Anesthetic Management Of Patient Research Articles

Anaesthetic management in patients with Duchenne muscular dystrophy

Editor, After reading the very informative article by Muenster et al.1 on the anaesthetic management of patients with Duchenne muscular dystrophy, some questions remain. First, this is an interesting case series because of the large number of general anaesthesia episodes included (232 in 191 Duchenne muscular dystrophy patients) and because 79 procedures were for corrective spinal fusion. This type of surgery can severely affect the immediate respiratory recovery of these patients as shown by the exclusive need of postoperative ventilatory support in the group with spinal fusion.1 Related to this aspect is the use of neuromuscular blocking agents. However, perhaps due to space restrictions in the journal, only the type of neuromuscular blocking agent and the type of monitoring (acceleromyography) were stated, together with the crude number of patients receiving it. However, in the discussion section, the topic is addressed in depth. Due to the variability in the response to neuromuscular blocking agent in patients with neuromuscular diseases, some general recommendations have been made and shall be briefly reported here.2,3 An individual evaluation of a patient's characteristics should be made and early extubation should be attempted. Reversal of neuromuscular blockade with neostigmine should be avoided; provided rocuronium was used, sugammadex has become – in our opinion – the drug of choice. A train-of-four ratio of 0.9 should be aimed for to guarantee a complete recovery of the diaphragm (despite the fact that the neurophysiologic conditions of the neuromuscular transmission in these patients, and the electrophysiological characteristics of both muscles and stimuli used, need to be improved in the future4). It is equally important to check for adequate coughing and swallowing before extubation, and to evaluate respiratory parameters (inspiratory force −20 cmH2O, vital capacity 1000 ml, PaO2 250 mmHg with O2 inspiratory fraction of 1, considering preoperative values). The variability in the onset of the neuromuscular block, which is usually delayed, and the prolonged duration were underlined by the authors.1 Although the authors support the use of pyridostigmine for the reversal of the neuromuscular block, the number of cases that were reversed with this drug was not shown, nor was the success of the reversal, or how many patients needed respiratory postoperative support in whom reversal was attempted. In addition, the adequacy of using sugammadex was shown in several case reports in patients with Duchenne muscular dystrophy5 and Becker muscular dystrophy,6 which is a minor form of the disease. Thus, it would be interesting to know whether the authors have any experience with reversal with sugammadex in these patients. Addressing the effects of anaesthesia or anaesthetic drugs in patients with rare diseases (so-called ‘orphan diseases’) is often only possible in case reports or case series. Recently, several cases of successful reversal of neuromuscular blocking agents with sugammadex have been reported in the European Journal of Anaesthesiology, suggesting the adequacy and safety of that drug in patients with further rare neuromuscular diseases such as myotonic dystrophy,7 or Huntington's chorea.8 Muenster et al.1 have reported on the successful anaesthetic management in a large sample of patients with Duchenne muscular dystrophy. In these patients, who are at risk for severe postoperative problems, all anaesthesiological knowledge and armamentarium should be used. Acknowledgements Assistance with the letter: none declared. Financial support and sponsorship: none declared. Conflicts of interest: CLE has received payments for lectures and meeting expenses from Organon española, Schering-Plough Spain and MSD Spain. PPC has received payments for meeting expenses from MSD Spain.

Reply to

Editor, We appreciate the interest and comments of Errando and Perez-Caballero1 concerning our paper on the anaesthetic management of patients with Duchenne muscular dystrophy2 and are grateful for the opportunity to reply. We agree with Errando and Perez-Caballero that the use of neuromuscular blocking agents in patients with Duchenne muscular dystrophy is of major concern. In our review, we considered many important points arising during anaesthesia and the perioperative period when treating patients with Duchenne muscular dystrophy. It is correct that we have not addressed in detail the use of neuromuscular blocking drugs and reversal agents. However, in the past, we have published several investigations regarding the use of neuromuscular blocking agents in patients with Duchenne muscular dystrophy.3–6 In addition, in one investigation, we reported on the efficacy of pyridostigmine to reverse rocuronium-induced neuromuscular block in patients with Duchenne muscular dystrophy after spinal surgery.7 In group A of our review (patients with minor surgery of the lower extremity), there was no case documented requiring postoperative ventilatory support whether or not neuromuscular blocking drugs had been used. In contrast, following major orthopaedic surgery, many factors influence weaning from the ventilator in patients with Duchenne muscular dystrophy. Apart from the strength of respiratory muscles mentioned by Errando and Perez-Caballero, parameters like perioperative blood loss, cardiac performance, need for sympathomimetic drugs, body temperature and others must be considered when deciding on the time of extubation. On average after spinal surgery, patients reported in our review were ventilated postoperatively for a duration of 19 h. Therefore, we do not routinely use reversal agents before removing the tracheal tube after spinal surgery. We have no experience with the use of sugammadex in patients with Duchenne muscular dystrophy. Acknowledgements Assistance with the letter: none declared. Financial support and sponsorship: none declared. Conflicts of interests: none declared.

Anesthesia for Cardiac Transplantation: Experience From a Single Center

BackgroundCardiac transplantation has become the established therapeutic modality in patients with end-stage heart failure. This article presents our institution's clinical experience in the anesthetic management of patients who underwent cardiac transplantation between February 1998 and August 2012. MethodsIn our institution, 175 patients (136 males and 39 females) diagnosed as having end-stage heart failure have undergone cardiac transplantation between February 1998 and August 2012. A retrospective review performed on this series of patients sought to analyze elements of perioperative anesthetic care, including preoperative characteristics, general anesthia, and blood product usage. ResultsThe patients were diagnosed as having either nonischemic cardiomyopathy (n = 128; 73%) or ischemic cardiomyopathy (n = 47; 27%). Seventy-three of them had undergone previous cardiac surgery. Invasive arterial, central venous, and pulmonary arterial pressures were monitored as well as intraoperative transesophageal echocardiography. Etomidate was used as the induction agent in 158/175 patients (average dose, 18.67 ± 1.91 mg). The average intraoperative fentanyl dose was 898.85 ± 211.65 μg. Anesthesia was maintained with either end-tidal 2%–4% sevoflurane (n = 132) or 4%–6% desflurane (n = 43). Dopamine, dobutamine, and epinephrine were used after weaning from cardiopulmonary bypass and continued upon exiting the operating room in 168, 159, and 143 patients, respectively. Inhaled nitric oxide (20–40 ppm) was used in 37 patients (21%). The total amount of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were 2.95 ± 2.05 (range, 1–15), 1.29 ± 0.97 (range, 0–6), and 1.23 ± 2.29 (range; 0–12) units, respectively. On average, patients were extubated 16 hours after arrival in the intensive care unit where they remained to day 6. A total of 67 patients (38%) died during the follow-up; infection and right ventricular failure were the most common causes. ConclusionAnesthesia for cardiac transplantation requires an appreciation of heart failure pathophysiology, invasive monitoring, and skillful anesthetic and postoperative care.

Postoperative neurological aggravation after anesthesia with sevoflurane in a patient with xeroderma pigmentosum: a case report

IntroductionXeroderma pigmentosum is a rare autosomal recessive disease that causes changes in skin pigmentation, precancerous lesions and neurological abnormalities. It is a defect in the nucleotide excision repair mechanism. It has been reported that volatile anesthetics has a possible genotoxic side effect and deranged nucleotide excision repair in cells obtained from a patient with xeroderma pigmentosum.We report an unusual case of postoperative neurological aggravation in a patient with xeroderma pigmentosum anesthetized with sevoflurane.Case presentationA 24-year-old African woman, who has had xeroderma pigmentosum since childhood, was admitted to our hospital for a femoral neck fracture. A preoperative physical examination revealed that she had a resting tremor with ataxia. She had cutaneous lesions such as keratosis and hyperpigmentation on her face and both hands. There was no major alteration of cognitive function, muscular strength was maintained and her osteotendinous reflexes were preserved. Surgical fixation was performed under general anesthesia after the failure of spinal anesthesia. All parameters were stable during surgery. When she woke up four hours later, the patient presented with confusion and psychomotor agitation, sharpened reflexes and the Babinski reflex was present. Her postoperative test results and a magnetic resonance imaging scan were unremarkable. It was suggested that sevoflurane had had a probable deleterious effect on the neurological status of this patient.ConclusionThe anesthetizing of a patient with xeroderma pigmentosum is associated with a risk of worsening neurological disorders. At present, there are no clear recommendations to avoid the use of volatile agents in the anesthetic management of patients with xeroderma pigmentosum. More clinical and experimental research is needed to confirm the sensitivity of patients with xeroderma pigmentosum to sevoflurane and other halogenated anesthetics.

Case scenario about TEE: Patient with dilated cardiomyopathy undergoing laparoscopic cholecystectomy

A 42-year-old woman, who presented with DCM (American Society of Anesthesia, ASA class IV), suffered from gallstone for years, and was scheduled for laparoscopic cholecystectomy. Echocardiography demonstrated a severely dilated left ventricle with global hypokinesia and reduction of left ventricular systolic function, ejection fraction (EF) 34% with mild mitral regurgitation and severe tricuspid regurgitation. After intubation, a transesophageal echocardiography (TEE) probe was inserted. When the IAP was gradually ascended to 14 mmHg during the laparoscopy, EF fell to 19% and the systolic pressure fell to 78 mmHg and TEE showed severely poor wall motion. But the central venous pressure (CVP) still showed about 4 mmHg throughout the whole procedure. After decreasing the IAP to 10 mmHg, we adjusted the rate of pacemaker to 70 times per minute then the systolic pressure was kept at around 100 mmHg, and the diastolic pressure was kept at 60 mmHg. EF was 30% after the reduction of IAP and the adjusting of the heart rate set. TEE is a helpful monitor in anesthesia management of patients with DCM during noncardiac surgery and CVP is useless especially for the procedure with severe hemodynamic effects.

Anesthesia Literature Review

Anesthesia Literature Review

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.

Anesthetic management of a patient with Marfan syndrome and severe aortic root dilatation undergoing cholecystectomy and partial hepatic resection

Due to high mortality associated with aortic dissection, anesthetic management of patients with Marfan syndrome with severe aortic root dilation is a challenging situation. We describe the anesthetic management of a patient with Marfan syndrome with severe aortic root dilation, who required major surgery like cholecystectomy with partial liver resection under general anesthesia. A 47-year-old female presented to pre-anesthetic clinic for cholecystectomy with partial hepatic resection for gall bladder carcinoma. Clinical features, transthoracic echocardiography and computed tomography of thorax supported a diagnosis of Marfan syndrome with severely dilated aortic root. Aortic dissection in patients with Marfan syndrome and severely dilated aortic root can be precipitated by major hemodynamic changes under anesthesia. Careful hemodynamic monitoring and avoidance of hemodynamic swings can prevent this life-threatening event.

Rescue of hemodynamic compromise in superior vena cava syndrome with transesophageal echocardiography

The anesthetic management of patients with an anterior mediastinal mass is very challenging due to the potential risk of hemodynamic and respiratory compromise. A specialized anesthetic plan should be developed for in patients with an anterior mediastinal mass based on the preoperative clinical symptoms as well as, radiographic, computed tomographic, spirometric, and echocardiographic data [1,2]. A 31-year-old man (height 173.5 cm, weight 70.4 kg) came to our emergency department with right-sided chest discom fort, dry cough, progressive dyspnea, and orthopnea for the previous 4 weeks. The initial chest X-ray evaluation revealed a large amount of right side pleural effusion and a bulky mediastinal mass. Multi directional computed tomography revealed a 12.3 cm homogenous soft tissue mass in the anterior mediastinum compressing the superior vena cava and dis placing the ascending aorta. The trachea and both main bronchi were patent, but a cross-sectional area of the right upper lobe bronchus (7.21 mm) was reduced 44% relative to the left upper lobe bronchus (12.97 mm). Right loculated pleural effusion, totally collapsed right lower lobe and subsegmental atelectasis in the right middle lobe were noted. A therapeutic and diagnostic thoracentesis was done under local anesthesia, and 1,600 ml of pleural fluid was removed. Cytology of pleural fluid revealed many lymphocytes and mesothelial cells, but these were negative for malignancy. However, because dyspnea persisted and pleural effusion was increased after admission, a mediastinoscopic biopsy and pleural decortication were performed under general anesthesia. In the operating room, the CAPIOX emergency bypass system (CAPIOX Ⓡ EBS TM , Terumo Corporation, Tokyo, Japan) was prepared in the event of cardiopulmonary collapse. Before the induction of general anesthesia, a 20-guage catheter was placed in the right radial artery for continuous blood pressure monitoring. The patient was placed in the Semi-Fowler’s position with the head elevated 30 degrees to relieve the discomfort of the supine position. Initial vital signs were blood pressure 105/65 mmHg, heart rate 100 beats/min, respiration 25 breaths/min, and O2 saturation 96%. Preoxygenation with 100% O2 was administered using a face mask, and anesthesia was induced with a continuous infusion of propofol (effect-site concentration 4.0-5.0 μg/ml and remifentanil (effect- site concentration 3.0 5.0 ng/ml using a target-controlled infusion pump (Orchestra Ⓡ Base Primea, Fresenius Vial, Brezins, France) and a bolus dose of rocuronium 50 mg via a preexisting 16-guage IV catheter in the vein on the medial surface of the right leg. Intubation was successfully achieved using the left-sided Robert-Shaw double lumen bronchial tube in the supine position. Breath sounds were heard on both sides of the chest. Mechanical ventilation was maintained with a tidal volume, respiratory rate and partial pressure of end-tidal carbon dioxide of 500 ml, 15 breaths/min, and 28-32 mmHg, respectively. After induction, the arterial blood pressure began to drop to 60/35 mmHg and the heart rate increased to 110 beats/min. Ephedrine 10 mg were administered intravenously, but the vital signs were not improved. A transesophageal echocardiography (TEE) was performed for evaluation of hemodynamic instability. It showed that a large mass compressed the right atrium

Anesthetic management for patients with perforation peritonitis

Perforation peritonitis is a common surgical emergency. Anesthesia in patients with perforation peritonitis can be challenging. Delayed presentations, old age, hemodynamic instability, presence of sepsis and organ dysfunction are some of the predictors of poor outcome in such patients. Pre-operative optimization can reduce intraoperative and post-operative morbidity and mortality, but surgery should not be unnecessarily delayed. Intensive care in critical care settings may be essential.

Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-

There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope® Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.

Anesthetic management of patient with hypertrophic cardiomyopathy and automatic implantable cardioverter defibrillator with a hand fracture

Anesthetic management of patient with hypertrophic cardiomyopathy and automatic implantable cardioverter defibrillator with a hand fracture

Perioperative care of a patient with neuronal ceroid lipofuscinoses

The neuronal ceroid lipofuscinoses (NCL) are a group of inherited, autosomal recessive, and progressive neurodegenerative diseases, which result from an enzymatic defect or the deficiency of a transmembrane protein, leading to the accumulation of lipopigments (lipofuscin) in various tissues. NCL results in the impairment of function in several end-organs including the central nervous system with loss of cognitive and motor function, myoclonus, and intractable seizures. Additional involvement includes the cardiovascular system with arrhythmias and bradycardia as well as impairment of thermoregulation leading to perioperative hypothermia. Given the complexity of the end-organ involvement and the progressive nature of the disorder, the anesthetic care of such patients can be challenging. Till date, there are a limited number of reports regarding the anesthetic management of patients with NCL. We present an 18-year-old patient with NCL who required anesthetic care during replacement of a vagal nerve stimulator. Previous reports of anesthetic care for these patients are reviewed, the end-organ involvement of NCL discussed, and options for anesthetic care presented.

Anaesthesia and orphan disease

Huntington’s disease is an autosomal dominant disorder that affects the basal ganglia with a prevalence of four to 10 per 100 000 people. Onset is typically between 30 and 50 years of age. There is also a juvenile onset of the disease wherein the symptoms begin before aged 20; this occurs in 10% of affected persons. This latter group is more prone to seizures, has impaired glucose metabolism and often inherits the disease in a sex-linked manner from the father. Genetic tests can confirm the diagnosis, even prenatally. Symptoms include choreic movements, personality disorders and impairment of swallowing and gag reflexes. The anaesthetic management of a patient with Huntington’s disease provides particular challenges due to the risk of pulmonary aspiration and altered responses to anaesthetic drugs. Prolonged apnoea of between 1 and 2 h has been reported after the use of thiopentone and suxamethonium, and there is an increased sensitivity to anticholinergics. Whether these patients have low levels of atypical pseudocholinisterases remains unanswered. We know of no previous reports of the use of sugammadex in the anaesthetic management of patients with Huntington’s disease. We have obtained the patient’s written consent for publication of this case report.

Anesthetic Management of a Patient With Narcolepsy

Morimoto, Yasuhiro; Nogami, Yuko; Harada, Kaori; Shiramoto, Hiroko; Moguchi, Takayo Author Information

Anaesthetic management in patients with Duchenne muscular dystrophy undergoing orthopaedic surgery

Patients with Duchenne muscular dystrophy are at increased risk of some anaesthesia-related hazards such as rhabdomyolysis, fever and hyperkalaemia. To evaluate the management of anaesthesia in patients with Duchenne muscular dystrophy, including preoperative evaluation, intraoperative performance, critical events and postoperative care. We performed a retrospective case review study of anaesthesia in patients with Duchenne muscular dystrophy covering the period between April 2000 and December 2008. 91 Duchenne patients undergoing 232 general anaesthetics for orthopaedic surgical interventions. University hospital. Anaesthesia was performed using propofol, opioids and, if required, a non-depolarising muscle relaxant. Eight difficult direct laryngoscopies were reported. All patients undergoing spinal fusion surgery received transfusion of homologous blood products and required postoperative invasive ventilatory support for an average of 19 h. There was no severe anaesthesia-related complication and no case of unexplained fever or rhabdomyolysis. This retrospective survey confirms clinical experience that total intravenous anaesthesia can be used safely in Duchenne patients without major concern. Further prospective studies are necessary to establish evidence-based clinical guidelines for daily practice.

Anesthetic management for patients with moyamoya disease

Background Moyamoya disease （MMD） is a chronic and progressive cerebrovascular occlusive disease with special pathophysiology features： cerebral peffusiou pressure goes down and cerebral blood flow decreases gradually along with the development of the disease in the anterior circulation; cerebrovaseular reserve is abated, the response to the carbon dioxide is unidirectional; the autoregulation of CBF to the ischemic cerebral areas is impaired and the CBF is totally pressure dependent. Objective Summarizing the features of anesthetic management for MMD is to provide reference data for clinical work. Content We have reviewed the aspects that include the pathophysiology of MMD, preanesthetic preparation, anesthetic induction and maintainance and prophylactic measures for cerebral ischemia so on. Trend With the medical technology progress, MMD detection rate is increased significantly, and surgical treatment is improved gradually. Positive and cautious anesthetic managements are the key to keep balance between anterior circulation cerebral oxygen supply and demand, and to prevent cerehrovascular accident. Key words: Moyamoya disease; Cerebral oxygen supply and demand balance; Clinical anesthesia

A national survey into perioperative anesthetic management of patients with a fractured neck of femur

BackgroundWe made a survey among Finnish anesthesiologists concerning the current perioperative anesthetic practice of hip fracture patients for further development in patient care.MethodsAll members of the Finnish Society of Anesthesiologists with a known e-mail address (786) were invited to participate in an internet-based survey.ResultsThe overall response rate was 55% (423 responses); 298 respondents participated in the care of hip fracture patients. Preoperative analgesia was mostly managed with oxycodone and paracetamol; every fifth respondent applied an epidural infusion. Most respondents (98%) employed a spinal block with or without an epidural catheter for intraoperative anesthesia. Midazolam, propofol and/or fentanyl were used for additional sedation. General anesthesia was used rarely. Postoperatively, paracetamol and non-steroidal anti-inflammatory drugs and occasionally peroral oxycodone, were prescribed in addition to epidural analgesia.ConclusionsThe survey suggests that the impact of more individualised analgesia regimens, both preoperatively and postoperatively, should be investigated in further studies.

Anesthetic management in patients undergoing hyperthermic chemotherapy

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important therapeutic option for selected patients with peritoneal surface malignancies. This aggressive multimodality treatment is complex, not only regarding surgical technique, but also regarding anesthesia. The present review represents our experience in anesthetic care. Improved prognosis compared with systemic chemotherapy alone has recently been demonstrated for cytoreductive surgery when combined with intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of HIPEC is further impacted by these developments. In addition to the ambitious, long-lasting surgery, HIPEC causes significant fluid, blood and protein losses, increased intra-abdominal pressure, systemic hyperthermia, and increased metabolic rate, leading to relevant pathophysiological alterations, and therefore represents a challenge for anesthetist and critical care physicians. Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis.

Hypertension pulmonaire et fracture du col fémoral : intérêt de la rachianesthésie continue

Anaesthetic management of patients with pulmonary hypertension is challenging and alternatives to general anaesthesia are encouraged. We report anaesthetic management of two patients with pulmonary hypertension admitted for femoral neck fracture. In order to reduce the risk of right-sided heart failure and systemic hypotension, it was decided to operate the patients under continuous spinal anaesthesia. Anaesthesia was induced with excellent hemodynamic tolerance. Quality and extension of the block was correct and allowed surgery. No postoperative complication was observed. These cases suggest that continuous spinal anaesthesia may be considered for the management of patients with pulmonary hypertension undergoing femoral neck fracture surgery.