Anesthesia and analgesia
-
Anesthesia and analgesia · Feb 2004
Case ReportsRigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie.
We describe a technique by which a gum elastic bougie (GEB) is used to facilitate an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy. After placing the GEB through the lumen of the rigid bronchoscope, the GEB-suction catheter assembly was used to safely withdraw the bronchoscope in a manner mimicking the withdrawal of an intubating laryngeal mask airway (LMA) over the endotracheal tube using a stabilizer rod. The rationale for management and potential advantages of this approach versus use of an airway exchange catheter (including increased stability of an intubation guide) are discussed. ⋯ We describe a technique of using a gum elastic bougie to facilitate an endotracheal intubation in a patient undergoing rigid bronchoscopy, which can be useful in a variety of clinical situations when the rigid bronchoscope is used in patients with abnormal airway.
-
Anesthesia and analgesia · Feb 2004
Case ReportsA suspected case of delayed onset malignant hyperthermia with desflurane anesthesia.
Desflurane has been identified as a weak triggering anesthetic of malignant hyperthermia that, in the absence of succinylcholine, may produce a delayed onset of symptoms. The prolonged interval after exposure may occur more than 6 h after the induction of anesthesia. The unintended underdosing of this patient with dantrolene and the prompt reversal of symptoms may be an attribute of the genetic expression of a weak triggering volatile anesthetic such as desflurane. ⋯ There are multiple genetic variations for malignant hyperthermia (MH) at the ryanodine receptor. Desflurane, as a sole trigger of MH, is weak, and on two occasions in the literature (including this case), less than optimal doses of dantrolene were given with a good result. There may be possible to engineer the risk of MH out of an anesthetic once the genetics of the ryanodine receptor are better understood.
-
Anesthesia and analgesia · Feb 2004
Case ReportsThe presence of working memory without explicit recall in a critically ill patient.
We describe an intubated patient sedated with propofol who interacted with caregivers, demonstrating intact "working memory." When neuromuscular blockade and bispectral index (BIS) monitoring were instituted, a greatly reduced amount of sedative achieved BIS values less than 60. Neither the sedation that allowed working memory nor the lighter sedation that produced BIS values less than 60 resulted in recall. This experience suggests that working memory demonstrated when BIS values are less than 60 is unlikely to lead to recall. ⋯ The presence of intact working memory during sedation is a poor predictor of explicit recall when bispectral index values are maintained less than 60.
-
Anesthesia and analgesia · Feb 2004
Case ReportsSevere hypotension in the prone position in a child with neurofibromatosis, scoliosis and pectus excavatum presenting for posterior spinal fusion.
A 34-mo-old boy with neurofibromatosis, scoliosis, and pectus excavatum developed severe hypotension when positioned prone. A magnetic resonance image study revealed neurofibromas encircling the great vessels. During the next anesthetic the patient was placed in the prone position on transverse bolsters and hypotension ensued again. A transesophageal echocardiogram (TEE) revealed compression of the right ventricle by the sternum. When the child was turned supine, the blood pressure returned to baseline. The patient was returned to the prone position, this time with bolsters placed longitudinally, without problem. This case supports a cardiac evaluation, possible intraoperative TEE, and avoidance of sternal pressure in patients with chest wall deformities requiring prone positioning. ⋯ A child with neurofibromatosis, scoliosis, and a chest wall deformity presenting for spinal fusion developed severe hypotension while prone. This was due to compression of the heart by the sternum, not compression of the great vessels by neurofibromas. Sternal pressure in prone patients with chest wall deformities should be avoided. Unique management included the use of transesophageal echocardiography to determine the cause of the hypotension.