Elif Bengi Sener

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.

Comparison of Neonatal Effects of Epidural and General Anesthesia for Cesarean Section

We assessed the influence of anesthetic technique for cesarean section on neonatal outcome. Thirty parturient women (ASA I/II) were randomly allocated into two groups. In Group GA general anesthesia was induced with 4 mg·kg–1 thiopental and 1.5 mg·kg–1 succinylcholine. In group EA epidural anesthesia was performed with 20 ml 0.375% bupivacaine through L3–4 inter-space. 1-min Apgar scores were significantly higher in group EA (p < 0.001). Neurologic and Adaptive Capacity scores at 2 and 24 h were higher in group EA (p < 0.001). In terms of blood gas values, umbilical arterial pH and pO2 values were higher in group EA (p < 0.05 and p < 0.001, respectively). The first breast-feeding intervals were found to be shorter in group EA (p < 0.001). We conclude that in terms of better Apgar and NAC scores, acid-base status and earlier initiation of breast-feeding, the epidural anesthesia may be preferred to general anesthesia in cesarean section.

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.

Prolonged apnea following succinylcholine administration in undiagnosed acute organophosphate poisoning

Organophosphates (OP) are irreversibly bound to cholinesterase, causing deactivation of acetylcholinesterase. As a result of inhibition of plasma cholinesterase, increased sensitivity to drugs hydrolyzed by this enzyme can occur, e.g. succinylcholine and mivacurium. A case of more prolonged succinylcholine‐induced paralysis in a child with undiagnosed acute OP insecticide poisoning is presented. A 7‐h period of apnea and paralysis after administration of succinylcholine was attributed to the decreased rate of succinylcholine metabolism resulting from inhibition of pseudocholinesterase by the insecticide. In seven previously reported cases of prolonged succinycholine apnea after OP poisoning, exposure to insecticide was in chronic or subacute form without any obvious symptoms, and the duration of apnea did not extend up to 4 h, whereas in our case with acute, severe poisoning, succinylcholine led to more prolonged muscle paralysis. In the anesthetic management of patients with acute OP poisoning, succinylcholine should be avoided.

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.

Effects of lidocaine and esmolol infusions on hemodynamic changes, analgesic requirement, and recovery in laparoscopic cholecystectomy operations

OBJECTIVE We compared the effects of lidocaine and esmolol infusions on intraoperative hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery in laparoscopic cholecystectomy surgery. METHODS The first group (n=30) received IV lidocaine infusions at a rate of 1.5mg/kg/min and the second group (n=30) received IV esmolol infusions at a rate of 1mg/kg/min. Hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery characteristics were evaluated. RESULTS In the lidocaine group, systolic arterial blood pressures values were lower after the induction of anesthesia and at 20min following surgical incision (p<0.05). Awakening time was shorter in the esmolol group (p<0.001); Ramsay Sedation Scale scores at 10min after extubation were lower in the esmolol group (p<0.05). The modified Aldrete scores at all measurement time points during the recovery period were relatively lower in the lidocaine group (p<0.05). The time to attain a modified Aldrete score of ≥9 points was prolonged in the lidocaine group (p<0.01). Postoperative resting and dynamic VAS scores were higher in the lidocaine group at 10 and 20min after extubation (p<0.05, p<0.01, respectively). Analgesic supplements were less frequently required in the lidocaine group (p<0.01). CONCLUSION In laparoscopic cholecystectomies, lidocaine infusion had superiorities over esmolol infusions regarding the suppression of responses to tracheal extubation and postoperative need for additional analgesic agents in the long run, while esmolol was more advantageous with respect to rapid recovery from anesthesia, attenuation of early postoperative pain, and modified Aldrete recovery (MAR) scores and time to reach MAR score of 9 points.

Re: Anaesthetic management for gynaecological surgery in a patient with essential thrombocythaemia

466 Australian and New Zealand Journal of Obstetrics and Gynaecology 2005; 45: 464–467 headquarters. No, its not the resting place of the ‘Surgeon’ that troubles me – although some New South Wales purists will be outraged by the transfer of what is obviously a Sydney icon to Melbourne – but the artwork itself. I cannot understand the pose of the man. Why are his knees so far apart, surely an uncomfortable position for anyone, let alone a surgeon. Is it to give a wide base to prevent the sculpture from overbalancing? The hunched left shoulder with the head turned to that side looks a slightly defensive pose and the down ward turn of the hands, I did not say limp wristed, is not a surgeon’s normal position because they are taught to keep their hands up. The clothes do not suggest a modern surgeon. I agree that he does have a gown on but no mask even around his neck where most surgeons, to the fury of the infectious disease personnel, wear them while not operating. Perhaps he came from Newcastle in the fifties. He doesn’t wear a head covering either which helps to show that he is a young surgeon because he still has hair. But – hey I’m probably merely jealous. Rosalind Winspear has suggested that the artist has concentrated on the person rather than his occupation suggesting ‘fleeting self doubt before the operation’. I have always believed that surgeons and self doubt was an oxymoron, although I do remember one surgeon who started to show signs of self doubt. Naturally, no one could understand it in the surgical world because it had never happened before but it was ultimately explained as a difficulty with his wife and a little problem with the tax commissioner. You will all assume that I do not admire the sculpture which I assure you is not true. I am merely a Philistine who cannot understand what the artist was attempting. Can anyone out there please explain?

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.

Efeitos das infusões de lidocaína e esmolol sobre as alterações hemodinâmicas, necessidade de analgésicos e recuperação após colecistectomia laparoscópica

OBJECTIVE We compared the effects of lidocaine and esmolol infusions on intraoperative hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery in laparoscopic cholecystectomy surgery. METHODS The first group (n=30) received IV lidocaine infusions at a rate of 1.5mg/kg/min and the second group (n=30) received IV esmolol infusions at a rate of 1mg/kg/min. Hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery characteristics were evaluated. RESULTS In the lidocaine group, systolic arterial blood pressures values were lower after the induction of anesthesia and at 20min following surgical incision (p<0.05). Awakening time was shorter in the esmolol group (p<0.001); Ramsay Sedation Scale scores at 10min after extubation were lower in the esmolol group (p<0.05). The modified Aldrete scores at all measurement time points during the recovery period were relatively lower in the lidocaine group (p<0.05). The time to attain a modified Aldrete score of ≥9 points was prolonged in the lidocaine group (p<0.01). Postoperative resting and dynamic VAS scores were higher in the lidocaine group at 10 and 20min after extubation (p<0.05, p<0.01, respectively). Analgesic supplements were less frequently required in the lidocaine group (p<0.01). CONCLUSION In laparoscopic cholecystectomies, lidocaine infusion had superiorities over esmolol infusions regarding the suppression of responses to tracheal extubation and postoperative need for additional analgesic agents in the long run, while esmolol was more advantageous with respect to rapid recovery from anesthesia, attenuation of early postoperative pain, and modified Aldrete recovery (MAR) scores and time to reach MAR score of 9 points.