Amar Nandhakumar

Erector spinae plane block may aid weaning from mechanical ventilation in patients with multiple rib fractures: Case report of two cases

Uncontrolled pain in patients with rib fracture leads to atelectasis and impaired cough which can progress to pneumonia and respiratory failure necessitating mechanical ventilation. Of the various pain modalities, regional anaesthesia (epidural and paravertebral) is better than systemic and oral analgesics. The erector spinae plane block (ESPB) is a new modality in the armamentarium for the management of pain in multiple rib fractures, which is simple to perform and without major complications. We report a case series where ESPB helped in weaning the patients from mechanical ventilation. Further randomised controlled studies are warranted in comparing their efficacy in relation to other regional anaesthetic techniques.

Anaesthesia for fixation of repeated pathological fractures in a patient with multiple myeloma

The introduction of new chemotherapeutic agents for the treatment of multiple myeloma (MM) has improved the life expectancy and quality of life for these patients in the last decade. Therefore, more patients with MM are being treated for repeated pathological fractures. The anaesthesiologist should continue the optimum supportive care received by these patients in the perioperative period also, by understanding the pathophysiology of the disease, the adverse effects of the chemotherapeutic agents and the guidelines for their supportive care. We report the perioperative management of a patient with MM and discuss the perioperative anaesthetic considerations.

Airway trauma during difficult intubation… from the frying pan into the fire?

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Post-reperfusion bronchospasm in a deceased donor liver transplant recipient: An enigma

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Reversible cause of intra operative hypoxia in an aspirated patient

We present a case of 19-year-old male with a history of road traffic accident with head injury and aspiration posted for decompressive craniotomy under general anaesthesia. Patient developed significant desaturation intraoperatively under general anaesthesia with isoflurane that reversed upon switching over to total intravenous anaesthesia (TIVA) with propofol. Apart from aspiration causing hypoxia, decrease in hypoxic pulmonary vasoconstriction (HPV) by inhalational agent could have also contributed to the desaturation.

Anaesthetic management of an unrecognized cerebral arteriovenous malformation bleed in a 45-day old baby

There is another case report of osteosarcoma of maxilla posted for total maxillectomy where in the swelling made mask ventilation impossible. In this case, anaesthesia was induced (inhalation) by using a nasopharyngeal airway and positive pressure ventilation was accomplished by packing oral cavity adequately and was confirmed by capnography, following which a check laryngoscopy was carried out, which revealed CL gradeIIa. After deepening anaesthesia, patient was intubated successfully.

A cost‐effective alternative to wire‐guided endobronchial blocker for lung isolation in children

reattachment as a cause of weakening, forceps were not used during the procedure (2). Luckily, reintubation for a third time was prevented as the fractured part was stuck in the cut portion of the ETT, and another size 3.5 tube ISO connector was available thus reducing the damage from reintubation (3). The ETT’s placed were from different batches so a faulty batch is unlikely. Previous cases of indented tracheal tube connectors have been reported and investigated by the manufacturer with no fault identified (4). The practice of cutting ETT’s to the correct length is widely accepted in pediatric care; however, it is not without potential hazard as these cases remind us and should be performed with extreme caution. S. J O H N S T O N P. H O L M E S Department of Aneasthesia, The General Infirmary at Leeds, Great George St, Leeds, LS1 3EX, UK (email: sharonjohnston1972@googlemail.com)

Unusual cause of near cardiac arrest following craniofacial reconstruction.

with the shortened airway tube to facilitate the cLMA guided fiberoptic intubation in children. Before insertion, the airway tubes of the age-appropriate cLMAs are measurably cut 4–8 cm off the distal part according the lengths of the preselected ETTs (Figure 1a). In this way, the cut end of airway tube is at 2–3 cm above the incisors when the modified cLMA is in place (Figure 1b). After the ETT is inserted into the trachea through the modified cLMA, a relatively long distal ETT is remained above the cut end of airway tube (Figure 1c). After the cuff is deflated, the cLMA it is slowly withdrawn while the ETT is simultaneously advanced downwards. When the proximal end of the ETT is flush with the cut end of airway tube, another similar size ETT is used to keep the ETT in place. Once the cLMA is removed from the mouth, the ETT is grasped at level of the incisor teeth. Then the cLMA is completely discharged from the ETT. This procedure is similar to the Fastrach (Laryngeal Mask Company, Henley-on-Thames, UK) intubating LMA guided intubation. 5. Just as authors pointed out in discussion, in older adolescents with a known difficult airway, the appropriate size Fastrach intubating LMA and Cookgas Air-Q (Mercury Medical, Clearwater, FL, USA) intubating LMA should be used as far as possible to maintain the patent airway and provide conduits for the fiberoptic intubation because they allow to insert appropriate size ETTs (1). Whereas the maximal size of the ETT to allow smooth insertion through the pediatric version cLMA is only 5.5 (4). Additionally, the two intubating LMAs have the special associated tools to remove them after intubation. If they are not available, a small size ETT may firstly be inserted via the cLMA. By a Cook airway exchange catheter, the ETT and cLMA are removed. Then the ETT of choice (e.g. an age-appropriate ETT, a preformed ETT or a reinforced ETT) is inserted using the airway exchange catheter as a guide. Fu Shan Xue Mao Ping Luo Xu Liao Geng Zhi Tang Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: fruitxue@yahoo.com.cn)