Anesthetic Management Of Patient Research Articles

Anesthetic management of placenta accreta in a low-resource setting: a case series

BackgroundCurrent recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting. MethodsA retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted. ResultsThirty-nine cases were identified. Mean (±SD) maternal age was 33±5.4years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100–2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0–6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred. ConclusionA multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.

Importancia de la simpatectomía inducida por el bloqueo continuo del plexo braquial para la cirugía de reimplante digital en un paciente con cirrosis hepática: reporte de caso

Hand microsurgeries are procedures performed by reconstructive surgeons and require a complex and highly individualized approach. The management of anesthesia in patients with cirrhosis may be challenging. Liver dysfunction may condition the extended use of anesthetic agents as a result of a disrupted metabolism and clearance.This case describes the anesthetic management of a patient with cirrhosis, using a combined anesthetic technique with continuous axillary block of the brachial plexus to prevent postoperative pain and maintain extended vasodilatation. The continuous brachial plexus block under local anesthesia has shown improved tissue perfusion following limb replantation surgery. This technique is particularly helpful to prevent vasospasm in the reconstructed tissue during the postoperative period. In patients with cirrhosis, this technique provides adequate postoperative pain control.

Anesthesia Management of Patients with Mental Retardation

Mental retardation is a condition likely to develop secondarily to several genetic diseases or to some negative conditions and diseases that occur before, during or after birth. Anaesthetic practices start with the preoperative visit of a patient and are then followed by premedication, preoperative preparation, intraoperative procedures and postoperative periods. All these steps with mentally retarded patients involve separate characteristics. The MR patients must be kept under observation in the recovery rooms for longer periods of time and must also be definitely re-evaluated by an experienced anaesthetist before being transferred to the service department. Since there may be several challenges/difficulties likely to be experienced at each stage of the mentally retarded patients’ anaesthesia, far more care and patience is required. A pre-anaesthetic evaluation involving a physical examination in depth and a detailed questioning should be performed. During the pre-medication period, a little amount of midazolam mixed with a proper drink can be used. Prior to applying the neuromuscle blocking agents, the airway opening must be maintained. In the presence of muscular dystrophies, the doses of neuromuscular blocking agents must be equalized. The MR patients must be kept under observation in the recovery rooms for longer periods of time and must also be definitely re-evaluated by an experienced anaesthetist before being transferred to the service department.

Importance of sympathectomy induced by continuous brachial plexus block for digital replantation in a patient with liver cirrhosis: Case report

Hand microsurgeries are procedures performed by reconstructive surgeons and require a complex and highly individualized approach. The management of anesthesia in patients with cirrhosis may be challenging. Liver dysfunction may condition the extended use of anesthetic agents as a result of a disrupted metabolism and clearance.This case describes the anesthetic management of a patient with cirrhosis, using a combined anesthetic technique with continuous axillary block of the brachial plexus to prevent postoperative pain and maintain extended vasodilatation. The continuous brachial plexus block under local anesthesia has shown improved tissue perfusion following limb replantation surgery. This technique is particularly helpful to prevent vasospasm in the reconstructed tissue during the postoperative period. In patients with cirrhosis, this technique provides adequate postoperative pain control.

Intra - operative Anesthesia Management in Patients Undergoing Surgical Irreversible Electroporation of the Pancreas, Liver, Kidney, and Retroperitoneal Tumors.

Background:Irreversible electroporation (IRE) is a relatively new approach to the management of multiple types of locally advanced soft tissue tumors. Unique peri-procedural anesthetic management is needed in the safe and effective delivery of this therapy.Objectives:This study analyzed IRE therapy in relation to anesthetic management for our initial cohort and then established and validated a set of best practical guidelines for general anesthesia in patients undergoing IRE for abdominal tumors.Patients and Methods:An IRB-approved prospective data collection outcome protocol was utilized. This study was broken up into two cohorts as follows: the initial 38 patients (pts) undergoing IRE in which anesthetic management was not defined or optimized and then a 40-pt validation cohort to establish the most efficacious anesthetic protocols.Results:During IRE delivery, a deeper neuromuscular blockade is required to ensure that all retroperitoneal muscle excitation was minimized. In the initial 38-pt cohort, attempts to treat hypertension (median SBP 190, range 185–215 and median diastolic 98, range 91–115) were made with various types of anti-hypertensives with minimal-to-insufficient effects. The established inhalation was sevoflurane with an approximate median dose of 8.0 volume percentage. Analgesic management of continuous remifentanil was utilized with epidural management, which optimized HTN and tolerance to IRE therapy.Conclusions:Anesthetic management for IRE of soft tissue deviates from standard anesthetic medical therapy in regards to depth of neuromuscular blockade and analgesic management during IRE energy delivery. However, minor modifications in anesthesia management allow for a safe and efficient patient procedure.

Sedasyon Sırasında Ani Gelişen Kardiak Değişiklikler: Wolff-Parkinson-White Sendromu: Olgu Sunumu

Wolff-Parkinson-White syndrome (WPW) is an uncommon cardiac disorder having an aberrant pathway between atria and ventricles. The major goals of analgesia and sedation are to provide pain control and anxiolysis and to facilitate therapeutic and diagnostic interventions. One major problem associated with the anesthetic management of patients with WPW syndrome is the risk of tachyarrhythmias as a result of the presence of the accessory pathway. Therefore it has been suggested that the aim of anaesthetic management should be the avoidance of tachyarrhythmia and sympathetic stimulation. We wanted to discuss, sudden cardiac changes which was developed during the sedation of a woman who was classified as American Society of Anesthesiologists (ASA) I according to physical examination and laboratory findings and had no point in her medical history apart from previous 1 regular caesarean section, the interventions and postoperatively diagnosed WPW syndrome. Especially, we wanted to emphasize that unexpected troubles which can cause morbidity and mortality can be experienced perioperatively in patients who are classified as ASA I during the preoperativly

Intraoperative awareness risk, anesthetic sensitivity, and anesthetic management for patients with natural red hair: a matched cohort study.

The red-hair phenotype, which is often produced by mutations in the melanocortin-1 receptor gene, has been associated with an increase in sedative, anesthetic, and analgesic requirements in both animal and human studies. Nevertheless, the clinical implications of this phenomenon in red-haired patients undergoing surgery are currently unknown. In a secondary analysis of a prospective trial of intraoperative awareness, red-haired patients were identified and matched with five control patients, and the relative risk for intraoperative awareness was determined. Overall anesthetic management between groups was compared using Hotelling's T(2) statistic. Inhaled anesthetic requirements were compared between cohorts by evaluating the relationship between end-tidal anesthetic concentration and the bispectral index with a linear mixed-effects model. Time to recovery was compared using Kaplan-Meier analysis, and differences in postoperative pain and nausea/vomiting were evaluated with Chi square tests. A cohort of 319 red-haired patients was matched with 1,595 control patients for a sample size of 1,914. There were no significant differences in the relative risk of intraoperative awareness (relative risk=1.67; 95% confidence interval 0.34 to 8.22), anesthetic management, recovery times, or postoperative pain between red-haired patients and control patients. The relationship between pharmacokinetically stable volatile anesthetic concentrations and bispectral index values differed significantly between red-haired patients and controls (P<0.001), but without clinical implications. There were no demonstrable differences between red-haired patients and controls in response to anesthetic and analgesic agents or in recovery parameters. These findings suggest that perioperative anesthetic and analgesic management should not be altered based on self-reported red-hair phenotype.

A New Threat in Anaesthesia-Bonzai.

To the Editor, Anaesthetists face problems in anaesthesia management of patients and have various preoperative problems in parallel with today’s changing conditions. Some of them are rare and some are common preoperative diseases. Another group includes cases realized because of changes in the patient’s clinical features. However, various drugs and herbal extracts taken by the patient without giving their medical history may leave us in an extremely difficult situation. In this paper, it was aimed to share the experience of a patient in whom ureterorenoscopy was planned for his urethral calculi. The patient was a 43-year-old male. His weight was 76 kg and height was 176 cm. He was taken to the operating room after receiving his written informed consent. There was no other feature apart from hypertension in his preoperative evaluation. He was receiving acetylsalicylic acid 100 mg and metoprolol succinate 50 mg tablets. The blood pressures were within the reference interval in his preoperative follow-ups. When he came to the operating room, his blood pressure was 210/126 mmHg and his heart rate was 86 pulses/min. Considering that he could have anxiety, the patient was sedated with midazolam and remifentanil hydrochloride. On being unable to lower the blood pressure, he was taken to the recovery room for follow-up. During the 2 h follow-up, he was given captopril 25 mg tablet. However, the blood pressure was still high. The problems that the he could face because of the situation were told him in detail. Thereupon, the patient mentioned that he was a drug addict and that he took Bonzai because he had a high stress the night before the operation. In view of this clinical picture of rising blood pressure, the operation was postponed until he became haemodynamically stable. As all of us watch the developments with anxiety, bonzai has become among the most important drug problems in our day. Bonzai is a semi-synthetic drug, obtained by adding various chemicals to some dried and shredded plants. It takes the name because the leaves of bonzai tree are generally used. The synthetic drug is known as Jamaican, Spice, Spice Gold, Spice silver, Yucatan Fire and K2 (1–3). Although there are not accurate data with respect to its prevalence, its use has increased because of its easy access and relatively low price. It is seen that synthetic cannabinoid, which is a content of Spice and Spice-like products, has just begun to be forbidden and kept under control in Austria and Germany (1, 2, 4). In our country, it was widely used, till it was added to the drug and stimulant list in the drug inspection law by the Decree of the Council of Ministers dated 07.01.2011 and numbered 2011/1310 (13.02.2011 dated and 27845 numbered official journal) (1). Although similar effects are seen with an excess of marijuana use, it is emphasized by researchers that bonzai is much more dangerous. One of the most important symptoms of it is its stimulant effect on the cardiovascular system (2–5). It causes sudden death because of a sudden and fast increase in blood pressure and a rise in the heart rate. There is some evidence indicating there is a correlation between synthetic cannabinoid use and acute renal failure (5). Moreover, it may lead to symptoms such as severe dryness of the mouth, eye redness, hallucination, convulsion and loss of consciousness (3, 4). To diagnose it is highly difficult unless the person himself reports or he is closely followed up (4). We realized with anxiety and worry in this patient that bonzai may be among the reasons in cases with hypertension of unknown origin. We aimed to share our experience.

Anesthetic Management of a Patient with Dilated Cardiomyopathy for Fracture Femur Surgery: A Case Report

Dilated cardiomyopathy (DCMP), especially alcoholic cardiomyopathy is a myocardial disease and is challenging for perioperative management. As anesthesiologist one should be aware of its pathophysiology, clinical features, diagnostic evaluations and the treatment modalities. Moreover, meticulous planning is required for safe and uneventful anesthesia. There is limited literature on anesthetic management of patients with alcoholic cardiomyopathy undergoing orthopedic surgery under combined spinal epidural anesthesia. We report a case of dilated cardiomyopathy scheduled for dynamic hip screw surgery for fracture neck femur.

The anaesthetic management of patient with amiodarone-induced thyrotoxicosis posted for thyroidectomy.

Sir, A 44-year-old male, case of arrhythmogenic right ventricular dysplasia was on treatment with tablet amiodarone 200 mg/day. After 2 years of treatment, he developed breathlessness, fatigability, increased appetite, tremors, and loss of weight. There was no thyroid swelling, but thyroid function tests were showing raised T3, T4 and decreased thyroid stimulating hormone. Thyroid scintigraphy and MIBI scan were suggestive of destructive thyroiditis. He was diagnosed to be suffering from mixed type amiodarone-induced thyrotoxicosis (AIT) and was treated with carbimazole and prednisolone, with no response to treatment. Amiodarone was stopped, but the patient was not relieved of symptoms for 4 months and hence total thyroidectomy was planned. Pre-operative electrocardiogram showed right bundle branch block, two-dimensional echocardiography showed left ventricular ejection fraction of 60% with right ventricular free wall thinning. Pulmonary function tests were done to rule out pulmonary toxicity. High-risk consent was taken, and the patient was pre-medicated with tablet metoprolol and injection dexamethasone. Pre-induction blood pressure was 150/94 mmHg with a pulse rate of 100/min and regular. Automated external defibrillator pads were attached in an anterolateral position to provide emergency defibrillation without disturbing surgical field drapes. After giving injection midazolam and fentanyl, right radial artery and left antecubital vein were cannulated under local anaesthesia. Invasive monitoring was done since the pre-induction period for early recognition of thyroid storm and cardiac failure. Cold intravenous fluids were infused and arterial blood gas monitoring was started. For pre-emptive analgesia, ultrasound-guided bilateral superficial and deep cervical plexus block was performed with 20 ml of 0.25% bupivacaine (5 ml at each point) to avoid stimulation due to thyroid handling and thus reduce requirement of analgesics and for post-operative analgesia. Anaesthesia was induced with injection propofol and vecuronium. Proseal® laryngeal mask airway (LMA) No. 4 was inserted and anaesthesia was maintained with oxygen, nitrous oxide and isoflurane. At the end of surgery, skeletal muscle paralysis was reversed, LMA removed, and patient shifted to Intensive Care Unit. In the post-operative period, oral metoprolol was continued with tapering doses of steroids. Serum calcium and thyroid function tests were monitored. Amiodarone is a class III antiarrhythmic drug used in the treatment of recurrent severe ventricular and supraventricular arrhythmias.[1] Due to structural similarity with thyroid hormone, 14–18% of patients develop overt thyroid dysfunction.[2] Depending on dietary iodine content, it can be either AIT or amiodarone induced hypothyroidism. AIT is classified as type 1 (pre-existing thyroid disease) and type 2 (destructive thyroiditis), but mixed forms frequently exist.[2] This classification does not affect the clinical outcome, but it is required for medical treatment. Type 1 is treated with methimazole and potassium perchlorate and type 2 with glucocorticoids.[1] There is controversy regarding the further continuation of amiodarone. Withdrawal can cause rebound rise in tri-iodothyronine. Due to long half-life thyrotoxic symptoms persists for months.[1] Before withdrawing amiodarone, underlying cardiac condition and availability of other antiarrhythmic agents or any cardiac intervention should be considered. Dronedarone is a congener of amiodarone. It is as potent as amiodarone and without any adverse effects.[3] (Automatic internal cardioverter-defibrillator) is a good option, but it is costly. Therapeutic options for refractory cases of AIT include radioiodine, plasmapheresis and surgery.[4] Radioiodine inhibits the peripheral conversion of T4 to T3, but not feasible due to destructive changes. Plasmapheresis is costly, and the effect is transient.[5] When a patient does not respond to medical management, total thyroidectomy is considered. Total thyroidectomy is performed under general or local anaesthesia with sedation. Local anaesthesia is good for the critically ill patient when operated by the experienced surgeon for faster recovery. Snyder et al. have found similar results and patient satisfaction for both types of anaesthesia.[6] Anaesthesia management of such patient is a high-risk scenario. We have to take into consideration underlying cardiac condition, possibility of thyroid storm because of uncontrolled thyrotoxicosis and effects of amiodarone on other systems of the body. While managing this patient, we have to avoid haemodynamic stress response related to intubation, extubation and thyroid handling, maintain fluid electrolyte balance, normothermia and good pain relief. Use of Proseal® LMA and pre-emptive analgesia with ultrasonography (USG) guided a cervical plexus block is a novel approach for managing this type of patients. Proseal® LMA is less likely to elicit a catecholaminergic stress response to laryngoscopy, intubation and extubation, but its drawback is that it can get displaced during retraction of trachea and thyroid handling. Though bilateral cervical plexus blocks are deferred, USG guided block is safe and allows for less volume of local anaesthetic to be used. It avoids complications like a puncture of vertebral artery and deposition near the dural sleeve. For stable haemodynamics and faster recovery, cardio-stable and short-acting anaesthetic and relaxant drugs are preferred. Post-operatively, patients must be monitored because of the risk of hypothyroidism and hypocalcemia.

Anesthetic management of a patient with penetrating thoracoabdominal trauma

Anesthetic management of a patient with penetrating thoracoabdominal trauma is a challenge for the anesthetist. Unstable hemodynamics, inadequate fasting, improper positioning for intubation, and the need for emergent surgery can complicate anesthetic management of such patients. We report a case of penetrating thoracoabdominal injury with arrow-shaped iron rods. Rapid and judicious management along with good communication between the surgeon and the anesthetist led to a successful outcome.

Comparative study of haemodynamic response to laryngeal mask airway versus endotracheal tube in hypertensive patients

Background: The hemodynamic response associated with laryngoscopy and tracheal intubation may be harmful to certain patients. The laryngeal mask air way (LMA) avoids the need for laryngoscopy and allows positive pressure ventilation of the lungs in appro priate patients. Aim : Study compared the haemodynamic response of tracheal intubation with that of laryng eal mask insertion in hypertensive patients. Methodology : Sixty hypertensive patients between 40-60 years of either sex of ASA grade II were randomly allotted to one of the two groups of 30 each (group ET vs group LMA). LMA insertion or tracheal intubation was performed after induction of anaesthesia with thiopentone, an d muscle relaxation with succinylcholine. Anaesthes ia was maintained with nitrous oxide, oxygen, and inhalati onal anaesthetic as per the need. The heart rate, s ystolic BP, diastolic BP, mean arterial pressure (MAP),SpO2 were measured after induction, immediately after intubation or insertion and at minute 1, 3 and 5. Results: There was a very highly significant difference (P < 0.001) in mean peak increase in heart rate (59.2% i n group ET vs 36% in group LMA). There was a fall in both systolic and diastolic BP after induction i n both the groups of our study. This was followed b y a very highly significant increase in both systolic and di astolic BP after airway instrumentation in both the groups. However the values in group LMA were significantly lower compared to group ET after 1 minute and 3 minutes. The MAP reached maximum value immediately after airway instrumentation. However, the va lues after LMA insertion were significantly lower compar ed to tracheal intubation after 1,3 and 5 minutes. Conclusion: Use of LMA may therefore offer some advantages over tracheal intubation in the anaesthetic management of patients where the avoidance of the pressor respons e is of particular concern.

Anaesthetic Management of Patients with Parkinson's Disease Undergoing Mitral Valve Replacement Surgery - Enteral L-dopa administration: A Case Report and Literature Review.

Anaesthetic Management of Patients with Parkinson's Disease Undergoing Mitral Valve Replacement Surgery - Enteral L-dopa administration: A Case Report and Literature Review.

Pre-operative optimisation of lung function.

The anaesthetic management of patients with pre-existing pulmonary disease is a challenging task. It is associated with increased morbidity in the form of post-operative pulmonary complications. Pre-operative optimisation of lung function helps in reducing these complications. Patients are advised to stop smoking for a period of 4–6 weeks. This reduces airway reactivity, improves mucociliary function and decreases carboxy-haemoglobin. The widely used incentive spirometry may be useful only when combined with other respiratory muscle exercises. Volume-based inspiratory devices have the best results. Pharmacotherapy of asthma and chronic obstructive pulmonary disease must be optimised before considering the patient for elective surgery. Beta 2 agonists, inhaled corticosteroids and systemic corticosteroids, are the main drugs used for this and several drugs play an adjunctive role in medical therapy. A graded approach has been suggested to manage these patients for elective surgery with an aim to achieve optimal pulmonary function.

Ultrasound-guided neural blockade in Proteus syndrome : case report

Summary: Proteus syndrome is a rare genetic disorder first described in 1979 and named after Proteus, a Greek demigod who was capable of changing his form to avoid capture. The incidence is < 1:1 000 000, but can be expected to be slightly higher in the surgical population, as these patients often present for repeat procedures. The disorder is characterised by sporadic and progressive overgrowth of tissue of any origin. Normal anatomy usually becomes distorted and serious functional and cosmeticsequelae may ensue. Regular anaesthetic interventions are required for diagnostic and therapeutic procedures, often to correct deformities related to overgrowth, tumour excision and otolaryngological procedures. Literature relating to the anaesthetic management of patients with Proteus syndrome is limited to case reports describing instances of general anaesthesia. Complications of general anaesthesia secondary to respiratory tract abnormalities appear prevalent. Regional anaesthesia is often used when respiratory compromise is anticipated due to any cause. Despite this, current guidelines suggest that regional anaesthesia be avoided in patients with Proteus syndrome, due to the gross anatomical variance and the high incidence of vascular abnormalities in these patients. The use of ultrasound-guided neural block enables practitioners to distinguish nerves from vascular structures and other tissues. It helps avoid neural injury during needle placement and improves success rate. This case report is the first to demonstrate the successful use of an ultrasound-guided regional anaesthetic technique in a boyrequiring surgery to his right forearm.

Anesthetic Management in Children with Congenital Lobar Emphysema

Background: The cause of congenital lobar emphysema (CLE) is unknown and characterized by hyperinflation of one or more lobes of the lung. The purpose of this retrospective study was to present the anesthetic management of children with congenital lobar emphysema (CLE) receiving treatment in our center.Methods: Ten children underwent CLE-related surgical treatment in our center between March 1995 and August 2014. All cases were diagnosed on the basis of postero-anterior chest radiography and computerized tomography. Age, sex, preoperative clinical findings, location of lesions, surgical and anesthetic procedures, results of anesthesia and duration of hospitalization were evaluated.Results: Six patients were male (60%) and four female (40%). Their ages ranged from 40 days to 6 years. Dyspnea was present in all cases and severe in four of them. Four patients had emphysema in the left upper lobe, three in the right middle lobe, one in the right upper lobe and one in the left lower lobe. All patients were extubated in the operating room and none experienced post-operative respiratory distress. Post-operative analgesia was provided via the previously placed intrapleural catheter. All the patients were extubated in the operation room. There was no post-operative mortality or morbidity.Conclusions: Anesthetic management of patients with CLE is challenging. In these patients the surgical team and anesthetists should collaborate closely and the time between anesthesia induction and thoracotomy should be as short as possible.

Concerns and challenges during anesthetic management of aneurysmal subarachnoid hemorrhage

Anesthetic management of patients with aneurysmal subarachnoid hemorrhage is challenging because of the emergency nature of the presentation, complex pathology, varied intracranial and systemic manifestations and need for special requirements during the course of management. Successful perioperative outcome depends on overcoming these challenges by thorough understanding of pathophysiology of Subarachnoid hemorrhage, knowledge about associated complications, preoperative optimization, choice of definitive therapy, a good anesthetic and surgical technique, vigilant monitoring and optimal postoperative care. Guidelines based on randomized studies and provided by various societies are helpful in the routine management of these patients and wherever there is a lack of high quality evidence, the available data is provided for practical management.

Carcinoid Crisis in a Patient without Previous Carcinoid Syndrome: Perioperative Management and Anesthetics Considerations - A Case Report

Anesthetic management of patients with carcinoid tumors can be challenging in the perioperative setting due to the risk of carcinoid mediators release which could precipitate a life-threatening carcinoid crisis. Octreotide is being used to prevent and treat carcinoid crisis, but its prophylactic scheme is not well established yet. We report a carcinoid crisis during the anesthetic management of a 71-year-old female undergoing resection of a carcinoid tumor of the terminal ileum. This report illustrates the importance of early recognition and treatment of clinical manifestations of carcinoid crisis in order to prevent its progression.

Anesthetic Management of a Child with Simpson-Golabi-Behmel Syndrome—A Case Report

Simpson-Golabi-Behmel syndrome (SGBS) is an X-linked recessive condition associated with pre-natal and postnatal overgrowth with visceral and skeletal anomalies. Abnormal airway anatomy may complicate the perioperative management of SGBS. However, there have been few reports regarding the anesthetic management of children with SGBS. We present the preoperative evalua-tion and intraoperative management of a 1.5-year-old child with SGBS undergoing plastic surgery for cleft palate. Sevoflurane-fentanyl anesthesia without a neuromuscular blocker was planned, due to the preoperative evaluation that airway management would be complicated by the macroglossia and short neck characteristic of SGBS. Fortunately, there was no difficulty in endotracheal intubation in the present patient due to careful planning of general anesthesia and meticulous airway management. Appropriate preoperative preparation for a difficult airway by the anesthe-siologist can ameliorate the difficulties inherent to the anesthetic management of patients with SGBS.

Unusual difficult airway due to the presence of a large facial foreign body

The anesthetic management of patients with facial trauma that directly or indirectly involves the airway can be challenging. We present this image that represents a 22-yrold female patient who suffered a penetrating stiletto shoe injury to the left eye incurred during an altercation. She arrived at the emergency department with the heel still embedded in the eye and the sole covering most of the facial structures and oronasal openings. A computed tomography scan indicated possible fractures of the left infraorbital canal/ orbital floor and the posterior wall of the left maxillary sinus along with the left maxillary hemosinus (Figure). Airway management was complicated by alcohol intoxication, recent food ingestion, agitation, and most importantly, significant elevation of intraocular pressure (33 mmHg). Emergent surgical removal was scheduled, and although cricothyrotomy and awake tracheostomy were considered, after the administration of an antisialagogue (glycopyrrolate 0.2 mg iv), dexmedetomidine (1 lgkg -1 hr -1 iv infusion), and 4% lidocaine airway toplicalization, an awake flexible fibreoptic intubation was performed through the very limited access to the patient’s mouth. Following induction of general anesthesia, the stiletto heel was extracted manually from the orbit, necessitating a significant amount of force. Afterward, the intraocular pressure decreased to 8 mmHg. No further surgery was required, tracheal extubation was performed at the end of the procedure, and the patient had an uncomplicated recovery. Although the use of awake video-assisted laryngoscopy for difficult airways has recently been described in the literature, this case re-emphasizes the role of flexible fibreoptic intubation as the ‘‘gold standard’’ in selected complex airway situations.