Poonam Bhadoria

Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass

Anesthetic management of superior vena cava syndrome carries a possible risk of life-threatening complications such as cardiovascular collapse and complete airway obstruction during anesthesia. Superior vena cava syndrome results from the enlargement of a mediastinal mass and consequent compression of mediastinal structures resulting in impaired blood flow from superior vena cava to the right atrium and venous congestion of face and upper extremity. We report the successful anesthetic management of a 42-year-old man with superior vena cava syndrome posted for cervical lymph node biopsy.

Use of intubating laryngeal mask airway in a morbidly obese patient with chest trauma in an emergency setting.

A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.

Donepezil: A cause of inadequate muscle relaxation and delayed neuromuscular recovery.

A 74-year-old female with diabetes mellitus type II and Alzheimers disease, taking donepezil for 4 months was operated for right modified radical mastectomy under general anesthesia. During the procedure a higher dose of non-depolarizing muscle relaxant was required than those recommended for her age yet the muscle relaxation was inadequate intra-operatively. Residual neuromuscular blockade persisted postoperatively, due to the cumulative effect of large doses of non-depolarizing muscle relaxant, needing post-operative ventilatory assistance. After ruling out other causes of resistance to non-depolarizing muscle relaxants, we concluded that acetylcholinesterase inhibitor donepezil was primarily responsible for inadequate muscle relaxation and delayed post-operative neuromuscular recovery.

Tracheal intubation through Igel conduit in a child with post-burn contracture

Sir, A 25 kg, 9 year old girl was scheduled for post-burn contracture (PBC) neck release and superficial skin grafting following burns. Contracture scar was in the anterior midline of the neck. Neck extension was limited, and interincisor gap was ~ 3.5 cm. All relevant investigations were within normal limits. Standard monitors were attached and intravenous (IV) access was secured on the dorsum of the left hand. Patient was administered glycopyrrolate 0.2 mg, ranitidine 25 mg, metoclopromide 8 mg and fentanyl 50 mcg (IV). Anesthesia was induced with Sevoflurane 2 8% in 100% oxygen (O2) using a size 2 facemask. After adequate jaw relaxation, Igel size 2.5 was inserted, and placement was confirmed by a square shaped capnography wave. Spontaneous ventilation was maintained. An assembly of two uncuffed endotracheal tubes (ETT) of 5.5 mm ID (up to 6 mm ID size, ETT can pass through Igel size 2.5[1]) with connectors removed was created [Figure 1], such that the proximal end of lower tube firmly fitted into the distal end of the upper tube making them a single unit to increase the length of ETT for Igel removal after endotracheal intubation. This assembly was mounted over flexible fiberscope (ED 3.7 mm). Flexible fiberscope with 5.5 mm ID (ETT) over it was kept ready. The surgeon was asked to standby for scar release in an emergency. Depth of anesthesia was maintained with sevoflurane 4-5% in 100% O2.

Management of swine-flu patients in the intensive care unit: Our experience

Background: H1N1 pandemic in 2009–2010 created a state of panic not only in India, but in the whole world. The clinical picture seen with H1N1 is different from the seasonal influenza involving healthy young adults. Critical care management of such patients imposes a challenge for anesthesiologist. Materials and Methods: A retrospective analysis of hospitalized positive H1N1 patients was performed from July 2009–June 2010. Those requiring the ventilatory support were included in the study. Result: 54 patients were admitted in the swine-flu ward during the study period out of which 19 required ventilatory support. The average day of presentation to the health care facility was 6th day causing delay in initiation of antiviral therapy and increased severity of the disease. 65% of the ventilated patients were having associated comorbidities. Mortality was 74% among ventilated patients. Conclusion: Positive H1N1 with severe disease profile have a poor outcome. Early identification of high-risk factors and thus early intervention in the form of antiretroviral therapy and respiratory care will help in reducing the overall mortality.

Anesthetic management of a patient with Montgomery t-tube in-situ for direct laryngoscopy

The Montgomery silicone t-tube used for post-procedural tracheal stenosis has advantage of acting as both stent and tracheostomy tube. The anesthetic management of patient with t-tube in situ poses a challenge. Safe management of such patients requires careful planning. We describe anesthetic management for direct laryngoscopy of a patient with t-tube in situ.

Use of two tracheal tubes and fibreoptic bronchoscope for intubation through a LMA Pro‐Seal® in a difficult paediatric airway

general anaesthetics. A laryngeal mask airway (LMA) was used in 14 cases, a tracheal tube in 19 and a facemask once. Airway difficulties were encountered in five patients, on 12 separate occasions. Eight involved difficult laryngoscopy, two required more than three attempts at LMA insertion and intubation was impossible in two further patients. Adequate laryngoscopy was impossible in one patient because of an immobile tongue and poor mouth opening and in a second, failure to intubate and ventilate was due to fibrous strands stretching from the base of the tongue to the oropharynx. Awake fibreoptic intubation was used to secure the airway in four patients on eight occasions, due to previous difficulties. None of our patients had encountered airway difficulties in childhood and all had undergone tracheal intubation without difficulty for their first surgical procedure in this series. However, by the end of the period, five had encountered airway difficulties and three required fibreoptic intubation. Airway deterioration in adult patients with epidermolysis bullosa has not previously been reported. Isolated difficulties have been reported in children [1–4], but with no failed intubations, and usually a Cormack and Lehane grade 2 or less [5]. Airway difficulties are exacerbated in adults by a repeated blistering– scarring cycle leading to neck contractures, microstomia, poor mouth opening, immobile tongue and oesophageal webs. Our series suggests that the airways of adult epidermolysis bullosa patients may deteriorate over time, although the number of cases was small. The need to achieve safe control of the airway in these patients must be balanced against avoiding frictional trauma. New bulla formation can be associated with difficult or failed airway management [6], LMA insertion, laryngoscopy and use of the facemask [7, 8]. Awake fibreoptic intubation minimises frictional trauma and reduces the risk of new bulla formation whilst safely securing the difficult airway. We believe that fibreoptic intubation is a technique that should be considered for airway control in all adult patients with this unique condition.

Awareness among resident doctors with regards to cardiac defibrillators

Background and Aims: Electrical defibrillation is the most important therapy for patients in cardiac arrest. The audit was aimed to assess awareness among residents with respect to routine preuse checking of cardiac defibrillators. Materials and Methods: The audit was conducted at a multispeciality tertiary care referral and teaching center by means of a printed questionnaire from anaesthesiology residents. A database was prepared and responses were analyzed. Results: Eighty resident doctors participated in the audit. Most (97.8%) of the residents were sure of the presence of a defibrillator in the operation room (OR); 70% of postgraduates (PG)s were aware of the location of the defibrillator in the OR as compared to 83.7% of the senior resident (SRs). Also, 32.1% residents routinely check the availability of a defibrillator. The working condition of the defibrillator was checked by 21.7% of the residents; 25.3% ensured delivery of the set charge. Further, 8.2% of residents ensured availability of both adult and paediatric paddles. About 27.8% of residents ensured the availability of appropriate conducting gel and 53.8% residents were of the opinion that the responsibility of checking the functioning and maintenance of the defibrillators lies with themselves. Some 22% thought that both doctors and technical staff should share the responsibility, while 19.5% opined that it should be the responsibility of the technical staff. Conclusion: All medical equipment is to be tested prior to initial use and periodically thereafter. An extensive, recurring training program, and continued attention to the training of clinical personnel is required to ensure that they are proficient in the operation and testing of specific defibrillator models in their work area. We conclude that apart from awareness of the use of the equipment we are using, its preuse testing is must. All resident doctors should be aware of the presence and adequate functioning of the defibrillator in their ORs and this audit reinforces the need for training of all resident doctors.

Attitude of resident doctors towards intensive care units' alarm settings.

Intensive care unit (ICU) monitors have alarm options to intimate the staff of critical incidents but these alarms needs to be adjusted in every patient. With this objective in mind, this study was done among resident doctors, with the aim of assessing the existing attitude among resident doctors towards ICU alarm settings. This study was conducted among residents working at ICU of a multispeciality centre, with the help of a printed questionnaire. The study involved 80 residents. All residents were in full agreement on routine use of ECG, pulse oximeter, capnograph and NIBP monitoring. 86% residents realised the necessity of monitoring oxygen concentration, apnoea monitoring and expired minute ventilation monitoring. 87% PGs and 70% SRs routinely checked alarm limits for various parameters. 50% PGs and 46.6% SRs set these alarm limits. The initial response to an alarm among all the residents was to disable the alarm temporarily and try to look for a cause. 92% of PGs and 98% of SRs were aware of alarms priority and colour coding. 55% residents believed that the alarm occurred due to patient disturbance, 15% believed that alarm was due to technical problem with monitor/sensor and 30% thought it was truly related to patient’s clinical status. 82% residents set the alarms by themselves, 10% believed that alarms should be adjusted by nurse, 4% believed the technical staff should take responsibility of setting alarm limits and 4% believed that alarm levels should be pre-adjusted by the manufacturer. We conclude that although alarms are an important, indispensable, and lifesaving feature, they can be a nuisance and can compromise quality and safety of care by frequent false positive alarms. We should be familiar of the alarm modes, check and reset the alarm settings at regular interval or after a change in clinical status of the patient.

Retrosternal goitre: Anaesthetic implications and management

Large retrosternal goitre is a challenge to the anaesthesiologist and the surgeon. We describe the successful anaesthetic management of a 44 year old male patient with extensive retrosternal goitre with severe tracheal compression, operated for total thyroidectomy under general anaesthesia by combined cervical approach and sternotomy. A multidisciplinary team approach with surgical colleagues allowed successful management of the patient. Keywords: Retrosternal goitre, Thyroidectomy, Sternotomy, Awake fibreoptic intubation.