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Laryngeal mask airway facilitates awake fiberoptic intubation in a patient with severe oropharyngeal bleeding

M anagement of a compromised airway in a patient with maxillofacial trauma is often hindered by severe hemorrhage (l-3). We report the airway management of a patient who had sustained blunt injury to the face with subsequent massive oropharyngeal bleeding and a suspected cervical spine injury. After awake fiberoptic endotracheal intubation orally failed twice because the severe hemorrhaging hindered the view through the fiberoptic intubating bronchoscope (FOB), awake fiberoptic endotracheal intubation was achieved by using the laryngeal mask airway (LMA) before it was necessary to implement the planned immediate awake tracheotomy.

Variations in ILMA external diameters: another cause of device failure

Purpose: To report failure of insertion of #5 and #4 intubating laryngeal mask airways (ILMAs) in a patient with a mouth opening of just under 25 mm, and the variances among same-size ILMAs.Clinical features: A 53-yr-old man with obstructive sleep apnea underwent elective ENT surgical repair. His mouth opening was just under 25 mm. Ventilation by mask was easy. Direct laryngoscopy failed after induction of anesthesia and neuromuscular block. Neither a #5 nor a #4 ILMA could be passed between the patient’s teeth, despite different twisting maneuvres. A #4 LMA was thus prepared as a conduit for fibreoptic intubation. Placement of the LMA was easy, as was fibreoptic-guided intubation. The LMA was removed over the tracheal tube (TT) to enable ENT surgery, and the further course was uneventful. Manual examination showed that, unlike others of the same type, the failed ILMAs were not sufficiently compressible either to allow insertion in this patient or to the 20 mm reported as the maximal outer dimension of the device. Radiological examination revealed that, at the point of the device where it is intended to be compressible, the silicone layer was thicker in the failed devices than in stock compressible ILMAs, and the end of the steel tube was not so sharply beveled.Conclusion: Our inability to insert an ILMA in a patient with an interdental distance of just under 25 mm was because the device was not sufficiently compressible although the manufacturer states the maximal outer dimension to be 20 mm.RésuméObjectif: Rapporter l’échec de l’insertion de masques laryngés d’intubation nos 5 et 4 (MLI) chez un patient dont l’ouverture de la bouche était d’un peu moins de 25 mm et préciser les différences entre les MLI de même taille.Éléments cliniques: Un homme de 53 ans, souffrant d’appnée du sommeil d’origine obstructive, a subi une réparation ORL. L’ouverture de sa bouche était d’à peine 25 mm. La ventilation par masque a été facile. La laryngoscopie directe a échoué après l’induction de l’anesthésie et le blocage neuromusculaire. Ni le MLI 5, ni le 4 n’ont pu être insérés entre les dents du patient en dépit de différentes manœuvres de torsion. Le ML 4 a alors été préparé comme un tube pour l’intubation fibroscopique. La mise en place du ML et l’intubation avec guidage fibroscopique ont été faciles. Le ML a été retiré du tube trachéale (TT) pour permettre l’intervention ORL qui s’est déroulée sans incident. L’examen manuel a d’abord montré, comparativement à d’autres du même type, que les MLI inefficaces n’étaient pas suffisamment compressibles pour permettre l’insertion ou mesuraient plus que les 20 mm reconnus comme la dimension extérieure maximale. L’examen radiologique a révélé qu’à la pointe de l’appareil, dans sa partie compressible, la couche de silicone était plus épaisse sur les dispositifs inefficaces à l’intubation que sur les autres MLI souples et que l’extrémité du tube d’acier comportait un biseau plus court.Conclusion: Notre incapacité à insérer un MLI chez un patient dont l’ouverture de la bouche était à peine de 25 mm relevait du manque de compressibilité de l’appareil même si le fabriquant assure que la dimension extérieure maximale est de 20 mm.

Removal of the connector on the laryngeal mask airway provides a useful alternative to the intubating laryngeal mask

PurposeWe describe two cases in which fiberoptic intubation through the standard laryngeal mask airway (LMA) was successful with large-bore tracheal tubes (TTs) when an intubating LMA (ILMA) could not be used.Clinical featuresPatient # I, with obstructive sleep apnea, underwent elective surgical repair. His mouth opening was just under 25 mm, but difficult intubation was not anticipated. We induced general anesthesia, easily ventilated the patient by mask, and established neuromuscular blockade. Direct laryngoscopy and attempts to insert either a #5 or a #4 ILMA into the mouth failed. A standard #4 LMA, with the connector removed, was inserted, through which a 7.0 mm nasal RAE™ TT, fiberoptically guided, passed into the trachea at the first attempt.Patient #2, with a loosened implant after left hip arthroplasty, under-went revision prosthesis. Her neck movement was limited. We thus planned awake securing of the airway, but the patient refused. We induced anesthesia and established bag-mask-valve ventilation. The limited neck movement prevented direct laryngoscopy. Visualizing the laryngeal inlet with the fiberoptic bronchoscope (FOB) proved impossible as bloody secretions obscured the FOB’s tip. Ventilation by mask was easy. As an ILMA was not available, we removed a #5 LMA’s connector and passed an 8.0 mm nasal RAE™ TT through the LMA. Fiberoptic-guided intubation was easy. In both cases, the remainder of the intraoperative course was uneventful.ConclusionA standard LMA whose connector has been removed to allow passage of TTs of > 6.0 mm internal diameter may be substituted for the ILMA when necessary.RésuméObjectifDécrire deux cas où l’intubation fibroscopique au travers du masque laryngé standard (ML) a été réussie avec des tubes trachéaux de grand calibre (TT) alors qu’un masque laryngé d’intubation (MU) ne pouvait être utilisé.Éléments cliniquesLe patient n∘ I, qui présentait une apnée du sommeil obstructive, devait subir une réparation chirurgicale. L’ouverture de sa bouche était d’un peu moins de 25 mm, mais on n’a pas envisagé d’intubation difficile. On a induit l’anesthésie, ventilé facilement le patient au masque et procédé au blocage neuromusculaire. La laryngoscope directe et les tentatives pour insérer dans la bouche, soit le MU n∘ 5, soit le n∘ 4, ont toutes échoué. On a inséré un ML n∘ 4 standard, sans connecteur, au travers duquel on a passé dans la trachée, dès le premier essai, un TT nasal RAETM de 7,0 mm sous guidage fibroscopique.La patiente n∘ 2 qui présentait un implant mobile, conséquence d’une arthroplastie de la hanche gauche, a subi une révision prothétique. Les mouvements de son cou étant limités, on a planifié une intubation vigile, mais la patiente a refusé. On a induit l’anesthésie et amorcé la ventilation manuelle au masque et au ballon. Les mouvements limités du cou ont empêché la laryngoscope directe et la visualisation de l’entrée du larynx au moyen du fibroscope bronchique (FOB) s’est révélée impossible étant donné les sécrétions sanguinolentes qui obstruaient la pointe du FOB. La ventilation au masque était facile et comme aucun MU n’était disponible, on a enlevé le connecteur d’un ML n∘ 5 et inséré un TT nasal RAETM de 8,0 mm au travers du ML. Ainsi, l’intubation sous guidage fibroscopique a été aisée. Dans les deux cas, le reste de l’intervention s’est bien déroulé.ConclusionUn ML standard dont le connecteur a été enlevé pour permettre le passage d’un TT de diamètre intérieur > 6,0 mm peut remplacer le MU s’il le faut.

An osteoid osteoma as an undiagnosed cause of three years of severe pain

0 steoid osteoma is a benign, bone-forming tumor representing approximately 12% of all benign bone neoplasias in young individuals (1). First described by Jaffe (2) in 1935, it has a predilection for the lower extremity, with 50% or more of lesions occurring in the femur and tibia. Of the remaining lesions, approximately 30% are equally distributed among the spine, hand, and foot (3). There are different types of osteoid osteomas, each with differing degrees of associated osteosclerosis (4). Pain is the leading and, in its early stages, often the only symptom of the disease and is typically described as mild and intermittent at first, later becoming more constant, more severe, and worse at night. Intense pain may be present even before the lesion is radiologically apparent. Male patients are more often affected than female patients by a ratio of 2:1, and the tumor is rare in the African-American population (5). Trauma has been considered a contributing factor (6). There are no pathognomonic signs or symptoms that unerringly lead to the correct diagnosis. Patients may undergo multiple procedures for the treatment of pain and/ or unnecessary surgical procedures, leading to a reduced of quality of life, as in the case we present. Although there are many reports of this tumor in the surgical literature, they leave the question of pain and its treatment aside (7-9).

Unbalancing the concept of the structured alarm systems for an anesthesia working area.

Continuous paravertebral sypathetic blockade was achieved by Thomason and Moretz (3) for lower extremities and then extended to the upper extremities by Betcher et al. (4) and Betcher and Casten (5) in the 1950s. Unaware of these precedents, Geraci published a case report of CSGB in 1967 (6). Linson et al.‘s 1983 series of CSGB (7) did acknowledge the earlier work. In turn, they were referenced in Cousins and Bridenbaugh’s text (8). Other textbooks also describe CSGB (9,lO). Hoepp et al. describe CSGB using an implanted drugreservoir pump (11). Finally, blockade of the cervicothoracic sympathetic chain can be achieved by a different approach (12). The conventional approach for CSGB is to locate C6, the carotid tubercle of Chassaignac (8), “. . .rendered doubly prominent by the absence of an anterior tubercle on the 7th” (13). This minimizes the risk of pneumothorax as well as intraarterial injection because the vertebral artery usually lies protected in the foramen transversarium behind C6. The vertebral artery may not enter the foramen until C6 or C5 up to 8% of the time (14-16).