Calvin Johnson

Transient cardiac standstill associated with embolic phenomena diagnosed by intraoperative transesophageal echocardiography during cemented total hip arthroplasty

emented total hip arthroplasty (THA) is associated with bone cement implantation synC drome (1,2). Bone cement implantation syndrome results from intramedullary fat, bone marrow debris, or air. The clinical effects of bone cement implantation syndrome are hypoxemia, hypotension, cardiac arrhythmias, and cardiac arrest. Cardiac arrest with cemented THA has been reported in 0.6%-10% of patients and is thought to be the result of intraoperative hypotension secondary to methyl methacrylate bone cement (3,4). We report emboli within the cardiac chambers with the use of intraoperative transesophageal echocardiography (TEE) and subsequent transient cardiac asystole, 45 s after the placement of methyl methacrylate bone cement and the femoral component. The embolic phenomenon preceded the cardiac standstill and systemic hypotension, suggesting that the cardiovascular effects of pressurization of methyl methacrylate (decreased cardiac output, increased pulmonary artery pressure, and systemic hypotension) are possibly the result of embolic phenomena, rather than the bone cement itself.

NASAL ENDOTRACHEAL TUBE CHANGE WITH AN INTUBATING STYLETTE AFTER FIBEROPTIC INTUBATION

Fiberoptic laryngoscopy and intubation has been shown to be one of the most effective ways of managing the difficult airway patient. Frequently, the situation arises in which the endotracheal tube needs to be changed in a patient with a history of a difficult intubation. The dilemma is how to change the endotracheal tube successfully while maintaining control of ventilation. The following case report describes such a dilemma and the successful management of it. A 13-yr-old boy with Goldenhar’s syndrome, a sporadically genetically transmitted disorder associated with facial asymmetry with mandibular hypoplasia, hypoplastic zygomatic arch, ocular dermoids, vertebral defects, microtia, cleft lip/palate, and occasional cardiac defects (septa1 defects, tetralogy of Fallot), presented for Harrington rod instrumentation secondary to severe scoliosis. Past medical history included multiple operations for the ocular, otologic, and mandibular defects. The patient had no cardiac lesions. Physical examination revealed a 162-cm, 40-kg boy with severe scoliosis, a mouth opening of only 2-3 cm, and limited neck range of motion. The uvula could not be visualized. It was decided that awake nasal fiberoptic intubation be performed to secure this very difficult airway. Preoperatively, the patient was given 10 mg intravenous (IV) metoclopromide, 50 mg IV ranitidine, and 0.2 mg IV glycopyrrolate. The oral pharynx was sprayed with Cetacaine, and oxymetazoline (Afrin) was sprayed into the nasal passages. The patient was sedated with 0.1 mg/kg IV midazolam, 2 &kg IV fentanyl, and 1.25 mg IV droperidol. An Olympus LFl fiberoptic scope (Tokyo, Japan) with an Intertech/Ohio #6.0 cuffed endotracheal tube (Bannockburn, Ill.) cut to a length of 24 cm was successfully passed through the left nasal passage and into the trachea. After successful awake nasal fiberoptic intubation, general anesthesia was induced. Examination of the nasal endotracheal tube before turning the patient onto the prone position, however, revealed the connector to be only 0.51.0 cm from the nares because the tube had been cut to Figure 1. Pictured is an uncut IntertechiOhio #6.0 cuffed endotracheal tube and a flexible endotracheal tube changing stylette (Eschmann, Germany).

Trial of labor: A study of 110 patients

STUDY OBJECTIVE The purpose of the study was to determine whether epidural analgesia is unsafe for trial of labor (TOL). DESIGN Retrospective chart review. SETTING Inpatient obstetric department at a university medical center. PATIENTS One hundred ten ASA physical status I and II term parturients who attempted a TOL between December 1987 and June 1988. INTERVENTIONS All the parturients previously had low transverse uterine incisions and received continuous electronic fetal and uterine pressure monitoring throughout labor. All the parturients were offered epidural analgesia during labor with bupivacaine 0.25%. MEASUREMENTS AND MAIN RESULTS Sixty-seven percent of the parturients had successful vaginal delivery. Fifty-one of the 110 parturients had epidural analgesia for labor. There were two complete uterine ruptures; neither had epidural catheters. Both of the complete ruptures presented with monitored fetal distress rather than abdominal pain. Both mothers and their infants recovered uneventfully. CONCLUSIONS Uterine rupture presents as monitored fetal distress rather than abdominal pain. Thus, epidural analgesia can be used in patients attempting a TOL.

Anesthetic Considerations in Intracranial Aneurysm Surgery

Rupture of an intracranial aneurysm generally has a poor outcome, though perioperative treatments have improved. At the present time, the important factors in the management of intracranial aneurysm surgery appear to be the maintenance of adequate cerebral perfusion pressure and the avoidance of hyperglycemia. Relevant features of the anesthetic management of this surgery are discussed.