E. Üstün

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction.

PurposeTo report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction.Clinical featuresA 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo devicein situ has seldom been reported in the medical literature.ConclusionAirway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.RésuméObjectifRapporter un cas d’intubation endotrachéaie vigiie au travers du masque iaryngé d’intubation (MLI) chez un patient avec un halo en traction.Éléments cliniquesUn garçon de 16 ans, pesant 40 kg, présentait une instabiiité atlanto-occipitale et portait un haio en traction. Il devait subir une intervention chirurgicaie sous anesthésie généraie. Sa tête a été immobiiisée en position de flexion, L’extension était impossible. Lexamen du crâne par résonance magnétique a montré l’alignement des axes du pharynx et du larynx, mais un plan très divergent pour l’axe buccal. La langue et l’oropharynx ont été anesthésiés avec une pulvérisation de lidocaïne à 10 % et un blocage du nerf laryngé supérieur bilatéral a été réalisé. L’intubation orotrachéale vigile au travers du MLI a été réussie sous sédation. La fibroscopie bronchique est recommandée pour l’intubation trachéale vigile chez ce type de patients. D’autres techniques, comme l’usage du laryngoscope de Bullard sont aussi décrites, mais l’intubation trachéale vigile au travers du MU chez des patients à qui on a installé un halo en traction in situ a rarement été mentionnée.ConclusionLa prise en charge des voies aériennes de patients souffrant d’instabilité de la colonne cervicale comprend l’évaluation préopératoire complète des voies aériennes et le choix d’une technique d’intubation appropriée. Le MLI semble un choix valable pour l’intubation trachéale vigile dans les cas d’instabilité de la colonne cervicale et d’immobilisation cervicale avec un appareil en halo.

Effects of Menstrual Cycle on Postoperative Analgesic Requirements, Agitation, Incidence of Nausea and Vomiting after Gynecological Laparoscopy

Background: Several studies have suggested that the menstrual cycle has an impact on postoperative nausea and vomiting (PONV). No previous study has evaluated the effect of the menstrual cycle on the incidence of postoperative agitation and analgesic/antiemetic requirements. Methods: On the basis of the phase of the menstrual cycle [pre±menstrual (Pd 25–6), early follicular phase (Pd 8–12), ovulatory phase (Pd 13–15), and luteal phase (Pd 20–24)], 67 patients enrolled in this blinded, prospective study. Anesthesia was standardized. Fentanyl was given to the patients who had severe pain in the recovery room. The patients who had agitation were given midazolam. When pain intensity was >5 on the Visual Analog Scale, metamizol was administered in the Gynecology Department. A blinded anesthesiologist recorded episodes of PONV in the recovery room, and 2 and 24 h postoperatively. Results: The opioid requirement and the frequency of agitation were similar in each group. Metamizol consumption was highest in the luteal phase (p < 0.05). The follicular and luteal phases were predictors for vomiting at recovery (p < 0.05 and p < 0.001, respectively). At the postoperative 2nd hour, nausea was higher in the follicular phase than in the other phases (p < 0.05) and the luteal phase was a predictor for retching (p < 0.001). At the postoperative 24th hour, nausea was the common symptom in the luteal phase (p < 0.05). The need for ondansetron was highest in the luteal phase (p < 0.01). Conclusions: In conclusion, we suggest that the scheduling of all surgical procedures according to the menstrual phase may serve to reduce the incidence of PONV and metamizol/ondansetron consumption and hospital costs.

Acute normovolemic hemodilution and nitroglycerin-induced hypotension: comparative effects on tissue oxygenation and allogeneic blood transfusion requirement in total hip arthroplasty.

STUDY OBJECTIVES To study the comparative effects of acute normovolemic hemodilution and nitroglycerin-induced hypotension on tissue oxygenation and blood transfusion requirement. DESIGN Prospective, randomized study. PATIENTS 30 ASA physical status I and II patients scheduled for primary total hip arthroplasty. INTERVENTIONS Patients were randomized to one of three groups of 10 patients each, to receive acute normovolemic hemodilutin (Group 1) or nitroglycerin-based hypotension (Group 2); Group 3 served as the control group. In Group 1, 2 U of blood was collected and replaced with an equal volume of hydroxyethyl starch (200/0.56%) immediately after anesthesia induction. In Group 2, nitroglycerin was infused at a rate sufficient to reduce mean arterial pressures to 60 to 65 mmHg before initiation of surgery. When hematocrit was reduced to 25%, at first autologous blood and then, if necessary, allogeneic blood was transfused to Group 1, and allogeneic blood was transfused to the other two groups, until hematocrit reached 30% for 5 days postoperatively. MEASUREMENTS AND MAIN RESULTS Total transfused allogeneic units of blood were determined by the fifth postoperative day. Arterial oxygen content (CaO2), venous oxygen content (CvO2), and oxygen extraction ratios (EO2) were calculated by standard formulas. The mean allogeneic transfusion requirement was significantly lower in Group 1 (1.3 +/- 0.8 U) than in Group 2 (2.3 +/- 0.8 U) or Group 3 (2.7 +/- 1.1 U) (p < 0.05). In Group 1, CaO2 and CvO2 were decreased at all times, but EO2 was significantly increased from 15 +/- 3.9% to 33.3 +/- 5.3% (p < 0.001). As for the other two groups, although CaO2 and CvO2 were decreased, EO2 was not significantly increased. CONCLUSIONS Acute normovolemic hemodilution is more effective than nitroglycerin-induced hypotension in reducing allogeneic blood transfusion requirement in total hip replacement surgery, without significant metabolic changes.

The optimal dose of remifentanil for acceptable intubating conditions during propofol induction without neuromuscular blockade.

STUDY OBJECTIVE To determine the optimal remifentanil dose required to provide acceptable intubating conditions following induction of anesthesia with propofol without using neuromuscular blockade. DESIGN Dose-response study. SETTING Operating room of a university hospital. PATIENTS 50 ASA physical status 1 men, aged between 20 and 40 years, who were scheduled for general anesthesia. INTERVENTIONS Intubating conditions were evaluated according to the scoring system described by Viby-Mogensen et al. Successful intubation was defined as excellent or good. MEASUREMENTS For induction of anesthesia, an intravenous (IV) bolus dose of propofol 2.0 mg/kg was given over 30 seconds followed by the administration of predetermined IV remifentanil over 30 seconds; intubation was performed 90 seconds after completion of the remifentanil administration. The dose of remifentanil used for each patient was determined by the response of the previously tested patients, using the modified Dixons up-and-down method (using 0.2 μg/kg as a step size). The first patient was tested with remifentanil 1.0 μg/kg. If intubation failed, the remifentanil dose was increased by 0.2 μg/kg; if intubation was successful, the dose was decreased by 0.2 μg/kg. Mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation were recorded during the study period. MAIN RESULTS According to probit analysis, the effective dose of remifentanil in 50% (ED(50)) and 95% (ED(95)) of patients were 1.40 μg/kg and 2.40 μg/kg, respectively. Preintubation and postinduction HR and MAP values were lower than preinduction values (P < 0.001). CONCLUSION The optimal bolus dose of remifentanil for acceptable intubating conditions was 2.40 μg/kg (95% confidence interval, 1.90-9.0 μg/kg) in 95% of patients during induction of anesthesia with propofol 2.0 mg/kg without neuromuscular blocking agents.

Hemodynamic responses and upper airway morbidity following tracheal intubation in patients with hypertension: conventional laryngoscopy versus an intubating laryngeal mask airway

OBJECTIVES: We compared hemodynamic responses and upper airway morbidity following tracheal intubation via conventional laryngoscopy or intubating laryngeal mask airway in hypertensive patients. METHODS: Forty-two hypertensive patients received a conventional laryngoscopy or were intubated with a intubating laryngeal mask airway. Anesthesia was induced with propofol, fentanyl, and cis-atracurium. Measurements of systolic and diastolic blood pressures, heart rate, rate pressure product, and ST segment changes were made at baseline, preintubation, and every minute for the first 5 min following intubation. The number of intubation attempts, the duration of intubation, and airway complications were recorded. RESULTS: The intubation time was shorter in the conventional laryngoscopy group than in the intubating laryngeal mask airway group (16.33±10.8 vs. 43.04±19.8 s, respectively) (p<0.001). The systolic and diastolic blood pressures in the intubating laryngeal mask airway group were higher than those in the conventional laryngoscopy group at 1 and 2 min following intubation (p<0.05). The rate pressure product values (heart rate x systolic blood pressure) at 1 and 2 min following intubation in the intubating laryngeal mask airway group (15970.90±3750 and 13936.76±2729, respectively) were higher than those in the conventional laryngoscopy group (13237.61±3413 and 11937.52±3160, respectively) (p<0.05). There were no differences in ST depression or elevation between the groups. The maximum ST changes compared with baseline values were not significant between the groups (conventional laryngoscopy group: 0.328 mm versus intubating laryngeal mask airway group: 0.357 mm; p = 0.754). The number and type of airway complications were similar between the groups. CONCLUSION: The intense and repeated oropharyngeal and tracheal stimulation resulting from intubating laryngeal mask airway induces greater pressor responses than does stimulation resulting from conventional laryngoscopy in hypertensive patients. As ST changes and upper airway morbidity are similar between the two techniques, conventional laryngoscopy, which is rapid and safe to perform, may be preferred in hypertensive patients with normal airways.

Effects of lidocaine and prednisolone on endoscopic rigid laryngoscopy

Objective/Hypothesis: The aim of this study is to compare the effects of lidocaine and methylprednisolone on postoperative respiratory complications caused by short‐term laryngeal surgery by way of rigid laryngoscope under general anesthesia. The effects of these drugs on recovery from anesthesia are also compared.

Complicated airway management in a child with prune-belly syndrome

We describe a 15‐month‐old boy with prune‐belly syndrome (PBS) in whom airway management was complicated. Following an inhalation induction using sevoflurane, tracheal intubation by direct laryngoscopy proved impossible after repeated attempts. A laryngeal mask airway (LMA™) was inserted and the child had an uneventful anaesthetic course.

Lumbar epidural anesthesia and celiac plexus blockade for cholecystectomy in two patients with severe chronic obstructive pulmonary disease.

To the Editor: Open cholecystectomy (OC) usually necessitates general anesthesia and endotracheal intubation. General anesthesia + epidural anesthesia (EA), thoracic EA, EA + intrapleural anesthesia, EA + iv anesthesia, and EA + local anesthesia have been used for upper abdominal surgery (UAS) in patients with pulmonary disease previously.1–3 Although celiac plexus blockade (CPB) can be recommended as an adjunct to EA for UAS, it is not common because of technical difficulties and risks. We report the effects of combined CPB and EA on metabolic and endocrine responses to surgery, respiratory function and pain intensity in two patients with chronic obstructive pulmonary disease (COPD) for OC. Case 1: A woman (44 yr old) with chronic cholelithiasis had bronchiectasis (wheezing, sibilant rhonchi and clubbing) for ten years. (FEV1/ FVC: 60% and pH: 7.43, PaCO2: 29 mmHg, PaO2: 85 mmHg, BE: -3 mmol·L–1, SaO2: 96%.) Case 2: A woman (65 yr old) had COPD (expiratory wheezing and rhonchi) and hypertension. (FEV1/ FVC: 58%, pH: 7.46, PaCO2: 44 mmHg, PaO2: 70 mmHg, BE: 6.9 mmol·L–1, SaO2: 95%). Both patients were admitted for OC. Other laboratory tests were normal. Lumbar EA and CPB were planned in order to prevent deep visceral pain during OC. Premedication and bronchodilator medication were given. With standard monitors in place, an epidural catheter was placed at the L1–2 level. A test dose (3 mL 1.5 % lidocaine with 1:200,000 epinephrine) was given and 6 mL bupivacaine 0.25% given to provide analgesia during CPB by a posterior approach with a 12-cm 22 gauge needle. After a test dose, 30 mL 0.25% bupivacaine were injected to the celiac plexus bilaterally. After 15 min, 16 mL 0.25% bupivacaine were given epidurally and sensory blockade reached the T4 dermatome level in both patients. During the procedure, mild hypotension was corrected with ephedrine 5 to 10 mg iv. Shivering was treated with meperidine 12.5 to 20 mg iv and midazolam 2 mg iv was administered for sedation. The patients felt moderate pain [visual analogue scale (VAS) 4–5] only during subhepatic retraction, relieved with fentanyl 50 μg iv. Forty-five minutes into surgery, blood glucose and cortisol levels were normal or slightly elevated. At the end of surgery, bupivacaine 0.25% 8 mL was given epidurally for postoperative analgesia. Eight hours after surgery, pain (VAS 5–7) was relieved with 0.25% bupivacaine 8 mL epidurally. Intraoperative and postoperative arterial blood gas analyses were normal. The epidural catheters were removed on the morning after surgery. Postoperatively, glucose and cortisol levels were in the normal range. No complications of CPB were observed. The patients were discharged on the fourth and fifth day after surgery. The celiac and splanchnic nerves are responsible for producing endocrine-metabolic responses to gastric surgery even under epidural blockade.4 Even when sensory blockade reaches the T4 dermatome sensory blockade to the viscera can be inadequate.5 It has been suggested that celiac plexus or superior hypogastric blockade should be performed in UAS.5 In conclusion, cholecystectomy can be performed under EA with CPB, almost inhibiting the stress responses to surgery, in patients with severe COPD. Cases should be selected carefully and CPB should be practiced by a skilled anesthesiologist. Alternatively, an intraoperative abdominal approach for CPB can be considered in order to prevent complications. Further studies are needed to compare EA and EA plus CPB for cholecystectomy in patients with severe COPD.

Anaesthetic and airway management in a child with Hanhart's syndrome

Hanharts syndrome (oromandibular‐limb hypogenesis syndrome) is a rare disease characterized by hypoglossia/aglossia, various distal limb defects and micrognathia. Difficult airway due to micrognathia may complicate anaesthetic management in this syndrome. We describe the anaesthetic management of a child with Hanharts syndrome undergoing plastic reconstructive surgery.

Classical Airway Assessment is Limited forPreoperative Recognition of Difficult Airway inLarynx Tumor: A Case

Larinks Tumorunde Preoperatif Guc Havayolu Tanisinda Klasik Havayolu Degerlendirilmesi Yetersiz Kalabilir: Bir Olgu Bildirimi Larinks tumorlu hastalarda guc havayolu cogu zaman preoperatif klinik degerlendirmelerle saptanabilmesine karsin, bu tip hastalarda preoperatif guc havayolu belirtileri olmadan beklenmedik entubasyon guclugu ile karsilasilmasi da olasi bir durumdur. Bu yazida preoperatif solunum yetersizligi ve guc havayolu bulgulari bulunmayan larinks tumorlu bir eriskin-. de gelisen basarisiz entubasyon girisimini sunuyoruz. Bilgisayarli Tomografi veya Manyetik Rezonans Goruntuleme gibi bazi ozel incelemeler laringeal kitleli hastalarin preoperatif degerlendirilmesinde daha yararli olabilir. Although preoperative recognition of difficult airway in the patients with larynx tumors Is often possible, sometimes unexpected intubation difficulty can be seen without preoperative signs of difficult airway. We present a case report of failed Intubation in an adult with larynx tumor without preoperative clinical findings of respiratory insufficiency and difficult airway. Some more specific analyses like computerized tomoghraphy (CT) or magnetic resonance imaging (MRJ) can be more helpful for preoperative airway assessment of the patients with laryngeal mass.