Irene P. Osborn

Use of the intubating lma-fastrach in 254 patients with difficult-to-manage airways

Background The laryngeal mask airway (LMA™; LMA North America, Inc., San Diego, CA) has a well-established role in the emergency and elective treatment of patients with difficult-to-manage airways (DA). In this study, the authors report their clinical experience with the intubating LMA (LMA-Fastrach™; LMA North America, Inc., San Diego, CA) in 254 patients with different types of DA. Methods The authors reviewed the anesthetic and medical records of patients with DA in whom the LMA-Fastrach™ was used electively or emergently at four institutions from October 1997 through October 2000. In each case, the number of insertion and intubation attempts was recorded. Success rates for blind and fiberoptically guided intubation through the LMA-Fastrach™ were calculated, up to a maximum of five attempts per patient. Results The LMA-Fastrach™ was used in 257 procedures performed in 254 patients with DA, including patients with Cormack-Lehane grade 4 views; patients with immobilized cervical spines; patients with airways distorted by tumors, surgery, or radiation therapy; and patients wearing stereotactic frames. Insertion of the LMA-Fastrach™ was accomplished in three attempts or fewer in all patients. The overall success rates for blind and fiberoptically guided intubations through the LMA-Fastrach™ were 96.5% and 100.0%, respectively. Conclusions The LMA-Fastrach™ was used successfully in a high percentage of patients who presented with a variety of DA. The clinical experience presented herein indicates that this device may be particularly useful in the emergency and elective treatment of patients in whom intubation with a rigid laryngoscope has failed and in the treatment of patients with immobilized cervical spines.

Scalp block during craniotomy: a classic technique revisited.

Local anesthesia of the nerves of the scalp is referred to as “scalp block.” This technique was originally introduced more than a century ago, but has undergone a modern rebirth in intraoperative and postoperative anesthetic management. Here, we review the use of “scalp block” during craniotomy with its anatomic basis, historical evolution, current technique, potential advantages, and pitfalls. We also address its current and potential future applications.

Pallidal deep brain stimulation for primary dystonia in children

BACKGROUND:Deep brain stimulation (DBS) at the internal globus pallidus (GPi) has replaced ablative procedures for the treatment of primary generalized dystonia (PGD) because it is adjustable, reversible, and yields robust clinical improvement that appears to be long lasting. OBJECTIVE:To describe the long-term responses to pallidal DBS of a consecutive series of 22 pediatric patients with PGD. METHODS:Retrospective chart review of 22 consecutive PGD patients, ≤21 years of age treated by one DBS team over an 8-year period. The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) was used to evaluate symptom severity and functional disability, pre- and post-operatively. Adverse events and medication changes were also noted. RESULTS:The median follow-up was 2 years (range, 1-8 years). All 22 patients reached 1-year follow-up; 14 reached 2 years, and 11 reached 3 years. The BFMDRS motor subscores were improved 84%, 93%, and 94% (median) at these time points. These motor responses were matched by equivalent improvements in function, and the response to DBS resulted in significant reductions in oral and intrathecal medication requirements after 12 and 24 months of stimulation. There were no hemorrhages or neurological complications related to surgery and no adverse effects from stimulation. Significant hardware-related complications were noted, in particular, infection (14%), which delayed clinical improvement. CONCLUSION:Pallidal DBS is a safe and effective treatment for PGD in patients <21 years of age. The improvement appears durable. Improvement in device design should reduce hardware-related complications over time.

Magnetic resonance imaging anesthesia: new challenges and techniques.

Purpose of review The increasing use of magnetic resonance imaging as a diagnostic modality has led to increased demand for sedation and monitoring during the procedure. This review is to acquaint the reader with the most recent developments in magnetic resonance imaging diagnostics and to describe the evolving techniques and strategies for patient management. Recent findings Many centers are meeting the challenges of increasing demand by streamlining their sedation/anesthetic protocols to achieve greater efficiency. Some have enlisted the help of nursing staff who are trained to provide sedation for certain patients. Continued experience in magnetic resonance imaging anesthesia has led to a better understanding of patient needs and decreased the number of failed procedures. The scope of magnetic resonance imaging diagnostics has expanded to include urology, otolaryngology, and neonatal evaluation. Although infants and children constitute the majority of patients, many adults also require anesthesia for magnetic resonance imaging and present their own challenges. Summary Anesthesia and sedation during magnetic resonance imaging have a unique set of constraints. However, most of the standards of modern, safe anesthetic care can be met in this environment. The growing experience at many hospitals has demonstrated that a wide range of patients can receive safe care during magnetic resonance imaging.

Anesthetic considerations for interventional neuroradiology.

In the past decade, the neuroradiological treatment of vascular disease of the central nervous system (CNS) has undergone significant evolution and improvement. Advances in technology are paving the way for new diagnostic and therapeutic radiologic procedures. As the types, number, and complexity of neuroradiological procedures increase, the need for anesthesia assistance during these cases will also increase. These cases can be quite challenging and the expertise of the neuroanesthesiologist has often been requested. This chapter will describe anesthetic considerations and management of several types of interventional neuroradiology (INR) procedures.

Anesthesia for Pediatric Deep Brain Stimulation

In patients refractory to medical therapy, deep brain stimulations (DBSs) have emerged as the treatment of movement disorders particularly Parkinsons disease. Their use has also been extended in pediatric and adult patients to treat epileptogenic foci. We here performed a retrospective chart review of anesthesia records from 28 pediatric cases of patients who underwent DBS implantation for dystonia using combinations of dexmedetomidine and propofol-based anesthesia. Complications with anesthetic techniques including airway and cardiovascular difficulties were analyzed.

Prevention of airway injury during spine surgery: rethinking bite blocks.

To JNA Readership: We read with interest the article ‘‘Prevention of Airway Injury During Spine Surgery: Rethinking Bite Blocks’’ by Deiner and Osborn. We would like to comment few points which has not been mentioned by the authors. We agree with the authors that the bite block must be soft enough to prevent dental trauma but also must resist force of human bite without being excessively bulky. Use of gauze roll (soft airway) as an alternative to bite block is a normal practice in our institute for both pediatric and adult patients receiving general anesthesia for all spine surgeries and intracranial surgeries. We have found it very useful not only for prevention of bite injuries but also for intraoral stabilization of the endotracheal tube in all patients, especially in infants and children as they usually have high arched palate. We are using 4-folded gauze roll ‘‘4 4’’ in adult patients and size is appropriately decreased in pediatric patients. Use of soft airway made of gauze rolls as bite block is recommended for neurosurgery in sitting position because presence of hard airway is a precipitating cause for tongue edema because of obstruction to the venous and lymphatic drainage of the tongue. We have been using gauze rolls as bite block also in all cerebellopontine angle tumor excision in which facial nerve monitoring is mandatory. The use of gauze roll for bite block is especially useful as an alternative to soft airway in cervical spine surgery during monitoring of motor-evoked potentials. Use of gauze roll as an alternative to bite block has also been documented to be safe even in children by Hasani. The problem of tongue being caught between the molars does not occur if one is vigilant enough to use proper size gauze roll block and placement should be laryngoscopic guided. The remedy to the problem of dislodgement is to avoid using undersized bite blocks.

The comparative study of video laryngoscopes to the Macintosh laryngoscope: defining proficiency is critical.

We read with interest the report by Frohlich et al. comparing the McGrath Series 5 Video Laryngoscope with the Macintosh direct laryngoscope. The role of various video laryngoscopes remains controversial. Unfortunately, much of the current literature pertaining to video laryngoscopy consists of case reports, mannequin studies or poorly designed clinical evaluations. Despite widespread enthusiasm for video laryngoscopy in routine and difficult airway management over the last decade, to date the scientific literature has imprecisely defined the role of these devices compared with traditional line of sight laryngoscopes. It is naive to assume that the negative findings of a published study lie entirely in the quality or utility of the new device, especially when compared with a device that has been the standard of practice for several decades. However, such comparative studies are critical in establishing the role of any new device or airway management technique. We must be cautious about drawing erroneous conclusions from inadequately rigorous studies.

Anesthesia for carotid and cerebrovascular procedures in interventional neuroradiology.

Interventional neuroradiology (INR) continues to evolve as a clinical specialty. About one-third of interventional neuroradiologists now report having admitting privileges. As the complexity of cases coupled with more patient comorbidities increases, the involvement of anesthesiologists in INR realm becomes more important. Research as to how to manage these patients in terms of anesthesia is slowly emerging. Procedures include embolization of arteriovenous malformations (AVMs), aneurysms, and vascular tumors. The procedures can be lengthy and uncomfortable, and patients often require sedation or anesthesia in addition to continuous monitoring of the cardiorespiratory and neurologic systems. Outcome studies indicate that endovascular coiling is superior to neurosurgical clipping if measured as survival and development of seizure states at 1 year even though the risk of rebleeding is higher in the coiling group. The case for carotid artery

Deep brain stimulation - Surgery for movement disorders and Parkinson's disease

A 66-year-old woman with Parkinson’s disease (PD) was scheduled for insertion of electrodes for deep brain stimulation (DBS). She was right handed, English speaking, and of normal intelligence. Her memory was good but a marked tremor interfered with her quality of life. Her current medications, levodopa (L-dopa) (Sinemet), bromocriptine (Parlodel), selegiline (Eldepryl), pramipexole (Mirapex), and amantadine (Symmetrel), afforded only fair movement control. She was very depressed and sertraline hydrochloride (Zoloft) had been prescribed. She had a history of hypertension treated with hydrochlorothiazide and diltiazem and type 2 diabetes controlled with diet and glyburide.