Ian McConachie

Anesthetic considerations in a parturient with Freeman–Sheldon syndrome

Freeman-Sheldon syndrome is a rare genetic disorder characterized by malformations of the face, oral cavity and musculoskeletal system. This case report describes the anesthetic management of a parturient with Freeman-Sheldon syndrome, kyphoscoliosis and a cardiac pacemaker for a cesarean delivery and tubal ligation. With a predicted difficult airway, our team decided to provide a combined spinal-epidural anesthetic. Problems encountered included difficult intravenous access, failure to identify the subarachnoid space and patient discomfort during surgery.

Limiting the accessibility of cost-prohibitive drugs: The story is incomplete

To the Editor, The study by Tabing et al. makes fascinating, if at times uncomfortable, reading. Nevertheless, further information would enable us to assess the applicability of their identified savings to one’s own institution. For example, what was the proportion of ambulatory cases in this major academic centre? I believe there is a general consensus that isoflurane would be a poor choice of volatile agent in ambulatory patients. Moreover, the authors appropriately acknowledge that their changes in practice which led to an increased use of isoflurane may not be applicable to same-day surgical centres. It would be a shame to lose the advances in anesthesia techniques that have facilitated the tremendous increases in the number of patients undergoing ambulatory surgical procedures in the last 20 years (and the considerably reduced healthcare costs). Another vital piece of information for us to learn would be the average fresh gas flow rates employed during anesthesia in the authors’ institution. Although sevoflurane is cheaper than desflurane at equivalent fresh gas flow rates, fresh gas flow rates of less than 1 L min can result in desflurane anesthesia being cheaper than sevoflurane anesthesia. Perhaps education on the use of low flow techniques would provide significant savings that are comparable to or greater than those achieved in this study. In addition, the use of nitrous oxide is relevant here. Nitrous oxide can reduce volatile requirements, but many are unaware that nitrous oxide is increasingly expensive. Indeed, the ambulatory centre where I work spends more each year on nitrous oxide than it spends on propofol! Lastly, I would also be concerned about the law of unintended consequences whereby intervention in a complex system may lead to undesirable outcomes. The authors’ reported increased use of naloxone is not a minor concern. The costs to the hospital and to society overall from one bad outcome relating to respiratory depression would more than negate any savings in anesthetic drug costs.

Neuraxial blocks in parturients with scoliosis and after spinal surgery

Neuraxial blocks in parturients with scoliosis and/or previous back surgery have traditionally been avoided due to concerns such as difficulty, increased complications, and decreased efficacy. Recent studies suggest that with attention to proper anesthetic technique and improvements in surgical procedures the success rate of neuraxial blocks is improved. The use of ultrasound may also improve the success rate of neuraxial blocks and should be considered. We review the recent literature and suggest practical approaches to neuraxial blocks in these parturients.