to eye opening, time until extubation, time to follow commands and
orientation to time, place were significantly better with desflurane compared to sevoflurane
(p<.001). Hundred percent of patients in the desflurane group and 97% in the sevoflurane group
demonstrated completely normal cognitive function at 6 h postoperatively (p=0.31).
Conclusion: Desflurane was associated with a faster early recovery than sevoflurane in
elderly patients. However, postoperative recovery of cognitive function was similar with both
volatile anaesthetics.
Conflict of interest: none
Sources of financial support: none
Key words: Desflurane, Sevoflurane, Cognition, Recovery, Elderly
*
MD, Department of Critical Care.
**
MD, Department of Anesthesia.
*** MD, Lecturer, Department of Medicine.
Affiliation: M S Ramaiah Medical College, Bangalore-560054, India.
****MBBS, MSc, Clinical Fellow Post-graduate, Level 3, Ealing Hospital NHS Trust, Uxbridge Road, Southall, UB1 3HW,
London, UK.
Corresponding author: Dr. T S Deepak, Department of Critical Care, M S Ramaiah Medical College, Bangalore-560054.
Email: [email protected]
143
M.E.J. ANESTH 22 (2), 2013
144
Introduction
Surgical intervention in the elderly population
is associated with significant postoperative morbidity
and mortality due to various reasons1-5. Brain function
is usually altered post-anesthesia, with altered level of
consciousness and impairment of attention, memory,
and reaction time. The incidence of Post-Operative
Cognition Dysfunction (POCD) has been reported to
be between 1% and 60%, depending on the type of
operation6.
Few studies suggest that use of volatile
anaesthetics that are rapidly eliminated with minimal
metabolic breakdown may reduce postoperative
delirium and cognitive dysfunction in elderly
surgical patients by facilitating a faster recovery
from general anesthesia7. Sevoflurane and desflurane
have pharmacokinetic properties that favour rapid
emergence from anesthesia. A lower blood:gas partition
co-efficient (0.42 vs 0.65) and fat:blood partition
coefficient (27 vs 48) of desflurane versus sevoflurane
respectively, favour its more rapid elimination from
the body and also provide shorter emergence times8.
Cognitive decline after cardiac operations has been
studied extensively but cognitive decline after noncardiac operations is not as well studied. Chen et
al compared POCD following sevoflurane and
desflurane use in elderly patients mostly consisting of
American Caucasians1. They reported that there was
no difference in the total incidence of POCD between
the desflurane and sevoflurane groups; however,
desflurane was associated with a faster cognitive
recovery than sevoflurane. A similar study done in
European population by Rortgen and group also found
the same results9.
Miles and group demonstrated that the clinical
and molecular aetiologies of dementia differ between
ethnic groups10. Genetic factors and educational
achievement together accounted for over half of
variance in cognitive functioning of older men in a
study done by Brandt and colleagues11. The Baltimore
Memory Study had similar reports with regards to
cognition and ethnicity12. While we are still not yet
clear on the exact mechanism of producing loss of
perception and or inducing unconsiousness of either
sevoflurane and desflurane, we cannot rule out genetic
Deepak T. S. et. al
influences on their mechanism of action. No previous
studies compared the effects of the two anaesthetics in
South Asian population.
We designed this study to investigate the speed
of recovery in elderly patients undergoing general
anesthesia with sevoflurane or desflurane and
compared the incidence and duration of cognitive
impairment in South Indian population. The level of
cognitive impairment as measured by MMSE scale
six hours post-operatively was defined as the primary
outcome in the present study.
Methods
This prospective randomized study was
conducted in a tertiary care medical teaching hospital
from November 2008 to March 2010. The study was
approved by the Institution’s Ethical Committee. We
designed the study in lines with the methodologies of
studies done by chen et al and Rortgen et al to facilitate
comparisons between the findings from the three
studies1,9. Patients above 65 years of age with American
Society of Anaesthesiology (ASA) physical status I,
II, III undergoing surgeries under general anesthesia
lasting from 45 min up to three hours were included
in the study following a written informed consent.
Patients who underwent general anesthesia within
seven days prior to the procedure under study and
those undergoing surgeries that required trendelenberg
position were excluded from the study. Also, patients
with history of neuropsychiatric disorders, alcohol
consumption, BMI>30 were excluded from the study.
Patients with clinically significant cardiovascular,
respiratory, hepatic, renal, neurological, psychiatric
and metabolic disease were also excluded from the
study. Patients unable to read and write and with
impaired hearing were excluded as they would not be
able to comprehend the guidelines of the study.
In the preoperative holding area, the Mini-Mental
State Examination (MMSE) test was conducted. The
MMSE is a screening test that quantitatively assesses
cognitive impairment by asking patients a variety of
questions. The maximum MMSE score is 30 points,
with scores of 23 or less being indicative of cognitive
impairment13. Hence patients with pre-operative
MMSE score <23 were excluded from the study. The
POST-OPERATIVE COGNITIVE FUNCTIONS AFTER GENERAL ANESTHESIA WITH SEVOFLURANE AND
DESFLURANE IN SOUTH ASIAN ELDERLY
criterion used to define a decline in cognitive function
in our study was a decrease of 2 or more points on the
MMS test compared to the pre-operative value.
The present study was double-blinded where
both patients and investigators were blinded to the
group. Patients were randomized to two groups
using a computer generated table. As soon as the
patient arrived in the operating room, an intravenous
infusion of ringer lactate was started at 100 ml/hr,
and monitors such as Non-invasive blood pressure
(NIBP), electrocardiogram (ECG), Pulse-oximeter
were applied. All patients received midazolam 1 mg
intravenously (IV) for preoperative medication.
Tracheal intubation was facilitated with
vecuronium (0.1mg/kg IV) or atracurium (0.5mg/
kg IV). Anesthesia was induced with fentanyl (1.02 mcg/kg IV) and propofol (1.0-2.0 mg/kg IV) until
loss of response to oral commands. After loss of
consciousness, patients received either desflurane 5%
or sevoflurane 2% (volume percent) through the tec6
and tec7 vaporizer.
Anesthesia was maintained with desflurane 2-6%
or sevoflurane 1-1.5% in combination with nitrous
oxide 66% in oxygen which corresponded to 1-1.8
MAC (Age adjusted MAC)14.
NIBP, heart rate and oxygen saturation were
recorded before induction of anesthesia then, along with
end-tidal carbon dioxide, every 2 min after induction
of anesthesia for 15 min and then every 5 min until the
end of surgery. Temperature was monitored and was
maintained at 360 C.
Inspired volatile anaesthetic concentration was
adjusted as necessary to maintain pulse and NIBP
within 20% of pre-induction values. If acute increases
occurred, the inspired concentration of desflurane/
sevoflurane was increased by up to 50%. Supplemental
doses of fentanyl, 0.5–1.0 mcg/kg IV (to maximum
dose of 200 mcg), was used to control acute changes
that did not respond to two consecutive 50% increases
in the inspired concentration of desflurane/sevoflurane
or if there were other signs of inadequate analgesia.
Patients who required higher inspired inhalational
agent concentration and patients who became
haemodynamically unstable during the procedure were
excluded from the study.
145
Atracurium/vecuronium
was
administered
during the maintenance period. All patients received
paracetamol infusion 15 mg/kg during intra-operative
period. During the maintenance period, ventilation
was controlled to maintain normocarbia using a semi
closed circle system with a total fresh gas flow rate of
3 L/min.
Ten minutes before the estimated end of surgery
the inhaled anaesthetics were reduced to 0.5 MAC. At
the end of surgery, residual neuromuscular blockade
was reversed using glycopyrrolate (0.01 mg/kg IV)
and neostigmine (0.05 mg/kg IV). Sevoflurane or
desflurane was discontinued at the start of skin closure,
and nitrous oxide was discontinued at the end of
surgery. The lungs were ventilated with 100% O2 at a
fresh gas flow rate of 8 L/min.
The times from discontinuing nitrous oxide to eye
opening, tracheal extubation, obeying commands (e.g.,
squeeze the investigator’s hand), as well as the time to
orientation to name and place were assessed at 30-60
s intervals. The durations of anesthesia (from the start
of induction to discontinuation of nitrous oxide) and
surgery (from surgical incision to skin closure) were
also recorded. At 1, 3, 6 h after the end of anesthesia, the
patient’s cognitive functions were assessed by asking
them to repeat the MMSE. Adverse side effects like
dizziness, headache, drowsiness, nausea, vomiting,
anxiety and restlessness were recorded.
The primary and secondary outcome of the study
was to compare the incidence of POCD in both groups
and to determine the speed of recovery respectively.
Statistical Analysis
A sample size of 35 was determined by using
power analysis based on an alpha error of 0.05, beta
error of 0.2.and the assumptions that a) the incidence
of postoperative cognitive impairment at one hour
after anesthesia would be 50%; b) 70% reduction (eg:
from 50% to 15%) would be of clinical significance.
Statistical analyses were performed using
Statistical Package for the Social Sciences (SPSS) for
Windows 16.0 (SPSS Inc., Chicago, USA). The results
for each parameter (numbers and percentages) for
discrete data and average (mean + standard deviation)
for continuous data are presented in tables and figures
using Microsoft office 2007 software package.
M.E.J. ANESTH 22 (2), 2013
146
Deepak T. S. et. al
Student t-test was performed for continuous
variables, and paired Student t-test was used to
compare the intra-group differences in the MMSE
scores at different assessment points with their baseline
values. Categorical data were analyzed by chi-square
test. A value of P< 0.05 was considered statistically
significant.
The gender distribution is given in table 1. The
various surgeries undergone by the study subjects
in the two groups are given in table 2. Statistically,
there was no significant difference with respect to age
(p=.800), gender (p=.071), ASA grading (p=.371),
BMI (p=.098), various surgeries undergone by the
study subjects (p=.066), propofol (p=.9) and fentanyl
(p=1.0) between the two groups.
Results
The mean duration of anesthesia for sevoflurane
and desflurane groups were 140.57±35.26 min and
145.33±40.77 min respectively (p=0.63). The average
duration of surgery for sevoflurane and desflurane
groups were 107.83±33.55 min and 119.17±36.34 min
respectively (p=.21). The various recovery indices
between the two groups are given in table 3. The
time to eye opening, time until extubation, time to
follow commands and orientation to time, place was
significantly better with desflurane (p<.001).
A total of 60 patients above 65 years of age who
were undergoing elective surgical procedures under
general anesthesia were included in the study. These
patients were randomized to two groups of 30 each
using a computer generated table.
The mean age in the sevoflurane and desflurane
group were 69.47±4.42 years (range: 65-88 years) and
69.17±4.73 years (range: 65-84 years) respectively.
Table 1
Gender distribution among the treatment groups
Treatment Group
Male (%)
Female (%)
Total (%)
Sevoflurane
Desflurane
19 (63.3)
11 (36.7)
30 (100)
Total
31 (51.7)
29 (48.3)
60 (100)
12 (40.0)
18 (60.0)
30 (100)
Table 2
Type of surgeries between the two treatment groups
Group
ENT (%)
Sevoflurane
0 (0.0)
Desflurane
2 (6.7)
Total
2 (3.3)
ENT- Ear, Nose and Throat
OBG-Obstetrics and Gynaecology
Orthopedics
(%)
11 (36.7)
5 (16.7)
16 (26.7)
OBG (%)
1 (3.3)
6 (20.0)
7 (11.7)
Surgery (%)
Urology (%)
Total (%)
11 (36.7)
13 (43.3)
24 (40.0)
7(23.3)
4 (13.3)
11 (18.3)
30 (100.0)
30 (100.0)
60 (100.0)
Table 3
comparison of recovery indices between the treatment groups
Index
Eye Opening (min)
Extubation (min)
Commands (min)
Orientation (min)
Group
N
Mean
Std. Dev
Minimum
Maximum
Sevoflurane
30
7.93
1.530
5
12
Desflurane
30
5.37
.999
4
8
Sevoflurane
30
10.10
1.583
7
14
Desflurane
30
7.17
.913
5
9
Sevoflurane
30
12.67
1.826
9
17
Desflurane
30
8.83
1.262
7
12
Sevoflurane
30
13.80
1.789
9
17
Desflurane
30
9.63
1.377
8
13
‘p’ value
<0.001
<0.001
<0.001
<0.001
POST-OPERATIVE COGNITIVE FUNCTIONS AFTER GENERAL ANESTHESIA WITH SEVOFLURANE AND
DESFLURANE IN SOUTH ASIAN ELDERLY
147
Table 4
Comparison of mean Mini Mental Scale Examination (MMSE) scores between the two groups
Pre op-MMSE
MMSE- 1h
MMSE- 3h
MMSE- 6h
Groups
N
Mean
Std. Deviation
Minimum
Maximum
‘p’ value
Sevoflurane
30
28.97
0.964
27
30
0.214
Desflurane
30
28.60
1.276
25
30
Sevoflurane
30
27.17
1.234
25
29
Desflurane
30
26.53
1.737
22
29
Sevoflurane
30
27.97
1.066
26
30
Desflurane
30
27.70
1.368
24
29
Sevoflurane
30
28.67
0.959
27
30
Desflurane
30
28.40
1.102
25
30
0.109
0.403
0.321
Table 5
Comparison of percentage of patients having Post-Operative Cognitive Dysfunction (POCD)
Group
POCD at 1h
POCD at 3h
POCD at 6h
Sevoflurane
15 (50%)
4(13%)
1(3.3%)
Desflurane
18(60%)
5(16.7%)
0
p-value
0.44
0.71
0.31
The trend of MMSE scores at 1, 3 and 6 h postoperatively show that MMSE scores at 1 hr were
significantly low in both groups (Table 4), but returned
to the baseline by 6h. The incidence of POCD in the
two study groups at various time-lines is gievn in table
5. There was statistically no difference between the
two groups in the incidence of POCD. In addition,
there were no significant differences in the amounts
of postoperative analgesic and the incidence of side
effects in the two study groups.
Discussion
Postoperative cognitive impairment is a
condition characterized by impairment of memory and
concentration, and the incidence has been reported to
be extremely frequent in elderly patients. The aged
brain is different from the younger brain in several
important aspects, including size, distribution and type
of neurotransmitters, metabolic function, and capacity
for plasticity. For this reason, early POCD is more
common in the elderly after major surgery, compared
to middle-aged patients15. In the present study, we
compared the speed of recovery in elderly patients
undergoing general anesthesia with sevoflurane or
desflurane and compared the incidence and duration of
cognitive impairment in them.
The two anaesthetic groups were comparable
with respect to age, gender, ASA grade, durations
of anesthesia and surgery, BMI as well as doses of
medications used for premedication, propofol induction
dose and intra-operative analgesic requirement.
The emergence times from the end of anesthesia
to eye opening, tracheal extubation, following verbal
commands, and orientation were significantly shorter
in the Desflurane (versus Sevoflurane) Group (p<.001)
consistent with previous studies16. In the present
study, there was no significant difference between
desflurane and sevoflurane groups with respect to
their MMSE score preoperatively and at 1h, 3h and 6h
postoperatively. Chen et al and Rortgen et al also did not
find any significant difference between desflurane and
sevoflurane groups with respect to POCD, indicating
that either of the agents are suitable for anesthetizing
elderly patients without causing significant POCD1,9.
The early recovery profiles (e.g., 0-4h) of
M.E.J. ANESTH 22 (2), 2013
148
modern anaesthetics such as sevoflurane, desflurane
and propofol have been well studied and recently
reviewed. Most psychometric tests appear to show
a return to baseline values between four and six
hours after anesthesia17,18. A meta-analysis on postoperative recovery after general anesthesia reported
that patients receiving desflurane followed commands,
were extubated, and were oriented 1.0-1.2 minutes
earlier than patients receiving sevoflurane19. However,
Heavner and colleagues did not find any difference
Deepak T. S. et. al
between desflurane and sevoflurane in the elderly after
general anesthesia with respect to recovery time when
they were assessed with the Digit–Symbol Substitution
Test20.
A smaller study group and use of single
neurobehavioural assessment tool might have masked
the subtle differences between the two compounds.
A large scale study with multiple neurobehavioural
assessment tools is needed to establish the present
findings as facts.
References
1. Chen X, Zhao M, White PF, Li S, Tang J, Wender RH, et al: The
recovery of cognitive function after general anesthesia in elderly
patients: a comparison of desflurane and sevoflurane. Anesthesia &
Analgesia; 2001, 93:1489.
2. Parikh SS, Chung F. Postoperative delirium in the elderly.
Anesthesia & Analgesia; 1995, 80:1223.
3. Cryns AG, Gorey KM, Goldstein MZ: Effects of surgery on the
mental status of older persons. A meta-analytic review. Journal of
geriatric psychiatry and neurology; 1990, 3:184-91.
4. Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca
B, Haslauer CM, et al. A clinical prediction rule for delirium after
elective noncardiac surgery. JAMA: The Journal of the American
Medical Association; 1994, 271:134.
5. Renck H. The elderly patient after anaesthesia and surgery. Acta
anaesthesiologica Scandinavica Supplementum; 1969, 34:1.
6. Hardman JG, Limbird LE: Goodman & Gilman’s the pharmacological
basis of therapeutics: McGraw-Hill New York; 1996.
7. Bekker AY, Berklayd P, Osborn I, Bloom M, Yarmush J, Turndorf
H: The recovery of cognitive function after remifentanil-nitrous
oxide anesthesia is faster than after an isoflurane-nitrous oxidefentanyl combination in elderly patients. Anesthesia & Analgesia;
2000, 91:117-22.
8. Steinmetz J, Funder K, Dahl B, Rasmussen L: Depth of anaesthesia
and post‐operative cognitive dysfunction. Acta Anaesthesiologica
Scandinavica; 2010, 54:162-8.
9. Rörtgen D, Kloos J, Fries M, Grottke O, Rex S, Rossaint R,
et al: Comparison of early cognitive function and recovery after
desflurane or sevoflurane anaesthesia in the elderly: a doubleblinded randomized controlled trial. British Journal of Anaesthesia;
2010, 104:167.
10.Miles TP, Froehlich TE, Bogardus JR ST, Inouye SK: Dementia
and race: are there differences between African Americans and
Caucasians? Journal of the American Geriatrics Society; 2001,
49:477-84.
11.Brandt J, Welsh KA, Breitner J, Folstein MF, Helms M, Christian
JC. Hereditary influences on cognitive functioning in older men: a
study of 4000 twin pairs. Archives of Neurology; 1993, 50:599.
12.Schwartz BS, Glass TA, Bolla KI, Stewart WF, Glass G,
Rasmussen M, et al. Disparities in cognitive functioning by race/
ethnicity in the Baltimore Memory Study. Environmental health
perspectives; 2004, 112(3):314.
13.Mondimore FM, Damlouji N, Folstein MF, Tune L. Post-ECT
confusional states associated with elevated serum anticholinergic
levels. The American Journal of Psychiatry; 1983.
14.Nickalls R, Mapleson W: Age‐related iso‐MAC charts for
isoflurane, sevoflurane and desflurane in man. British Journal of
Anaesthesia; 2003, 91:170.
15.Johnson T, Monk T, Rasmussen LS, Abildstrom H, Houx P,
Korttila K, et al: Postoperative cognitive dysfunction in middleaged patients. Anesthesiology; 2002, 96:1351.
16.Pensado CA, Rama MP, Molins GN, Fiqueira MA, Vásquez FA.
[Immediate anesthesia recovery and psychomotor function of
patient after prolonged anesthesia with desflurane, sevoflurane
or isoflurane]. Revista espanola de anestesiologia y reanimacion;
2000, 47:386.
17.Pollard B, Bryan A, Wilson A, Burkill M, Beatty P, Healy T, et
al. Recovery after oral surgery with halothane, enflurane, isoflurane
or propofol anaesthesia. British Journal of Anaesthesia; 1994,
72:559.
18.Sanou J, Goodall G, Capuron L, Bourdalle-Badie C, Maurette
P: Cognitive sequelae of propofol anaesthesia. Neuroreport; 1996,
7:1130.
19.Agoliati A, Dexter F, Lok J, Masursky D, Sarwar MF, Stuart SB,
et al: Meta-analysis of average and variability of time to extubation
comparing isoflurane with desflurane or isoflurane with sevoflurane.
Anesthesia & Analgesia; 2010, 110:1433.
20.Heavner JE, Kaye A, Lin Bk, King T: Recovery of elderly patients
from two or more hours of desflurane or sevoflurane anaesthesia.
British Journal of Anaesthesia; 2003, 91:502.
ULTRASOUND GUIDED PERITUBAL
INFILTRATION OF 0.25% ROPIVACAINE FOR
POSTOPERATIVE PAIN RELIEF IN PERCUTANEOUS
NEPHROLITHOTOMY
Geeta P. Parikh*, Veena R. Shah**,
Kalpana S. Vora***, Beena K. Parikh*, Manisha P Modi*
and A run Panchal ****
Abstract
Background: Percutaneous nephrolithotomy (PCNL) is a common endourologic procedure
with less morbidity than open surgery. However, pain around the nephrostomy tube requires good
post operative analgesia. So we hypothesize that infiltration of local anesthetic from the renal
capsule to the skin around the nephrostomy tract would relieve the pain in the initial postoperative
period.
Methods: 60 adult patients of either sex with ASA physical status I to III and undergoing
percutaneous nephrolithotomy were randomized for a prospective double-blind controlled study.
Patients were divided into control group (n=30) and ropivacaine group (n=30). Balanced general
anesthesia was given. After completion of surgical procedure, 23 gauge spinal needle was inserted
at 6 and 12 o’clock position under ultrasonic guidance up to therenal capsule along the nephrostomy
tube. 10 ml of 0.25% ropivacaine or normal saline solution was infiltrated in each tract while
withdrawing the needle from renal capsule to the skin. Post-operative pain was assessed using
visual analogue scale (VAS) and dynamic visual analogue scale (D-VAS) during deep breathing
and coughing on a scale of 0-10 during the initial postoperative 24 hours. Rescue analgesia was
given in the form of injection tramadol 1.0 mg/kg intravenously when VAS > 4 and maximum up
to 400mg in 24 hours. Time to first rescue analgesic, number of doses of tramadol and total amount
of tramadol required in the initial postoperative 24 hours were noted. Patients were observed for
any side effect and treated accordingly.
*
MD, Professor.
** MD, DA. Prof. and Head of Department.
*** MD, Associate Professor.
**** Resident Doctor.
Affiliation: Department of Anaesthesia and Critical Care, Smt. K.M. Mehta and Smt. G.R. Doshi Institute of Kidney
Diseases and Research Center. Dr. H.L. Trivedi Institute of Transplantation Sciences. Civil Hospital Campus, Asarwa,
Ahmedabad-380016. Gujarat - INDIA.
Corresponding author: Dr. GEETA P. PARIKH, 28/ Yogashram Society, Near shyamal char rasta, Ahmedabad 380015.
Gujarat, INDIA. Tel: 09375525588. E-mail: [email protected]
149
M.E.J. ANESTH 22 (2), 2013
150
Parikh G. P. et. al
Results: VAS at rest (VAS) as well as during deep
breathing and coughing (DVAS) were significantly
lower in ropivacaine group during first 24 hours.
Mean time to 1st rescue analgesic in ropivacaine group
was longer (10.7±2.64 hours) as compared to control
group (2.05±1.44 hours) (P=0.0001). Mean number of
doses of tramadol in 24 hours in group-R were less
(2.25±0.51) than group-C (4.4±0.68) (P= 0.0001).The
mean total amount of tramadol in 24 hours in group-R
was significantly lower than group-C. Side effects like
nausea and vomiting and sedation were minimum and
non-significant in both groups.
Conclusion: Local anesthetic infiltration of 0.25
% ropivacaine along the nephrostomy tract is efficient
in alleviating post-operative pain after percutaneous
nephrolithotomy surgery. The number of doses and
total consumption of rescue analgesic were also
decreased in the initial postoperative 24 hours.
Conflict of interest: NIL.
Sources of financial support: NIL.
Key words: Percutaneous nephrolithotomy,
Post-operative pain, Ropivacaine, Ultrasound.
Introduction
The efficacy, safety and superiority of percutaneous
approach to manage large renal calculi have been well
established over the past two decades. Placement of
nephrostomy tube after percutaneous nephrolithotomy
(PCNL) is still considered a standard practice since not
all patients are candidates for a tubeless PCNL and thus
several investigations have focused on the impact of
reduced percutaneous catheter size on post-operative
pain, analgesic requirements and duration of cutaneous
drainage1. Even though analgesics such as NSAIDS
and opioids have been used for postoperative analgesia,
pain around nephrostomy tube can be distressing. Skin
infiltration of local anesthetic drug at surgical site is
not so effective. So we hypothesized that infiltration of
local anesthetic from the renal capsule to the skin along
the nephrostomy tract would relieve the postoperative
pain during the initial postoperative period.
The aim of present study was to investigate the
efficacy of peritubal infiltration of 20 ml of 0.25%
ropivacaine under ultrasonic guidance for postoperative
pain relief after PCNL and to assess the of number of
doses as well as total requirement of rescue analgesic
during the first postoperative 24 hours.
Methods
A prospective randomized double-blind
controlled study was conducted in 60 ASA physical
status I -III adult patients posted for PCNL surgery
after obtaining institutional ethics committee’s
approval and informed consent from each patient.
Patients were randomly divided in two equal groups
of 30 patients in each group. Group R is Ropivacaine
group (0.25 % ropivacaine infiltration) and group C
is Control group (normal saline infiltration). Patients’
inclusion criteria were 18 to 60 years of age, 35 to 85
kg of weight with BMI <30 kg/m2, renal stone size less
than 3.0 cm requiring a single nephrostomy tube (22
F) and a duration of surgery less than 3 hours. Patients
having supracostal puncture, excessive bleeding and
more than one puncture were excluded from the study.
In all patients, balanced general anesthesia was given
using fentanyl as a premedication in dose of 2 µg/
Kg intravenously during induction. Anesthesia was
induced with thiopentone sodium and succinylcholine.
Trachea was intubated with appropriate sized
endotracheal tube. Anesthesia was maintained with
N2O, O2, Isoflurane and Atracurium. PCNL surgery
was performed in the prone position. After insertion
of nephrostomy tube and before the extubation of the
patients, 23 gauge 90 mm spinal needle was inserted up
to renal capsule under ultrasonographic guidance along
the nephrostomy tube at 6and 12’ O clock positions. In
group R, 20 ml of 0.25% ropivacaine and in group C,
20 ml of normal saline was infiltrated (10 ml in each
tract ) while gradually withdrawing the needle from
renal capsule to the skin and infiltrating renal capsule,
perinephric fat, muscles, subcutaneous tissue and skin.
Patients were extubated and kept in post-anesthesia
care unit under observation for 24 hours.
During follow up, patients were assessed for pain
and side effects by an independent observer blinded
to the infiltration immediately after extubation,
and at 0.5, 1, 1.5, 2, 4, 6, 8, 12, 16, 20 and 24 hours
postoperatively. The pain score was assessed using
0-10 point visual analogue scale (VAS) at rest and
ULTRASOUND GUIDED PERITUBAL INFILTRATION OF 0.25% ROPIVACAINE FOR POSTOPERATIVE PAIN RELIEF
IN PERCUTANEOUS NEPHROLITHOTOMY
151
Table 1
Demographic Data
Parameters
Ropivacine group
(mean ± SD)
Control group
(mean ± SD)
P-Value
Age (Yrs)
43.9 ± 14.55
41.2 ± 11.94
0.435
Sex (male: female)
21:09
20:10
0.781
Weight (kg)
54.4 ± 9.18
62.5 ± 12.56
0.008
Duration of Surgery (Hrs)
1.45 ± 0.25
1.61 ± 0.32
0.678
dynamic visual analogue scale (DVAS) on deep
breathing and coughing where 0 means no pain and 10
means unbearable pain.
were compared using Chi-square analysis. P-values <
0.05 were considered to be statistically significant.
When VAS score > 4, the patient was given1 mg/
kg intravenous tramadol slowly as a rescue analgesia
and the patient was reassessed for pain. Maximum 400
mg of tramadol was allowed in the initial 24 hours.
Intravenous ondansetron was given if there was nausea
and vomiting. Nausea was scored as 0-3 where 0
means none and 3 means severe nausea while sedation
was scored as 0-3 where 0 means patient is awake and
alert and 3 means deep sleep. Time for 1st need of
rescue analgesic and duration of analgesia was noted.
Number of doses of tramadol and total consumption of
tramadol required in 24 hours were noted.
Results
Statastical Analysis
Sample size calculation was done on the basis
of total consumption of tramadol in 24 hours to
compare the effect of ropivacaine infiltrated along
the nephrostomy tract with control group. Power
analysis was performed. This analysis was based on
two samples with statistical significance of 0.05 and
90% power. The sample size required to detect the
standardized difference of 0.87 are approximately 56
(28 in each group). Considering rejection in the study,
we decided to take 30 patients in each group.
Sixty adult patients scheduled for PCNL
were enrolled in the study. There was no dropouts
or exclusions in the study. The demographic data
regarding age, sex and duration of surgery were
comparable and non-significant (Table-1). VAS (at rest)
and DVAS (during coughing and deep breathing) were
significantly lower in ropivacaine group than control
group (Fig. 1 and 2). The mean time for first demand
of analgesia was 10.7±2.64 hours in ropivacaine group
and 2.05 ± 1.44 hours in control group (P=0.0001).
The mean number of analgesic demands during initial
24 hours was 2.25± 0.51 in R group and 4.4± 0.68
in group C. The mean total consumption of tramadol
in 1st 24 hours was 123.2±30.16 mg in group R and
276.8±62.45 mg in group C. The side effects like
nausea and vomiting and sedation were non-significant
in both groups (Table-2).
Fig. 1
Mean VAS
Statistical Analysis was performed using
Statistical package of social sciences i.e. SPSS
version 12. Continuous data are described as mean +/standard deviation and categorical variables are given
as percentages. Continuous variables were compared
using t-test for two independent samples. Percentages
M.E.J. ANESTH 22 (2), 2013
152
Parikh G. P. et. al
Fig. 2
Mean dynamic VAS
Discussion
In PCNL surgery, the cause of post operative pain
is mainly due to nephrostomy tube which produces
local inflammatory reaction. So we designed to
infiltrate the nephrostomy tract by local anaesthetic
solution, ropivacaine because local anesthetic can
inhibit inflammatory and local sensitising responses
by directly suppressing some phases of inflammation
like neutrophil priming and by blocking some of the
neuronal pathways which are activated by inflammation
that is protein kinase C and G protein-coupled
receptors8. We compared this study with control group
and data assessed were post-operative pain score, time
to 1st demand analgesia, number of analgesic demand
and total requirement of rescue analgesic, tramadol
in first 24 hours. In our study, VAS and DVAS scores
of pain in ropivacaine group were significantly lower
as compared to saline group and correlates with the
studies of Dalela et al10, Jornavithula et al11, Gokten et
al12 and Ugras et al13. While Haleblian et al9 evaluated
the use of subcutaneous infiltration of 1.5 mg/kg of
0.25% bupivacaine after PCNL in 25 patients. Their
results did not showed significant difference in VAS
score and pain relief around nephrostomy site area after
PCNL surgery in the study group. It was postulated that
the cause for pain after PCNL surgery which requires
nephrostomy tube could result from structures beyond
the skin puncture site like the renal capsule. Dalela
et al10 performed PCNL under renal capsular block
by infiltrating renal capsule with 2% lignocaine in 11
patints.They used a numeric pain rating scale (NRS) to
quantitate the degree of pain. The NRS scores during the
initial 1.5 hours were <3 in all patients. In two patients
in whom the procedure extended beyond 1.5 hours, the
NRS scores were 6 and 7. They confirmed that most of
the pain during PCNL is felt at the time of dilatation
of renal capsule and parenchyma that is heavily
innervated by pain conducting neurons. Jornavithula
et al11 evaluated post-operative pain relief using 0.25%
bupivacaine infiltration along the nephrostomy tract
after PCNL under fluoroscopic guidance. The mean
VAS and DVAS scores for pain observed were IQR
of 5-7 and IQR 6-8 in control group while IQR of 2-5
and IQR 2-6 in the block group. Gokten et al12 did the
same study using 0.25% levobupivacaine infiltration
followed by intravenous paracetamol infusion. They
found lesser requirement of opioid, lower VAS score,
shorter time to full mobilization and higher patient
satisfaction score compared to the control group.
Ugras et al13 used 30 ml of either 0.02%
ropivacaine or saline instillation into renal puncture
site, nephrostomy tract and skin after PCNLin 34
Table 2
Comparison of Analgesic Requirements and Side Effects
Control group (mean
[95% CI])
(mean ± SD)
P-Value
10.7 ± 2.64
2.05 ± 1.44
0.0001
No. of doses of tramadol required in 24 hours
2.25 ± 0.51
4.4 ± 0.68
0.0001
Total consumption of tramadol in 24 hours (mg)
123.2 ± 30.16
276.8 ± 62.45
0.0001
Side effects
Vomiting – 1 (3.3%)
Nausea – 1 (3.3%)
Sedation – 1 (3.3%)
Vomitting-2 (6.6%)
Nausea-2 (6.6%)
Sedation-1 (3.3%)
0.554
0.554
Parameters
Ropivacine group
[95% C
(mean ± SD)
Mean time for 1st demand of tramadol (hrs)
(mean
ULTRASOUND GUIDED PERITUBAL INFILTRATION OF 0.25% ROPIVACAINE FOR POSTOPERATIVE PAIN RELIEF
patients. They assessed the effect of ropivacaine
infiltration on post-operative pain status and
pulmonary functions.. Their results showed that VAS
at 6 hours, time to first analgesic demand and total
analgesic need were significantly lower in ropivacaine
group.In our study, time to first rescue analgesia was
prolonged and number of analgesic demand as well
as total requirement of rescue analgesics in first 24
hours were decreased in ropivacaine group, which
were comparable with studies by Haleblian et al9,
Dalela et al10, Jornavithula et al11, Gokten et al12 and
Ugras et al13. In our study, incidence of side effects
like nausea vomiting or sedation were minimum and
comparable in both groups since all patients had post-
153
operative urinary catheter, urinary retention could not
be evaluated.
The limitation of our study was that it was not
performed in supracostal or multiple punctures or in
patients having stone size >3.0 cm. We also excluded
patients with BMI>30.
Conclusion
Local anesthetic infiltration with ropivacaine
along the nephrostomy tract from renal capsule to
the skin gives excellent postoperative analgesia and
significantly reduced rescue analgesic requirement
after percutaneous nephrolithotomy.
M.E.J. ANESTH 22 (2), 2013
154
Parikh G. P. et. al
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KETAMINE IMPROVES POSTOPERATIVE PAIN
AND EMERGENCE AGITATION FOLLOWING
ADENOTONSILLECTOMY IN CHILDREN.
A RANDOMIZED CLINICAL TRIAL
Mohammad Hossein Eghbal*, Shujaulhagh Taregh*,
Ayeh Amin** and Mohammad Ali Sahmeddini ***
Abstract
Background: Management of postoperative pain and emergence agitation following
adenotonsillectomy in pediatrics has been a major challenge for anesthesiologists. Although
analgesic sparing effect of ketamine has been studied during tonsillectomy in pediatrics, there
is a lot of controversy about its efficacy. Present study was designed to evaluate the effect of
intravenous low dose ketamine (0.25mg/kg) during induction of anesthesia on postoperative pain
and emergence agitation following adenotonsillectomy in children.
Methods: In this randomized clinical trial 66 children aged 5 to 15 years who underwent
elective adenotonsillectomy were randomly allocated into two groups. Patients in the control group
received 5ml of normal saline while patients in the ketamine group received 0.25 mg/kg of ketamine
in 5 ml volume during induction of anesthesia. After termination of surgeries and transferring the
patients to recovery, emergence agitation, pain score, paracetamol requirements and incidence of
postoperative nausea & vomiting were assessed every hour for 6 hours.
Results: Emergence agitation score was significantly lower in the ketamine group (P
=0.002). Pain score at all hours was lower in the ketamine group than the control group (P< 0.05).
The requirements for intravenous paracetamol were significantly lower in the ketamine group
(P=0.0036). There was no difference in the incidence of postoperative nausea and vomiting
between the two groups (P=0.99).
Conclusion: Low-dose ketamine during induction of anesthesia improves emergence
agitation and postoperative pain following adenotonsillectomy in children.
Conflict of interest: None.
Key words: Ketamine; Postoperative pain; Tonsillectomy; Children.
*
**
***
Assistant Professor of Anesthesiology, Shiraz Anesthesiology and Intensive Care Research Center.
Resident of Anesthesia, Shiraz Anesthesiology and Intensive Care Research Center.
Associate Professor of Anesthesiology, Shiraz Anesthesiology and Intensive Care Research Center.
Affiliation: Shiraz University of Medical Sciences, Shiraz, IRAN.
Corresponding author: Sahmeddini. Mohammad Ali. Shiraz Anesthesiology and Intensive Care Research CenterNemazi Hospital-Nemazi Sq-Shiraz-Fars-Iran. Tel and fax: +98711 6474270. E-mail: [email protected]
155
M.E.J. ANESTH 22 (2), 2013
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Eghbal M. H. et. al
Introduction
systemic during tonsillectomy in pediatrics14, there is a
lot of controversy about its efficacy15,16.
Adentonsillectomy is one of the most common
surgeries in pediatric age group1. This procedure is
usually associated with immediate moderate to severe
postoperative pain and agitation that causes bleeding2,
laryngospasm, and delays discharge from recovery3.
Traditionally opioids have been used for management
of pain that have many complications such as
respiratory depression specially in these patients with
edema at the operative site that may cause airway
obstruction and hypoxemia, nausea and vomiting and
even central sensitization4,5,6.
The aim of the present study is to determine the
effect of intravenous low dose ketamine (0.25mg/kg)
on postoperative pain score, needs to paracetamol as
a rescue analgesic following adenotonsillectomy in
pediatric patients.
Other analgesics recommended for control of
postoperative pain in adenotonsillectomy include
local anesthetics, nonsteroidal anti-inflammatory
drugs (NSAID) and N-methyl-D-aspartate receptor
antagonist7,8,9. Local anesthetics and NSAID are
associated with vasoconstriction and increased risk of
bleeding at site of operation respectively9,10. Ketamine
hydrochloride is a noncompetitive antagonist of
NMDA receptors11. In adult patients, it was found
that ketamine has both analgesic-sparing and
antisensitization effects12,13. Although analgesic sparing
effect of Ketamine has been studied both locally and
Fig. 1
Flowchart of the patients
according to the consort guidelines
Methods: In this double blind randomized
control trial, seventy pediatric patients aged 5 -15
years old who underwent elective adenotonsillectomy
were enrolled in this study. Patients with history of
convulsion, high intracranial pressure, common cold,
favism, congenital heart disease, hypersensitivity
to paracetamol or ketamine and pediatrics with
developmental or cognitive disorder were excluded
from the study. After our institutional board approval,
written informed consent was obtained from parents.
Eligible pediatric patients were randomly allocated in
two groups by computer base program, the ketamine
group and the control group (Figure 1).
Upon arrival of patient to operating room, routine
monitors including: blood pressure, electrocardiogram
and pulse oximetry were applied to all children.
Anesthesia was induced with intravenous sodium
KETAMINE IMPROVES POSTOPERATIVE PAIN AND EMERGENCE AGITATION FOLLOWING
ADENOTONSILLECTOMY IN CHILDREN. A RANDOMIZED CLINICAL TRIAL
thiopental 5-7mg/kg and 0.6mg/kg atracurium as
muscle relaxant. In the ketamine group, patients
received ketamine 0.25 mg/kg in 5 ml total volume
and in the control group, patients received physiologic
normal saline in 5 ml total volume. A nurse in
anesthesia prepared the ketamine and placebo drugs in
two identical 5 ml syringes. At induction of anesthesia,
an anesthesiologist unaware of the prepared drug
delivered the solution as per the allocation of the
patients to the relevant groups. After oral endotracheal
intubation, general anesthesia was maintained with
1.2% isoflurane, 50% N2O in oxygen and controlled
ventilation to maintain end tidal about CO2 30-35
mmHg. Adenotonsillectomy was done by dissection
by the same surgeon and upon the end of operation and
discontinuation of general anesthesia the patients were
transferred to recovery room and remained intubated
till became fully awake. Emergence from anesthesia
was recorded by same resident from anesthesia who
was blinded to the groups of patients. Emergence
agitation was assessed using a simple assessment scale
as follows: 1: asleep; 2: awake but calm; 3: agitated
but comfort; and 4: severely agitated and difficult to
comfort. Then pain score of both groups was assessed
ten minutes after extubation using the Baker-Wong
faces pain rating scale every one hour till six hours
after extubation. The Wong-Baker FACES Pain scale
is often useful for assessing pain in patients who do
not have ability to use language to describe pain. This
scale uses faces: Face 0 is very happy because he
doesn’t hurt at all. Face 2 hurts just a little bit. Face
4 hurts a little more. Face 6 hurts even more. Face 8
hurts a whole lot. Face 10 hurts as much as you can
imagine (Figure 2).
If pain score was ≥ 4 then patients received
15mg/kg intravenous paracetamol as rescue analgesic.
Postoperative nausea and vomiting (PONV) were
157
recorded every one hour during these six hours.
Vomiting was defined as the forceful expulsion of
gastric contents from the mouth and was brought about
by the powerful sustained contraction of the abdominal
muscle; nausea was defined as a subjectively
unpleasant sensation associated with awareness of the
urge to vomit.
Statistical analysis
By using the power static software collection
(SSC), sample size calculation was based on the
assumption that the primary end point was the number
of patients required paracetamol as a rescue analgesic
in postoperative period. Power calculations indicated
with a power of 80% and α level of 0.05, a sample
size for each group of at least 33 patients (total of
66patients) would detect a 50% reduction in number
of patients that required rescue analgesic drug during
the first 6 hours post operation.
The data were prospectively transferred into
a computer database for further analysis by SPSS
for Windows; Version 19.0 (SPSS Inc., Chicago, IL,
USA). Independent t-test and chi- square was used to
compare sex, weight, age between two groups. For
test hypothesis, chi-square, t test and Mann- Whitney
U were used. Data were reported as means± SD. The
statistical significance was considered at P<0.05.
Results
Sixty six pediatric patients undergoing elective
adenotonsillectomy, were randomly allocated to
the ketamine group (n=33) and the control group
(n=33). There were no significant differences in the
demographic variables in the two groups (Table 1).
Fig. 2
Wong-Baker FACES Pain Rating Scale
M.E.J. ANESTH 22 (2), 2013
158
Eghbal M. H. et. al
Table 1
Demographic data in both groups
Control Group(n=33)
Ketamine Group(n=33)
P Value
Age(Years)
8.24±3.07
9.12±3.29
0.07
Weight(Kg)
25.67±12.95
28.41±9.65
0.33
Sex(M/F)
20/13
19/14
0.80
The pain scores during the first 6 postoperative
hours were significantly lower in the ketamine
group compared to the control group (Figure 3). The
percentage of patients requiring paracetamol for
postoperative pain control was significantly lower in
the ketamine group compared to the control group
(Table 2).
Fig. 3
Postoperative pain intensity in the ketamine and control both
groups during six hours post-operation
Emergence agitation score: 1: asleep; 2: awake but calm; 3:
agitated but comfortable; and 4: severely agitated and difficult
to become comfortable. PONV: Postoperative nausea and
vomiting.
Furthermore emergence agitation was lower in
the ketamine group than the control group and this
differences were statistically significant between two
groups (P=0.002) (Table 2).
There was no significant difference between two
groups regarding incidence of the postoperative nausea
and vomiting (P=0.996) (Table2).
Discussion
The present study showed that intravenous low
dose ketamine (0.25 mg/kg) at induction of anesthesia
may reduce postoperative pain, reduce paracetamol
need as a recue analgesic, and reduce emergence
agitation.
Table 2
Postoperative emergence, nausea and vomiting, and
paracetamol use in both groups
Control
Ketamine P Value
Group(n=33) Group(n=33)
Agitation Score(1:2:3:4)
3:0:17:13
14:9:7:3
0.002
PONV
4(12.1)
5(15.1)
0.996
Paracetamol Use
(number of patients)
24(75%)
12(36.4%)
0.003
Abu-Shahwan showed that ketamine 0.25mg/
kg at induction time did not decrease postoperative
pain in pediatric patients undergoing tonsillectomy15.
Batra et al in another study found that postoperative
pain score after tonsillectomy in pediatric patients
was not decreased by small dose ketamine16.
However, all these studies used remifentanyl in the
maintenance of anesthesia which could have made
ketamine effective in reducing postoperative pain17.
DA Conceição et al reported that a single small dose
of ketamine (0.5mg/kg) in the pediatric patients
undergoing tonsillectomy could reduce postoperative
pain and use of rescue analgesia18. Likewise Murray et
al concluded that ketamine (0.5 mg/kg) was effective
in reducing postoperative pain in pediatric population
undergoing tonsillectomy19. In our study a further
decrease in the ketamine dose e (0.25mg/kg)
was effective in reducing postoperative pain
and in reducing rescue analgesic usage.
KETAMINE IMPROVES POSTOPERATIVE PAIN AND EMERGENCE AGITATION FOLLOWING
ADENOTONSILLECTOMY IN CHILDREN. A RANDOMIZED CLINICAL TRIAL
Emergence agitation in pediatric population
undergoing adenotonsillectomy remains a major
problem. Emergence agitation is reflected by self
aggressive movement during emergence of anesthesia
in recovery room20. Yoon Sook Lee et al found that
ketamine was effective in the prevention of emergence
agitation without delay in awakening and both subhypnotic doses of ketamine 0.25 and 0.5 mg/kg
were effective21. Also Kararmaz et al concluded that
oral ketamine was effective in reducing incidence of
emergence agitation22. Similarly in the present study
we showed that low dose ketamine (0.25mg/kg) is
effective in preventing of emergence agitation in
pediatric patients following adenotonsillectomy.
The incidence of postoperative nausea and
vomiting (PONV) after adenotonsillectomy is more
than 70% and may cause serious complications such as
pulmonary aspiration, hypoxemia, increase chance of
bleeding23,24 and may cause unplanned hospitalization
in 3-4.7% of patients25. This complication may result
from using opioids26,27. Hasnain et al in their study that
compared ketamine with morphine for management
159
of postoperative pain following tonsillectomy in
pediatrics reported that postoperative nausea and
vomiting in the ketamine group was significantly less
than the morphine group28. The other studies that used
low dose ketamine to decrease postoperative pain
showed that low dose ketamine did not increase the
incidence of PONV29,30. Similarly, the current study
showed that the incidence of PONV did not increase in
the ketamine group as compared to the control group.
In conclusion intravenous low dose ketamine
(0.25mg/kg) was effective in reducing postoperative
pain following adenotonsillectomy in pediatric patients,
in decreasing incidence of emergence agitation, and in
decreasing the incidence of PONV in these patients.
Acknowledgment
The present article was extracted from the thesis
written by AYEH AMIN and was financially supported
by Shiraz University of Medical Sciences grants
No: 3550.
M.E.J. ANESTH 22 (2), 2013
160
Eghbal M. H. et. al
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1. Oomen KP, Modi VK, Stewart MG: Evidence-based practice:
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2. Schommer MC: Improving the care of postoperative pain in
tonsillectomies. Soins Pediatr Pueric; 2012, 264:39.
3. Muninobpamasa T, Khamproh K, Mounghong G: Prevalence of
tonsillectomy and adenoidectomy complication at Phramongkutklao
Hospital. J Med Assoc Thai; 2012, 95:69.
4. Inci N, Basut O, Kasapoglu F, Coskun H: Management of pain
after tonsillectomy: a prospective, randomized clinical study. Kulak
Burun Bogaz Ihtis Derg; 2009, 19:1.
5. Brown KA, Laferriere A, Moss IR: Recurrent hypoxemia in young
children with obstructive sleep apnea is associated with reduced
opioid requirement for analgesia. Anesthesiology; 2004, 100:806.
6. Englelhardt T, Steel E, Johnston G, Veitch DY: Tramadol for
pain relief in children undergoing tonsillectomy: a comparison with
morphine. Paediatr Anaesth; 2003, 13:249.
7. Miniche S, Rmsing J Dahl JB, Tramer MR: Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after
tonsillectomy: a quantitative systematic review. Anesth Analg; 2003,
96:68.
8. Elia N, Tramer MR: Ketamine and postoperative pain – a
quantitative systematic review of randomised trials. Pain; 2005,
113:61.
9. Uzun B, Ozkiris M, Akbulut S, Unver S: The efficacy of
preoperative local bupivacain application on postoperative pain in
patients who had undergone tonsillectomy. Kulak Burun Bogaz Ihtis
Derg; 2009, 19:134.
10.Marret E, Flahault A, Samama CM, Bonnet F: Effects of
postoperative, nonsteroidal, anti-inflammatory drugs on bleeding
risk after tonsillectomy: meta-analysis of randomized, controlled
trials. Anesthesiology; 2003, 98:1497.
11.Clifford T: Ketamine for pain management. J Perianesth Nurs;
2012, 27:423.
12.De Kock MF, L Avand Homme PM: The clinical role of NMDA
receptor antagonists for the treatment of postoperative pain. Best
Pract Res Clin Anaesthesiol; 2007, 21:85.
13.Elia N, Tramer MR: Ketamine and postoperative pain – a
quantitative systematic review of randomized trials. Pain; 2005,
113:61.
14.D Al D, Celebi N, Elvan EG, Celiker V, Aypar U: The efficacy of
intravenous or peritonsillar infiltration of ketamine for postoperative
pain relief in children following adenotonsillectomy. Paediatr
Anaesth; 2007, 17:263.
15.Abu-Shahwan: Ketamine does not reduce postoperative morphine
consumption after tonsillectomy in children. Clin J Pain; 2008,
24:395.
16.Batra YK, Shamsah M, Al-Khasti MJ, Rawdhan HJ, Al-Qattan
AR, Belani KG: Intraoperative small-dose ketamine does not
reduce pain or analgesic consumption during perioperative opioid
analgesia in children after tonsillectomy. Int J Clin Pharmacol Ther;
2007, 45:155.
17.Yuan Y, Wang JY, Yuan F, Yu YH, Wang GL: Changes of glycogen
synthase kinase-3β and its phosphorylation in spinal cord neurons
in rats with incisional pain-remifentanil-induced hyperalgesia.
Zhonghua Yi Xue Za Zhi; 2012, 92:435.
18.Da Conceicao MJ, Bruggemann Da Conceicao D, Carneiro Leao
C: Effect of an intravenous single dose of ketamine on postoperative
pain in tonsillectomy patients. Paediatr Anaesth; 2006, 16:962.
19.Murrar WB, Yankelowitz SM, Le Roux M, Bester HF: Prevention
of post-tonsillectomy pain with analgesic doses of ketamine. S Afr
Med J; 1987, 72:839.
20.Uezono S, Goto T, Terui K, Ichinose F, Ishguro Y, Nakata Y,
Morita S: Emergence agitation after sevoflurane versus propofol in
pediatric patients. Anesth Analg; 2000, 91:563.
21.Yoon Sook Lee, Woon Young Kim, Jae Ho Choi, Joo Hyung
Son, Jae Hwan Kim, Young Cheol Park: The effect of ketamine
on the incidence of emergence agitation in children undergoing
tonsillectomy and adenoidectomy under sevoflurane general
anesthesia. Korean J Anesthesiol; 2010, 58:440.
22.Karamaz A, Kaya S, Turhanoglu S, Ozyilmaz MA: Oral ketamine
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24.Rawlison E, Walker A, Skone R, Thillaivasan A, Bagashw O:
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L, Douglas G, Brown C: Day stay pediatric tonsillectomy – a safe
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26.Mukherjee K, Esuvaranathan V Streets C, Johonson A, Carr As:
Adenotonsillectomy in children: a comparison of morphine and
fentanyl for peri-operative analgesia. Anaesthesia; 2001, 56:1181.
27.Allford M, Guruswamy V: A national survey of the anesthetic
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28.Hasnain F, Janabaz KH, Qureshi MA: Analgesic effect of ketamine
and morphine after tonsillectomy in children. Pak J Pharm Sci;
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29.Erk G, Omek D, Donmez NF, Taspinar V: The use of ketamine
or ketamine-midazolam for adenotonsillectomy. Int J Pediatr
Otorhinolaryngol; 2007, 71:937.
30.Elshammaa N, Chidambaran V, Housny W, Thomas J, Zhang
X, Michael R: Ketamine as an adjunct to fentanyl improves
postoperative analgesia and hastens discharge in children following
tonsillectomy - a prospective, double-blinded, randomized study.
Paediatr Anaesth; 2011, 21:1009.
USE OF THE BILATERAL BIS MONITOR AS
AN INDICATOR OF CEREBRAL VASOSPASM
IN ICU PATIENTS
Jess W. Brallier* and Stacie G. Deiner**
Abstract
Earlier diagnosis of cerebral vasospasm and delayed cerebral ischemia (DCI) and treatment
has the potential to decrease post-bleed morbidity after subarachnoid hemorrhage (SAH). Previous
studies have shown that electroencephalogram (EEG) can detect blood flow changes associated
with DCI sooner than other modalities potentially leading to earlier diagnosis. However, continual
monitoring with raw EEG requires significant expertise and effort, and may be difficult due to
the intermittent need for MRI studies in these patients. Here we describe a series of patients with
subarachnoid hemorrhage in the Neurosurgical ICU who underwent monitoring with the Bilateral
Bispectral Index (BIS) monitor.
Conflict of interest: None.
Sources of financial support: None.
Introduction
Subarachnoid hemorrhage (SAH) affects 30,000 Americans each year1. It is initially fatal in
33- 50% of cases2,3, with a large percentage of remaining patients suffering from late complications
due to rebleeding or cerebral vasospasm. Twenty to 40 percent of patients who survive the initial
hemorrhage will develop cerebral vasospasm which results in delayed cerebral ischemia (DCI).
Early diagnosis and treatment of is critical in preventing infarction4. Recognition of clinical
neurologic deterioration in the absence of hydrocephalus or rebleeding is often the first clinical
sign leading to a diagnosis of vasospasm1.
Current modalities used to diagnose cerebral vasospasm include transcranial Doppler (TCDs),
angiography, and several Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
techniques1. These diagnostic tools are invasive, require specially l trained personnel to administer,
*
**
Assistant Professor of Anesthesiology; Contribution: Conduct of study, Data analysis, and Manuscript preparation.
Assistant Professor of Anesthesiology, Neurosurgery, and Geriatrics; Contribution: Study Design, Conduct of study, Data
analysis, Manuscript preparation.
Affiliation: The Department of Anesthesiology, the Mount Sinai School of Medicine.
Corresponding author: Stacie Deiner MD, One Gustave Levy Place, New York, NY 10029. 3 East 101st Street (between
Madison and Fifth Avenue), 1st Floor, New York, NY 10029. Mailing address: Mount Sinai School of Medicine, One
Gustave L. Levy Place, Box 1075, New York, NY 10029-65749. Tel: 631 974 2444. E-mail: [email protected]
161
M.E.J. ANESTH 22 (2), 2013
162
and are not continual. There is electroencephalograghic
(EEG) evidence that blood flow related changes
associated with vasospasm precede clinical
deterioration by as much as two days5. However, the
use of continuous standard EEG is difficult because it
requires trained personnel, must be removed for follow
up MRI, etc...
We thought that processed EEG with BIS had
the potential to be very useful because uses a single
sensor on the forehead which can be removed and
reapplied, and the interpretation is simple. To this end
we performed a small case series utilizing bedside
monitoring with bilateral Bispectral Index (BIS)
(Aspect Medical Systems Inc., Newton, MA) as a
means to follow real time changes in processed EEG
patterns in SAH patients.
Methods
After IRB approval, written informed consent
was obtained from each subject or a legal surrogate.
All patients received standard intensive care unit
(ICU) monitoring with the addition of a bilateral
BIS probe applied within 48 hours of SAH. Left and
right BIS values were recorded every 12 hours until
discharge from the Neurosurgical ICU. Additionally,
Glasgow Coma Scale (GCS) scores and focal
Fig. 1
Divergent bilateral BIS
scores in a patient with
right-sided cerebral
vasospasm after SAH
and aneurysm clipping.
The BIS scores converge
after intraarterial
injection of verapamil
during angiography
Brallier J. W. et. al
neurologic deficits were recorded every 12 hours.
Modalities used to diagnose vasospasm included TCD,
angiography, MRI and CT. The formal diagnosis was
made by a neurointensivist using a combination of
modalities and clinical criteria. Bilateral BIS data was
analyzed for trends and correlated with clinical and
radiographic evidence of vasospasm as determined by
the neurointensivist.
Results
15 patients completed the protocol. The number
of days in the ICU ranged from 2 to 15. Five patients
had vasospasm diagnosed by a neurointensivist. In two
of these individuals there was significant divergence
between right and left BIS scores at the time of
vasospasm. During angiography in these patients,
selective injection of calcium channel blockers was
associated with a resolution of the discrepancy in
right and left BIS scores (Figure 1). Divergent BIS
scores also correlated with elevated unilateral TCDs
and cerebral infarction even when vasospasm was not
diagnosed. However, similar discrepancy between left
and right signals were episodically present at times
when patients did not have vasospasm, elevated TCDs,
or cerebral infarction (Figure 2).
USE OF THE BILATERAL BIS MONITOR AS AN INDICATOR OF CEREBRAL VASOSPASM IN ICU PATIENTS
163
Fig. 2
Divergent bilateral
BIS scores in a patient
without cerebral
vasospasm. The BIS
scores converge and
diverge in the absence
of vasospasm
Conclusions
Divergent BIS values between left and right side
of the brain seems to be a nonspecific and insensitive
indicator of cerebral vasospasm. Reasons for the mixed
results include: depressed level of consciousness from
the underlying condition or sedation may mask left and
right sided differences in EEG, spontaneous muscle
activity, electrical interference and patient movement.
In some cases it was likely that the spastic vessels
did not supply the frontal lobes thus making it unlikely
to detect a divergent BIS score.
The condition of DCI is more complex than just
vasospasm or decreased cerebral blood flow; cerebral
infarction correlates with the territory of angiographic
vasospasm in only 25% to 81% of SAH patients.
However, DCI correlates more closely with clinical
outcomes than the presence of vasospasm6. Interestingly
even in the absence of significant vasospasm, one sided
BIS score discordance may develop with infarction and
increasing pulsatility indices on TCDs. This suggests
that EEG is a sensitive indicator for blood flow but
may not capture the complexity of this more inclusive
definition of vasospasm for the reasons above.
There were some limitations in our observation
of the patients; BIS scores can fluctuate significantly in
a small time period, but for the purposes of this study
we recorded the value at a single time point and not
as error bars over a period of time. While it seems a
minor issue, many patients had significant headache
associated with their condition and did not wish to
wear the probe for a significant period of time.
Bilateral BIS may be a good indicator of
hemispheric changes in blood flow to the frontal lobes
and may be better suited for situations or procedures
where the frontal lobes are most likely to be affected
e.g. carotid endarterectomy. Use of the BIS monitor
in an ICU setting on awake patients is complicated
by discomfort, muscle activity, and movement. The
diagnosis of cerebral vasospasm after SAH continues
to be made via clinical signs, bedside Doppler, and
radiographic testing.
M.E.J. ANESTH 22 (2), 2013
164
Brallier J. W. et. al
References
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JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB,
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EFFECTS OF LIBERAL VS. CONVENTIONAL VOLUME
REGIMEN ON PULMONARY FUNCTION IN
POSTERIOR SCOLIOSIS SURGERY
Burkhard
Jennifer Niescery*, Nina Huhmann**,
Dasch*, Viola Bullmann***, Thomas Peter Weber****,
Martin Bellgardt* and Heike Vogelsang*
Abstract
Background: We observed an increased rate of pulmonary complications (hypoxemia,
pulmonary edema, re-intubation) in some patients after posterior spinal fusion, though standardized
intraoperative volume regimens for major surgery were used. Therefore, we focused on the effects
of two different standardized fluid regimens (liberal vs. conventional) as well as on two different
types of postoperative pain management (thoracic epidural catheter vs. intravenous analgesia)
concerning pulmonary function in patients undergoing posterior spinal fusion.
Methods: 23 patients received a conventional intraoperative fluid management (crystalloids
≈ 5.5ml/kg/h), whereas 22 patients obtained a liberal regimen (crystalloids ≈ 11ml/kg/h) during
surgery. After surgery a thoracic epidural catheter was used in 29 patients, whereas 16 patients
got a conventional intravenous analgesia. Regarding pulmonary outcome, the re-intubation rate,
the postoperative oxygen saturations as well as delivery volumes and retention times of pleural
drainages were evaluated.
Results: Patients with conventional intraoperative fluid management had a less frequent reintubation rate (p= 0.015), better postoperative oxygen saturations (p= 0.043) and lower delivery
volumes of pleural drainages (p= 0.027) compared to those patients with liberal volume regimen.
Patients with thoracic epidural catheter had improved oxygen saturations on pulse oximetry at the
first day after surgery (p<0.001) and lower delivery volumes of pleural drainages than patients with
intravenous analgesia (p= 0.008).
Conclusions: The combination of a more restrictive fluid management (better pulmonary
oxygen uptake and ventilation, less pulmonary edema) and a thoracic epidural catheter
(sympatholysis, pain management) in posterior spinal fusion may be advantageous as both factors
can improve pulmonary outcome.
Conflict of interest: No conflicts of interest are to be stated by the authors.
Sources of financial support: none declared.
*
**
***
****
MD, Department of Anesthesiology, St. Josef-Hospital, Ruhr-University Bochum, Germany.
MD, Department of Spine Surgery, St. Franziskus Hospital, Cologne, Germany.
MD, PhD, Professor; Department of Spine Surgery, St. Franziskus Hospital, Cologne, Germany.
MD, PhD, Professor; Department of Anesthesiology, St. Josef-Hospital, Ruhr-University Bochum, Germany.
Corresponding author: Mrs. Jennifer Niescery, Department of Anesthesiology, St. Josef-Hospital Bochum, Gudrunstr.
56, D-44791 Bochum, Germany. Tel.: +49-234-5093211, Fax: +49-234-5093209. E-mail: [email protected]
165
M.E.J. ANESTH 22 (2), 2013
166
Introduction
The adolescent idiopathic scoliosis is defined
as a lateral curvature of the spine with simultaneous
vertebral rotation that occurs in children aged 10 years
to maturity. Children undergoing posterior spinal
fusions are usually due to their young age in good
health condition, though the long duration of surgery,
the occasionally high blood loss and the considerable
damage of soft tissue are often accompanied by a
high peri- and postoperative morbidity. In particular,
pulmonary complications are frequent problems.
First, the patient’s prone position causes reduced lung
compliance and rising airway pressures1. Secondly,
a heaped incidence of atelectasis can occur, leading
to a ventilation-perfusion-mismatch with right-leftshunt and arterial hypoxia2. Thirdly, pulmonary
edema often occur as a result of arterial hypoxia and
intraoperative fluid replacements3,4. Therefore, a
lung protective intraoperative volume regimen is of
particular importance. Interestingly, at our institution
we observed an increased rate of re-intubations in
some patients after posterior spinal fusion, though
standardized volume regimens for major surgery
were used on a regular basis (restrictive-conventional
≈5ml.kg-1/h or liberal ≈10ml.kg-1/h). Hence, this study
focused on the effects of two different intraoperative
volume regimens concerning pulmonary outcome
(oxygen saturation, re-intubation rate, delivery volume
and retention time of pleural drainages) in patients
undergoing posterior spinal fusion.
Methods
Ethical approval for this study was provided by
the Ethical Committee (Registration: 2009-350-f-S,
University of Muenster).
We analyzed retrospectively 45 patients after
posterior spinal fusion in adolescent idiopathic
scoliosis. Data collected included patients’ age,
gender, body size and body weight, ASA physical
status classification, Cobb-angle, number of operated
segments, duration of surgery, duration of ventilation,
intraoperative volume regimen, postoperative pain
management (with or without thoracic epidural
catheter), oxygen saturation on pulse oximetry at the
Niescery J. et. al
first day after surgery (highest value throughout the
day), re-intubation rate, delivery volume and retention
time of pleural drainages as well as the length of ICU
stay. Older patients (> 25 years), patients with severe
scoliosis (Cobb angle > 100°) as well as patients with
any kind of pre-existing pulmonary disease, renal
disease or heart failure were excluded.
The posterior spinal fusions were performed by
surgeons from the Department of Orthopedics and
Tumor Orthopedics, Muenster University Hospital,
during the period 2003-2009. Data were collected from
the hospital information systems Medico//s (Siemens),
Centricity Critical Care (GE Medical Systems) and
Orbis (Agfa HealthCare), as well as from anesthesia
protocols and documentation in ICU.
Intraoperative management
For induction of general anesthesia Sufentanil
(Sufenta mite®, JANSSEN-CILAG GmbH, Neuss,
Germany; 0.5-2µg.kg-1) and Propofol (Propofol
Fresenius 1%®, Fresenius Kabi Austria, Graz,
Austria; 1.5-2.5mg.kg-1) were used. Muscle relaxation
was performed with Cis-Atracurium (Nimbex®,
GlaxoSmithKline Pharma, Vienna, Austria; 0.2mg/
kg). During surgery, all 45 patients received a balanced
anesthesia with Sufentanil (0.15-0.7µg.kg-1/h) and the
volatile anesthetic Sevoflurane (Sevorane®, Abbott,
Vienna, Austria; MAC 2.2%-2.8%).
Ventilation was volume-controlled with a tidal
volume of 7-8ml per kilogram body weight. The
inspiratory oxygen concentration was adjusted to
maintain the arterial oxygen partial pressure above 150
mmHg and the oxygen saturation per pulse oximetry​​
reached values above 95%. Each patient was ventilated
with a positive end-expiratory pressure of 5 cm H2O.
During surgery all patients received crystalloids
however with either restrictive-conventional approach
(5ml.kg-1/h) or liberal approach (10ml.kg-1/h). The
anesthesiologist’s decision for a more conventional or
more liberal intraoperative volume regimen depended
primarily on the clinical performance of the patient and
on the anesthesiologist’s preference. The total volume
of given crystalloids was heterogeneous, mainly
influenced by the patient’s body weight, duration of
surgery and intraoperative blood loss. Colloids, cell
EFFECTS OF LIBERAL VS. CONVENTIONAL VOLUME REGIMEN ON PULMONARY FUNCTION IN POSTERIOR
SCOLIOSIS SURGERY
saver blood, packed red blood cells (RBC) and fresh
frozen plasma (FFP) were given if necessary (distinct
hypovolemia, high blood loss and hemoglobin
concentration < 7mg/dl, coagulopathy). To ensure
that differences in pulmonary outcome didn’t appear
as a result of a higher blood loss, the hemoglobin
concentration was measured at least at the beginning
and at the end of surgery.
Pleural drainages were fit by surgeons in every
patient at the end of surgery. They were removed when
the residual flows were less than 150ml per day.
Postoperative management
After completion of surgery patients were brought
mechanically ventilated to the recovery room. The
Train of Four testing was performed in every patient
to measure the degree of neuromuscular blockade
before weaning started. Shortly before extubation
an arterial blood gas analysis was done to ensure an
adequate gas exchange. Extubation criteria included an
adequate respiratory rate (≥ 10/min) with a sufficient
tidal volume (> 5ml.kg-1), an adequate gas exchange
([PaO2/FIO2] ratio > 150-200) with a normal arterial
partial pressure of carbon dioxide during spontaneous
ventilation, an appropriate level of consciousness and
sufficient airway protective reflexes (cough, swallow).
Every patient received oxygen (2l / min) via a nasal
cannula directly after extubation for two hours.
Whenever oxygen saturation on pulse oximetry​​ was
< 95%, patients received oxygen again. Criteria for
re-intubation included an inadequate respiratory rate
(> 35/min), an impaired gas exchange ([PaO2/FIO2]
ratio < 150) with an arterial oxygen partial pressure
< 55mmHg and a PaCO2 > 60mmHg or rising levels
of PaCO2 > 10mmHg / h, as well as clinical signs of
dyspnea and increased work for breathing.
A thoracic epidural catheter (TEC) for
postoperative pain management and sympatholysis
was offered to every patient and fixed by the surgeons
before the wound was closed, so that its correct position
could be ensured. Patients obtained a mixture of 5ml
Bupivacaine and Sufentanil (Bucain®, Actavis Group,
Hafnarfjördur, Island; 0.175% and Sufenta mite®,
1µg.ml-1) per hour as soon as they left the recovery
room. Those patients who had to be reintubated or
167
rejected the TEC received a conventional intravenous
analgesia with Sufentanil (Sufenta mite®, 0.1-0.5µg.
kg-1/h) or Piritramid (Dipidolor®, Janssen - Cilag
Pharma, Vienna, Austria; 0.04-0.15mg.kg-1/h) and
Paracetamol (Perfalgan®, Bristol-Myers Squibb,
Vienna, Austria; 15mg.kg-1, 4x/day) for postoperative
pain management. Pain nurses ensured that no patient
had a pain score of ≥4 (out of 10) using a numerical
rating scale during their stay in hospital.
Statistical analysis
All statistical evaluations were performed using
the program IBM SPSS version 20. Categorical
patient characteristics were presented in frequencies
or percentages and continuous variables as mean ±
standard deviation. Categorical traits were checked
for independence from each other by using the chi square test according to Pearson or Fisher’s exact test
(cell size less than 5). Continuous variables were prior
to statistical analysis tested for normal distribution
by using the Kolmogorov - Smirnov - Test. Group
differences were either performed with the parametric t
test for independent samples or with the non-parametric
Mann-Whitney-Wilcoxon-test. The significance level
was set as a two-sided test with an error probability
less than 5% (p - value <0.05).
Results
1. Patient characteristics
Among the analyzed 45 patients were 12 men
and 33 women. They were 16.5 ± 2.9 years old, had
a body size of 168 ± 23 cm and a body weight of 58.5
± 9.69kg. All patients were of ASA-class I or II. The
preoperative average measured Cobb angle was 66
± 13°. The posterior fusion covered ordinary 8.7 ±
2.5 vertebrae with duration of surgery of 317 ± 119
minutes (Table 1).
2. Pulmonary function outcome
Patients who received a conventional
intraoperative volume regimen had a less frequent
re-intubation rate than those patients with a liberal
M.E.J. ANESTH 22 (2), 2013
168
Niescery J. et. al
Table 1
Patient characteristics
Conventional fluid regimen
n = 23
(5.5 ± 1.3ml.kg-1/h)
Liberal fluid regimen
n = 22
(11 ± 2.6ml.kg-1/h)
p-value
16.9 ± 3.53
16.1 ± 2.84
p= 0.438
6:17 (n = 23)
6:16 (n = 22)
Body size (m)
1.66 ± 0.39
1.70 ± 0.07
p= 0.632
Body weight (kg)
57.5 ± 9.77
59.4 ± 9.61
p= 0.514
ASA (Score)
1.45 ± 0.51
1.41 ± 0.51
p= 0.796
Cobb-angle (°)
66.8 ± 15.7
65.5 ± 10.2
p= 0.083
Operated segments
9.1 ± 3.28
8.4 ± 1.64
p= 0.37
Duration of surgery (min)
306 ± 111
327 ± 127
p= 0.559
Patient characteristics
Age (years)
Gender ♂:♀ (n)
Surgery
volume management (conventional: 0% vs. liberal:
22.7%; p= 0.015).
The postoperative oxygen saturation at the first
day after surgery was higher in the patients with a
conventional regimen compared to patients in the
liberal regimen (Table 2).
The need for oxygen therapy two hours after
extubation was higher in the liberal group, although the
difference was not statistically significant (Table 2).
The volumes of pleural drainages were lower
in patients with a more conventional regimen than
in those patients with a liberal volume management
(Table 2).
The patients’ stay in the ICU was not statistically
significant between the two groups (Table 2).
Patients with a TEC had improved oxygen
saturations at the first day after surgery compared
to those patients with a conventional analgesia,
statistically smaller volumes of pleural drainages, but
similar duration of ICU stay (Table 3).
Table 2
Intraoperative volume regimen and outcome
Conventional fluid regimen
n = 23
(5.5 ± 1.3ml.kg-1/h)
Liberal fluid regimen
n = 22
(11 ± 2.6ml.kg-1/h)
p-value
0
5
p= 0.015
Outcome
Re-intubated patients (n)
Need for oxygen therapy 2h after extubation (%)
39.1
50
p= 0.463
st
98.96 ± 1.19
97.59 ± 2.9
p= 0.043
Volume pleural drainage (ml)
661 ± 295
946 ± 514
p= 0.027
Length of ICU stay (days)
4.78 ± 1.45
5.45 ± 1.26
p= 0.104
Oxygen sat. 1 day after surgery (%)
EFFECTS OF LIBERAL VS. CONVENTIONAL VOLUME REGIMEN ON PULMONARY FUNCTION IN POSTERIOR
SCOLIOSIS SURGERY
169
Table 3
Postoperative pain management and outcome
TEC
n = 29
Intravenous analgesia
n = 16
p-value
6.8 ± 2.5
10.6 ± 3.5
p< 0.001
Outcome
Crystalloids during surgery (ml.kg-1/h)
Re-intubated patients (n)
0
5
p< 0.001
st
Oxygen sat. 1 day after surgery (%)
99.1 ± 0.94
96.9 ± 3.0
p< 0.001
Volume pleural drainage (ml)
674 ± 248
1028 ± 597
p= 0.008
Length of ICU stay (days)
4.55 ± 0.94
4.75 ± 1.39
p= 0.573
3. Intraoperative volume regime
The amounts of given colloids (conventional: 3.6
± 9.5ml.kg-1/h vs. liberal: 4.6 ± 11.5ml.kg-1/h; p= 0.75),
RBC units (conventional: 1.1 ± 0.5ml.kg-1/h vs. liberal:
0.8 ± 0.6ml.kg-1/h; p= 0.08) and FFP (conventional: 0.7
± 0.7ml.kg-1/h vs. liberal: 0.5 ± 0.7ml.kg-1/h; p= 0.34)
were similar in both groups. Accordingly, observed
blood losses were nearly identical (conventional: 1258
± 310ml vs. liberal: 1236 ± 295ml; p= 0,215). None
of the patients had a hemoglobin concentration of less
than 7.5g/dl or a hemoglobin difference of >4g/dl (prevs. postoperatively) after completion of surgery.
4. Postoperative management
Time till extubation (period between completion
of surgery and extubation) was slightly longer in the
conventional group, though the difference did not reach
statistical significance (conventional: 154 ± 54 min vs.
liberal: 114 ± 68 min; p= 0.06). Five patients who had
obtained a liberal intraoperative fluid management
developed some kind of respiratory failure (mainly
pulmonary edema) and had to be reintubated. Those
patients received diuretics and were transferred to the
ICU.
Discussion
Our data show that pulmonary outcome in young
patients undergoing spinal fusion can be improved by
using a conventional (5.5 ml/kg/h) versus a liberal (11
ml/kg/h) crystalloids infusion regimen.
The intraoperative volume management has
because of its diverse effects on the patients’ overall
morbidity a particular priority. Unfortunately, an ideal
volume management is difficult to achieve.
On the one hand, a high volume fluid
management (> 4-6 liters of crystalloids during
surgery apart from replacement of blood losses) in
major surgery is generally less advantageous as it may
lead to overhydration, including reduced pulmonary
functions and decreased cardiac output5. Reduced
pulmonary functions after isotonic saline infusions
occur even in healthy volunteers, as infusions of 1
liter crystalloids decrease functional residual capacity,
reduce diffusing capacity and can lead to an increase
in pulmonary blood-flow6. This higher blood flow
through pulmonary capillaries increases pulmonary
vascular pressure and is associated with increasing
fluid transudation, resulting finally in impaired gas
exchange7. Furthermore, rapid crystalloid infusions
can cause mild airflow obstruction, thus resulting
probably from airway wall edema on the bronchial
lumen8. Therefore, it is not surprising that patients
undergoing major posterior scoliosis surgery are at
high risk for developing pulmonary complications
such as pulmonary edema or hypoxemia. Additionally,
impaired cardiac output can occur, as high fluid
regimens may generate a shift to the right on the
Starling myocardial performance curve, resulting in a
depression of ventricular function, leading secondary
to fluid accumulation in the lungs5.
On the other hand, restrictive fluid regimens are
M.E.J. ANESTH 22 (2), 2013
170
often equally complicated. Again, the Frank-Starling
mechanism is of importance, as hypovolemia results
in a shift to the left on the Starling performance curve,
caused by decreased ventricular filling (preload),
which impairs the cardiac output. This reduced
cardiac output is accompanied by increased plasma
norepinephrine (stress response) and declined mean
arterial pressure (clinical signs of hypovolemia)9.
Additionally, dehydration from preoperative fasting
and intraoperative blood losses have to be corrected.
Summarized, there are still no data concerning a
pulmonary protective intraoperative volume regimen
in adolescent idiopathic scoliosis surgery.
In this study patients in the conventional group
received significantly less crystalloids than those in
the liberal group. We assume that the better pulmonary
outcome of patients in the conventional group (less
frequent re-intubation rate, better postoperative
oxygen saturation at the first day after surgery,
lower delivery volumes of pleural drainages) can be
primarily explained by avoidance of fluid overload
and less pulmonary edema. We furthermore suppose
that the tendency of prolonged mechanical ventilation
after surgery in the conventional group (conventional:
154 ± 54 min. vs. liberal: 114 ± 68 min.) might have
additional lung protective effects by faster elimination
of intraoperatively formed atelectasis (ventilation with
PEEP).
Several studies reported improvement in
pulmonary function in patients receiving TEC after
surgery compared to patients with intravenous
analgesia. Movafegh and Tenenbein showed that
patients with TEC had significantly better lung
functions reflected by forced expiratory volume in 1
second (FEV1) and FEV1/FCV (FEV 1/forced vital
capacity) compared to patients receiving conventional
analgesia within the first two days after surgery and
less atelectasis already four hours after suregry10,11.
Our data show that other pulmonary functions such as
SpO2 and rate of re-intubation can also be improved
with the use of TEC while maintaining adequate
analgesia.
Effects of TEC include sympatholysis and
reduced activations of physiological stress responses.
It was previously shown that epinephrine and cortisol
Niescery J. et. al
concentrations under combined anesthesia (patients
with TEC) were considerably lower during surgery
compared to general anesthesia without TEC12.
These higher concentrations of catecholamines,
glucocorticoids as well as proinflammatory cytokines
may potentially lead to an upregulation of sodium
channels, which are involved in the pathogenesis of
pulmonary edema13. Therefore, the smaller volume of
pleural drainages with TEC could also be explained
by lower stress responses and less inflammatory
reaction.
Most likely, the intraoperative volume
regimen is the most important factor for pulmonary
function outcome after posterior scoliosis surgery.
Nevertheless, a TEC should be seen as “gold standard”
for postoperative pain management in posterior spinal
fusion as it might have additional lung protective
effects.
There are two limitations that need to be
acknowledged and addressed regarding the present
study. One limitation was the relatively small sample
size (n = 45). Although posterior spinal fusions were
performed regularly, we had to exclude all patients with
structural pulmonal or cardiac disorders, with severe
scoliosis (Cobb angle > 100°), those patients with an
ASA Score ≥3 as well as all patients whose scoliosis
didn’t result from adolescent idiopathic scoliosis in
order to ensure comparability. Nevertheless, significant
differences between the groups could be detected
although the sample size of this study is small.
The second limitation concerns the selectivity
of observed lung protective effects, since 20 patients
with a TEC received a more restrictive volume
regimen, whereas 9 patients obtained a liberal
volume management. Additionally only 5 out of 16
patients with a conventional analgesia got a restrictive
intraoperative volume regimen. It must be considered
that high volume fluid regimens do not always cause
pulmonary complications, though they can probably
make them worse.
In summary, our results indicate that the
combination of a more restrictive fluid management and
a TEC in posterior spinal fusions may be advantageous
as both factors can improve pulmonary outcome even
in young and generally healthy patients.
EFFECTS OF LIBERAL VS. CONVENTIONAL VOLUME REGIMEN ON PULMONARY FUNCTION IN POSTERIOR
SCOLIOSIS SURGERY
171
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and Madhkhan S: Post-thoracotomy analgesia-comparison epidural
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M.E.J. ANESTH 22 (2), 2013
EFFECT OF PREOPERATIVE LICORICE
LOZENGES ON INCIDENCE OF POSTEXTUBATION
COUGH AND SORE THROAT IN SMOKERS
UNDERGOING GENERAL ANESTHESIA
AND ENDOTRACHEAL INTUBATION
Diyva Gupta*, Sanjay Agrawal**,
and J agdish P. S harma ***
Abstract
Introduction: Post-Operative Sore Throat (POST) is an undesirable side effect of endotracheal
intubation. Pharmacological and non-pharmacological measures have been utilized for minimizing
the morbidity caused by POST. We have tested whether medicated lozenges of Licorice provides
efficacy in decreasing POST in smokers presenting for surgery under general anesthesia with
endotracheal intubation.
Methods: 100 patients, 20 - 65 years, American Society of Anaesthesiologists (ASA) physical
status Grade I & II, of either sex, with history of smoking, and posted for elective surgical procedure
lasting more than one hour and requiring general anesthesia with endotracheal intubation were
included and randomly divided into two groups (n= 50) to receive Licorice lozenges (Group A)
and Sugar Candy (Group B). The patients were assessed for cough, sore throat and hoarseness of
voice immediately after extubation and then at 30 min, 12 hrs and 24 hrs after extubation utilizing
scoring system of Harding and McVey.
Results: Overall incidence of postextubation cough was less in Group A (12patients, 24%)
compared to Group B ( 26 patients,52%) (p= 0.002). Magnitude of sore throat (Grades 0/1/2/3) was
seen in 48/2/0/0 patients (Group A) and 46/4/0/0 (Group B) at extubation (p= 0.40) and 34/16/0/0
(Group A) and 28/20/2/0 (Group B) at 30 min (p= 0.17). At 12 and 24 hours, the magnitudes of
sore throats were 24/25/1/0 (Group A) & 12/38/0/0 (Group B) (p=0.02) and 26/23/1/0 (Group A)
& 15/35/0/0 (Group B) (p= 0.03) respectively.
Conclusion: Use of licorice lozenges is efficacious for reducing the distressing complaint of
POST in postoperative period among smokers.
Key words: POST, lozenges, Licorice.
*
Assistant Professor.
**
Associate Professor.
***Professor.
Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun, India.
Corresponding author: Dr. Sanjay Agrawal, Associate Professor, Department of Anesthesia, Himalayan Institute of
Medical Sciences, Swami Ram Nagar, Dehradun, India. E-mail: [email protected]
173
M.E.J. ANESTH 22 (2), 2013
174
Gupta D. et. al
Introduction
The symptoms of postoperative pharyngeal
dryness, throat pain, uncoordinated / inability / pain
on swallowing associated with cough and hoarseness
of voice is commonly termed as Postoperative Sore
Throat (POST)1. Tracheal intubation has been found
to be the foremost cause of POST2 with an incidence
of 21- 65%3,4. Chronic smoking is associated with
inflammation of tracheal mucosa secondary to effects
of substances in cigarette smoke, leading to increased
respiratory problems in perioperative period. These
patients have an increased incidence of POST5. Various
techniques have been utilized to decrease the incidence
of POST. Use of licorice gargles 5 minutes before
induction of anaesthesia are effective in decreasing
the incidence of POST by 50%6. Lozenges of licorice
are available for management of sore throat associated
with pharyngitis due to varied causes in traditional
Indian medicine. Such lozenge contains a lower
dosage of licorice and has been found efficacious for
management of pharyngitis.
In this study, we evaluated the effectiveness of
low dose licorice lozenges for decreasing the incidence
of POST in smokers undergoing surgery under general
anesthesia and endotracheal intubation.
Methods
This randomized placebo controlled study was
conducted between March 2012 and August 2012 at
Himalayan Institute of Medical Sciences. Institution
Ethical Committee review was obtained and written
informed consent of patients were taken. 100 patients,
of either sex, 20-65 years of age, American Society
of Anesthesiologists(ASA) physical grade I and II,
posted for elective surgical procedures lasting more
than one hour, and requiring general anesthesia and
endotracheal intubation were included. Exclusion
criteria included surgeries lasting less than one hour,
anticipated difficult intubation, Mallampatti Grade
III and IV, pregnancy, Body Mass Index > 30 kg/m2,
surgeries requiring insertion of Ryles’ tube, throat
packing or rapid sequence intubation, history of upper
respiratory tract infection, gastroesophageal reflux
disease, asthma and significant cardiovascular disease.
The patients were divided into 2 groups by
sealed envelope technique to receive Licorice lozenges
(Sualin; Hamdard Pharma, India) (Group A) and Sugar
Candy (Dabur India Limited) (Group B). All patients
were asked to refrain from smoking for 48 hrs prior
to surgery and were asked to suck (and not chew) the
lozenges as per group allotment, 30 minutes prior to
expected induction of anesthesia. Before shifting to
operating room (OR), it was ensured that any leftover
lozenges was not present in oral cavity. In the OR
after establishing intravenous (i.v.) access, standard
monitoring electrocardiogram (ECG), non - invasive
blood pressure (NIBP) and pulse oximetry (SpO2)
were attached. Induction of anaesthesia was achieved
with injection (inj.) fentanyl 2 mcg/kg and inj. propofol
2 mg/kg till loss of verbal contact. Ease of mask
ventilation was confirmed and neuromuscular blockade
was achieved with inj. vecuronium 0.1mg/kg. Patients
were ventilated with 66% nitrous oxide in oxygen
and isoflurane for 3 minutes. Endotracheal intubation
was completed using size 3 Macintosh curved blade
and a high volume low pressure cuffed endotracheal
tube (Portex, Smiths Medical International Limited,
UK ) of size 7-7.5 for females and 8-8.5 for males.
The tube size selection was at the discretion of single
anaesthesiologist with an experience of > 5 years.
Duration of laryngoscopy and number of attempts for
intubation was noted. The cuff of endotracheal tube
was filled with air to maintain cuff pressure ≤ 25 mm
of Hg as assessed periodically in the intraoperative
period utilizing Portex Cuff Manometer (Smiths
Medical International Limited, Germany).
Anesthesia was maintained with 66% nitrous
oxide in oxygen, isoflurane, intermittent boluses
of inj. vecuronium and inj. fentanyl. Last dose of
opioids was administered at least 30 minutes prior
to expected extubation and inj. Diclofenac Sodium
75 mg (Dynapar AQ, Troikka Limited, India) in 100
ml normal saline was administered 20 min prior to
expected extubation. Isoflurane was switched off 10
minutes prior to extubation. Neuromuscular paralysis
was reversed with inj. Neostigmine(0.05 mg/kg) and
inj. Glycopyrrolate(0.01 mg/kg). With resumption of
spontaneous respiration, nitrous oxide was switched
off and patients were made to breath spontaneously
with 100 % oxygen. Gentle oral suction was done
once and patients were extubated. Care was taken to
avoid bucking on endotracheal tube and too harsh or
repeated suctioning was not allowed. The patients
EFFECT OF PREOPERATIVE LICORICE LOZENGES ON INCIDENCE OF POSTEXTUBATION COUGH AND SORE
THROAT IN SMOKERS UNDERGOING GENERAL ANESTHESIA AND ENDOTRACHEAL INTUBATION
Software, IBM Corporation Amrok, New York).
Results are presented as mean ± standard deviation
(SD) for parametric data and as percentage (%) for
non-parametric data. Analysis of variance (ANOVA)
was used to analyze the continuous data while nonparametric data was compared by using Chi-square
test (χ2). Mann - Whitney test was applied to compare
the independent groups considering mean of sum of
ranks. p value of < 0.05 was considered significant.
were assessed for cough, sore throat and hoarseness
of voice at extubation, 30 min, 12 hrs and 24 hrs postanesthesia by framing the questions in the local dialect
and language of the patients,utilizing the scoring
system of Harding and McVey (Table 1)7.
Table 1
Scoring system of Harding and McVey
Sore throat
No sore throat at any time since the operation
Minimal sore throat (Complains of sore throat only
on asking)
Moderate sore throat (Complains of sore throat on his
/ her own)
Severe sore throat (Complains of throat pain)
Cough
No cough at any time since the operation
Minimal cough or scratchy throat (Light or single
episode of cough)
Moderate cough (more than one episode of nonsustained cough)
Severe cough (Sustained and repetitive cough with
head lift)
Hoarseness
No evidence of hoarseness at any time since the
operation
No evidence of hoarseness at the time of interview
Hoarseness at the time of interview noted by patient
only
Hoarseness that is easily noted at the time of interview
175
Score
0
1
Results
2
The patients in both groups were comparable
in their demographic profile (Table 2). Intubation
characteristics such as duration of laryngoscopy
(DOL), number of intubation attempts, duration of
surgery (DOS) and duration of anaesthesia (DOA)
were also comparable (Table 3).
3
Score
0
1
Table 2
DEMOGRAPHIC PROFILE
2
Criteria
3
Score
0
1
2
3
Sample size was calculated on the basis of
previous studies6. Presuming the reduction in
incidence of POST by 50%, α error of 5% and power
of 80%, 46 patients were needed in each group. So,
50 patients were selected in each group. Statistical
analysis was performed using SPSS version 19 (SPSS
Group A
Group B
p value
Number (n)
50
50
--
Male: Female
45:5
46:4
0.12
ASA I/II
46 / 4
41 / 9
0.46
Age(yr) (Mean±SD)
39.48±11.15
41.60±14.63 0.87
Range of Age (yr)
20 – 65
20 - 65
--
Weight (kg) (Mean±SD) 57.20±11.65
61.08±9.86
0.12
Range of Weight (kg)
45 - 85
--
40 – 80
12 patients (24%) in Group A and 26 patients
(52%) in Group B had cough of grade 1 at extubation
(p=0.002). Only 1 patient in Group B complained of
cough at 12 hrs and 24 hrs postoperatively (p > 0.05)
(Table 4).
Table 3
INTUBATION CHARACTERSTICS
Criteria
Group A
Group B
p value
DOL (sec) (Mean±SD)
11.00±3.64
10.56±3.11
0.68
No. of Attempts (1 / 2)
44 / 6
45 / 5
0.44
DOA (min) (Mean±SD)
149.00±51.67
156.00±62.825
0.70
DOS (min) (Mean±SD)
125.60±50.24
131.80±61.60
0.69
DOL: duration of laryngoscopy; DOA: duration of anesthesia; DOS: duration of surgery
M.E.J. ANESTH 22 (2), 2013
176
Gupta D. et. al
Table 4
COUGH IN SMOKERS
At Extubation
At 30 Min
At 12 Hrs
At 24 Hrs
Scores
Scores
Scores
Scores
Cough
Group A
Group B
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
n
38
12
0
0
50
0
0
0
50
0
0
0
50
0
0
0
%
76
24
0
0
100
0
0
0
100
0
0
0
100
0
0
0
n
23
26
1
0
50
0
0
0
49
1
0
0
49
1
0
0
%
46
52
2
0
100
0
0
0
98
2
0
0
98
2
0
0
p value*
* Mann-Whitney test
0.002
1.00
0.31
0.31
Agrawal et al in their study have utilized a dosage
of 0.5 g as gargle 5 minutes prior to intubation6. Similarly
Sessler et al have also demonstrated effectiveness of
licorice gargle for attenuation of POST. In contrast, we
have utilized lozenges of licorice which contained only
97mg of licorice. Secondly, the time of administration
was 30 minutes prior to intubation compared to 5
minutes in other studies. Only two studies are available
in literature showing the effectiveness of lozenges
for decreasing the incidence of POST: one utilizing
Strepsils lozenges8 and other being magnesium
lozenges9. To our knowledge, our study is probably the
only study where effectiveness of lozenges of licorice
is evaluated for decreasing the incidence of POST.
We evaluated the incidence of sore throat utilizing
the scale as derived by Harding and McVey which is
a more subjective assessment of the symptomology
while the majority of the other studies have utilized
VAS as the tool for measuring POST. The etiology of
POST is multifactorial with incidences ranging from
0-50%10,11,12,13,14 to as high as 100%15,16,17,18,19, 20. The
method and type of airway instrumentation is the single
most influential factor in development of pharyngeal
complication21. Patient related factors such as female
Complaint of sore throat was present at all times
with the lowest, incidence being at extubation and at
30 min postoperatively (p>0.05). At 12 hrs, scores
of 0/1/2 were present in 24 (48%), 25 (50%), 1(2%)
(Group A) and in 12 (24%), 38 (76%), 0 (0%) (Group
B) (p=0.02). Scores at 24 hrs were 26 (52%), 23 (46%),
1 (2%) (Group A) and 15 (30%), 35(70%), 0 (0%)
(Group B) (p=0.03). There was an overall reduction in
severity of sore throat in group A except for 1 patient
who complained of persistent sore throat of Score 2 up
to 24 hours (Table 5).
None of the patients complained of hoarseness of
voice at any time of observation.
Discussion
Our study demonstrated that preoperative use
of licorice lozenges is effective in decreasing the
incidence of postextubation cough and sore throat. This
study differs from previous reports of effectiveness of
licorice in the following ways: dosage, formulation
and time of administration.
Table 5
SORE THROAT IN SMOKERS
At Extubation
At 30 Min
At 12 Hrs
At 24 Hrs
Scores
Scores
Scores
Scores
Sore Throat
Group A
Group B
p value*
n
%
n
%
0
48
96
46
92
1
2
4
4
8
0.40
2
0
0
0
0
3
0
0
0
0
0
34
68
28
56
1
16
32
20
40
0.17
2
0
0
2
4
3
0
0
0
0
0
24
48
12
24
1
25
50
38
76
0.02
2
1
2
0
0
3
0
0
0
0
0
26
52
15
30
1
23
46
35
70
0.03
2
1
2
0
0
3
0
0
0
0
EFFECT OF PREOPERATIVE LICORICE LOZENGES ON INCIDENCE OF POSTEXTUBATION COUGH AND SORE
THROAT IN SMOKERS UNDERGOING GENERAL ANESTHESIA AND ENDOTRACHEAL INTUBATION
sex, younger age groups, gynecological surgeries, use
of succinylcholine for intubation, history of smoking
or lung disease all predispose to POST2,14.
Smokers
develop
laryngeal
epithelial
inflammation, metaplasia and dysplasia due to
chronic irritation by substances in cigarette smoke.
This impairs laryngeal integrity and function causing
greater exposure of subepithelial airway receptors to
stimuli22. Erskine et al evaluated airway reflexivity
to chemical and mechanical stimulations. Tracheal
intubation results in stretch stimulation of trachea
leading to respiratory complications23.
Various pharmacological and non – pharmacological modalities are utilized to decrease the incidence
of POST. Use of smaller size tube, avoidance of
nitrous oxide, maintaining intracuff pressure <25 mm
of Hg, careful instrumentation and intubation after
full neuromuscular blockade have all been found to
prevent POST24. Similarly use of lubricants, gargles
or medications in preoperative period have also been
found to decrease the incidence of POST.
Licorice is extracted from the plant Glycyrrhiza
glabra Linn and has been used in traditional
medicine worldwide for the treatment of ailments of
respiratory tract, digestive tract, hepatitis and cancer.
Licorice consists of a number of active ingredients
such as glycyrrhizin, glycyrrhizic acid, liquilitin,
liquiritigeninglabridin, and hispaglabridins25. Antiinflammatory and antiallergic properties are due to
glycyrrhizin26. while glycyrrhizic acid decreases the
inflammatory process by inhibiting cyclooxygenase
activity, prostaglandin formation, and inhibition of
platelet aggregation27. Liquilitin and liquiritigenin
have peripheral and central antitussive properties28.
Glabridin has significant antioxidant and ulcer-healing
properties which might be helpful in minimizing the
extent of ischemic injury to the pharyngeal and tracheal
177
mucosa and expedite their healing29.
Side effects of the use of licorice have
been reported. Prolonged use is associated with
pseudoaldosteronism30,31
hypertension32,33
and
34,35
hyperkalemia . Liquorice extract and glycyrrhizin
have also been reported to induce changes in
Cytochrome P450 linked activities resulting in
accelerated metabolism of co-administered drugs and
adverse effects due to change in cytochrome profiles
such as toxicity/ cytotoxicity36. In the current study, no
side effects were reported as a once and low dose of
licorice was used in the study group.
Shortcomings of our study were the absence of
patients’ blinding as patients were able to recognize the
taste of these commonly available lozenges. Also, we
didn’t assess the incidence of POST at other shorter times
post operatively (e.g. 4-8 hours) Another shortcoming
was not categorizing the patients according to the
number of pack years of smoking. Does this influence
the incidence and severity of POST needs to be further
studied? Moreover relation between type of surgery and
intraoperative position of patient with the incidence of
POST was also not taken into consideration.
A further study investigating use of licorice lozenges
for prevention of POST in surgeries requiring Ryles tube
insertion, pharyngeal packing, surgeries in positions other
than supine, LMA insertion, intubation by anesthesiology
residents could give an idea of its further effectiveness in
different clinical situations and conditions.
Conclusion
Incidence of post intubation cough and sore throat
can be decreased with the preoperative use of one
licorice lozenge. This low dose serves as an effective,
cost limited and ready to use method for decreasing the
distressing symptoms of POST.
M.E.J. ANESTH 22 (2), 2013
178
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success of ultrasound guided popliteal
Sciatic Nerve catheters is not influenced
by nerve stimulation
Christopher B. Robards*, Steven B. Porter*,
Ilana Logvinov** and Steven R. Clendenen*
Abstract
Background: There is debate as to whether nerve stimulation (NS) is required to place
peripheral nerve catheters when using ultrasound (US) guidance. There is conflicting evidence
for whether stimulating catheters improve postoperative analgesia compared to non-stimulating
catheters. The use of US in combination with NS has been shown to be superior to NS alone in
terms of popliteal nerve blockade. Given the previously published reports, we hypothesized that
there is improvement in sensory and motor blockade for stimulating popliteal perineural catheters
placed under US guidance when NS is used.
Methods: Following IRB approval, 21 patients undergoing elective foot and ankle surgery
were randomly assigned to either a US or US+NS-guided continuous popliteal sciatic nerve block
using a lateral approach. The primary end-point of the study was successful nerve blockade at 20
minutes. Secondary end-points included: block performance time, minimum stimulating current,
pain scores on postoperative day 1 and day 2, and patient satisfaction.
Results: There was no significant difference in successful nerve blockade at 20 minutes in the
US versus US+NS groups (73% vs. 80%, p=1). Procedure time was significantly shorter in the US
only group (median 62 seconds vs. 130.5 seconds, p<0.01). Postoperative pain scores and overall
patient satisfaction were not significantly different between the two groups.
Conclusion: We have found that the addition of NS provides no benefit over US alone. US
alone was associated with a significantly shorter block performance time. US+NS showed no
significant difference in pain control, patient satisfaction, or block success.
Conflict of interest: The authors have no conflicts of interest to declare.
Sources of financial support: This project received no internal or external funding.
Key words: postoperative analgesia; popliteal sciatic nerve block; ultrasound; nerve
stimulation; foot and ankle surgery.
*MD.
**RN.
Department of Anesthesiology, Mayo Clinic, Jacksonville, FL.
Corresponding author: Christopher B. Robards, MD, Assistant Professor, Mayo Clinic, 4500 San Pablo Road,
Jacksonville, FL 32224, USA. Tel: 904-956-3327, Fax: 904-956-3332. [email protected]
179
M.E.J. ANESTH 22 (2), 2013
180
Introduction
There is debate as to whether nerve stimulation
(NS) is required to place peripheral nerve catheters
when using ultrasound (US) guidance. US guidance
has been shown to improve the onset, decrease the
amount of local anesthetic required, and improve the
quality of peripheral nerve blockade1,2. There is also
information that indicates nerve block needles can
have an intimate relationship with a nerve (including
intraneural needle tip location) and fail to elicit an
appropriate motor response3,4. Furthermore, there is
conflicting evidence as to whether stimulating catheters
improve postoperative analgesia when compared to
non-stimulating catheters1,5,6. There is also evidence
that US in combination with NS is superior to NS
alone when performing popliteal nerve blockade7.
In a recent study, when combined with NS, US was
shown to increase block success compared to NS alone
during popliteal sciatic nerve blockade8. Given the
previously published data, we hypothesized that there
is improvement in sensory and motor blockade for the
placement of stimulating catheters for popliteal sciatic
nerve block when NS is combined with US guidance.
Methods
Following institutional board review approval,
full description of the study, and informed consent, 21
volunteers (male or female, age greater than 18 years)
scheduled for foot or ankle surgery were assigned
to receive a US-guided continuous popliteal sciatic
nerve block using a lateral approach. Randomization
of the two arms of the study was performed via
sealed envelopes. Based on previous studies7,8 and
the experience of the research team, it was felt that a
reasonable estimate for the rate of complete blockage
for catheters placed without nerve stimulation would
be approximately 70%. An absolute increase of 15%
in the successful block rate is considered clinically
significant. The detection of this increase with 80%
power, using a chi-square test at the at the α=0.05
le.vel, will require 58 participants per group. Thus,
we proposed to enroll a total of 120 participants All
volunteers received an intravenous catheter and an
infusion of Lactated Ringer’s solution. Pateints were
Robards C. B. et. al
sedated using a combination of midazolam (2-5
milligrams) and fentanyl (50-250 micrograms). Under
US guidance, the sciatic nerve was identified at the point
where the nerve divides into its two components, the
tibial (TN) and common peroneal nerves (CPN). That
point was marked on the skin and measured from the
popliteal crease and documented. Following thorough
chlorhexadine prep and sterile drape placement, the
skin was infiltrated using a solution of 1% lidocaine.
In one arm of the study (US/NS), a nerve stimulator
was connected (initial current setting of 1.0 mA, pulse
duration 100 µs, frequency 2 Hz) to a 17 gauge 4
inch (100 cm) Tuohy needle (Arrow International,
Reading, PA) and advanced towards the bifurcation of
the sciatic nerve under US guidance (Logiq-e General
Electric, 12 L probe, Milwaukee, WI). The needle
was advanced and repositioned until a dorsiflexion
(indicating CPN stimulation) or plantar flexion motor
response (indicating TN stimulation) was obtained.
After eliciting a motor response, a stimulating catheter
(19 gauge X 60 cm Stimucath, Arrow International,
Reading, PA) was advanced to 5 cm past the tip of the
needle. Dorsi- or plantar flexion through stimulation
of the catheter was confirmed at a current of less than
1.0 mA and documented. After securing the catheter in
place, 30 mL of plain mepivacaine 1.5% was injected
incrementally with aspiration every 5 mL.
In the second arm of the study (US), the same
stimulating catheter and needle system was used.
However, the nerve stimulator was not turned on during
the placement of the catheter. The end point for needle
advancement was ultrasonographic appearance of the
Tuohy needle being beneath the thick epineurial sheath
of the sciatic nerve at the level of the bifurcation of
the sciatic nerve proximal to the popliteal fossa. After
advancing the needle to that point, the catheter was
advanced 5 cm past the needle tip and secured in place.
The nerve stimulator was turned on and an attempt was
made to elicit a motor response. If one was obtained, it
was documented. No catheter maniupulations occurred
based upon the presence or absence of a motor response.
At that point, 30 mL of plain mepivacaine 1.5% was
injected incrementally with aspiration every 5 mL. The
anesthesiologist performing the block was aware of the
randomization of each patient so that he or she knew
how to perform the nerve block procedure. A separate
success of ultrasound guided popliteal Sciatic Nerve catheters is not influenced by nerve
stimulation
anesthesiologist assessing motor and sensory blockade
was blinded to the randomization. The time from
Touhy needle insertion into the skin, after attainment
of a US image of the nerve, to final catheter positioning
at 5 cm past the needle tip was documented for each
patient. After injection of local anesthetic, sensory
and motor distribution of anesthesia was assessed by
a blinded observer at 5, 10, and 20 minutes using pinprick test. Sensory distributions assessed included the
superficial peroneal, deep peroneal, sural, and tibial
nerves. Assessment was based on a three point scale:
no sensation (0), dull sensation (1), and sharp sensation
(2). Motor strength was assessed in the distribution of
the CPN and the TN by testing the patient’s strength
with respect to dorsiflexion (CPN) and plantar flexion
(TN) using a 3 point scale: no visible contraction (0),
able to dorsiflex/plantarflex against gravity (1), and
able to dorsiflex/plantar flex against resistance (2). A
successful nerve block was defined as a score of <2
in all four sensory nerve distributions at 20 minutes.
A follow up visit (if the patient was an inpatient) or
181
a telephone call (if the patient was an outpatient) was
made every 24 hours for the duration of catheter use
(approximately 48-72 hours) to assess for patient
satisfaction and numeric pain score on an 11 point scale
(no pain [0], worst pain imaginable [10]). Descriptive
statistics, Fisher’s exact test, and the Mann-Whitney U
test were performed using http://www.vassarstats.net.
Results
Patient characteristics for both groups are
presented in Table 1. The overall success of catheter
placement as defined by a sensory deficit in both the
TN and CPN components of the sciatic nerve at 20
minutes following injection of local anesthetic was
72.73% in the nonstimulating group and 80% in the
stimulating group, and was not statistically significant
(p = 1) (Table 2). Pain score assessment was not
significantly different at any point assessed during the
postoperative period, and overall patient satisfaction
was similar between the two groups. The time required
Table 1
Patient Characteristics
Table 2
Block Characteristics and Results
M.E.J. ANESTH 22 (2), 2013
182
to place the catheters was significantly longer in the
stimulating group (130.5 seconds vs. 62 seconds,
p=0.01). The average distance from the bifurcation
of the sciatic nerve above the popliteal crease was 5.8
cm (US/NS) and 6.0 cm (US) in the two groups and
similar to previous data9.
Discussion
The results of this data set suggest that the use
of NS during placement of a stimulating catheter at
the popliteal sciatic nerve under US guidance does
not significantly add to the success rate as measured
by sensory deficit at 20 minutes, postoperative pain
scores, or overall patient satisfaction. By adding
nerve stimualtion there is a significant increase in the
time it takes to place the catheter. Recent studies on
popliteal sciatic nerve blockade have shown that US
guidance can reduce local anesthetic consumption10,
as well as improve the success rate of sensory block,
number of needle passes, patient satisfaction during
catheter placement, and morphine consumption11
when compared to NS alone. Whether a stimulating
catheter improves continuous catheter placement
depends on which block is being performed and the
data are mixed6,12,13. It appears from our limited data
set that there is no benefit to using NS when placing a
stimulating catheter under US guidance at the popliteal
fossa. Therefore, it would seem that using a stimulating
catheter is not necessary when perfoming this block
and that a multiorificed flexible catheter (for example,
an epidural catheter) may be simlarly effective, faster,
and less costly to place.
While seemingly low, the 72.3% and 80% success
rate in the the US and US/NS groups respectively is
comparable to recently published data at 20 minutes
Robards C. B. et. al
following popliteal sciatic nerve blockade14. It is
known that the sciatic nerve has a slow onset of nerve
blockade15, and the fact that postoperative pain scores
were low and satisfaction was high in our patients
suggests successful blockade. We suspect that if time
had permitted and we would have continued to assess
both sensory and motor blockade for 30 minutes postblock we would have been able to demonstrate a higher
success rate. Furthermore, our definition of successful
blockade was strict in that it was sensory deficit in all
four terminal branches of the sciatic nerve.
We made the decision to stop our study prior
to enrollment of the initially planned 120 patients
because of a series of complications we experienced
with stimulating catheters at our institution16,17. We did
not feel it appropriate to continue enrolling patients in
a study that used stimulating catheters following these
incidents. Of note, the complications we experienced
with stimulataing catheters did not involve any of
the study patients, and all involved upper extremity
blocks. Despite stopping enrollment early, our data
agrees with previous studies that US is superior to NS
for popliteal sciatic nerve blockade11,18. Anecdotally,
a patient in the US group had a successful nerve
block with a minimum stimulating current of 3.77
mA. This undescores the fact that there is still a gap
in understanding when it comes to the relationship
betweeen minimum stimulating current, elicited
motor response, and succcessful nerve blockade. In
conclusion, in this limited data set, it appears that there
is no benefit to adding NS when placing a stimulaing
catheter under US guidance when performing a
continuous popliteal sciatic nerve block. The addition
of NS only adds time to the procedure without offering
an increase in successful nerve blockade.
success of ultrasound guided popliteal Sciatic Nerve catheters is not influenced by nerve
stimulation
183
Reference
1. Marhofer P, Schrogendorfer K, Koinig H, Kapral S, Weinstabl C,
Mayer N. Ultrasonographic guidance improves sensory block and
onset time of three-in-one blocks. Anesth Analg; 1997, 85:854-7.
2. Marhofer P, Schrogendorfer K, Wallner T, Koinig H, Mayer N,
Kapral S: Ultrasonographic guidance reduces the amount of local
anesthetic for 3-in-1 blocks. Reg Anesth Pain Med; 1998, 23:584-8.
3. Tsai TP, Vuckovic I, Dilberovic F, Obhodzas M, Kapur E, Divanovic
KA, Hadzic A: Intensity of the stimulating current may not be a
reliable indicator of intraneural needle placement. Reg Anesth Pain
Med; 2008, 33:207-10.
4. Robards C, Hadzic A, Somasundaram L, Iwata T, Gadsden J, Xu D,
Sala-Blanch X: Intraneural injection with low-current stimulation
during popliteal sciatic nerve block. Anesth Analg; 2009, 109:673-7.
5. Barrington MJ, Olive DJ, McCutcheon CA, Scarff C, Said
S, Kluger R, Gillett N, Choong P: Stimulating catheters for
continuous femoral nerve blockade after total knee arthroplasty: a
randomized, controlled, double-blinded trial. Anesth Analg; 2008,
106:1316-21, table of contents.
6. Birnbaum J, Kip M, Spies CD, Hein OV, Labs K, Moeckel G,
Volk T: The effect of stimulating versus nonstimulating catheters
for continuous interscalene plexus blocks in short-term pain
management. J Clin Anesth; 2007, 19:434-9.
7. Perlas A, Brull R, Chan VW, McCartney CJ, Nuica A, Abbas S:
Ultrasound guidance improves the success of sciatic nerve block at
the popliteal fossa. Reg Anesth Pain Med; 2008, 33:259-65.
8. Dufour E, Quennesson P, Van Robais AL, Ledon F, Laloe PA,
Liu N, Fischler M: Combined ultrasound and neurostimulation
guidance for popliteal sciatic nerve block: a prospective, randomized
comparison with neurostimulation alone. Anesth Analg; 2008,
106:1553-8, table of contents.
9. Vloka JD, Hadzic A, Kitain E, Lesser JB, Kuroda M, April EW,
Thys DM: Anatomic considerations for sciatic nerve block in the
popliteal fossa through the lateral approach. Reg Anesth; 1996,
21:414-8.
10.Maalouf D, Liu SS, Movahedi R, Goytizolo E, Memstoudis SG,
Yadeau JT, Gordon MA, Urban M, Ma Y, Wukovits B, Marcello
D, Reid S, Cook A: Nerve stimulator versus ultrasound guidance for
placement of popliteal catheters for foot and ankle surgery. J Clin
Anesth; 2012, 24:44-50.
11.Bendtsen TF, Nielsen TD, Rohde CV, Kibak K, Linde F: Ultrasound
guidance improves a continuous popliteal sciatic nerve block when
compared with nerve stimulation. Reg Anesth Pain Med; 2011,
36:181-4.
12.Gandhi K, Lindenmuth DM, Hadzic A, Xu D, Patel VS, Maliakal
TJ, Gadsden JC: The effect of stimulating versus conventional
perineural catheters on postoperative analgesia following
ultrasound-guided femoral nerve localization. J Clin Anesth; 2011,
23:626-31.
13.Morin AM, Kranke P, Wulf H, Stienstra R, Eberhart LH: The
effect of stimulating versus nonstimulating catheter techniques
for continuous regional anesthesia: a semiquantitative systematic
review. Reg Anesth Pain Med; 2010, 35:194-9.
14.Sala-Blanch X, de Riva N, Carrera A, Lopez AM, Prats A, Hadzic
A: Ultrasound-guided popliteal sciatic block with a single injection
at the sciatic division results in faster block onset than the classical
nerve stimulator technique. Anesth Analg; 2012, 114:1121-7.
15.Robards C, Hadzic A: Lumbar Plexus Block. In: Hadzic A, ed. The
New York School of Regional Anesthesia Textbook of Regional
Anesthesia and Acute Pain Management. 1st ed. New York: Mc
Graw Hill Medical, 2007:481-8.
16.Abrahams MS, Noles LM, Cross R, Horn JL: Retained stimulating
perineural catheters: a report of four cases. Reg Anesth Pain Med;
2011, 36:476-80.
17.Clendenen SR, Robards CB, Greengrass RA, Brull SJ:
Complications of peripheral nerve catheter removal at home: case
series of five ambulatory interscalene blocks. Can J Anaesth; 2011,
58:62-7.
18.Mariano ER, Cheng GS, Choy LP, Loland VJ, Bellars RH,
Sandhu NS, Bishop ML, Lee DK, Maldonado RC, Ilfeld BM:
Electrical stimulation versus ultrasound guidance for poplitealsciatic perineural catheter insertion: a randomized controlled trial.
Reg Anesth Pain Med; 2009, 34:480-5.
M.E.J. ANESTH 22 (2), 2013
case reports
MONITORED ANESTHESIA CARE FOR
A PATIENT WITH ADVANCED
HUNTINGTON’S CHOREA
Taylor White* and Steven Neustein**
Introduction
Huntington’s disease (HD), a rare, autosomal dominant disorder of the central nervous
system, has been associated at times with unusual responses to anesthetic agents such as thiopental,
midazolam, succinylcholine, and nondepolarizing neuromuscular blocking drugs. We describe
the anesthetic management of a 50 year-old female with advanced HD, complicated by chorea,
dementia, dysphagia, and dysarthria, undergoing percutaneous endoscopic gastrostomy (PEG)
placement. To the best of our knowledge, there have not been any prior reports describing the use
of propofol for sedation in a patient with Huntington’s disease.
Case
A 50 year-old, 50 kilogram female with Huntington’s disease (HD) complicated by chorea,
dementia, dysphagia, and dysarthria, with no history of cardiopulmonary disease, presented for
percutaneous endoscopic gastrostomy (PEG) placement. Despite redirection by the patient’s sister
at bedside, the patient was agitated in the endoscopy holding area and suffering from violent
choreoathetoid movements. Although she was unable to follow commands, she spontaneously
demonstrated a Mallampati Class 1 airway, with adequate mouth opening, thyromental distance,
and neck range of motion.
Given her agitation, intramuscular sedation with a benzodiazepine and/or an antipsychotic
was considered; however, with the aid of the nursing team and the patient’s sister, a 20-gauge
intravenous catheter was placed in the left forearm and well secured. Midazolam was administered
in one-milligram increments over the span of approximately 20 minutes, to a total dose of four
milligrams, with little decrease in the patient’s movements or level of agitation. The decision was
made to proceed to the endoscopy suite to continue with further sedation.
Standard ASA monitors and a nasal cannula were placed with difficulty, and an initial
30-milligram bolus of propofol was administered. Within 60 seconds, the patient’s choreoathetoid
movements ceased, and she closed her eyes. With intermittent propofol boluses to a total dose
of 200 milligrams, and local anesthesia administered by the proceduralist, PEG placement
*
MD, MFA.
**MD.
Corresponding author: Steven Mark Neustein, MD, Professor of Anesthesiology, Icahn School of Medicine at Mount
Sinai, 1 Gustave L Levy Place, Box 1010, New York, N.Y. 10029. E-mail: [email protected]
185
M.E.J. ANESTH 22 (2), 2013
186
proceeded without incident, with adequate respiratory
and cardiovascular parameters throughout the fifteenminute procedure. The patient’s recovery room course
was uneventful, and she was able to return to her
skilled nursing facility without any undue delay.
Discussion
Huntington’s disease was first fully described
by 22-year old New York family physician George
Huntington in 18721. It is a devastating disease of the
human central nervous system, now known to be caused
by a toxic gain-of-function mutation of the Huntingtin
gene2. This mutation, an increase in the number of
cytosine-adenine-guanine trinucleotide repeats present
in the gene’s coding portion, creates a polyglutamine
region in the Huntingtin protein which alters its function
and leads to neuronal degeneration, particularly
affecting the basal ganglia. Greater than 40 CAG repeats
produces fully penetrant disease, which is inherited in an
anticipatory autosomal dominant pattern2.
Through the latter portion of the 20th century,
case reports have at times associated HD with
prolonged recovery from benzodiazepines and
barbiturates, as well as with increased duration of
paralysis after administration of both depolarizing
and nondepolarizing neuromuscular blocking
drugs (NMBDs)3,4. In addition, at least one genetic
study has found an increased incidence of atypical
pseudocholinesterase in patients with HD5.
A recent review of eleven patients with HD who
underwent seventeen general anesthetics, by Kivela et
al of the Mayo Clinic, did not find any atypical reactions
to midazolam, sodium thiopental, succinylcholine,
nor nondepolarizing NMBDs6. Prolonged sedation
White T. et. al
observed after benzodiazepines and barbiturates in
prior reports was attributed by these authors to relative
overdosing of these drugs, not abnormal patient
response. While no abnormal response to NMBDs was
observed, the authors still recommended caution with
succinylcholine given the association with atypical
pseudocholinesterase. Succinylcholine may still be
needed, however, due to the possible increased risk of
aspiration in these patients.
The administration of propofol to individuals
with HD has been previously described7,8. However,
in those two case reports, the tracheas of both patients
were intubated, and the anesthetics were general
anesthetics with mechanical ventilation. There was no
report on any effect that propofol had on the chorea.
The use of sedation has been reported previously in a
patient with Huntington’s disease, but the sedation was
achieved solely with midazolam, which in that case did
have a beneficial effect on the choreiform movements9.
With regards to our case, midazolam did not control
the patient’s motor symptoms or agitation. In addition,
we note that the recovery course was not prolonged
despite this 50-kilogram patient’s receiving four
milligrams of midazolam prior to her brief procedure.
A small dose of propofol quickly and effectively
ceased her choreoathetoid movements and established
a plane of anesthesia appropriate for beginning the
PEG placement. Propofol has been associated with
involuntary movements including athetosis, seizures,
and dystonia, likely due to inhibition of inhibitory
pathways in the basal ganglia, leading to a net increase
in excitatory cholinergic outflow10. In that case report,
the movements were lessened by benztropin. The use
of propofol in our case was effective in quieting the
debilitating motor symptoms of Huntington’s disease.
References
1. Huntington G: On chorea. Med Surg Rep; 1872, 26:317.
2. Walker FO: Huntington’s disease. The Lancet; 2007, 369: 218.
3. Rodrigo MRC: Huntington’s chorea: midazolam, a suitable
induction agent? Br J Anaesth; 1987, 59:388.
4. Davies DD: Abnormal response to anesthesia in a case of
Huntington’s chorea. Br J Anaesth; 1966, 38:490.
5. Whittaker M, Berry M: The plasma cholinesterase variants in
mentally ill patients. Br J Psychiatry; 1977, 130:397.
6. Kivela JE, Sprung J, Southorn PA, Watson JC, Weingarten TN:
Anesthetic management of patients with Huntington disease. Anesth
Analg; 2010, 110:515.
7. MacPherson P, Harper I, MacDonald I: Propofol and remifentanil
total intravenous anesthesia for a patient with Huntingtons Disease.
J Clin Anesth; 2004, 16:537.
8. Kaufman MA, Erb T: Propofol for patients with Huntington chorea?
Anaesthesia; 1990, 45:889.
9. Holland R: Huntington’s chorea and anaesthesia. Anaesth Intensive
Care; 1992, 20:256.
10.Schramm BM, Orser BA: Dystonic reaction to propofol attenuated
by benztropine (Cogentin). Anesth Analg; 2002, 94:1237.
USE OF AIRWAY EXCHANGE CATHETER FOR
BRONCHOSCOPY OF A PATIENT WITH
DOWN’S SYNDROME
Ayşe Karci*, Seden Duru**,
Elvan Öçmen** and Volkan Karaçam***
Tracheobronchial injuries (TBI) are highly fatal, and early diagnosis and repair are crucial
for survival.1-3 The anesthesiologist and the surgeon must secure the integrity and patency of the
airway for these cases. These injuries remain infrequent, and are becoming less fatal due to the
availability of the resources necessary to achieve a secure airway, and thus some of them can be
managed conservatively.4 We report an unusual case of upper airway compromise and extensive
subcutaneous emphysema due to traumatic bronchial rupture and its conservative repair in a patient
with Down’s syndrome.
Conflict of interest: The authors declare that they have no conflicts of interest to disclose.
Case Presentation
A 33-year-old, 120 kg man with Down’s syndrome presented to the Emergency Department
with dyspnoea and cough which began while he was having his meal. Radiography and
computed tomography of the chest showed a foreign body present in the left lung. On examination
he was tachypneic with severe suprasternal retractions and subcutaneous emphysema of face, chest
wall, axillae, and back which was thought to be caused by the massive air leak due to the foreign
body. Upon development of severe respiratory distress and subcutaneous emphysema, he was
intubated and mechanically ventilated while taken to the operating room for bronchoscopy. (Fig. 1)
Fig. 1
Posteroanterior chest
radiograph of the patient with
subcutaneous emphysema
due to rupture of left main
bronchus
*
**
***
Associate Professor, Department of Anesthesiology and Reanimation, Dokuz Eylül University, School of Medicine, İzmir,
Turkey.
Consultant Doctor, Department of Anesthesiology and Reanimation, Dokuz Eylül University, School of Medicine, İzmir,
Turkey.
Consultant Doctor, Department of Thoracic Surgery, Dokuz Eylül University, School of Medicine, İzmir, Turkey.
Corresponding author: Ayşe Karci, Dokuz Eylül Üniversitesi Tıp Fakültesi Hastanesi Anesteziyoloji ve Reanimasyon
Anabilim Dalı, İnciraltı, İZMİR. Tel: +90 232 412 28 01; E-mail addresses: [email protected]
187
M.E.J. ANESTH 22 (2), 2013
188
In addition to massive subcutaneous emphysema
in the face, neck and anterior chest, the tongue was
severely swollen and laryngoscopic view (as far as
it could be performed) revealed that the edema was
not limited to the tongue and the lips, but the oral
cavity was also involved. Therefore, extubation of the
patient was deemed potentially hazardous (Fig. 2).
Since emphysema had progressed rapidly following
endotracheal intubation and mechanical ventilation,
the patient was suspected of having sustained a
tracheal injury due to the foreign body. Bronchoscopy
was required for removal of the foreign body and
also for the diagnosis and treatment of the suspected
rupture. The only surgical indication for repairing the
laceration was the reluctance to extubate the patient and
the surgeon’s first choice was conservative treatment.
The decision was to use an airway exchange catheter,
which has a high success rate when used as a guide for
re-intubation, but has not been reported for extubation
before bronchoscopy.
Fig. 2
Extensive swelling of the tongue and subcutaneous emphysema
of the neck and the anterior chest
An 14-F airway exchange catheter (AEC) 83-cm
long, with an outer diameter of 6.5-mm was introduced
through the endotracheal tube before the tube was
removed, and was left in situ during bronchoscopy.
Using a rigid bronchoscope, a chicken bone about 4
cm long was extracted from the distal part of the left
main bronchus. The bronchoscopic view showed a
tear just above the level where the chicken bones was
located. The bronchial rupture was endoscopically
treated using fibrin glue.
Karci A. et. al
On the second postoperative day, the patient
was extubated without any complications when the
standard extubation criteria were met, and when the
patient was conscious, hemodynamically stable, and
could protect and clear the airway. Furthermore, the
subcutaneous edema had disappeared. (Fig 3)
Fig. 3
Posteroanterior chest radiograph of the patient
soon after extubation
Discussion
Tracheal injuries are rare events and their
management requires a fast and straightforward
diagnostic evaluation. They are not diagnosed
immediately in 25-68% of the cases but tachypnoea
and subcutaneous emphysema are frequent physical
findings and can alert the physician tor diagnosis.
Although it is commonly agreed that posttraumatic
injuries require surgical intervention the management
of iatrogenic injuries is presently shifting towards
a more conservative treatment. For both urgent
bronchoscopy and re-intubation, maintaining a
continuous access to the airway following extubation
was mandatory in our case, presented above. A
compromised airway such as this presents an
uncommon diagnostic and surgical challenge to the
anesthesiologist and the surgeon5.
Cassada et al.1 reported that independent of
mechanism or anatomic location of injury, delay
in the diagnosis of injuries to the trachea and major
bronchi was the most important prognostic factor for
postoperative morbidity in foreign body aspirations
causing rupture in respiratory tract. Since the patient
was intubated when he was brought to the operating
room, extubation should be performed as soon as
USE OF AIRWAY EXCHANGE CATHETER FOR BRONCHOSCOPY OF A PATIENT WITH DOWN’S SYNDROME
possible to enable bronchoscopy for diagnosis.
The American Society of Anesthesiologists Task
Force on the Management of the Difficult Airway
recommends consideration of placement of a stylet
prior extubating the difficult airway, to facilitate reintubation if necessary, and also to allow ventilation6.
Airway exchange catheters (AEC) are long, thin hollow
tubes which have distal terminal and side holes for
ventilating the patient and are supplied with removable
15-mm connectors that are compatible with the
anesthetic circuit5. Continuous access to the airway via
an AEC seemed to be the only safe extubation strategy
for this patient with Down’s syndrome. Maintaining
a conduit within the trachea that affords the ability to
resecure the airway and ventilate the patient was the
planned extubation strategy.
A prospective analysis by Mort8 supports the
concept of an AEC- facilitated extubation strategy.
In the analysis, the benefit of airway exchange
catheters was demonstrated in selected patients, but
its use in patients with Down’s syndrome and airway
deterioration has not been mentioned.
Previous investigators who incorporated an
airway 11F (3.7 mm ED) catheter for securing the
airway in difficult extubation patients, have reported
that it is well tolerated7,9. The larger sized AEC, the
14F (4.7 mm ED) which has not been previously
reported for difficult extubation patient, have been
found to be useful for maintaining access to the airway
and re-intubating the trachea. The larger sized AEC
189
was preferred for this case because, first, it can be used
as a stylet for tracheal reintubation; second, we wanted
a larger diameter, in case we would use the ventilator
port of the airway exchanger catheter to ventilate the
patient.
The presence of the AEC to assist in reintubating
the trachea is a major step toward improving safety
in patients whose reintubation was considered a
risk. In addition to the use of an AEC for a difficult
extubation and bronchoscopy in a patient with Down’s
syndrome, this case presents a conservative approach
to tracheobronchial injuries. When Lampl et al.10
presented their experience for the first time in 1994,
hardly anyone appeared to be convinced about the
advantages of this procedure. Later on, the effects of
conservative treatment of tracheal lacerations were
confirmed by Ross11 and Molins12. Non-operative
management of TBIs should be reserved for patients
with small laceration of the membranous tracheal
wall (<2 cm) and in severely injured patients with a
high operative risk13. However recently, Gómez-Caro
et al.14 have stated that conservative treatment for
tracheobronchial injuries is effective regardless of the
mechanism of production, length, or site of injury.
Conservative treatment should be carefully assessed in
patients who meet strict selection criteria.
This case reconfirms that the AEC is an efficient
method of maintaining continuous access to the airway
after extubation, as it potentially offers a clinically
valuable conduit for both bronchoscopy and reintubation in difficult airways.
M.E.J. ANESTH 22 (2), 2013
190
Karci A. et. al
References
1. Cassada DC, Munyikwa MP, Moniz MP, Dieter RA, Schuchmann
GF, Enderson BL: Acute injuries of the trachea and major bronchi:
Importance of early diagnosis. Ann Thorac Surg; 2000, 69:1563.
2. Benfield JR: Traumatic bronchial rupture and other major thoracic
injuries. Ann Thorac Surg; 1990, 50:523.
3. Koletsis E, Prokakis C, Baltayiannis N, Apostolakis E,
Chatzimichalis A, Dougenis D: Surgical decision making in
tracheobronchial injuries on the basis of clinical evidences and the
injury’s anatomical setting: A retrospective analysis. Injury Int J
Care; 2012, 43:1437.
4. Jougon J, Ballester M, Choukroun E, et al: Conservative treatment
of postintubation tracheobronchial rupture. Ann Thorac Surg; 2000,
69:216, 2000.
5. Popat M, Mitchell V,Dravid R, Patel A, Swampillai C, Higgs A:
Difficult Airway Society Guidelines for the management of tracheal
extubation. Anaesthesia; 2012, 67:318.
6. Caplan RA, Benumof JL, Berry FA, et al: the American Society
of Anesthesiologists Task Force on Difficult Airway Management.
Practice guidelines for management of the difficult airway: an
updated report by the American Society of Anesthesiologists Task
Force on Management of the Difficult Airway. Anesthesiology;
2003, 98:1269.
7. Biro P, Priebe HJ: Staged extubation strategy: Is an Airway
Exchange Catheter the Answer? International Anesthesia Research
Society; 2007, 105:1182.
8. Mort TC: Continuous airway access for the difficult extubation:
the efficacy of the airway exchange catheter. Anesth Analg; 2007,
105:1357.
9. Cooper RM: The use of an endotracheal ventilation catheter in the
management of difficult extubations. Can J Anaesth; 1996, 43:90.
10.Lampl L. Tracheobronchial injuries. Conservative treatment.
Interactive Cardiovascular and Thoracic Surgery; 2004, 3:401.
11.Ross HM, Grant FJ, Wilson RS, Burt ME: Nonoperative
management of tracheal laceration during endotracheal intubation.
Ann Thorac Surg; 1997, 63:240.
12.Molins L, Buitrago LJ, Vidal G: Conservative treatment of tracheal
lacerations secondary to endotracheal intubation. Ann Thorac Surg;
1997, 64:240.
13.Warwick HS, Bush W, Northrop C: Traumatic bronchial rupture.
AJR; 1980, 134:1189.
14.Gómez-Caro A, Ausín P, Moradiellos FJ, Díaz-Hellín V, Larrú E,
Pérez JA, de Nicolás JL: Role of conservative medical management
of tracheobronchial injuries. J Trauma; 2006, 61:1426.
INCIDENTAL FINDING OF FOREIGN BODIES DURING
NASAL INTUBATION IN A MENTALLY
CHALLENGED PATIENT
Abdul Kader Mahfouz* AND
Mohammad Suleiman Khan**
Abstract
Nasal foreign bodies are frequently encountered among children and mentally challenged
patients. They are often asymptomatic and may remain undetected for years. We are presenting
a case of an incidental finding of foreign bodies during nasal intubation in a mentally challenged
patient.
Key words: Intubation, nasal, foreign body.
Conflict of interest: There is no conflict of interest.
Sources of financial support: The authors have no financial support from any institution.
Introduction
Nasal foreign bodies are frequently reported among children and mentally challenged
patients. This could be explained by accidents, trauma or curiosity of children and mentally retarded
patients which leads them to explore their body orifices1,2. The foreign bodies may be inert and can
remain in the nose for years without mucosal damage3. We are presenting a case of an incidental
finding of foreign bodies during nasal intubation of a mentally challenged patient posted for dental
restoration and extractions under general anesthesia. Written consent from relatives was obtained
for publication of this report.
Case report
A 21 year old female was posted for dental restoration and extractions under general anesthesia.
Since the patient was mentally challenged and violent, the dentist was unable to do this procedure
at the dental clinic. The patient had a history of epilepsy but was not on any medication. The
clinical examination was unremarkable, except that the patient was highly uncooperative. Routine
laboratory investigations were within normal limits but dental ortho-pan-tomogram showed badly
decayed teeth. The patient’s body weight was 45 Kg, heart rate 82/min and noninvasive arterial
blood pressure (NIBP) was 108/74 mmHg. She was kept fasting overnight at the hospital. The
patient was premedicated with midazolam 7.5 mg tablet orally given half an hour before the
expected time of surgery.
*
**
MSc, PhD, Sr. Consultant Anesthesiologist, Al Nahda Hospital, Muscat- Sultanate of Oman.
MD, Registrar Anesthesiologist, Al Nahda Hospital, Muscat- Sultanate of Oman.
Corresponding author: Abdul Kader Mahfouz, MSc, PhD; Sr. Consultant Anesthesiologist, Al Nahda Hospital, MuscatSultanate of Oman. PO: 937, PC: 112 Ruwi. Tel: +96899360867. E-mail: [email protected]
191
M.E.J. ANESTH 22 (2), 2013
192
On arrival at the operating theatre the patient was
sedated and she was talking to the medical staff in a
friendly but incoherent manner. She did not allow the
insertion of an intravenous cannula or attachment of
routine monitoring. Therefore inhalational induction
was started with 8% sevoflurane in a mixture of oxygen
and N2O in a ratio of 1:1. After loss of consciousness,
routine monitoring of ECG, NIBP and pulse
oximetry was started. An IV cannula was inserted,
fentanyl 50 µg and atracurium 25 mg were given and
sevoflurane was reduced to1%. A nasal vasoconstrictor
(Xylometazoline hydrochloride 0.1%) was instilled
in both nostrils. After adequate lubrication, the
anesthesiologist tried to insert a preformed north-pole,
6.5 endotracheal tube nasally into the left nostril but
failed to do so. With gentle manipulation, he was able
to pass it through the right nostril with the sensation of
a sudden give. Once the anesthesiologist felt that the
tip of the tube was in the oro-pharynx, a Macintosh
laryngoscope was inserted orally to direct the tip of the
tube to the larynx. He noticed some blood in the oropharynx, and after aspirating it, he was able to see two
shining metallic objects on the posterior pharyngeal
wall. After the two objects were removed using Magill
forceps, the tip of the endotracheal tube was directed
into the larynx. When the correct position of the
tube was confirmed with equal bilateral air entry on
auscultation, mechanical ventilation was started. The
metallic objects were found to be “pop can openers”. At that time it was decided to start the dental
surgery and to call an ENT surgeon for nasal endoscopy
to check the nasal cavities for any unrecognized foreign
bodies.
At the end of the dental procedure, the ENT
surgeon examined the nasal cavities with an endoscope.
He was able to remove six more pop can openers
from the left nostril and wanted to examine the right
nostril where the endotracheal tube was inserted. After
adequate oral suction the nasal tube was removed and
replaced with same size oral tube. Three more pop can
openers were extracted from the right nostril. The nasopharynx and oro-pharynx were thoroughly checked for
any possible missed foreign bodies, but nothing more
could be detected. Esophagoscopy and examination
of both ears were carried out and the findings were
negative. The total number of pop can openers
Mahfouz A. K. et. al
removed from the patient was 11 (Fig. 1). Reversal of
muscle relaxant was done by neostigmine 2.5 mg and
atropine 0.9 mg, and extubation was carried out in the
recovery position after return of reflexes. Paracetamol
0.75 gm IV was given for postoperative analgesia. The
relatives were informed about the foreign bodies and
were counseled to take a better care of the patient.
They denied any history of epistaxis, nasal discharge
or foul odour coming from the patient’s nose. Patient
was kept under observation for 2 hours at the recovery
area, and then discharged to the ward.
Fig. 1
All foreign bodies removed from the patient’s nose after
endoscopic examination.
Discussion
Nasal Foreign bodies are uncommon in adults1.
Some foreign bodies are inert and may remain for
years without clinical manifestations3. Patients may
present to outpatient clinics or accident and emergency
department complaining of nasal occlusion, headache,
unilateral mucopurulent nasal discharge with foul
odour, or epistaxis4. If a nasal foreign body is suspected,
removal can be attempted in the clinic in cooperative
patients. General anesthesia will be an alternative in
the case of children, mentally challenged patients or
failure of attempted removal in the clinic4.
In the present case, the patient was mentally
challenged, violent and difficult to approach. There
was no previous complaint of any nasal problem.
The physical examination did not reveal any nasal
discharge or foul odour which might give rise to
suspicion of the presence of a foreign body. The dental
ortho-pan-tomogram did not show any clues of the
presence of a foreign body. However, the X-ray was
INCIDENTAL FINDING OF FOREIGN BODIES DURING NASAL INTUBATION IN A MENTALLY CHALLENGED
PATIENT
done one week before the scheduled time of surgery
which is enough time for the patient to insert these
foreign bodies in her nose. The hazards of nasal
intubation in a patient having an unrecognized nasal
foreign body include the unnoticed displacement of the
foreign body to the posterior part of the naso-pharynx
with the risk of inhalation and choking at the time of
recovery. The foreign body might be pushed down the
airway with the tube with the risk of partial or total
airway obstruction5,6. This would greatly endanger the
patient’s life especially if bronchoscopic facilities are
not available in the place. If the foreign body is small,
it might be impacted in one of the small bronchioles.
This would carry the risk of distal emphysema
and super-added infection which would need time
postoperatively to manifest and diagnose7.
The incidental finding of foreign bodies in this
case on the posterior pharyngeal wall raised the doubt
193
about other unrecognized foreign bodies. An ENT
surgeon was consulted to check the nasal cavities and
was able to remove more foreign bodies from both
nostrils. Examinations of both ears and esophagoscopy were done and were negative.
This case suggests that special attention
should be paid during nasal intubation of children
or mentally challenged patients for the possibility of
foreign bodies even if the patient is free of symptoms.
Another alternative would be to request an X-ray
of the paranasal sinuses in children and mentally
challenged patients-in whom nasal intubation is
planned-to exclude the presence of foreign bodies.
However, not all patients have foreign bodies and it
would be unjustified to expose patients to the X-ray
hazards. In addition, not all foreign bodies are radioopaque8. Anesthesiologists’ vigilance should remain
the cornerstone during management of these cases.
M.E.J. ANESTH 22 (2), 2013
194
Mahfouz A. K. et. al
References
1.Burduk PK, Garstecka A, Betlejewski S: Nasal foreign body in an
adult. Eur Arch Otorhinolaryngol; 2005, 262(6):517-8.
2.Ibekwe MU, Onotai LO, Otaigbe B: Foreign body in the ear, nose
and throat in children: A five year review in Niger delta. Afr J
Paediatr Surg; 2012, 9(1):3-7.
3.Kelesidis T, Osman S, Dinerman H: An unusual foreign body as
cause of chronic sinusitis: a case report. J Med Case Reports; 2010,
(26)4:157.
4.Kalan A, Tariq M: Foreign bodies in the nasal cavities: a
comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures. Postgrad Med J; 2000, 76:484-7.
5.Patil PM, Anand R: Nasal foreign bodies: A review of management
strategies and a clinical scenario presentation. Craniomaxillofac
Trauma Reconstr; 2011, 4(1):53-8.
6.Vijayakumar A, Malempati AR, Neema PK, Rathod RC:
Unrecognized nasal foreign body: potential consequences. J
Cardiothorac Vasc Anesth; 2007, 21(3):478-9.
7.Wani NA, Qureshi UA, Kosar T, Laway MA: Subcutaneous
emphysema due to bronchial foreign body demonstrated by
multidetector-row computed tomography. Lung India; 2011,
28(4):291-3.
8.Baluyot ST: Foreign bodies in the nasal cavity. In: Paparella M
M, Shumrick D A, editors. Otolaryngology. Philadelphia: W.B.
Saunders; 1980, pp. 2009-16.
CARDIORESPIRATORY CRISIS AT THE END OF
PREGNANCY: A CASE OF PHEOCHROMOCYTOMA
SAMIR HADDAD*, BASEL AL-RAIY**, AZZA MADKHALI***,
SAAD AL-QAHTANI****, MOHAMMAD AL-SULTAN*****
AND YASEEN ARABI******
Abstract
Pheochromocytoma during pregnancy is extremely rare. Its clinical manifestation includes
hypertension with various clinical presentations, possibly resembling those of pregnancy-induced
hypertension. The real challenge for clinicians is differentiating pheochromocytoma from other
causes of hypertension (preeclampsia, gestational hypertension, and pre-existing or essential
hypertension), from other cause of pulmonary edema (preeclampsia, peripartum cardiomyopathy,
stress or Takotsubo cardiomyopathy, pre-existing cardiac disease [mitral stenosis], and high doses
betamimetics), and from other causes of cardiovascular collapse (pulmonary embolism, and
amniotic fluid embolism). Although, several cases of pheochromocytoma during pregnancy have
been published, fetal and maternal mortalities due to undiagnosed cases are still reported. We report
a case of a patient whose delivery by cesarean section was complicated by severe hemodynamic
instability resulting in a cardiac arrest. Later on, pheochromocytoma was suspected based on
computed tomography (CT) scan findings. Diagnosis was confirmed with special biochemical
investigations that showed markedly elevated catecholamines in urine and metanephrines in serum,
and later by histopathology of the excised left adrenal mass. This case illustrates the difficulty of
diagnosing pheochromocytoma in pregnancy and raises the awareness to when this rare disease
should be suspected.
*
MD, CES, Intensive Care Department, MC 1425, Director, Surgical Intensive Care Unit, King Abdulaziz Medical City,
Riyadh, Kingdom of Saudi Arabia.
**
MD, Intensive Care Department, MC 1425, Assistant Professor, College of Medicine, King Saud Bin Abdulaziz University
for Health Sciences, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
*** MD, Obstetrics-Gynecology Department, Assistant Professor, College of Medicine, King Saud Bin Abdulaziz University
for Health Sciences, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
**** MD, FCCP, FRCP (C), Intensive Care Department, MC 1425, Associate Professor, College of Medicine, King Saud Bin
Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
*****MD, FCCP, FRCP (C), Intensive Care Department, Emergency Medicine Department, Associate Professor, Dean
of Admission and Registration, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King
Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
****** MD, FCCP, FCCM, Chairman, Intensive Care Department, Associate Professor, King Saud Bin Abdulaziz University
for Health Sciences Medical Director, Respiratory Services, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi
Arabia.
Corresponding author: Samir Haddad, MD, CES, Intensive Care Department, MC 1425 Director, Surgical ICU, King
Abdulaziz Medical City, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. Tel: ++966-1-8011111 x18855 /
x18877, Fax: ++ 966-1-8011111 x18880. E-mail: [email protected]; [email protected]
195
M.E.J. ANESTH 22 (2), 2013
196
Introduction
Pheochromocytoma is a rare catecholaminesecreting tumor and extremely rare in pregnancy. The
clinical manifestations of a pheochromocytoma result
from excessive catecholamine secretion by the tumor
that may precipitate life-threatening cardiovascular
complications. Diagnosis is often difficult and can be
easily missed, as pheochromocytoma may present a
broad spectrum of clinical manifestations, particularly
mimicking pre-eclampsia.
Case presentation
A 31-year-old gravida-8, para-6 + 1 woman at
42 weeks gestation presented to the emergency
department with abdominal pain. At 16:30, she was
admitted to the delivery ward as being in labor.
All her previous pregnancies ended in a normal
spontaneous vaginal delivery except the last one that
ended in a cesarean section (CS). Her past medical,
family and social histories were unremarkable. She
was not on any medication, or known to have any
allergy. On physical examination, she was afebrile.
Her heart rate (HR) was 112 beats per minute (BPM),
blood pressure (BP) was 107/80 mm Hg, respiratory
rate (RR) was 20 breaths per minute, and her oxygen
saturation (SpO2) was 98-100% while she was
breathing room air. Her abdomen was gravid and not
tender to palpation. Mild uterine contractions were
noted (3 to 4 in 10 minutes) with mild to moderate
pain (pain score 2 to 4). No edema was found on
her lower extremities. On pelvic examination, her
cervix was 4 to 5 cm dilated and 80% effaced, with
the head at -3 station. Her initial blood analysis
revealed a hemoglobin of 110 g/L, a white cell count
of 8.8 × 109/L, and a platelet count of 281 × 109/L.
All electrolyte levels were unremarkable, her serum
creatinine was 46 µmol/L and uric acid 195 µmol/L.
An intravenous cannula was inserted and infusion of
a crystalloid solution at the rate of 125 mL/hours was
commenced. Two doses of 100 mg of meperidine
and 25 mg of promethazine, with 6 hours interval,
were administered intramuscularly for pain control.
Continuous cardiotocograph (CTG) monitoring
showed normal fetal HR with acceleration and
HADDAD S. et. al
normal variability, and uterine hyperstimulation for
which 2 doses of 0.25 mg of terbutaline, with 4 hours
interval, were administered subcutaneously.
At 21:50 hours, she became moderately
distressed, her BP was recorded at 152/119 mm Hg
and her HR at 155 BPM. Distress, hypertension and
tachycardia were attributed to anxiety, pain and the
use of terbutalin. On obstetrician request and patient
agreement for analgesia, an epidural catheter was
sited at the L3-4 interspace. A bolus of 1 liter Lactated
Ringer (LR) was administered as preparation for the
epidural analgesia. A test dose (3 ml of lidocaine 1.5%
with 1:200,000 epinephrine), followed by a 5-ml dose
of 0.125 % bupivacaine were injected and provided
adequate analgesia. During the following hour, her
BP ranged 125-150/76-111 mm Hg, HR 80-163 BPM;
however, both RR and SpO2 remained stable (20-22
and 98-100%, respectively).
At 22:55, the patient was transferred to the
operating theatre for an emergency CS for failure to
progress and persistent fetal tachycardia. Epidural
anesthesia was extended using 11 ml of 2% lidocaine
and 100 µg of fentanyl preceded by a bolus of 1 liter
LR to prevent secondary hypotension. A male infant
in poor condition was delivered with Apgar scores of
3 and 8 (at one and five minutes, respectively) and
an umbilical arterial pH of 6.90. Oxytocin (10-units)
was administered as a slow intravenous (IV) bolus on
delivery of the baby. CS was uneventful and blood loss
was estimated at 500 ml. However, her BP remained
elevated ranging from 140 to 160/90 to 100 mm Hg
with persistent sinus tachycardia at 130 to 163 BPM.
Two 10-mg increments of esmolol were administered
intravenously to control the HR; however, there was
no significant response.
Suddenly, at the end of the CS and while she was
breathing through a face mask with an FiO2 of 0.4, the
SpO2 fell to 89% and sero-sanguinous fluid emerged
from her mouth. Urgent intubation of the trachea was
performed without administering any additional drug,
and positive pressure ventilation was started. A large
amount of pink frothy secretions were suctioned from
the endotracheal tube, diagnosed as frank pulmonary
edema. She remained hypoxemic (SpO2 80-90%),
tachycardic (150-170 BPM) and hypertensive (150160/90-100 mm Hg). Labetalol 10 mg and amiodarone
CARDIORESPIRATORY CRISIS AT THE END OF PREGNANCY: A CASE OF PHEOCHROMOCYTOMA
150 mg were administered as slow IV bolus to control
HR for a suspected atrial fibrillation (AF) with rapid
ventricular response (irregular tachyarrhythmia).
Shortly, the HR dropped to 30 BPM, the BP fell to 40/25
mm Hg and she became pulseless. Cardiopulmonary
resuscitation (CPR), as per the Advanced Cardiac Life
Support (ACLS) recommendations, was performed for
3 minutes and restored the BP to 130/80 mm Hg and
the HR to 150 BPM. Pulmonary edema, secondary to
the use of terbutaline and fluid shift, was considered to
be the most likely etiology of the event. Sixty mg of
furosemide was administered as IV bolus. The patient
was transferred to the intensive care unit (ICU) at
00:10 of the next day.
On admission to the ICU, she was sedated,
intubated and mechanically ventilated with an FiO2
of 1.0 and a lung protective strategy (respiratory rate
30 breaths/min, tidal volume 300 ml [6 mL/kg of
predicted body weight], and PEEP of 16 cm H2O).
She was severely hypoxemic with SpO2 around 60%.
Arterial blood gas (ABG) analysis was pH 7.15,
PaCO2 57.2 mm Hg, PaO2 41.1 mm Hg, HCO319.8 mmol/L, base excess -9.1 mmol/L and SaO2
63%. Chest X-ray showed pulmonary edema (Fig.
1). She was hemodynamically unstable with labile
and rapidly fluctuating blood pressures. The systolic
blood pressure (SBP) varied from 200 to 60 mm
Hg and the HR from 140 to 170BPM. Vasopressor
infusions (norepinephrine, dopamine, phenyephrine,
vasopressin and epinephrine) were used on and off
according to the BP. Central and arterial cannula were
inserted. Routine chest X-ray, following the central
line insertion, confirmed the presence of pulmonary
edema. The central venous pressure (CVP) was 20
mm Hg. A bolus of furosemide 60 mg IV was given
followed by a continuous infusion at 10 mg per hour
with poor response so a dialysis catheter was inserted
for fluid removal. One hour after admission to the ICU,
an episode of severe hypotension and bradycardia was
followed by a pulseless electrical activity cardiac
arrest. CPR for 42 minutes, epinephrine 5 mg (total),
atropine 2 mg (total), vasopressin 40 units, 10%
calcium chloride (20 ml) and 8.4% NaHCO3 (250
mmol) resulted in restoration of cardiac activity and
hemodynamic stability.
197
Fig. 1
Chest radiography showing pulmonary edema.
As diagnosis was uncertain, a pulmonary
artery catheter (PAC) was inserted, 3 hours after
ICU admission, for hemodynamic assessment and
monitoring. Cardiac index was at 2.2 to 2.8 L•min-1•m2
and the pulmonary capillary wedge pressure (PCWP)
ranged from 6 mmHg to 9 mmHg. Transesophageal
echocardiography (TEE) showed global hypokinesia
of the left ventricle (LV) with ejection fraction (EF) of
25 to 30%. Supportive therapy was continued with full
neurological, respiratory and hemodynamic recovery.
However, her stay in the ICU was complicated with
the development of fever and leukocytosis. A septic
screen was performed and included a computerized
tomography (CT) scan of the abdomen which showed
a large (44 × 39 mm), heterogeneous, enhancing,
left adrenal mass. A presumptive diagnosis of
pheochromocytoma was confirmed with biochemical
investigations that showed markedly elevated
catecholamines in urine (Table 1) and metanephrines
in serum (Table 2). The patient was treated with
alpha-adrenergic blockade (phenoxybenzamine),
with additional beta-blockade (metoprolol), and
discharged home with the above medications. Two
months after discharge, she underwent uneventful
elective laparoscopic excision of the left adrenal mass.
The histopathology described a nodular, encapsulated
mass arising from the adrenal medulla measuring
2.5 × 2.3 × 1.5 cm, and confirmed the diagnosis of
pheochromocytoma.
M.E.J. ANESTH 22 (2), 2013
198
HADDAD S. et. al
Fig. 2
Abdominal computed tomography (CT) scan showing
a large (44 × 39 mm), heterogeneous, enhancing, left
adrenal mass.
Fig. 3
Photomicrograph of the lesion, showing a well
demarcated mass (left) with a residual normal adrenal
gland (right).
Fig. 4
The tumor cells are arranged in nests surrounded by a
thin fibrovascular stroma, so called “Zellballen”. There
is slight pleomorphism, but no atypia.
CARDIORESPIRATORY CRISIS AT THE END OF PREGNANCY: A CASE OF PHEOCHROMOCYTOMA
Table1
Twenty-four hour urinary analysis
(catecholamines: HPLC) (u)
Epinephrine
Epinephrine / Creatinine
Norepinephrine
Norepinephrine / Creatinine
Dopamine
Dopamine / Creatinine
Creatinine
475+ nmol/24 h
N <147
145+ µg/g
N <25.0
2330 + nmol/24 h
N <573
657 + µg/g
N <115
2612 nmol/24h
N <3265
667 + µg/g
N <540
1.83- mmol/L
N 2.48-19.2
N: normal
Table2
Serum catecholamines (HPLC)
Epinephrine
1.31+ nmol/l
N: up to 0.445
Norepinephrine
7.29 nmol/l
N: up to 2.44
Dopamine
0.766 nmol/l
N: up to 0.553
N: normal
Discussion
Pheochromocytomas are rare neuroendocrine,
catecholamine-secreting tumors derived from the
chromaffin cells of the adrenal medulla or extraadrenal
paraganglia. Their incidence during pregnancy is
even more infrequent with an estimated prevalence
of 1 in 50,000 to 54,000 in full-term pregnancies.
The maternal mortality rate is 2 to 4% if the tumor is
diagnosed in the antenatal period, compared to 14 to
25% if it is diagnosed intra- or postpartum1-3.
There are limited case-reports in the literature4-12.
Bullough et al. reported a case of pheochromocytoma
as an unusual cause of hypertension in pregnancy.
Intravenous magnesium sulfate infusion proved
successful in controlling hypertension in the
postpartum period4. Magnesium sulfate has also been
used as the sole drug for control of hemodynamic
disturbances during pheochromocytoma excision
surgery5. Dugas et al. described a patient who was
diagnosed with pheochromocytoma in the third
trimester of pregnancy and discussed the perioperative
and anesthetic management6. A fatal, undiagnosed
pheochromocytoma mimicking severe preeclampsia in
199
a pregnant woman at term was reported by Hudsmith
et al. Post mortem examination of the patient revealed
a 5.5-cm tumor of the right adrenal gland confirmed
histologically as a pheochromocytoma7. Pearson
et al. reported a case of pheochromocytoma in an
18-year-old-woman. She presented with aproteinuric
hypertension and intermittent panic attacks.
Ultrasonography showed a structure obscuring the left
adrenal gland. In the postpartum period, the tumor was
resected and histologically arose from the sympathetic
paraganglion cells; the left adrenal gland itself
was normal8. A pheochromocytoma was diagnosed
following a crisis in late pregnancy (sudden onset
of bitemporal headache and shortness of breath) in a
31-year-old-woman in the 37th week of pregnancy9.
In 2010, a case-report and literature review was
published by George et al. The authors recommended
evaluating for pheochromocytoma all patients with the
typical triad of headache, sweating and palpitation in
the presence of resistant or labile hypertension10. Oliva
et al. reviewed six cases of pheochromocytoma in
pregnancy and concluded that pheochromocytoma was
a rare but important cause of hypertension in pregnant
women because of its high morbidity and mortality to
both mother and fetus11.
The excess release of catecholamines
(norepinephrine, epinephrine and dopamine) accounts
for the typical presentation of pheochromocytoma.
Clinical manifestations can differ greatly, resembling
several
clinical
conditions.
Consequently,
pheochromocytoma has often been referred to as the
great mimic. However, the most common clinical
feature is hypertension, associated with tachycardia
and paroxysmal symptoms such as headache, sweating,
nausea, tremor, palpitations and feelings of anxiety or
panic. Although, hypertension is common and may be
insidious or severe with hypertensive crises, there is
growing number of normotensive and asymptomatic
patients who are diagnosed with the disease12-15.
Consequent to an increased use of advanced imaging
technology, nearly 25% of all pheochromocytomas are
now diagnosed incidentally during imaging studies for
distinct disorders16,17.
Pheochromocytoma-related signs and symptoms
may occur for the first time during or in late pregnancy.
Furthermore, the earliest clinical presentation may
M.E.J. ANESTH 22 (2), 2013
200
develop at the end of pregnancy during vaginal
delivery18 or cesarean section. Increased vascularity
of the tumor, hemorrhage into the tumor, mechanical
effects such as enlarging gravid uterus or vigorous
fetal movements which can stimulate catecholamine
secretion, vaginal delivery, anesthesia and cesarean
section (CS) are precipitating factors for crisis or
worsened condition19. Our patient was completely
asymptomatic before and during pregnancy; her first
presentation was as a sudden cardiorespiratory crisis.
One or more of the above mentioned factors may have
contributed to her deterioration.
In pregnant patients, the diagnosis of
pheochromocytoma is often missed since the classical
signs and symptoms may mimic pre-exisiting
essential hypertension and other forms of pregnancyrelated hypertensive syndromes including gestational
hypertension and preeclampsia. Usually, pre-existing,
essential hypertension is diagnosed and treated
prior to pregnancy while pre-eclampsia develops
after 20 weeks gestation and includes proteinuria.
Conversely, pheochromocytoma is rarely associated
with proteinuria, and the hypertension may occur
throughout the entire pregnancy20. A differential
diagnosis of pheochromocytoma in pregnancy
includes beta-mimetic-induced pulmonary edema21-22,
cardiomyopathy (preeclampsia, peripartum, stress or
Takotsubo)23-27, pre-existing cardiac diseases such as
mitral stenosis, pulmonary embolism (PE), aspiration
pneumonitis (Acute Respiratory Distress Syndrome:
ARDS), sepsis-related acute lung injury (ALI),
and amniotic fluid embolism. Thus, a high index of
suspicion is required for early diagnosis.
A combination of alpha- and betaadrenergic receptor blockers for the treatment of
pheochromocytoma-induced
hypertension
must
directed by their pharmacodynamic effects and
should follow a certain sequence. Commencement
of nonselective beta blocker treatment without prior
alpha blockade in a patient with pheochromocytoma
may precipitate a hemodynamic crisis28,29. Premature
initiation of a nonselective beta blocker results in a
loss of beta-2 receptor-mediated vasodilatation and
the unopposed alpha-adrenergic receptor stimulation.
This causes vasoconstriction, arterial hypertension
and increased afterload, leading to myocardial
HADDAD S. et. al
dysfunction and pulmonary edema. Sibal et al.
reported that the initiation of beta blockers in four
patients with pheochromocytoma was associated
with further deterioration in hemodynamic status,
labile blood pressure and cardiac arrhythmias30.
They concluded that “unexplained cardiopulmonary
dysfunction, particularly after the institution of beta
blockers, should alert clinicians to the possibility of
pheochromocytoma”. Our patient suffered exactly the
same consequences following the administration of
emolol (a beta1-cardioselective adrenergic receptor
blocking agent) and later labetalol (both selective
alpha1-adrenergic and nonselective beta-adrenergic
receptor blocking agent) and amiodarone. Nonselective
beta blockers should be initially avoided in patients
with a suspected pheochromocytoma, but can be used
only after adequate alpha blockade.
Although, patients with pheochromocytoma
are hypertensive, their intravascular volume may be
reduced. Initiation of fluid removal, by administering
diuretics or instituting hemofiltration, may precipitate
cardiovascular collapse, and should be avoided.
This might explain why our patient deteriorated
further (PEA cardiac arrest) after administration of
furosemide and fluid removal by hemofiltration.
Invasive hemodynamic monitoring with a PAC
suggested a low intravascular volume (PCWP 6 to 9
mmHg) and excluded other possible diagnosis such as
pregnancy induced cardiomyopathy, fluid overload,
and beta-mimetic-induced pulmonary edema31,32.
Moreover, most reported cases of beta-mimeticinduced pulmonary edema occurred with higher
doses (more than 30 mg) of these drugs especially
when administered intravenously21 (our patient
received only 0.5 mg SC), making this diagnosis to
be unlikely.
In our patient, pheochromocytoma was
suspected by the finding of an adrenal mass on CT
scan of the abdomen as a work up for septic shock in
ICU. It was confirmed by high level of catecholamine
in serum and urine and by biopsy after surgical
resection. Our case report represents an atypical
presentation of pheochromocytoma, including acute
respiratory failure followed by PEA arrest, in a
pregnant patient.
CARDIORESPIRATORY CRISIS AT THE END OF PREGNANCY: A CASE OF PHEOCHROMOCYTOMA
Conclusions
Pregnant women with pheochromocytoma may
remain asymptomatic until the end of pregnancy. The
first clinical presentation may develop during vaginal
delivery or cesarean section and may manifest as a
severe cardiorespiratory crisis.
Pheochromocytoma should be considered in the
differential diagnosis of hemodynamic crisis occurring
201
during or at the end of pregnancy.
Cardiovascular
collapse
following
the
administration of a beta blocker should alert one to the
possibility of pheochromocytoma.
In patients who are suspected to have
pheochromocytoma, beta blockers should be avoided
until adequate alpha blockade is established.
Careful fluid management is also essential.
M.E.J. ANESTH 22 (2), 2013
202
HADDAD S. et. al
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11.Oliva R, Angelos P, Kaplan E, et al: Pheochromocytoma in
Pregnancy. A Case Series and Review. Hypertension; 2010, 55:600606.
12.Mantero F, Terzolo M, Arnaldi G, et al: A survey on adrenal
incidentaloma in Italy. Study Group on Adrenal Tumors of the
Italian Society of Endocrinology. J Clin Endocrinol Metab; 2000,
85:637-644.
13.Bryant J, Farmer J, Kessler LJ, et al: Pheochromocytoma: the
expanding genetic differential diagnosis. J Natl Cancer Inst; 2003,
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14.Baguet JP, Hammer L, Mazzuco TL, et al: Circumstances of
discovery of phaeochromocytoma: a retrospective study of 41
consecutive patients. Eur J Endocrinol; 2004, 150:681-686.
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adrenal mass: update in diagnosis and management. Endocr Rev;
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features at presentation, and risk of recurrence in patients with
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pheochromocytoma during pregnancy. J Neurol; 2007, 254:16121613.
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Pheochromocytoma complicated with cardiomyopathy after
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ECHOCARDIOGRAPHY GUIDED THERAPY
FOR MASSIVE INTRA-OPERATIVE PULMONARY
EMBOLI DURING ARTERIO-VENOUS
FISTULA/GRAFT THROMBECTOMY
JAHAN PORHOMAYON* AND NADER D. NADER**
Abstract
Various techniques’ are currently employed for thrombectomies of the arterio-venous (AV)
fistula/ graft to restore flow. Sub massive or massive pulmonary emboli’s have been reported
following such procedures both intra-operatively and post-operatively. The hemodynamic
responses depend not only on the size of the emboli’s but also on the pre existing cardiac or
pulmonary reserve of the patient. Rapid intra-operative echocardiography by anesthesiologist
not only will help the clinicians with diagnosis but also can guide treatment plan as well as
prognosis.
Conflict of interest: None
Key words: Pulmonary Emboli, Echocardiography, Hypotension, Intra-operative,
Hemodialysis, Fistula
Introduction
Hemodialysis graft or fistula occlusion is a common event that occurs frequently in patient
with end stage renal disease. As a result, the vast majority of dialysis patients with AV graft/ fistula
thrombosis undergo surgery for thrombectomy1-3. Surgical approach and techniques include,
thrombolysis4, suction thrombectomy5, balloon thrombectomy6, mechanical thrombectomy with
surgical devices7 or combinations of these methods. Restoration of flow can be achieved with
balloon angioplasty and in some instances endovascular stents8-9. Embolization could occur during
extraction process and result in mild to severe cardio-respiratory complications10.
Intra-operative echocardiography is not only a valuable tool for the anesthesiologist to
diagnose pulmonary emboli (PE) but also help the surgical team to make appropriate treatment
plan.
*
**
MD, FCCP, Associate Professor of Anesthesiology and Critical Care Medicine, Division of Critical Care.
M.D., PH.D., FCCP, Professor of Anesthesiology, Surgery and Pathology, Division of Cardiovascular Anesthesia VA
Western New York Healthcare System, Department of Anesthesiology, State University of New York at Buffalo School of
Medicine and Biomedical Sciences, Buffalo, New York.
Corresponding author: Jahan Porhomayon MD, FCCP, FABHP, VA Medical Center, Rm 203C, 3495 Bailey Ave, Buffalo,
NY 14215. Tel 716 862-8707, Fax 716 862-8707. E-mail: [email protected]
203
M.E.J. ANESTH 22 (2), 2013
204
Case Report
We report a case of a 58 year old male with
past medical history significant for end stage renal
disease (ESRD), hypertension and liver disease
secondary to hepatitis C infection. Surgical history
was significant for multiple hemodialysis and AV
graft/fistula thrombectomies. He was admitted to the
hospital with the chief complain of non functioning
AV fistula. Vascular team evaluations revealed AV
fistula thrombosis and patient was scheduled for
thrombectomy of AV fistula. Prior to surgery, bilateral
lower extremities venous doppler ultrasound did not
detect deep venous thromboses. He was brought to
the operating room for attempted thrombectomy of
the AV fistula. Vital signs on arrival to the operating
room were blood pressure of 100/60 mm/Hg, heart
rate of 110 beat /min, oxygen saturation of 97% and
axillary temperature of 36.5 centigrade. On arrival to
the operating room, he was placed on 100% oxygen
via face mask. He was induced with propofol/
fentanyl/oxygen/air and trachea was intubated without
difficulty. He was maintained on desflurane/air/ and
50% oxygen. He was placed on controlled mechanical
ventilation with respiratory rate of 14 beat /minute,
tidal volume of 600 ml, positive end expiratory
pressure of 5 cmH2O and end tidal CO2 of 25 mm/
Hg with pulse oximetery reading of 97% saturation.
Arterial blood gas analysis showed pH = 7.32, PaCO2
= 35 mm/Hg, PaO2 = 120 mm/Hg. Operation begun
with a longitudinal incision above the antecubital
crease and dissection was carried down until fistula was
identified. The basilic vein appeared to be pulsatile. An
attempt was made to puncture the fistula and passed
the wire in a retrograde fashion but unsuccessful. The
fistula was then opened with a #11 blade and manually
large amount of thrombus was evacuated from the
basilic vein. A fogarty catheters was also passed
through the basilic vein with return of brisk bleeding.
A left brachio-basilic fistulogram was performed. The
basilic vein appeared to be widely patent. A short
period after thrombectomy patient vital signs became
unstable with a drop in arterial oxygen saturation to
low 60% with low end tidal CO2 below 10 mm/Hg.
Systolic blood pressure dropped below 40 mm/Hg.
PORHOMAYON J. et. al
Patient was immediately placed on 100% oxygen and
vasopressors and rapid infusion of crystalloids were
started. Vasopressin infusion was started at 0.1 units per
minute and norepinephrine at10 mcg/min to maintain a
mean arterial pressure of 65 mm/Hg. Transesophageal
echocardiography was performed intra-operatively
and confirmed the presence of large pulmonary emboli
in pulmonary artery [Fig. 1, 3] and superior vena cava
[Fig. 2]. It was decided to start thrombolytic therapy
with the tissue plasminogen activator (tPA) 100 mg IV
over 2 hours. Patient was immediately transferred to
MICU and his post operative course was complicated
with respiratory failure with mechanical ventilation
and hypotension requiring vasopressor therapy. He
gradually recovered with supportive care and was
transferred to floor a week later.
Fig. 1
TEE demonstrates several large emboli are observed in the
superior vena cava. Arrows point to emboli.
TEE = Tranesophageal echocardiography, RA = Right Atrium,
IVC = Inferior vena cava, LA = Left Atrium, SVC = Superior
Vena Cava
Fig. 2
TEE features of an acute PE includes: Right ventricular dilation,
Tricuspid regurgitation, Ventricular septal wall bulging (arrow),
Right atrial dilation
TEE = Trans-esophageal echocardiography, RA = Right atrium.
LA = Left atrium, LV = Left ventricle, IVS = Intra-ventricular
septum
ECHOCARDIOGRAPHY GUIDED THERAPY FOR MASSIVE INTRA-OPERATIVE PULMONARY EMBOLI DURING
ARTERIO-VENOUS FISTULA/GRAFT THROMBECTOMY
Fig. 3
TEE = Transesophageal echocardiography indicate large emboli
in the pulmonary artery (arrow)
AO = Aorta, RPA = Right pulmonary artery, LPA = Left
pulmonary artery, MPA=Main pulmonary artery
Discussion
The United States annual renal report in 2008
indicated that a total of 112,476 patients started
ESRD therapy, and the ESRD population reached
547,982 including 382,343 dialysis patients11. The vast
majority of patients had interventional procedures for
thrombosis of hemodialysis fistula/ graft in the USA1213
. To restore flow, catheter intervention techniques
have become the primary mode of restoring flow in
about 80% of cases14. Complications arising from
such interventions include bleeding, PE, vein rupture,
cerebral embolism and arterial embolism10,15.
The true incidence and rate of successful
lysis and outcome of massive intra-operative PE
following such procedures remains largely unknown.
205
Massive pulmonary embolism remains the most
feared complication intra-operatively. Thrombolytic
therapy remains the treatment of choice and surgical
management is reserved for high risk patient16.
Catheter embolectomies have also been reported
and are currently limited to centers with specialized
training and dedicated staff17.
In general, standard diagnostic modalities
utilized for evaluation of PE includes ventilation
perfusion scan of lung18, contrast enhanced
computed tomography of lung with PE protocol19
and echocardiography. Transesophageal (TEE) ot
transthoracic echocardiography remains the most
valuable tools in the operating room and can be useful in
providing therapeutic and prognostic information20-21.
Echocardiographic finding useful in diagnosis of PE
include: Right ventricular dysfunction and dilation,
dilated pulmonary artery, and reduced left ventricular
size22. A recent study by Aymard et al suggested that
right ventricule (RV) to left ventricule (LV) ratio
of > 1.5 should be considered as the cut off value for
allocating patients to surgical embolectomy23. TEE in
our patient not only confirmed the presence of a saddle
embolus in pulmonary artery [Fig. 3] and several
smaller PE’s in the superior vena cava (SVC) but also
an RV/LV ratio of 0.9 favoring thrombolytic therapy.
Thrombolysis with tPA in combination with heparin
were initiated at the end of the operation after surgical
homeostasis was achieved24-26.
Other clues for supporting diagnosis of PE,
includes the presence of a wide arterial to end tidal
CO2 gradient 27 as well as hemodynamic instability.
Echocardiography can play a valuable role and is
a useful diagnostic test for early diagnosis, risk
stratification, and management of patient with large PE.
M.E.J. ANESTH 22 (2), 2013
206
PORHOMAYON J. et. al
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1997, 8(5):813-824.
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MP: Pulse-spray pharmacomechanical thrombolysis of thrombosed
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SB: Detection and treatment of dysfunctional hemodialysis access
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incidence of thrombosis. Radiology; Jun 1996, 199(3):653-657.
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outcomes: an international perspective from the Dialysis Outcomes
and Practice Patterns Study. Nephrol Dial Transplant; Oct 2008,
23(10):3219-3226.
13.Paulson WD, Work J: Controversial vascular access surveillance
mandate. Semin Dial; Jan-Feb 2010, 23(1):92-94.
14.III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access:
update 2000. Am J Kidney Dis; Jan 2001, 37(1 Suppl 1):S137-181.
15.Briefel GR, Regan F, Petronis JD: Cerebral embolism after
mechanical thrombolysis of a clotted hemodialysis access. Am J
Kidney Dis; Aug 1999, 34(2):341-343.
16.Akay TH, Sezgin A, Ozkan S, Gultekin B, Aslim E, Aslamaci S:
Successful surgical treatment of massive pulmonary embolism after
coronary bypass surgery. Tex Heart Inst J; 2006, 33(4):498-500.
17.Kuo WT, van den Bosch MA, Hofmann LV, Louie JD, Kothary
N, Sze DY: Catheter-directed embolectomy, fragmentation, and
thrombolysis for the treatment of massive pulmonary embolism after
failure of systemic thrombolysis. Chest; Aug 2008, 134(2):250-254.
18.Kiil J, Jensen FT: Pulmonary embolism associated with elective
surgery, detected by ventilation-perfusion scintigraphy. Acta Chir
Scand; 1978, 144(7-8):427-430.
19.Burns SK, Haramati LB: Diagnostic imaging and risk stratification
of patients with acute pulmonary embolism. Cardiol Rev; Jan 2012,
20(1):15-24.
20.Simpson N, Orford N: Early transoesophageal echocardiography
(TOE) in cardiac arrest: a case study. Crit Care Resusc; Mar 2006,
8(1):31-35.
21.Lin T, Chen Y, Lu C, Wang M: Use of transoesophageal
echocardiography during cardiac arrest in patients undergoing
elective non-cardiac surgery. Br J Anaesth; Feb 2006, 96(2):167170.
22.Kasper W, Meinertz T, Henkel B, et al: Echocardiographic findings
in patients with proved pulmonary embolism. Am Heart J; Dec
1986, 112(6):1284-1290.
23.Aymard T, Kadner A, Widmer A, et al: Massive pulmonary
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Jan 2013, 43(1):90-94; discussion 94.
24.Toosy K, Saito S, Patrascu C, Jean R: Cardiac arrest following
massive pulmonary embolism during mechanical declotting of
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M: Successful thrombolytic therapy for massive pulmonary
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26.Kim MS, Kim KM, Woo SH, Lim YH, Yon JH, Jeon SG: Successful
thrombolytic therapy with recombinant tissue-type plasminogen
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27.Bonderman D, Lang IM: End-tidal CO2 for exclusion of suspected
pulmonary embolism: a new partner for Wells? Eur Respir J; Apr
2010, 35(4):723-724.
HIGH DOSE STREPTOKINASE FOR THROMBOLYSIS
IN THE IMMEDIATE POSTOPERATIVE PERIOD:
A CASE REPORT
Rakesh V Sondekoppam*, Manjeet Kanwar**,
Latha Y S** AND Banashree Mandal***
Abstract
Venous thrombo-embolism is a life threatening condition with often non specific presentation.
The detection of massive pulmonary embolism in the intra and immediate post-operative period
is not only difficult due to the variety of conditions with similar presentation, but the therapy
for the same is complicated with concerns of surgical and intracranial bleeding precluding
various options. We present a case of massive pulmonary embolism presenting as intraoperative
hypotension with an increased alveolar to arterial CO2 gradient which was subsequently managed
with an accelerated regimen of streptokinase without increased postoperative bleeding. Accelerated
regimen of streptokinase may be used as a safe low cost alternative modality in selected cases of
massive pulmonary embolism in the immediate postoperative period.
Conflict of interest: None
Sources of financial support: None
Key words: Alveolar-arterial gradient, Intraoperative, major abdominal surgery, Pulmonary
embolism, Streptokinase.
Venous thromboembolism (VTE) and Pulmonary embolism (PE) are one of the commonest
preventable life threatening emergency of surgical patients having nonspecific presentation but,
thrombolysis in the immediate post-operative period is contraindicated due to increased concerns
of surgical and intracranial bleeding. The improvement in hemodynamics and gas exchange in
massive PE is greatest in the first 48 hours of diagnosis1. Although there is an overall decrease in
the incidence of life threatening bleeding complications probably owing to an increased use of
non-invasive modalities for the diagnosis of PE2, there is little evidence on the use of thrombolysis
in the immediate postoperative period. We present a case of pulmonary embolism with shock
recognised in the immediate postoperative period successfully managed with accelerated dose of
streptokinase after obtaining ethical committee approval and patient consent for publication.
*
**
***
MD.
MBBS.
MD, DM.
Department of Anaesthesia and Intensive care, Postgraduate institute of Medical Education and Research, Chandigarh,
India.
Corresponding address: Dr. Rakesh Sondekoppam Vijayashankar, Senior resident, Department of Anaesthesia and
Intensive care, Postgraduate institute of Medical Education and Research, Chandigarh, India. Tel: +91-9855012313.
Email: [email protected]
207
M.E.J. ANESTH 22 (2), 2013
208
Case report
A 65 year old ASA-1 female (52 Kg weight), a
follow up case of antrectomy, gastrojejunostomy and
vagotomy for benign stricture of pylorus presented
with symptoms of small gastric volume and dumping
syndrome for which an operative exploration and
adhesiolysis followed by total gastrectomy and
feeding jejunostomy was planned. Patient did not
have any underlying co-morbidity and was apparently
healthy on the preoperative examination without any
functional limitation but complained of weight loss
and weakness due to the dumping syndrome. After
ensuring overnight fasting, the patient was shifted to
the operating room and large bore intravenous access
obtained. The patient complained of anxiety during
shifting on to the operating table. After attachment of
ECG, NIBP and pulse oximeter, baseline tachycardia
(HR 136 beats/min) was noted but presumed to be due
to anxiety and possible dehydration. Her other vital
parameters (BP of 126/84 and SPO2 of 97%) were
normal. A thoracic epidural was put for analgesia
and right internal jugular vein cannulated for central
venous pressure monitoring and fluid resuscitation.
Initial CVP was low. After volume expansion with 500
ml of crystalloid patient was induced with IV morphine
6 mg, titrated dose of propofol 80 mg and vecuronium
6 mg to facilitate endotracheal intubation. A sudden
hypotension was noted (72/40 mm Hg) soon after
induction and was presumed to be due to exaggerated
response to propofol and hence IV phenylephrine (100
µg) bolus was injected but did not improve the BP
to normal levels and hence patient was immediately
intubated and fluid bolus of 500 ml rapidly infused
following which, the blood pressure came up to
116/72 mm Hg and HR settled. An invasive arterial
blood pressure was transduced and an arterial blood
gas analysis done which showed blood gas parameters
with a Ph of 7.23, PO2 of 130 (50% FIO2), PaCO2 of 46
mm Hg, HCO3 of 20 Base deficit of -6 and an SAO2 of
98% revealing an increased (A-a) O2 and CO2 gradient.
The patient had stable intraoperative haemodynamics
except increasing tachycardia which did not respond
to fluid boluses or increasing depth of anesthesia and
analgesia. End tidal CO2 did not respond to changes
in ventilatory strategies. Intermittent ABGs revealed
increased (A-a) CO2 gradient but oxygenation was
Sondekoppam R. V. et. al
maintained. Anesthesia was maintained by oxygen
and nitrous (50:50) with isoflurane titrated to 1 MAC
and intermittent boluses of vecuronium titrated to train
of four count < 2. The surgical course was uneventful.
The total duration of surgery was about 3 hours
following which patient was reversed for residual
neuromuscular blockade at the end of anesthesia
but the patient did not respond to verbal commands
or painful stimuli even after about 45 minutes of
stopping anesthetic agents and complete recovery of
train of four counts. Pupils were normal and reactive
to light. Suspecting possible intraoperative pulmonary
thromboembolism the patient was transferred to PACU
for postoperative ventilation and further management.
Patient had persistent and increasing tachycardia
and alveolar to arterial gradient of CO2 and became
hemodynamically unstable for which dopamine 5
µg/kg/min was started post-operatively. The cardiac
markers were negative and twelve lead ECG was
normal except for tachycardia and chest X-ray was
unremarkable. Echocardiography revealed dilatation
of right sided chambers with RV hypokinesia and
hence suspecting pulmonary embolism, a pulmonary
CT-angiography was performed which confirmed RV
dilatation (Fig. 1) with bilateral pulmonary embolism
extending from segmental branches of upper, middle
& lower lobes (Fig. 2). After arranging blood
products and informing the blood bank, patient was
thrombolysed with 1.5 million units of streptokinase
over half an hour without any bleeding episodes in
the subsequent postoperative period. The patient was
extubated after overnight ventilation. A search for the
source of embolus revealed a DVT of left calf region on
compression ultrasound without any physical evidence
like swelling or warmth on examination. The patient
sustained paroxysmal supraventricular tachycardia
(HR of 230/min & hypotension of 60/40mmHg)
in the next post-operative day which responded to
carotid massage. The cause of PSVT was found to
be hypokalemia which was subsequently corrected.
Second day repeat ECHO showed improvement in RV
hypokinesia although dilatation of RA and RV was still
present. The rest of the hospital course was uneventful
and the patient was subsequently discharged after 14
days of hospital stay.
HIGH DOSE STREPTOKINASE FOR THROMBOLYSIS IN THE IMMEDIATE POSTOPERATIVE PERIOD: A CASE
REPORT
209
Fig. 1
CT angiogram showing dilated
right ventricle
Fig. 2
pulmonary CT angiogram
demonstrating bilateral pulmonary
emboli starting from the lobar
division.
M.E.J. ANESTH 22 (2), 2013
210
Discussion
Our case represents a typical presentation of
massive pulmonary embolism with high alveolararterial CO2 gradient, increased pressures in the right
heart chambers, delayed awakening probably due to
systemic embolization from opening of foramen ovale
with the condition further progressing to hemodynamic
instability following right heart failure. Pulmonary
thromboembolism (PE) is a frequent life threatening
disorder presenting diagnostic difficulties. It is often
unrecognised in upto 75% of cases and cadaveric
studies have shown approximately 3% to 5% of the
necropsies harbouring emboli in the pulmonary
vessels3. The problem in early detection of VTE is
the insensitivity of physical examination to detect
it with even the most sensitive screening methods
missing upto 30% of patients with PE4. Hence, a
fairly high percentage of undetected DVT might have
an associated asymptomatic pulmonary embolism.
Around 30-50% blockade of pulmonary vasculature
is necessary to produce hemodynamic instability and
shock1 the prognosis of which depends on the time to
diagnosis and institution of appropriate management.
Although immediate postoperative period is a relative
contraindication for the performance of thrombolysis
in acute PE, it might be a last resort in life threatening
cases with severe right ventricular failure and shock.
Usual doses of streptokinase recommended for
pulmonary embolism (loading dose of 250 000 IU over
30 min, followed by 100 000 IU/h over 12–24 h) might
take a longer duration for complete thrombolysis and
hence accelerated regimens (1.5 million IU over 2 h)
have been studied for utility. A study by MENEVEAU
ET AL5 showed the safety and efficacy of a 2-h regimen
of high dose streptokinase in improving cardiac output
similar to high dose therapy with alteplase. With an
Sondekoppam R. V. et. al
increasing evidence of inefficient thrombolysis in
worsening early outcomes, goal of the thrombolytic
regimens are to achieve complete thrombolysis as soon
as possible which might be possible with accelerated
regimens. One of the major concerns after thrombolysis
is the occurrence of intracranial or surgical site bleeding
which can range from 14% with older studies to around
4 % with the use of noninvasive methods used for
diagnosis6. Hence a high dose streptokinase might be
a life-saving option in massive pulmonary embolism.
Although patients having major surgery were excluded
in the study by Meneveau et al5, massive pulmonary
embolism in immediate postoperative period may
require thrombolytic therapy with considerations to the
type of surgery, intraoperative course and pre-existing
co-morbidity.
A major vascular, spine or neurosurgery, injury
to a major vessel during the intraoperative course, or a
preexisting cerebrovascular disease or previous stroke
can preclude thrombolysis. These patients and others
with contraindications to thrombolysis or those patients
failing thrombolytic therapy might be better candidates
for surgical thrombo-embolectomy. Although recent
evidence suggests a decreasing bleeding complications
and better survival rates with surgical embolectomy,
intracranial bleeds and neurological events were
similar with surgical or pharmacological therapies7.
Conclusion
To conclude, accelerated regimen of thrombolysis
can be selectively utilized in massive pulmonary
embolism associated with hemodynamic instability in
the immediate postoperative period. Considerations
to preoperative patient condition and type of surgery
should aid in the decision making between surgical
and pharmacological therapies.
HIGH DOSE STREPTOKINASE FOR THROMBOLYSIS IN THE IMMEDIATE POSTOPERATIVE PERIOD: A CASE
REPORT
211
References
1. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N,
Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko
W, Mayer E, Remy-Jardin M, Bassand JP: ESC Committee
for Practice Guidelines (CPG). Guidelines on the diagnosis and
management of acute pulmonary embolism: the Task Force for
the Diagnosis and Management of Acute Pulmonary Embolism
of the European Society of Cardiology (ESC). Eur Heart J; 2008,
29:2276-315.
2. Stein PD, Hull RD, Raskob G: Risks for major bleeding from
thrombolytic therapy in patients with acute pulmonary embolism.
Consideration of noninvasive management. Ann Intern Med; 1994,
121:313-317.
3. White RH: The epidemiology of venous thromboembolism.
Circulation; 2003, 107(23 Suppl. 1):14-18.
4.Kearon C: Natural history of venous thromboembolism. Circulation;
2003, 107(23 Suppl. 1):122-130.
5. Meneveau N, Schiele F, Metz D, et al: Comparative efficacy of a
two-hour regimen of streptokinase versus alteplase in acute massive
pulmonary embolism: immediate clinical and hemodynamic
outcome and one-year follow-up. J Am Coll Cardiol; 1998, 31:105763.
6. Stein PD, Hull RD, Raskob G: Risks for major bleeding from
thrombolytic therapy in patients with acute pulmonary embolism.
Consideration of noninvasive management. Ann Intern Med; 1994,
Sep 1;121(5):313-7.
7. Aymard T, Kadner A, Widmer A, et al: Massive pulmonary
embolism: surgical embolectomy versus thrombolytic therapyshould surgical indications be revisited? Eur J Cardiothorac Surg;
2012 Mar 30. [Epub ahead of print]
M.E.J. ANESTH 22 (2), 2013
PATHOLOGY QUIZ: ONCOCYTIC CYST OF
THE VENTRICULAR FOLD
HAMDAN AL*, MARIE-THERESE HOMSI**,
ZAAHIR TURFE*** AND FOUAD BOULOS****
Case Presentation
A 56 year old woman presented to the Voice Clinic with recent history of change in voice
quality associated with foreign body sensation in the throat and globus pharyngeus. Patient denied
any symptoms of gastro-esophageal reflux, namely heartburn and or regurgitation. She had history
of smoking but no history of phonotraumatic behavior. Medical history was negative for any
systemic illness. On perceptual evaluation, she had a rough voice with mild straining. Laryngeal
video-endostroboscopy revealed a 0.5 cm × 0.5 cm polypoidal smooth mass arising from the
anterior aspect of the right false vocal fold (see Fig. 1). The true vocal folds were intact and mobile.
The patient underwent suspension microlaryngoscopy under general anesthesia with resection of
the mass using Carbon Dioxide Laser. The pathology revealed the following: (see Fig. 2).
Fig. 1
Laryngeal video-endostroboscopy
showing a polypoidal smooth
mass arising from the right false
vocal fold measuring 0.5cm x 0.5.
*
MD, EMBA, FACS, Department of Otolaryngology-Head & Neck Surgery, American University of Beirut Medical
Center-Beirut-Lebanon.
**
BS, Faculty of Medicine, American University of Beirut, Beirut-Lebanon.
*** BS, Michigan State University College of Human Medicine.
****MD, Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, Beirut-Lebanon.
Corresponding author: Abdul-Latif Hamdan, MD, EMBA, FACS, Professor, Vice-Chairman, Director of Hamdan Voice
Unit, Department of Otolaryngology-Head & Neck Surgery, American University of Beirut Medical Center, P.O. Box:
110236 Beirut- Lebanon. Tel/Fax: 961-1-350000. E-mail: [email protected]
No conflict of interest or financial support in relation to this manuscript.
213
M.E.J. ANESTH 22 (2), 2013
214
HAMDAN AL et. al
Fig. 2
Hematoxylin & Eosin stainLow magnification (40X):
Microscopic examination of
the biopsy reveals a simple cyst
lined by respiratory mucosa.
Higher magnification (400X);
The cystislined by cuboidal
to pseudostratified columnar
epithelium with abundant
oncocytic cytoplasm and
uniform round nuclei without
atypia or mitotic activity.
Pathology Quiz: Oncocytic cyst of the
ventricular fold
Oncocytic cysts are benign lesions lined by
oncocytes1. Many names have been attributed to
these cysts such as oncocytic papillary cystadenoma,
oncocytoma, cystic adenoma, eosinophilic granular
cell cystadenoma, eosinophilic papillary cystadenoma
and oncocytic hyperplasia2.Oncocytic cysts rarely
occur in the larynx despite the fact that oncocytes can
be found in the normal epithelium of the thyroid and
parathyroid glands, salivary glands, tongue, lacrimal
system, uvula, respiratory tract, esophagus, pharynx
and larynx2-4. In this later the prevalance of oncocytes
increases with aging and smoking. When present,
oncocytic cysts account for 0.5-1% of laryngeal
biopsies4 and represent 7% of all laryngeal cysts
and one third of cysts of the ventricular folds5. The
distribution of these lesions is highest in supraglottic
sites and lowest in subglottic region6. In the supraglottic
region, the ventricles and the false vocal cords are
the two most common sites due to the abundance of
seromucinous glands in their epithelium1. Invariably,
the lesion appears as a single polypoidal mass or as
a submucosal enlargement measuring less than 1cm
in dimension6,7. Multiple lesions are rarely reported.
In our case the mass was isolated, polypoid in shape
with a cystic appearance. The differential diagnosis
included laryngocele, hemangioma, amyloidal
deposition, among other lesions7.The patient may be
asymptomatic or reports hoarseness of several months
duration, less often with pain, stridor or respiratory
obstruction1,7. Our patient presented with a foreign
body sensation, globus pharyngeus and mild change
in voice quality. The treatment of choice is endoscopic
excision with cold steel instruments or laser. Close
follow up is recommended due to the risk of recurrence
especially in cases of multiple cysts1.
There several theories behind the origin of
oncocytic cysts. These include occlusion of the ducts,
inflammatory and degenerative changes as well as
aging1,2,5. The long exposure to the oxidants can lead to
inflammation of the mucosal lining which in turn results
in metaplastic changes of acinar and ductal cells of the
salivary glands and respiratory mucosal lining. The
altered metabolism is associated with compensatory
hyperplasia of mitochondria and the subsequent
appearance of oncocytic cells1. The metaplasia of the
distal segment of the duct leads to cystic dilatation with
resultant cyst formation8. Oncocytes are energetic cells
because of their ability to divide and the abundance
of mitochondria in their cytoplasm2,9. With aging and
degeneration, oncocytes may undergo mitochondrial
alterations which render the cells unable to produce
energy10. Metaplastic changes are rare but have been
reported in patients above the age of 50 with a female
predominance (F/M = 2:1)1,8
PATHOLOGY QUIZ: ONCOCYTIC CYST OF THE VENTRICULAR FOLD
215
References
1.Samuel J, Chrystal V, Akerman BS: Oncocytic cyst of the larynx. A
case report. S Afr Med J; 1986 Nov 22; 70(11):695-696.
2.Travis B, Palacios E, McCarty CL: An uncommon case of
laryngeal oncocystoma. Ear Nose Throat J; 2011, 90(5):208-210.
3.De Santo LW, Devine KD, Weiland LM: Cysts of the larynxclassification. Laryngoscope; 1970, 80:145-176.
4.Yamase HT, Putman HC: Oncocytic papillary cystadenomatosis
of the larynx.A clinicopathological entity. Cancer; 1979, 44:23062311.
5.Salerno G, Mignogna C, Cavaliere M, Angelo LD, Galli
V: Oncocytic cyst of the larynx: An unusual occurrence. Acta
Otorhinolaryngol Ital; 2007, 27(4):212-215.
6.Arens C, Glanz H, Kleinsasser O: Clinical and morphological
aspects of laryngeal cysts. EurArch Otorhinolaryngol; 1997,
254:430-436.
7. Brandwein M, Huvos A: Laryngeal oncocytic cystadenomas. Eight
cases and a literature review. Arch Otolaryngol Head Neck Surg;
1995, 121(11):1302-1305.
8.Puttasiddaiah PM, Berry S, Whittet HB, Kumar M: Laryngeal
oncocytic cyst presenting with an acute onset of stridor. Ear Nose
Throat J; 2009, 88(7):1003-1004.
9. Oliveira CA, Roth JA, Adams GL: Oncocytic lesions of the larynx.
Laryngoscope; 1977, 87(10 Pt 1):1718-1725.
10.Tallini G: Oncocytictumours. Virchows Arch; 1998, 433:5-12.
11.McDonald SE, Pinder DK, Sen C, Birchall MA: Oncocytic cyst
presenting as laryngocele with surgical emphysema. EurArch
Otorhinolaryngol; 2006, 263:237-240.
12.Hamperl H: Benign and malignant oncocytoma. Cancer; 1962,
15:1019-1027.
13.Le Jeune FE, Putman HC, Yamase HT: Multiple oncocytic papillary
cystadenomas of the larynx: a case report. Laryngoscope; 1980,
90:501-504.
M.E.J. ANESTH 22 (2), 2013
ANESTHESIA CONSIDERATIONS
IN STIFF PERSON SYNDROME
MOISES A. SIDRANSKY*, NEILSON V. TRAN**
AND ALAN DAVID KAYE***
Abstract
A 34 year old morbidly obese stiff person syndrome (SPS) patient was scheduled for a permanent
catheter placement. SPS is a rare neurologic condition with a suspected autoimmune etiology. SPS
most common manifestations are progressive, including severe muscle rigidity or stiffness affecting
the spine and lower extremities more than other muscle groups. SPS have superimposed episodic
muscle spasms that may resemble myotonic-like contractions and are precipitated by unexpected
noises, tactile stimuli, or emotional stress. This case report describes a patient with SPS and morbid
obesity, and his subsequent management perioperatively for a permanent catheter placement under
monitored anesthesia care. Careful and methodical management of patients with SPS is strongly
suggested given their sensitivity to inhalational anesthetics and neuromuscular blockers.
Key words: stiff person syndrome, inhalational anesthetics, monitored anesthesia care,
neuromuscular blockers
Introduction
Stiff Person Syndrome (SPS) is a rare neurologic condition with a suspected autoimmune
etiology. It is estimated to occur in less than one in a million people, is caused by involuntary
action of the motor unit, and was first described by Moersch and Woltman in 19561. Patients
commonly present with progressive, severe muscle rigidity or stiffness, which tends to affect the
spine and lower extremities more than other muscle groups2. In addition to rigidity, patients with
SPS have superimposed episodic muscle spasms that occasionally may resemble myotonic-like
contractions and are precipitated by unexpected noises, tactile stimuli, or emotional stress1. These
manifestations occur in the absence of any other neurologic disease or underlying chronic pain
syndrome that might produce prolonged muscle rigidity and spasms.
Although the cause of this disease has not been discovered, it has been postulated that
the pathophysiology of SPS is created by antibodies against the 65kD isoform of glutamic acid
decarboxylase (anti-GAD 65), the enzyme essential for the creation of gamma aminobutyric acid
(GABA). High levels of anti-GAD 65 are found in the serum and/or cerebral spinal fluid of 85% of
patients3. It is also associated with autoimmune diseases, particularly diabetes mellitus. By decreasing
GABAergic input from inhibitory spinal interneurons and causing malfunction in GABAergic
*
MD, Senior Resident, Department of Anesthesiology, Louisiana State University School of Medicine in New Orleans.
**
MD, anticipated, May, 2014, Senior Medical Student, Louisiana State University School of Medicine in New Orleans.
*** MD, PHD, Professor and Chairman, Department of Anesthesiology, Louisiana State University School of Medicine in
New Orleans.
Corresponding author: Alan David Kaye, MD, PhD, DABA, DABPM, DABIPP, Professor and Chairman, Department
of Anesthesiology, Professor, Department of Pharmacology, Louisiana State University School of Medicine, 1542 Tulane
Avenue, Room 656, New Orleans, LA 70112. Tel: (504) 568-2319, Fax: (504) 568-2317. Email: [email protected]
217
M.E.J. ANESTH 22 (2), 2013
218
SIDRANSKY M. A. et. al
cortical neurons, this leads to the hyperexcitability of
motor neurons and consequently progressive muscle
rigidity and spasms4,5. SPS can be treated with one
or a combination of several medications including
diazepam, baclofen, gabapentin, clonazepam,
dantrolene, and vigabatrin. Their beneficial effects
are likely mediated by their action on the gammaaminobutyric acid (GABAA) receptor6,7. The use of
these medications with certain general anesthetics
causes concern amongst anesthesia providers because
it has been shown that the combination causes delayed
awakening and neuromuscular weakness in some SPS
patients8,9. Though Lorish et al.10 established criteria
for diagnosis of SPS over two decades ago (Table 1),
subsequent patients have demonstrated numerous other
abnormalities not associated with the neuromuscular
system. The case report presented involves a morbidly
obese patient with SPS who underwent surgery for
permanent catheter placement.
Table 1
Criteria for Diagnosis of Stiff Person Syndrome
1. Prodromes centered on swelling and stiffness of the axial
musculature.
2. Slow progression to the point of affecting the musculature
near the extremities, making voluntary movements and
walking difficult.
3. Demonstrated deformity of the spinal column.
4. Intercurrent episodes of episodic spasms, precipitated by
brusque movements, sudden noises, stress, or emotional
events.
5. No deficits in either motor and sensory examination.
6. No deficits in intellect.
(Modified from Lorish TR, Thorsteinsson G, Howard FM: Stiff-man
higher than normal limits. The patient reported that
when going through stressful situations, such as losing
his job, he would develop symptoms. He was being
treated with carisoprodol 250 mg daily, diazepam 10
mg BID, gabapentin 600 mg TID, and baclofen 30 mg
daily. His symptoms were poorly controlled requiring
IVIG therapy, one of the newer therapies in treating
SPS. A monitored anesthesia care (MAC) anesthetic
was planned for the procedure.
Carisoprodol, diazepam, gabapentin, and
baclofen were given on the day of surgery.
Electrolytes were within normal limits, and no other
premedication was prescribed. Standard American
Society of Anesthesiology monitors were used which
included: temperature, blood pressure, heart rate,
electrocardiogram, and end tidal CO2 assessment.
Monitored anesthesia care was started by administering
to the patient 60 mg of lidocaine, and a propofol
drip at 200 mcg/kg/hr. Vital signs all stayed within a
normal range, and there was no significant pulmonary
ventilator depression noted. There were no surgical
complications. The patient had mild discomfort
during part of the procedure and was given 50 mcg
of fentanyl in a bolus dose, twice. After completion
of the procedure, the patient was followed closely in
Post Anesthesia Care Unit for approximately one and a
half hours without any events. His vital signs remained
stable and then he was transferred back to a regular
hospital floor and returned to the floor on continuous
pulse oximetry to start IVIG therapy.
Discussion
syndrome updated. Mayo Clin Proc; 1989, 64:629-636.)
Case Report
A 34 years old patient weighing 300 lbs. (136 Kg)
and 157 cm in height (BMI= 55 kg/m2) was scheduled
for a permanent catheter placement. He was diagnosed
with SPS based on his symptoms and was relatively
asymptomatic in regards to his morbid obesity. He
denied dyspnea, angina, or any other cardiopulmonary
manifestations. Six months prior to the surgery,
symptoms presented as muscle stiffness in his back
and painful spasms in his lower extremities. A plasma
anti-GAD antibody level was found to be 5,000 times
Treating a patient with SPS involves certain
challenges for anesthesiologists. To date, there are
a number of different anesthetics that have been
performed on patients with SPS (Table 2). Our
literature has reported that some patients undergoing
general anesthesia with muscle relaxation have had
weakness despite appropriate reversal of muscle
relaxation and the need for postoperative mechanical
ventilation for up to 48 hours8. It has also been
postulated that prolonged neuromuscular blockade
could be explained by the synergistic effects of baclofen
preoperatively and volatile anesthetics via a GABAb
receptor mediation or modulation. Though successful
ANESTHESIA CONSIDERATIONS IN STIFF PERSON SYNDROME
219
Table 2
Anesthesia Management in Patients with SPS
Patient
Female, 46 years old
8
Surgery
Drugs
Outcome
Repair of intrathecal baclofen
pump
Sufentanil, Thiopental,
Vecuronium, Neostigmine,
and Glycopyrrolate
Muscle weakness (hypotonia) in the
presence of a vigorous response to ulnar
nerve stimulation
Need of mechanical ventilation overnight
Recovery of strength on postoperative
day 2
Uneventful
Midazolam, Halothane,
and no relaxant
5 months later
11
Male, 58 years old
Thymectomy
Uneventful
Midazolam, Propofol,
Remifentanil, Rocuronium,
and Isoflurane (0.2%0.4%)
Male, 76 years old12
Thymectomy
Fentanyl, Propofol,
Sevoflurane (0.5%-1.7%),
and Ropivicaine (0.25%,
epidural)
Uneventful
ENT surgery
Propofol and Remifentanil
Uneventful
Double heart-valve replacement
Midazolam, Diazepam,
Fentanyl, Etomidate,
Pancuronium, Propofol,
Remifentanil
Pain in arms and legs, and mild
contractions in a forearm and lower limbs
without spasms (7 hours after admission
into critical care unit)
Male, 74 years old13
Female, 44 years old
16
Moderate pain and mild stiffness in legs
(11 hours after admission into critical
care unit)
No further reference to muscular
discomfort or contractions
Female, 40 years old20 Thymectomy
Fentanyl, Thiopental,
Vecuronium, Isoflurane,
and
Neuromuscular blocking recovery within
normal range
Temporary clinical improvement
Appendectomy (6 weeks after)
Endoscopic nasal sinus surgery
(1 year after)
Female, 60 years old22 Respiratory failure, no surgery
required
Diazepam, Fentanyl,
Thiopental, Vecuronium,
Isoflurane, and Nitrous
Oxide
Fentanyl, Propofol, and
Vecuronium
Midazolam, Propofol, and
Atracurium
Uneventful
(Modified from Ferrandis R, Belda J, Llau JV, Belda C, Bahamonde JA: Anesthesia for cardiac surgery on a patient with stiff person
syndrome. J Cardiothorac Vasc Anesth; 2005, 19:370-372.)
M.E.J. ANESTH 22 (2), 2013
220
anesthetics have been reported with both inhalational
anesthetics and neuromuscular blockers, reduced
doses and conservative postoperative management
appears to be prudent for the clinical anesthesiologist
managing patients with SPS11,12.
Cases have been performed successfully using
total intravenous anesthesia (TIVA) with no muscle
blockade alone or in combination with epidural
anesthesia, and using a paravertebral block with
conscious sedation for an inguinal hernia repair12-14.
In the case presented, the patient was receiving a
permanent catheter for treatment of his SPS with IVIG.
By utilizing a propofol drip with fentanyl for sedation
and breakthrough pain, a safe MAC anesthetic was
provided without complications and a rapid recovery.
In recent years, patients with other co-morbidities
have been identified with SPS whom underwent
procedures requiring anesthetics in some capacity. A
review of the literature indicates other co-morbidities
found in patients with SPS including: cardiac valvular
disease, breast cancer, colon adenocarcinoma,
appendicitis, lymphoma, and thymoma15-20. There
SIDRANSKY M. A. et. al
is even documentation of a patient who became
pregnant two months after her diagnosis of SPS and
was administered an epidural with a smooth delivery21.
In the case presented, the patient presented with the
potential challenge of being morbidly obesity, which
can dramatically affect cardiopulmonary status, rate of
desaturation, and potentially increase morbidity and
mortality. However, by using monitored anesthesia
care with avoidance of inhalational anesthetics,
the patient was able to receive permanent catheter
placement without any exacerbation of his SPS.
In summary, MAC with IV anesthetics can
be used successfully in patients with SPS for minor
procedures. For more complex cases, TIVA without
muscle relaxants, or TIVA without muscle relaxants
and regional anesthesia, or regional anesthesia with
conscious sedation should be considered12-14. The use
of these techniques avoids exposure of SPS patients
to the risk of hypotonia and mechanical ventilation,
which may result from the use of volatile anesthetics
and neuromuscular blocking agents8,9. Because this
is an extremely rare disease, a conservative approach
with a careful laid out plan is warranted.
ANESTHESIA CONSIDERATIONS IN STIFF PERSON SYNDROME
221
References
1.Moersch FP, Woltman HW: Progressive fluctuating muscular
rigidity and spasm (“stiff-man” syndrome); report of a case and
some observations in 13 other cases. Mayo Clin Proc; 1950, 31:421427.
2.Dalakas MC, Fujii M, Li M, McElroy B: The clinical spectrum
of anti-GAD antibody-positive patients with stiff-person syndrome.
Neurology; 2000, 55:1531-1535.
3.De la Casa-Fages B, Anaya F, Gabriel-Ortemberg M, Grandas F:
Treatment of stiff-person syndrome with chronic plasmapheresis.
Mov. Disord.; 2013, 28:396-397.
4.Murinson BB, Butler M, Marfurt K, Gleason S, De Camilli P,
Solimena M: Markedly elevated GAD antibodies in SPS: effects of
age and illness duration. Neurology; 2004, 63:2146-2148.
5. Sandbrink F, Syed NA, Fujii MD, Dalakas MC, Floeter MK:
Motor cortex excitability in stiff-person syndrome. Brain; 2000,
123:2231-2239.
6. Whelan JL: Baclofen in treatment of the “stiff-man” syndrome.
Arch Neurol; 1980, 37:600-601.
7. Westblom U: Stiff-man syndrome and clonazepam. JAMA; 1977,
237:1930.
8. Johnson JO, Miller KA: Anesthetic implications in stiff-person
syndrome. Anesth Analg; 1995, 80:612-613.
9. Bouw J, Leendertse K, Tijssen MA, Dzoljic M: Stiff person
syndrome and anesthesia: case report. Anesth Analg; 2003, 97:486487.
10.Lorish TR, Thorsteinsson G, Howard FM: Stiff-man syndrome
updated. Mayo Clin Proc; 1989, 64:629-636.
11.Qin X, Wang DX, Wu XM: Anesthetic management of a patient
with stiff-person syndrome and thymoma: a case report. Chinese
Medical Journal; 2006, 119:963-965.
12.Yamamoto K, Hara K, Horishita T, Sata T: Consideration for
general anesthesia combined with epidural anesthesia in a patient
with stiff person syndrome. J Anesth; 2007, 21:490-492.
13.Ledowski T, Russell P: Anaesthesia for stiff person syndrome:
successful use of total intravenous anaesthesia. Anaesthesia; 2006,
61:725.
14.Elkassabany N, Tetzlaff JE, Argalious M: Anesthetic management
of a patient with stiff person syndrome, J Clin Anesth; 2006, 18:218220.
15.Hadavi S, Noyce AJ, Leslie RD, Giovannoni G: Stiff person
syndrome. Pract Neurol; 2011, 11:272-282.
16.Ferrandis R, Belda J, Llau JV, Belda C, Bahamonde JA: Anesthesia
for cardiac surgery on a patient with stiff person syndrome. J
Cardiothorac Vasc Anesth; 2005, 19:370-372.
17.Krishna VR, Knievel K, Ladha S, Sivakumar K: Lower extremity
predominant stiff-person syndrome and limbic encephalitis with
amphiphysin antibodies in breast cancer. J Clin Neuromuscul Dis;
2012, 14:72-74.
18.Tsai T, McGrath R: Lymphoma, thymoma and the wooden man:
stiff-person syndrome post-thymoma excision and non-Hodgkin
lymphoma remission. Intern Med J; 2012, 42:205-207.
19.Liu YL, Lo WC, Tseng CH, Tsai CH, Yang YW: Reversible stiff
person syndrome presenting as an initial symptom in a patient with
colon adenocarcinoma. Acta Oncol; 2010, 49:271-272.
20.Obara M, Sawamura S, Chinzei M, Komatsu K, Hanaoka K:
Anaesthetic management of a patient with Stiff-person syndrome.
Anaesthesia; 2002, 57:511.
21.Goldkamp J, Blaskiewicz R, Myles T: Stiff person syndrome and
pregnancy. Obstet Gynecol; 2011, 118:454-457.
22.Haslam N, Price K: Anaesthesia for Stiff-Person Syndrome.
Anaesthesia; 2002, 57:298-299.
M.E.J. ANESTH 22 (2), 2013
ROLE OF LARYNGEAL MASK AIRWAY IN INTERVENTIONAL
BRONCHOSCOPY PROCEDURES FOR UPPER
TRACHEAL STENOSIS: CASE SERIES
LIDA FADAIZADEH* , MAHSA SADAT HOSSEINI**,
SHIDEH DABIR***
Abstract
Background: Bronchoscopic interventional procedures are novel means of treating airway
lesions which are less invasive and well tolerated for patients with endo-luminal lesions, but
managing the airway and oxygenating the patient in a field that is shared by both anesthesiologist
and bronchoscopist is a major concern. Also in cases with subglottic and upper tracheal stenotic
lesions an airway device placed inside the lumen interferes with the procedure and occasionally
bears the hazard of ignition. Therefore, an airway device placing above the glottis with effective
oxygenation is required. Laryngeal mask airway is a supra-glottic device which facilitates assisted
or spontaneous positive pressure ventilation.
Methods: In this study, eight patients with subglottic stenoses due to different etiologies are
presented who underwent fiberoptic bronchoscopy and therapeutic interventions through laryngeal
mask.
Results: In all these patients, we experienced simple access to the vocal cord, glottis and trachea
and also the lesion, besides effective oxygenation of the patient. Furthermore, bronchoscopist and
patients were both comfortable with the procedures.
Conclusion: Laryngeal mask airway could be regarded as a reliable alternative for airway
management during interventional bronchoscopic procedures, especially when they are located
near the glottis or in the upper third of the trachea.
Conflict of interest: All authors explicitly state that there is no conflict of interest in this
manuscript.
Sources of financial support: none declared.
Keywords: Fiberoptic bronchoscopy; Laryngeal mask airway; Tracheal stenosis
*
**
***
Assistant Prof. of Anesthesiology.
Affiation: Telemedicine Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD),
Shahid Beheshti University of medical Sciences, Tehran, Iran.
General Practitioner.
Affiation: Telemedicine Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD),
Shahid Beheshti University of medical Sciences, Tehran, Iran.
Associate Prof. of Anesthesiology
Affiliation: Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD),
Shahid Beheshti University of medical Sciences, Tehran, Iran.
Corresponding Author: Shideh Dabir, Tracheal Diseases Research Center, National Research Institute of Tuberculosis
and Lung Diseases (NRITLD), Daar-Abad, Niavaran, Tehran, Iran, Zip Code: 19569-44413, P.O. Box: 19575-154, Tel:
+98 9122171609, Fax: +98 (21) 26105385. E-mail: [email protected]
223
M.E.J. ANESTH 22 (2), 2013
224
Introduction
Upper airway lesions, especially in the sub glottic
region, can cause serious conditions that are hardly
tolerated by the patients and occasionally may be life
threatening. These lesions have several etiologies with
the most common of them being prolonged tracheal
intubation or tracheostomy in the Intensive care unit
(ICU). Other causes include: trauma, infection, burn,
tumors, connective tissue diseases such as systemic
lupus erythematosus and Wegener`s granulomatosis;
and even idiopathic subglottic stenosis1-3.
Treatment of tracheal stenosis is categorized to
two main fields: surgical resection and reconstruction;
and endoscopic therapies. Interventional bronchoscopic
techniques, including: electrocautery, Argon Plasma
Coagulation (APC), cryotherapy, laser, balloon
bronchoplasty, and stent placement are novel means
of treatment that have opened new horizons in upper
airway management4,5.
All these procedures require a secure method
for airway management besides endotracheal tube,
since it might either bypass the lesion or if introduced
into stenotic trachea, might cause edema, bleeding
and laceration and is also associated with the risk of
ignition during bronchoscopic thermal therapies6-7.
Laryngeal mask airway (LMA) is a supraglottic
airway devices which can be utilized for bronchoscopic
procedures and has the benefit of being placed above
the glottis with excellent visibility of glottis and
subglottis and thus, feasibility for treating subglottic
and upper tracheal lesions7-9.
In this study, we present 8 patients with
upper tracheal stenosis who underwent therapeutic
bronchoscopy through the laryngeal mask airway
under general anesthesia.
Methods
In this study, we present 8 patients with upper
airway lesions who were referred to Interventional
Bronchoscopy Unit of Masih Daneshvari Hospital.
Patients were initially evaluated by the
anesthesiologist for their underlying condition and
then they signed an informed written consent regarding
FADAIZADEH L. et. al
the procedure.
Method of anesthesia was almost similar in
all patients. Initially, Lidocaine in the form of 10%
spray with a maximum dosage of 1 mg/kg was used
to anesthetize the pharynx and then Midazolam (1
mg) and Sufentanyl (5 microgram/kg) were injected
intravenously as premedication. After 3 minutes,
standard doses of Thiopental as hypnoic and
Atracurium were injected to induce general anesthesia.
Titrated propofol (up to a total dose of 1-2 mg/kg) was
also used as hypnotic agent.
Bispectral index (BIS) was used to evaluate the
level of anesthesia, Therefore; After reaching a BIS
level of 60, LMA (LMA company, sizes 4-5 depending
on patient) was inserted and mechanical ventilation
was started using a standard anesthesia machine with
following setting: tidal volume: 10cc/kg, respiratory
rate: 12/min, O2 flow: 5lit/min (PEEP = 0). To ensure
adequate level of anesthesia, BIS was monitored
throughout the procedure and was kept around 60
using propofol infusion (100-150 microgram/kg/min).
Thereafter, FOB was introduced into LMA to
perform the interventional procedures. During the
procedure, vital signs and blood O2 saturation (SpO2)
were monitored.
The incidence of post bronchoscopy sore throat
was assessed in all patients. Also, the bronchoscopist’s
satisfaction with the use of LMA was determined by
asking about the ease of bronchoscope insertion and
procedure performance and a score resembling their
satisfaction given between 1-10.
Ethical approval for this study was provided by
the Medical Research Ethics Committee of National
Research Institute of Tuberculosis and Lung Diseases
(NRITLD).
Case 1
A 32 year-old female who had been intubated for
1 week because of suicide attempt resulting in loss of
consciousness, presented with cough, dyspnea, and
wheezing 10 days after. She was referred to this center
with primary diagnosis of post intubation tracheal
stenosis. FOB through LMA (size 4) showed a nodule
at the posterior commissure of right vocal cord and
ROLE OF LARYNGEAL MASK AIRWAY IN INTERVENTIONAL BRONCHOSCOPY PROCEDURES FOR UPPER
TRACHEAL STENOSIS: CASE SERIES
also multiple granulation tissue formation at upper and
middle parts of the trachea. The nodule was removed
by cryotherapy and then APC was performed to ablate
the granulation tissue. Throughout the procedure which
lasted 40 minutes, patient`s hemodynamics were stable
and no complication occurred. SpO2 was always above
96% except for two episodes of drop (87% and 72%,
respectively). After the procedure, patient reported just
a mild sore throat and the bronchoscopist’s satisfaction
score was 10.
Case 2
A 21 year-old male presented with dyspnea and
hoarseness 1 month after ICU admission and intubation
for 12 days, due to electric shock. FOB was performed
for the patient after inserting LMA (size 5); and 2
nodular lesions at the posterior commissure of vocal
cords, and 3 web-like stenoses were seen at the middle
part of the trachea. Cryotherapy was done to ablate the
nodules and the tracheal webs were removed using
APC. While performing the procedure, no decrease
in SpO2 or other complications occurred. Patient and
Bronchoscopist satisfaction was optimum.
Case 3
A 77 year-old female who was a known case
of metastatic lung adenocarcinoma originating from
thyroid cancer was referred for dyspnea, hoarseness,
hemoptysis and stridor. After inserting the LMA
(size 4), FOB was performed and subglottic tracheal
stenosis and some nodular lesions due to tumoral
invasion were revealed. APC was done to remove the
stenotic lesions. Throughout the 1 hour procedure,
patient’s SPO2 varied from 85% to 98% and she was
hemodynamically stable. Also, minimal bleeding
occurred which was treated by APC and eventually
she did not complain of sore throat after awakening.
Bronchoscopist satisfaction score was 10.
Case 4
A 33 year-old female with a history of exertional
dyspnea and hoarseness since 3 years ago which
had been already diagnosed as Idiopathic subglottic
225
stenosis, was referred for therapy. FOB was introduced
and a stenosis of 20 mm length was seen at about 10
mm below the vocal cords. The diameter of the trachea
at the site of stenosis was around 6 mm. Initially,
the bronchoscopist tried to dilate the airway by rigid
bronchoscope size 7.5, but during the procedure, severe
oxygen desaturation happened and therefore, LMA
(size 4)was used and APC was performed through
the working channel of FOB to open the airway.
The procedure lasted 30 minutes and was completed
successfully with no complication. Patient`s vital signs
were completely stable, and SPO2 remained around
90% throughout the procedure. Patient reported
moderate sore throat after the procedure and the
bronchoscopist was fully satisfied.
Case 5
A 29 year old female with post intubation tracheal
stenosis was referred to our center for continuing her
therapeutic interventions. Ten years ago, she had
experienced a severe car accident resulting in coma
state for 3 months. She had undergone bronchoscopic
dilation and also stent placement before. In our center,
she underwent flexible bronchoscopy via LMA (size
4) which showed severe stenosis at the upper part
of the trachea and also granulation tissue inside the
stent. APC was utilized to destruct the granulation
tissue. Vital signs were within normal range during
the procedure and SPO2 was always greater than 98%.
A mild sore throat was reported by the patient after
the bronchoscopy and the bronchoscopist satisfaction
was 8 due to bronchoscope adhesion to shaft of LMA
which hindered the procedure.
Case 6
A 22 year old female with subglottic stenosis
secondary to Wegener granulomatosis, presented with
cough and dyspnea. Fiberoptic bronchoscopy was
performed through LMA (size 4) to resolve the stenosis
by the means of APC. Throughout the 30-minute
procedure, the lowest oxygen saturation was 96% and
no instability in vital signs occurred. Patient reported
a mild sore throat after recovery from anesthesia and
bronchoscopist satisfaction was complete.
M.E.J. ANESTH 22 (2), 2013
226
Case 7
A 25 year old male patient was referred with
subglottic stenosis due to prolonged intubation in ICU.
He had experienced car accident about 2 months ago
and had been unconscious and intubated for about
20 days. After recovery and discharge from hospital
he had experienced dyspnea and during preliminary
examination had been diagnosed with subglottic
stenosis. After LMA (size 5) insertion Fiberoptic
bronchoscopy was performed and the stenosis was
managed with APC. Since the stenosis was placed
exactly below the glottis severe edema was expected,
therefore; corticosteroid was administered in advance.
The procedure was well performed and the patient
recovered from anesthesia uneventfully and with mild
sore throat. Bronchoscopist satisfaction score was 9
due to adhesion of bronchoscope to LMA.
Case 8
A 32 male patient, a known case of Down
syndrome, was emergently referred to our ward with
cyanosis, dyspnea and hypoxia. He had experienced
several similar episodes during the previous months
and was repeatedly intubated and admitted to ICU,
therefore; a severe subglottic stenosis had been
developed gradually. In addition to typical Down
syndrome features with large tongue and short neck, he
was morbidly obese. After induction of anesthesia the
patient turned out to be a non-ventilate, non-intubate
patient. LMA was inserted and both ventilation
and APC treatment were performed uneventfully.
Therefore, in this special case LMA had a life saving
role in addition to simply a route for ventilation and
device insertion. The patient was sent to ICU for
further management. Bronchoscopist satisfaction was
optimum.
Discussion
In this case series, we described 8 patients with
tracheal stenosis consisting of 5 post intubation tracheal
stenoses, 1 idiopathic subglottic stenosis, 1 tracheal
stenosis secondary to Wegener granulomatosis and 1
tumoral invasion. For all these patients interventional
FADAIZADEH L. et. al
bronchoscopy procedure was performed through LMA
and each procedure was completed with no important
complication.
Since the introduction of Laryngeal mask airway
in 1988, it has been utilized for routine and emergency
anesthetic procedures, difficult airway cases, and
cases of impossible intubation while resuscitation 10.
It has been described to be an airway device which
fills the gap between face mask and endotracheal
tube and facilitates assisted or spontaneous positive
pressure ventilation 11. Hemodynamic changes
have been shown to be less, using LMA for airway
management, compared to other invasive airway
devices like endotracheal tube8. Other advantages
mentioned for LMA include rapid insertion without
a laryngoscope, acceptable protection of airway
and effective ventilation during general anesthesia
and deep sedation, easy access to glottis and upper
trachea, low frequency of cough and sore throat during
recovery, and less involvement of anesthesiologist’s
hands compared to mask ventilation12-14.
We experienced LMA as a suitable device because
of its supra-laryngeal placement and accessibility
and visualization of vocal cords, glottis and trachea.
Besides, it maintained effective gas exchange in
all patients, especially the patient who developed
hypoxia during rigid bronchoscopy and the patient
with Down’s syndrome, for whom it was life saving.
The bronchoscopist passed the FOB through the large
bore of LMA with no inconvenience and in one patient
with bleeding, he was able to control the hemorrhage
quickly and effectively. Sore throat was one of our
major concerns, but fortunately except for one patient
with moderate degree of sore throat, all others reported
none or just mild degree of discomfort.
Myers described use of an LMA along with a
flexible fiberoptic bronchoscope as a safe and effective
method to visualize and manage lesions of the laryngotracheal region, especially when combined with a
fiberoptic laser15. Jameson has stated the convenience
of FOB placement, ease of access to subglottic region,
and acceptible lung ventilation as advantages of
LMA9 and Chhetri described LMA as a simple and
safe alternative to other ventilating methods during
endoscopic laser treatment of subglottic stenosis7.
Also, Park has described the valuable role of LMA
ROLE OF LARYNGEAL MASK AIRWAY IN INTERVENTIONAL BRONCHOSCOPY PROCEDURES FOR UPPER
TRACHEAL STENOSIS: CASE SERIES
in insertion of T-tube in sub-glottic stenosis, which
is yet another challenge for anesthesiologists, since
ventilation is sometimes severely impaired during the
procedure16.
227
be regarded as a reliable alternative for airway
management during interventional bronchoscopic
procedures, especially when they are located near the
glottis or in the upper third of the trachea.
In conclusion, laryngeal mask airway could
References
1. Gillbe C, Hillier J: Anaesthesia for bronchoscopy, tracheal and
airway surgery. Anaesthesia and Intensive Care Medicine; 2005
Dec, 6 (12):422-25.
2.Nouraei SA. R, Ma E, Patel A, Howard DJ, Sandhu GS: Estimating
the population incidence of adult post-intubation laryngotracheal
stenosis. Clinical Otolaryngology; 2007, 32(5):411-412.
3.Ghorbani A, Abbasi A, Saghebi R, Ghare-Daghi AS, Farzanegan
R, Jahanshahi N: A Proposed Grading System for Post-Intubation
Tracheal Stenosis. Tanaffos; 2012, 11(3):10-14.
4. Ross AF, Ferguson JS: Advances in interventional pulmonology.
Curr Opin Anaesthesiol; 2009 Feb, 22(1):11-7.
5. Jabbardarjani HR, Kiani A, Sheikhi N, Arab A, Masjedi MR:
Balloon Bronchoplasty: Case Series. Tanaffos; 2012, 11(2):42-48.
6. Yavaşcaoğlu B, Tokat O, Mogol Basagan E, Kaya FN, Erisen L,
Kutlay O: The use of the laryngeal mask airway in children with
subglottic stenosis. The Journal of International Medical Research;
2001, 29:541-545.
7. Chhetri D, Long J: Airway management and CO2 laser treatment
of subglottic and tracheal stenosis using flexible bronchoscope and
laryngeal mask anesthesia. Operative Techniques in OtolaryngologyHead and Neck Surgery; 2011 June, 22(2):131-134.
8. Sung A, Kalstein A, Radhakrishnan P, Yarmush J, Raoof S:
Laryngeal Mask Airway: Use and Clinical Applications. J Bronchol;
2007, 14(3):181-188. doi: 10.1097/LBR.0b013e3181132119.
9. Jameson J, Moses RD, Vellayappan U, Lathi KG: Use of the
laryngeal mask airway for laser treatment of the subglottis.
Otolaryngol Head Neck Surg; 2000 Jul, 123(1 Pt 1):101-2.
10.Nguyen A, Popat K: Airway Management Devices and Approaches.
Advances in Anesthesia; 2007, 25:205-232.
11.Badr A, Tobias JD, Rasmussen GE, Stokes DC, Neblett WW 3rd,
Campbell P: Bronchoscopic airway evaluation facilitated by the
laryngeal mask airway in pediatric patients. Pediatr Pulmonol; 1996
Jan, 21(1):57-61.
12.Brimacombe J: The advantages of the LMA over the tracheal tube or
facemask: a meta-analysis. Can J Anaesth; 1995 Nov, 42(11):101723.
13.Niggemann B, Haack M, Machotta A: How to enter the pediatric
airway for bronchoscopy. Pediatr Int; 2004 Apr, 46(2):117-21.
14.Slonim AD, Ognibene FP: Enhancing patient safety for pediatric
bronchoscopy: alternatives to conscious sedation. Chest; 2001 Aug,
120(2):341-2.
15.Myers LL, Bakthavachalam S, Thomason TS, Klein K: Holmium:
YAG Laser Fiberoptic Bronchoscopy Via Laryngeal Mask Airway.
The Internet Journal of Otorhinolaryngology. 2007 Volume 6
Number 2. DOI: 10.5580/1ea2.
16.Park JS, Kwon YS, Lee S, Yon JH, Kim DW: Korean J Anesthesiol;
2010 December, 59(Suppl):S33-S36.
M.E.J. ANESTH 22 (2), 2013
Transglottic Basaloid Squamous Cell
Carcinoma Of The Larynx
Abdul-Latif Hamdan*, Roger Moukarbel**,
Ayman Tawil***, Hanna Kaspar***
and M ohammad N atout **
Abstract
Objective: To report a rare case of Transglottic Basaloid Squamous cell carcinoma of the
larynx and review the pathologic features of these lesions.
Case report: A 64 year old male, heavy smoker and alcohol abuser, presented with a 6 month
history of hoarseness. Laryngoscopy revealed a right transglottic lesion involving the epiglottis,
aryepiglottic fold, ventricle and true vocal fold.
Microscopically, the tumor was characterized by infiltrating solid sheets of basaloid cells
showing palisading pattern along the edges. In areas of solid growth, tumor cells displayed scant
cytoplasm, and hyperchromatic nuclei. A portion of the tumor abutting the thyroid cartilage
showed squamous differentiation. An island of tumor cells with comedonecrosis was also noted.
Immunohistochemical staining for a number of markers was performed.
Conclusion: Basaloid squamous cell carcinoma displays a biphasic histology. The stage of
the disease at presentation is invariably advanced with metastatic lymphadenopathy in two thirds
of the patients.
Keywords: basaloid; squamous cell carcinoma; larynx.
Introduction
Basaloid squamous cell carcinoma is considered a high grade histological variation of
squamous cell carcinoma in view of its tendency to spread regionally and distally. The advanced
stage of presentation of this disease has proven its poor prognosis and local aggressiveness. It was
first described by Wain et al in 1986 as an independent neoplasm believed to arise either from the
totipotential primitive cell in the epithelial basal layer or the epithelial lining of the salivary duct1.
Despite its rare occurrence in different sites of the body, it has a predilection for the head
and neck region. Laryngeal involvement is rare with most of these tumors arising in the glottis or
supraglottis with a preference to the later. We would like to report a case of transglottic Basaloid
Squamous cell carcinoma of the larynx with emphasis on the clinico-pathological features2.
*MD, FACS, EMBA, Professor, Department of Otolaryngology/Head & Neck Surgery, American University of Beirut
Medical Center-Lebanon.
**MD, Assistant Professor, Department of Otolaryngology/Head & Neck Surgery, American University of Beirut Medical
Center-Lebanon.
***MD, Professor of Pathology, Department of Pathology, American University of Beirut Medical Center-Lebanon.
Corresponding Author: Abdul-Latif Hamdan, MD, FACS, EMBA, American University of Beirut, Department of
Otolaryngology. P. O. Box: 110236. Tel/Fax: 961 1 746660. E-mail: [email protected], [email protected]
229
M.E.J. ANESTH 22 (2), 2013
230
Case Report
A 64 year old male, heavy smoker and alcohol
abuser, presented with a 6 month history of hoarseness.
He denied any history of hemoptysis, dysphagia,
odynophagia or otalgia. Fiberoptic nasopharyngeal
laryngoscopy revealed a right transglottic lesion
involving the epiglottis, aryepiglottic fold, ventricle
and true vocal fold.
Computerized Tomography of the neck after IV
contrast showed a large soft tissue mass occupying
the right side of the laryngeal vestibule, involving the
right aspect of the epiglottis and extending to the level
of the true vocal folds crossing the midline anteriorly
and posteriorly. A single prominent lymph node was
seen at level two on the left side of the neck. Direct
laryngoscopy and biopsy from the lesion revealed
poorly differentiated squamous cell carcinoma. Patient
underwent total laryngectomy, right selective neck
dissection for level II, III and IV with left lymph node
biopsy.
Gross examination showed a right transglottic
tumor measuring 3 cm in greatest dimension.
Microscopically, the tumor was characterized by
infiltrating solid sheets of basaloid cells showing
palisading pattern along the edge and some cystic
Fig. 1
Infiltrating solid sheets of basaloid cells showing palisading
pattern along the edges (thin arrows) and small cystic spaces
are seen in some areas (thick arrows). H & E × 100. The
inset demonstrates tumor cells with scant cytoplasm and
hyperchromatic nuclei and a mitotic figure is noted (small
arrow). H & E × 1000
Hamdan A. L. et. al
spaces. In areas of solid growth, tumor cells displayed
scant cytoplasm, and hyperchromatic nuclei. A mitotic
figure was also noted (Fig. 1). The material within
the cystic spaces is periodic acid-Schiff and Alcian
blue positive, however mucicarmine was negative.
A portion of the tumor abutting the thyroid cartilage
showed squamous differentiation. An island of tumor
cells with comedonecrosis was also noted (Fig. 2).
Immunohistochemical staining for a number of
markers was performed. The tumor showed strong
positivity for cytokeratin 34βE12 and cytokeratin
AE1/AE3 in areas of squamous differentiation, but
only focal and weak positivity in basaloid cells.
Epithelial membrane antigen was distinctly
focal and limited to areas of squamous differentiation.
Carcinoembryonic antigen highlighted keratin pearls
but was totally negative elsewhere in the tumor. There
was diffuse moderately intense staining for neuron
specific enolase (NSE). Cytokeratin 8/18 (CAM 5.2),
S-100, and smooth muscle acting were negative. There
was strong nuclear positivity for P53 in basaloid
tumor cells and less intense positivity in the squamous
component.
Fig. 2
A portion of the tumor with squamous differentiation. The
tumor is seen abutting thyroid cartilage. H & E × 100. The
inset shows an island of tumor with comedonecrosis (arrow). H
& E × 400
Transglottic Basaloid Squamous Cell Carcinoma Of The Larynx
Discussion
Because of the biphasic histology of basaloid
squamous cell carcinoma, there is a potential
for misdiagnosis in biopsies that are not fully
representative. When the basaloid component is noted,
the tumor must be differentiated from adenoid cystic
carcinoma or neuroendocrine carcinoma. The presence
of a squamous component should suggest basaloid
squamous cell carcinoma. Another differentiating
point is the continuity of the infiltrating tumor with a
dysplastic overlying epithelium in basaloid squamous
cell carcinoma, which is not present in adenoid cystic
carcinoma (NSE may be positive in both basaloid
squamous cell carcinoma and neuroendocrine
carcinoma, however only the latter expresses the more
specific neuroendocrine markers synaptophysin and
chromogranin)3.
Keratin and CEA staining is generally limited to
the squamous component, and is weak to absent in the
basaloid component.
Basaloid squamous cell carcinoma has been
reported in sites such as the lungs, thymus, cervix,
anus, and esophagus. In the head and neck, the regions
most frequently involved are the larynx, hypopharynx,
231
tonsils and base of tongue2. Squamous cell carcinoma
accounts for 85% of the epithelial malignancies of
the larynx. Basaloid squamous cell carcinomas are
sporadic cases affecting mainly the supraglottis. The
typical case is that of a male elderly smoker with
history of alcohol abuse, presenting with history of
hoarseness and neck fullness. The role of the EpsteinBarr virus and human papilloma virus as contributory
factors is still controversial4. Laryngeal endoscopy
usually reveals a large invasive, ulcerated, tan white
lesion with ill defined borders. The sites involved
are the aryepiglottic folds, epiglottis, true and false
vocal cords, arytenoids and retro-cricoid region and
ventricles. In our case the tumor was transglottic
extending from the ventricle, involving the left false
cord, ventricle, true vocal fold and crossing the midline.
The stage of the disease at presentation is invariably
advanced with regional lymph nodes involvement
in two thirds of the patients. Distant metastasis is
common in 40% to 80% of the cases which reflects an
aggressive clinical behavior and a high mortality rate
in the first year5. Radical surgery be it total, vertical
or supraglottic laryngectomy with selective or radical
neck dissection is usually required. Radiation therapy
is usually recommended and systemic chemotherapy is
warranted in selective cases.
M.E.J. ANESTH 22 (2), 2013
232
Hamdan A. L. et. al
References
1. Wain SL, Kier R, Vollmer RT, Bossen EH: Basaloid-squamous
carcinoma of the tongue, hypopharynx and larynx: report of 10
cases. Hum Pathol; 1986, 17:1158-60.
2. Bahar G, Feienmesser R, Popovtzer A: Basaloid Squamous Cell
Carcinoma of the Larynx. American Journal of Otolaryngology;
2003, 24(3):204-8.
3. Gnepp DR: Diagnostic surgical pathology of the head and neck. W.
B. Saunders Company; 2001, p. 57-59.
4. Borel DM: Cutaneous basoquamous carcinoma. Arch Pathol; 1973,
95:293-7.
5. Ferlito A, Altavilla G, Rinaldo A, Doglioni C: Basaloid squamous
cell carcinoma of the larynx and hypopharynx. Ann Otol Rhinol
Laryngol; 1997, 106:1024-30.
letter to the editor
PREVENTION OF BLOOD RETURN INTO
INTRAVENOUS INFUSION TUBING
*
Mahesh Nagappa , Sandeep Kumar Mishra **
AND Lenin Babu Elakkumanan ***
Letter to the Editor
Different techniques have been described to prevent return flow of the blood into an
intravenous line when both the intravenous infusion and blood pressure cuff have to be placed in
the same arm especially during orthopedic surgeries of the upper limbs and with patients in lateral
position. Some of these techniques involve placement of the part of the tubing under the blood
pressure cuff, which would then occlude when the pressure in the cuff goes up. However, having
tried this technique, we found it not fully effective in preventing the regurgitation of blood into
infusion tubing. The events may distract the anesthesiologist from maintaining full intraoperative
monitoring of anesthesia delivery and patients’ vital signs.
At our institution we use pressure bags to administer intravenous fluids at a faster rate. We
decided to use these pressure bags in situations where the intravenous infusion is in the same arm
as blood pressure cuff. Initially the pressure at which the return of blood into intravenous infusion
tubing occurs is determined. The pressure in the pressure bag is subsequently raised 20-30mmHg
above the pressure that results in no blood return. As such, the flow of the intravenous fluid can be
controlled independently using the intravenous fluid controller. The counter pressure exerted by the
pressure bag can be extremely useful in preventing return of blood and we suggest their use more
widely as it is a very simple solution to a very old problem.
*
**
***
MD, DNB, MNAMS, Assistant Professor SLIMS, Puducherry, India.
MD, Assistant Professor.
MD, DNB, Assistant Professor.
Affiliation: Department of Anesthesiology and critical care JIPMER, Puducherry, India.
Corresponding author: Dr Mahesh Nagappa, No135, 4th Main 6th Block, 3rd Stage, 3rd Phase, BSK, Bangalore 560085,
Karnataka, India. Tel: +91-9843631992. E-mail: [email protected]
233
M.E.J. ANESTH 22 (2), 2013
RADIAL NERVE LESION AFTER MALPOSITION AND
SEDATION BY CONTINUOUS TARGET CONTROLLED
INFUSION OF PROPOFOL FOR EXTRACORPOREAL
SHOCK WAVE LITHOTRIPSY
Adriano BS Hobaika* AND Cristiano HV Horiguchi**
Extracorporeal shock wave lithotripsy (ESWL) is the gold standard treatment for ureteral
calculosis. Radial neuropathy related to anesthetic or surgical procedures is a very rare complication
and it is generally related to compression factors1. To date and to our knowledge, there are no
descriptions of radial nerve lesion after ESWL procedure. A 36 years old female patient (61 Kg)
with ureter calculosis disease, presented to ambulatory ESWL on the left lumbar region. She had
previous history of post-spinal anesthesia headache. Pre-operative examinations were normal.
Conflict of interest: No conflicts of interest
Sources of financial support: No financial support
MeSH: Radial Nerve Lesion, Extracorporeal Shockwave Lithotripsy, Anesthesia.
A peripheral venous catheter was inserted on the right hand and the patient was monitored
with oximetry, cardioscopy and non-invasive blood pressure measurements on the right lower
limb. The patient was positioned on the table with the left arm abducted, bent elbow and the left
hand on the back of the head for a better calculus approach. The patient received midazolam (2.0
mg), sufentanil (10 mcg) and a continuous infusion of propofol (plasma target 1.2 mcg.ml-1) in
order to maintain sedation between level 4 and 5 on the Ramsay scale. Four thousand two hundred
and twenty-five shock waves were administered until a partly fragmented calculus was shown
on fluoroscopy during a 62-minute procedure. The patient was home discharged home after 95
minutes of the end of the procedure without complaints. The next day, the patient presented to
the emergency service complaining of slight paresthesia on the lateral region of the left forearm
with slight paresia on fingers’ extensors and paresia of the brachioradial muscle. She was referred
to a neurologist who diagnosed radial neuropathy. Electroneuromyography presented moderate
injury of sensitive and motor fibers compatible to radial neuropraxia. Six months later, the patient
came for a new urological procedure with a discrete improvement of the clinical picture. The
radial nerve is originated from fibers of C6, C7, C8 and T1. It traces along the spiral groove of
the humerus, along with the deep radial artery, and exits through the lower 1/3 of the lateral side
of the upper arm, penetrating the external fascia. The radial nerve is situated near the skin, and is
*
**
Master of Science in Medicine, Co-responsible for the Anesthesiology Teaching and Training Center Santa Casa de Belo
Horizonte, Staff anesthesiologist of Mater Dei Hospital, Rua Des.
Superior Title in Anesthesiology, Staff anesthesiologist of Mater Dei Hospital, Institution: Mater Dei Hospital.
Corresponding author: Adriano BS Hobaika, Master of Science in Medicine, Co-responsible for the Anesthesiology
Teaching and Training Center Santa Casa de Belo Horizonte, Staff anesthesiologist of Mater Dei Hospital. Rua Gonçalves
Dias 2700, Belvedere, Belo Horizonte, MG, Brasil. CEP: 30320670. Tel: 31-55-3339-9368. Email: [email protected]
235
M.E.J. ANESTH 22 (2), 2013
236
covered with a thin fat layer2. In the lateral region of
the arm, about 3 cm proximal to lateral epicondyle
of the humerus, it is possible to compress the nerve
against the bone, what may be a mechanism of nerve
injury. Anesthetic causes of radial nerve lesion include
automatic pressure monitors, contention brackets,
venoclysis, radial artery puncture and malpositioning1.
A lesion of the ulnar nerve has been reported during the
administration of ESWL for the treatment of ureteral
calculus and was attributed to bad positioning3. In our
patient, the genesis of the lesion seems to involve an
unfavorable positioning of the limb and/or contact of
the limb with the lithotripter machine, exposing the
Hobaika A. B. et. al
radial nerve to shock waves, directly or indirectly. In
a recent study, it was shown that extracorporeal shock
waves have caused multiple microscopically damages
on rats´ spinal cord structures, including degenerated
mitochondria and destruction of myelin sheaths4.
These findings may imply that some types of shock
waves are harmful for nervous tissue. Nevertheless,
it is interesting to note that ESW therapy have been
administered to treat some painful syndromes5,6. This
is the first case that reports radial nerve injury after
ESWL associated with malposition and sedation by
continuous target controlled infusion of propofol.
References
1.Sturzenegger M, Kutz M: Radial nerve paralysis-causes, site and
diagnosis. Analysis of 103 cases. Nervenarzt; 1991, 62:722-9.
2.Lee HC, Kim HD, Park WK, Rhee HD, Kim KJ: Radial nerve
paralysis due to Kent retractor during upper abdominal operation.
Yonsei Med J; 2003, 44:1106-9.
3.Konczak CR: Ulnar nerve neuropraxia after extracorporeal shock
wave lithotripsy: a case report. J Can Chiropr Assoc; 2005, 49:40-5.
4.Karatas A, Dosoglu M, Zeyrek T, Kayikci A, Erol A, Can B: The
effect of extracorporeal shock wave lithotripsy on the rat spinal
cord. Spinal Cord; 2008, 46:627-32.
5.Peled E, Portal-Banker T, Norman D, Melamed E: Plantar fasciitis
and extracorporeal shock wave therapy-essence, diagnosis and
treatment methods. Harefuah; 2011, 150:122-6.
6.Storheim K, Gjersing l, Bølstad k, Risberg MA: Extracorporeal
shock wave therapy (ESWT) and radial extracorporeal shock wave
therapy (rESWT) in chronic musculoskeletal pain. Tidsskr Nor
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technical note
HIGH INSPIRED CARBON DIOXIDE LEVELS
DUE TO MISPLACED CENTRAL TUBING OF
THE ABSORBENT CANISTER
NIMISHA VERMA* AND PRATIBHA TOAL**
Abstract
The authors present a case of unusual rise in inspired carbon dioxide due to misplaced
absorbent canister.
Source of financial support: Nil
Key words: high ICO2, sodalime, Fabius.
Technical Note
A thirty seven year old female was posted for left mastoidectomy. The procedure was initiated
under general anesthesia using a Dragger Fabius Anesthesia machine. Pre use check of the machine
was normal, however after induction and intubation, an increasing trend of the inspiratory carbon
dioxide was noticed. This was followed by an increase in end tidal carbon dioxide after a few
minutes. On inspection of the sodalime canister, we observed that the sodalime was filled till the
base of the canister and the chain connected to the baffle system was inside the canister instead of
being at the base (Fig. 1). Immediately the soda lime canister was replaced by another one. There
was a quick return of the inspired carbon dioxide to 0 mmHg and the normalization of end tidal
carbon dioxide level and the case conducted uneventfully thereafter.
Fig. 1
White arrow-chain up in the
canister instead of being at the base
Grey arrow-absorber filled even in
the base
*
**
M.D, P.D.C.C, Department of Anesthesia *G.S. Memorial Hospital, Mahmoorganj, Varanasi, INDIA-221105.
M.D, Department of Anesthesia # BARC Hospital, Anushakti Nagar, Trombay, Mumbai, INDIA
Corresponding author: Nimisha Verma, Department of Anesthesia *G.S. Memorial Hospital, Mahmoorganj, Varanasi,
INDIA-221105. Tel: +91-9559955988. E- mail: [email protected]
237
M.E.J. ANESTH 22 (2), 2013
238
Upon inspection of the removed canister, an
inadvertent oblique tilt of the central tubing was
noticed, with the screen being turned upside down and
hence placed above the soda lime. This arrangement
caused a part of expiratory gases to bypass the absorber
and reach the inspiratory limb to induce carbon
dioxide rebreathing. This misplacement occurred
VERMA N. et. al
due to variations in the configuration of the screens
in different types of canisters1. We have notified this
to the manufacturers and suggested modifications.
Any wrong position of the canister that will cause the
exhaled gases to bypass the sodalime could lead to a
high inspired CO22.
References
1. Dorsch J A, Dorsch SE: Understanding Anesthesia Equipment.
Chapter 9, page 224-79, Fifth edition. Lippincott, Williams and
Wilikins.
2. Milne AD, Cashen D: High inspired carbon dioxide levels due to
faulty absorber engagement pin on a Dragger fabius GS machine.
Can J Anest; 2010, 57:280-81.
GUIDELINES FOR AUTHORS
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M.E.J. ANESTH 22 (2), 2013
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