Lakshmi N. Kurnutala

Tension Pneumothorax During Surgery for Thoracic Spine Stabilization in Prone Position: A Case Report and Review of Literature

The intraoperative progression of a simple or occult pneumothorax into a tension pneumothorax can be a devastating clinical scenario. Routine use of prophylactic thoracostomy prior to anesthesia and initiation of controlled ventilation in patients with simple or occult pneumothorax remains controversial. We report the case of a 75-year-old trauma patient with an insignificant pneumothorax on the right who developed an intraoperative tension pneumothorax on the left side while undergoing thoracic spine stabilization surgery in the prone position. Management of an intraoperative tension pneumothorax requires prompt recognition and treatment; however, the prone position presents an additional challenge of readily accessing the standard anatomic sites for pleural puncture and air drainage.

A surprising cause of wheezing in a morbidly obese patient: a case report

A typical patient with chronic obstructive pulmonary disease has small airway disease, which often responds to bronchodilators. If the patient is obese, he or she may be further compromised and not tolerate being in the supine position. We present a case of a patient with history of chronic obstructive pulmonary disease and obstructive sleep apnea with acute renal failure and urosepsis scheduled for an emergent debridement of Fournier’s gangrene. In this patient, the fiberoptic intubation was performed in semi-Fowler’s position, and tracheomalacia was observed.

Aspiration during electroconvulsive therapy under general anesthesia.

Electroconvulsive Therapy Under General Anesthesia To the Editor: We often assume that patients who have had nothing by mouth (NPO) for more than 8 hours have nothing in their stomach. Exceptions include the very anxious (eg, trauma), the big-bellied patient (eg, pregnancy, obese), the neurologically impaired patient (eg, diabetes, renal failure), ileus or bowel obstruction, hiatal hernia, and enteral tube feeding. We present a case of aspiration during electroconvulsive therapy (ECT) under general anesthesia. A 51-year-old man (weight 77 kg) was admitted to the hospital for major depression because he was not responding to antidepressants. After evaluation by the psychiatric team, the patient was scheduled for ECT in the morning. The patient had a history of hyperlipidemia. His medications included rosuvastatin, quetiapine, and venlafaxine. The patient did not have any surgical history. The preanesthetic evaluation revealed a severely depressed patient communicating in a low voice, with no anticipated airway difficulties. The patient had nothing by mouth for approximately 14 hours before the procedure. The patient complained of constipation and lower abdominal discomfort that had fully resolved 4 hours before the procedure, after a normal bowel movement. Anesthetic Management The patient was connected to standard American Society of Anesthesiologists monitors in the ECT room. The patient was scheduled to undergo a standard-dose titration protocol for the ECTVstarting with a low dose of right unilateral ultrabrief pulse of 0.3 millisecond, 1-second duration, 20 Hz, at 800 mA. Isolated limb technique (left lower limb isolation by using the tourniquet inflation before the muscle relaxant) was used during ECT to measure the motor activity along with electroencephalogram monitoring. He was preoxygenated with 100% oxygen as he was spontaneously breathing through a transparent facemask covering the nose and mouth with a tight seal using a Mapleson F (Jackson-Rees) anesthesia circuit for 3 minutes. General anesthesia was induced with methohexital 80 mg (È1 mg/kg) intravenously (IV). Succinylcholine 60 mg (È0.75 mg/kg) IV was given next after a bite block was placed, and ventilation was possible with the transparent facemask secured with head straps. The first stimulus of ECTwas administered following clinical cessation of eyelid fasciculation. No nerve stimulator was used to assess the depth of paralysis. The first dose of ECT was administered without a response. After 30 seconds, a second stimulus was administered, and the patient started convulsing, but without arching his back. The motor seizure duration was 65 seconds and the electroencephalogram seizure duration was 94 seconds. He immediately began producing copious amounts of semisolid food and secretions through the mouth and nose. His heart rate was 124 beats/min, blood pressure 156/86 mm Hg, and oxygen saturation (SpO2) 96%. At this juncture, the patient was given an additional dose of methohexital 60 mg IV and succinylcholine 40 mg IV. He was rapidly intubated orally with a 7-mm cuffed endotracheal tube (ETT). Aspiration from the ETT revealed particulate matter, whereas aspiration from an orogastric tube revealed minimal secretions. The patient was sedated with a propofol infusion 25 to 50 Hg/kg per minute and transferred to the intensive care unit maintaining an SpO2 of 88% to 90% on 100% oxygen. Bronchoscopy and lavage through the ETT tube showed partially digested rice and beans that were consumed more than 20 hours before the procedure. The consulting gastroenterologist diagnosed a ‘‘possible depression-associated gastroparesis.’’ The patient appeared to have had sustained an irreversible pulmonary injury and died 35 days after the event because of sepsis and multiorgan failure.

Neurophysiological Monitoring during Surgery on the Central Nervous System: The Role of Evoked Responses

Neurosurgical, orthopedic and vascular interventions may be associated with an inherent risk of ischemia and structural damage to the central nervous system. Along with other modalities used to monitor the intraoperative nervous function, registration of evoked responses is intended to provide real-time feedback about the functional integrity of the central nerv- ous system and help to prevent avoidable trauma during surgery. In this review, the principal indications and limitations of monitoring various evoked responses during surgery on the brain and spinal cord are discussed. Current approaches, recent advances and problems associated with intraoperative rhomboid fossa mapping, cranial nerve stimulation and electroocu- lographic monitoring are presented as well. The authors discuss the effects of general anesthesia on evoked responses and possible ways to avoid signal variability during registration. It is emphasized that only with close cooperation between neuro- surgeons, anesthesiologists and neurophysiologists it will be possible to maximize the benefits of intraoperative monitoring of evoked responses and avoid misinterpretation of the results.

Persistent Spinal Headache After Removal of Intrathecal Drug Delivery System: A Case Report and Review of Literature.

Introduction: To report and discuss the spinal headache following insertion and removal of intrathecal drug delivery system in patients with chronic pain disorders. Case Presentation: Intrathecal drug delivery system (IDDS) was initially used for the management of chronic malignant pain; it has since been used to manage pain from other nonmalignant conditions as well. Spinal headache is one of the complications during the trial, permanent placement and after removal of intrathecal drug delivery catheter systems. A 48-year-male patient with chronic pain disorder developed a refractory spinal headache after removing the intrathecal drug delivery system requiring a surgical intervention to resolve the problem. Conclusions: Conservative management is successful in the vast majority of patients with spinal headache. Interventional procedures are required in a small fraction of patients for symptomatic relief.

How clean are the overhead lights in operating rooms

facilitated by antibiotic use and the lack of infection control routines, leading to increased morbidity and mortality of individuals due to preventable diseases. This brief study describes the profile of bacterial resistance and strategies for prevention and control in a teaching hospital in southern Brazil. The analysis of microbiological cultures of infections and colonization identified the hospital’s microorganism profile. It was observed that hospitalizations due to infections increased the length of hospital stay by an average of 35 days. Analysis of data for the second half of 2011, with a total of 210 microorganisms identified, showed 48% of Staphylococcus spp resistant to methicillin, 26% of Pseudomonas spp resistant to carbapenem, 9% of Acinetobacter spp resistant to carbapenem, 7% of Klebsiela spp resistant to amikacin, and 12% of the CESP group resistant to amikacin. No resistance to polymyxin was noted. Once these indicators were established, guidelines for contact precautions were reinforced. These precautions are ideally performed in private rooms with specific routines to reduce crosstransmission and management of infected patients at the bedside and on transport, provide guidance to family members and visitors, and provide alcoholic chlorhexidine at the bedside. To identify these patients, illustrative plates are placed on the doors of their rooms, listing routine use of materials and equipment specific for each type of precaution, as well as color charts according to each routine. An electronic surveillance system containing information on the colonized/infected patients helps maintain control of these measures. In this context, it is necessary to establish educational activities with the teams regarding the use of personal protective equipment, as well as hand hygiene of professionals and management of catheters and care protocols. The efforts of all health professionals are essential to the control of infections related to health services, and their co-participation will favor the main outcome of minimizing bacterial resistance. Success is related to an approach that addresses the individual practice. Furthermore, thisunderstandingconfirms that thehealthprofessionals and institutions should abandon the simplistic idea that the infection control and transmission of nosocomial pathogens in health care facilities is the sole responsibility of Infection Control Committee members, and understand that professionals must actually be part of the process as members, and co-responsible for this process.

Fiberoptic nasopharyngoscopy for evaluating a potentially difficult airway in a patient with elevated intracranial pressure

A 62-year-old man with a left temporal lobe tumor was scheduled for a semiurgent craniotomy for tumor excision. Previously, the patient had a laryngeal carcinoma that was resected and treated with chemotherapy and radiotherapy and a history of laryngeal biopsy with awake fiberoptic intubation. Because a difficult airway was anticipated, awake fiberoptic nasopharyngoscopy of the airway was performed under topical anesthesia in the operating room. This revealed a narrow glottic opening with no supraglottic pathology or friable tissue. Based on these airway observations, we proceeded safely with intravenous induction and secured the airway in a controlled fashion, thereby minimizing the risk of increased intracranial pressure and catastrophic complications. Nasopharyngoscopy can be used safely to evaluate the upper airway to stratify airway management in patients with a history of head and neck cancer presenting for neurosurgical procedures in the setting of elevated intracranial pressure.

Semisitting Position and Venous Air Embolism in Neurosurgical Patients with Patent Foramen Ovale: A Systematic Analysis

Proper positioning of a patient during surgery is an important determinant of the success of the procedure. Each type of position during surgery confers its own advantages and disadvantages, from the surgical and anesthetic points of view, but the final decision should serve the best interests of the patient. The benefits of, and alternatives to, semisitting craniotomy have been a source of contention since the early 1930s [1]. This position offers excellent working conditions to the surgeon during performance of posterior fossa and cervical spine surgeries, but also presents significant challenges to anesthesiologists, of which the most important is venous air embolism (VAE).

Emergency tracheal intubation through intubating laryngeal mask airway in patients with stereotactic frame in situ

Sir, Stereotactic radiosurgery is a major advance in the treatment of intracranial lesions. Stereotactic surgery is performed with patients fully awake or with minimal sedation. However, the stereotactic frame used for neurosurgical procedures interferes with access to the airway and limits neck mobility. The presence of frame poses significant difficulty for airway interventions such as conventional mask ventilation, laryngoscopy, and tracheal intubation. Fibreoptic bronchoscopy and laryngeal mask airway (LMA) are suitable for emergency airway access, but an intubating laryngeal mask airway (ILMA) might be suitable for emergency airway management in those patients who need endotracheal intubation.[1] We report management of two patients who underwent stereotactic guided biopsies of a thalamic lesion and brainstem lesion, respectively, and who developed respiratory depression and sudden deterioration in consciousness under monitored anaesthesia care. Immediate intubation was accomplished with a size #4 ILMA inserted from a position anterior to the patient without disturbing the stereotactic frame in both patients. The endotracheal tube easily placed through the ILMA in the first patient while the stereotactic frame needed to be released in the second. In both patients, the airway was secured to prevent aspiration and for the possibility of prolonged postoperative ventilation related to intraoperative events. The applications of stereotactic surgery are increasing. Except for the paediatric patient population, general anaesthesia is not usually required for the stereotactic procedures. Sedation is provided to improve patient comfort and to decrease extreme blood pressure swings during frame placement. The intraoperative anaesthetic complications during stereotactic surgery include depressed consciousness, impaired respiration, and airway obstruction requiring emergency airway management. Tracheal intubation can be challenging with the placement of a stereotactic frame for many reasons. These patients have intracranial disease and might be particularly sensitive to hypoxia or severe hypercapnia as a complication of airway obstruction in the presence of the stereotactic device, stabilising the neck and head to ensure a patent airway might be difficult. Fibreoptic bronchoscopy has been recommended for tracheal intubation in these patients, but considerable intubation experience is required to perform fibreoptic in an emergency. Flexible fibreoptic bronchoscopes are expensive and might not be readily available. Therefore, it is prudent to have alternative management techniques. Intubation techniques using a light wand or gum elastic bougie might allow easy passage of the tube without direct visualisation of the glottis, but not without complications.[2] A supraglottic airway device for airway management and an Allen wrench for removal of the crossbar must be immediately available if intubation proves unsuccessful. Placement of the ILMA and subsequent intubation are blind techniques, and placement is not affected by heavy secretions or blood, which might impair fibreoptic techniques. Moreover, the ILMA allows for ventilation and oxygenation during tracheal intubation attempts. It can be used in patients with a difficult airway,[3] and can facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.[4] Fukutome et al.,[5] found that tracheal intubation through the ILMA was successful in 93% of patients with a difficult airway. The advantage of the ILMA in stereotactic surgery is that ventilation and intubation might be accomplished without disturbing the frame. Failure to intubate through the ILMA can be overcome by fibreoptic-guided intubation, failing which release of the stereotactic frame might be required.

Perioperative acute hypertension—role of Clevidipine butyrate

Arterial hypertension (AH) is one of the most common pathological conditions affecting the general population which contributes to pathogenesis of various diseases and worsens the treatment outcome (James et al., 2014). It increases the perioperative morbidity and mortality, frequently result in cancelation of surgical procedures and increases treatment-associated costs (Handler, 2006). Perioperative hypertension may occur in patients with pre-existing arterial hypertension or manifest as a de novo phenomenon (Vuylsteke et al., 2000; Varon and Marik, 2008).