Precision Plus is the only system with SmoothWaveTMTechnology. There are eight contacts on each lead, and the therapy is delivered through the individual contacts. SmoothWave Technology gives your physician the ability to precisely control the stimulation being delivered from each and every contact on the implanted leads.

Precision Plus also offers a small implant with a contoured, oval shape. In fact, the PrecisionTM IPG has the smallest “footprint” of any rechargeable SCS device. Precision Plus is the only SCS system to offer a cordless remote with a 24-inch communication range. This remote is easy to use and is designed to put pain control at your fingertips

Precision Plus offers a cordless on-the-go charger.

New drug delivery system uses magnetism

Researchers in Children’s Hospital Boston introduce a tiny implantable device whose membrane releases drugs with extreme precision, on demand, when triggered by a magnetic field, a tiny, implantable device that releases the medication through a membrane whose porousness responds to the switching on or off of a magnetic field. The membrane is embedded with nano particles that contain magnetite, a mineral with natural magnetic properties. When a magnetic field near the device turns on, the nanoparticles heat up, collapsing the gels in the membrane so that the drug can pass through the open pores. When the field turns off, the cooling membrane causes the gels to re-expand, thereby cutting off the drug.

Tomorrow’s operating room to harness Net, RFID

In the operating room of the future, however, telling a doctor he or she is making a mistake could be as easy as pointing to a computer screen, a thoroughgoing summary of background data, vital signs and strategic information designed to prevent mistakes during surgery.

The center for Integration of Medicine and Innovative Technology at Massachusetts General Hospital in Boston say that human error and poor communication are the most common reasons one in 25 patients experience avoidable injury  under the knife.

The ORF computer system is an integration system with a single, secure Web interface for many different data sources. With technology from LiveData, based in Cambridge, Mass., the ORF takes high-speed data streams from hospital databases and various networks, synchronizes them and then time-stamps them for display onto a Web portal, which can be transmitted on an Internet-connected PC in the room.

Vital stats displayed

The digital display includes the patient’s name, weight, age, gender and the procedure he or she is undergoing. It includes a detailed list of medical staff on duty and where they are according to RFID tags they’re wearing. It lists critical information such as allergies, precautions and special needs, followed by charts on the patient’s heart rate, ventilation, fluids, body temperature and so on. That information is documented before, during and after the surgery.

http://news.cnet.com/Tomorrows-operating-room-to-harness-Net%2C-RFID/2100-1008_3-5900990.html#

TAP 20™

In many ambulatory care settings, blood sampling can be a significant barrier to adoption of point of care testing, as it requires trained personnel, creates anxiety and discomfort for patients, and can disrupt workflow

TAP 20™, Seventh Sense’s lead product in development, collects up to 20 microliters of whole blood – sufficient volume for many routine point-of-care blood tests, and has several advantages: It is painless for the patient, sample is contained until used for testing, no sharps disposal In addition to TAP 20™, Seventh Sense is developing TAP 100™ for point-of-care panels and tests requiring up to 100 microliters of blood; the development of TAP 100 is supported by a grant from the Gates Foundation

http://www.7sbio.com/products/tap-products.html

New Cannula Design with Integrated Local Anesthetic Delivery System

Oliver Blackwell, an English product designer, has come up with a new device for easing the pain of intravenous cannula insertions by automatically delivering local anesthesia through a small needle before the big one is stuck in.

http://www.plymouth.ac.uk/pages/view.asp?page=38663

NeuroSENSE NS-701 Electroencephalogram Monitor from NeuroWave

This bilateral brain monitor, designed with independent indices for each brain hemisphere, now comes with a 10.4″ monitor screen.

Delay-free tracking of patient state via low-noise WAVCNS1 bilateral indexes

WAVCNS (Wavelet Anesthetic Value for Central Nervous System) indexes provide instantaneous tracking of the patient state
Automatic trending facilitates immediate response without increasing the index noise

True bilateral monitoring with great inter-hemispheric reproducibility

Superior prediction of loss of consciousness
Linear response to increasing EEG suppression
Advanced automated artifact detection and removal
Electro-surgical interference detection and filtering
Cardiac defibrillation proof
Continuous measurement of electrode-skin contacts

Compliant with the guidelines of International Federation of Clinical Neurophysiology (IFCN) and American Clinical Neurophysiology Society (ACNS)

Availability of raw EEG data
Transparent, published algorithm

http://www.medgadget.com/2011/09/the-new-neurosense-ns-701-electroencephalogram-monitor-from-neurowave.html

Mindray A5 Anesthesia Device

Mindray out of Shenzhen, China has a 15″ touchscreen for selecting settings, as well as a central brake and an integrated cable sweeps for mobility.

A5 is the first and only anesthesia machine that conforms to the IHE (Integrating the Healthcare Enterprise) Patient Care Domain (PCD) profile. At no additional charge, every A5 provides data output in the industry standard HL7 protocol. HL7, with the IHE PCD profile, is recognized among anesthesia information management systems (AIMS) and electronic medical records (EMR) systems as the demonstrated industry standard for unambiguous interoperability.
The A5 provides a range of advanced ventilation modes enabling effective care across different patient acuity types. Integrated spirometry offers additional information which enhances careful decision making.
The unique, auxiliary O2/Air Blender reduces the risk of surgical fires by controlling the oxygen concentration under the drape, near the patient’s head and chest.

http://ir.mindray.com/phoenix.zhtml?c=203167&p=irol-newsArticle&ID=1532197&highlight=

Continuous Hemoglobin Monitor

.

Masimo‘s noninvasive hemoglobin monitor is a part of Masimo Rainbow SET. SpHb monitoring clearly changes clinician behavior and results in lower intraoperative blood transfusion rates and lower overall blood utilization.

http://www.medgadget.com/2010/10/masimos_continuous_hemoglobin_monitor_helps_reduce_blood_transfusions.html

The stress of anesthesia and surgery had somehow, provocated a silent tumor in this asymptomatic young man, which precipitated an episode of acute rise of BP and pulmonary edema.

Dr. Nabil Estemalik

Consultant /HoD Anesthesiology, Oasis Hospital,

United Arab Emirates

KRL General Hospital, Islamabad (Pakistan)

i-gel is being widely used as a supraglottic airway device, in spontaneously breathing patients as well as for mechanical ventilation. It has been used as an emergency use airway device with success. The manufacturer has launched i-gel in many sizes. Each size is recommended for patients of a particular weight category, e.g. size 1 for 2-5 kg, size 1.5 for 5-12, size 2 for 10-25 and size 2.5 for 25-35 kg body weight. We observed that the length of the connector as well as the shaft of the i-gel for these smaller sizes is in excess of what is required, thus adding to dead space and difficulty in holding it firmly in place. No filter was used in both of these patients to reduce the resistance to spontaneous breathing and the dead space.

References:

1.  Wharton NM, Gibbison B, Gabbott DA, Haslam GM, Muchatuta N, Cook TM. I-gel insertion by novices in manikins and patients. Anaesthesia. 2008 Sep;63(9):991-5.
2. Soar J: The i-gel supraglottic airway and resuscitation – some initial thoughts Resuscitation: doi: 10.1016/j.
3. Schmidbauer W, Bercker S, Volk T, Bogusch G, Mager G, Kerner T: Oesophageal seal of the novel supralaryngeal airway device i-gel in comparison with the laryngeal mask airways Classic and ProSeal using a cadaver model: BJA doi:10.1093/bja/aen319
4. Liew, B. John, S. Ahmed (2008) Aspiration recognition with an i-gel airway: Anaesthesia 63 (7);786.

Figure 1&2: Intact i-gel size 1.5 and 2 in use. Note the extra long shaft and the connector

Figure 3: Size 2 i-gel in use, which was cut short by 4 cm

Figure 4: An intact and a cut i-gel size 2

*Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014 (India); Cell: 08004967745; Email: dr.sukhensamanta@gmail.com

**Department of Anesthesiology & Intensive Care, Post Graduate Institute of Medical Education & Research, Channdigarh 160012 (India)

Citation: Samanta S and Samanta S. Accidental intra arterial injection of diclofenac sodium and their consequences: report of two cases. Anaesth Pain & Intensive Care 2013;17(1):101-102

Dear Editor,

Diclofenac  is a nonsteroidal anti-inflammatory drugs (NSAID) used  as an analgesic reducing  moderate pain  in intra operative and post operative, commonly used along with  general anesthesia cases for analgesia purpose. Several commertial preparations are available. Accidental intra-arterial injections of anesthetic drugs cause arterial spasm with variable poor results.[1] There are  some drugs which are given unintentionally or intentionally without  any bad consequences.[2] Controlled study helps in identification of the pathophysiology underlying such arterial spasm following such intra-arterial injections,but have logical limitation.[2] Unintentional use of intra-arterial route has not been reported  for its adverse effects with diclofenac sodium. We report two cases of unintentional intra-arterial injection of different preparation of diclofenac with two different outcomes.

Our first case was a 39 year old, obese (body mass index 32) gentleman, with black complexion posted for removal of retroperitoneal tumor(sarcoma)  under general anesthesia. Lower  thoracic epidural  insertion for analgesia was tried but failed due to  difficult anatomy. Induction of anesthesia was done with propofol, fentanyl (in view of obstructive sleep apnea) and vecuronium In  view of  expected major blood loss  post induction arterial line was inserted for real time blood pressure monitoring and  blood gas analysis. Intubation and intra operative course was uneventful. He was given intra-arterial alcohol (benzyl alcohol) based preparation of diclofenac (Volicad^™,Cadila^®) 100 mg in the late intraoperative period for postoperative pain relief. Following recovery from anesthetic effect he complained of pain in his right hand. Rapid search of the cause revealed diclofenac injection unintentionally through a tri-way with 10 cm extension line attached to right radial artery. Bluish discoloration was noted on two fingers in radial artery distribution noticed 45 minutes after injection. Treatment initiated with intra arterial heparin 2.5000 IU and intravenous preservative free lidocaine 80 mg. He developed gangrene (Fig 1) after 2 days of accidental injection and had undergone amputation of distal part of his affected finger but on radiological examination his brachial arterial cross section area and flow was normal.

The second patient was a 19 year old young adult posted for craniotomy for meningioma. In view of major neurosurgical procedure and highly vascular meningioma, arterial line inserted in left radial. In tra operative course was uneventful. He was extubated in full conscious status.  Aqueous based preparation of diclofenac (Voveron^™, Novatis^®) was given accidentally through intra-arterial cannula in the postoperative period by nurse posted in post anesthesia care unit.  This time the patient complained of burning sensation along arterial course. Immediate heparin and lignocaine administered in arterial line and  radial artery Doppler shown normal arterial pulse waves. and   remain uncomplicated even after 7 days follow up with Doppler study.

Many case reports have been published on upper limb catastrophy after unintentional arterial injection.[3] We consider, benzyl alcohol, preservative used in nonaqueous preparation of diclofenac (Volicad^™) may be the cause of vasospasm  due to endothelial edema and capillary endothelial dysfunction in the first case.[4] Vasospasm, intravascular thrombosis, chemical endoarteritis are the proposed pathophysiological mechanism.[5] Complications of intra-arterial injection of non aqueous agents (phenytoin, propofol) [6] and highly alkaline drugs (thiopentone)[1] are known for years, on the contrary drugs like atropine, vecuronium, fentanyl  have been used without untoward effects.[7] Membrane soluble drugs are known to cause more complications. Multiple theories are postulated for the cause of arterial spasm, or hypoperfusion which is the final common pathway for limb ischemia. Iatrogenic complications are prone to occur in postoperative setting when patient is recovering from anesthesia. Intentional induction using IA route was reported in children from operation theatre, in emergency situation, where intravenous access was difficult.[8] Though guidelines are not available, case reports and review reported that water soluble drugs and drug’s with pH closer to arterial blood pH may be used through IA route. Different preparation of the same analgesic diclofenac  never been reported to the best of our knowledge. In conclusion although aqueous preparation with preservative free of diclofenac administration didn’t match the results of nonaqueous preparation of same drug, definitive statement regarding its safety during intra arterial injection and causative agent for arterial spasm couldn’t be formulated. Any way intention intra arterial diclofenac of any preparation should be avoided at any cost.

REFERENCES

1. Stone HH, Donnelly CC.The accidental intraarterial injection thiopental. Anesthesiology1961;22:995-1006
2. Ahmed F. Ghouri .Accidental intrarterial drug injection via intravascular catheters placed on the dorsum of the hand. Anesth & Analg. 2002;95:487-491
3. Lindfors NC, Vilpponen L, Raatikainen T. Complications in the upper extremity following intra-arterial drug abuse. J Hand Surg Eur 2010;35:499-504
4. Knill RL, Evans D. Pathogenesis of gangrene following intra-arterial injection of drugs: a new hypothesis. Can Anaesth Soc J. 1975 Nov;22(6):637-646
5. Sen S, Chini EN, Brown MJ. Complications after unintentional intra- arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin Proc 2005;80:783-795.
6. Bernard G. Fikkers, Eveline W. Intra-arterial injection of anesthetic drugs. Anesth & Analg 2006;103:792-794.
7. Nicolson SC, Pasquariello CA, Campbell FW. Intra-arterial injection of pancuronium and fentanyl: an alternative. Crit Care Med 1988;16:915
8. Joshi G, Tobias JD. Intentional use of intra-arterial medications when venous access is not available. Paediatr Anaesth 2007;17:1198-1202.

Fig 1: Bluish discoloration of the hand after intra arterial diclofenac injection.

Central venous catheterization (CVC) is routinely being practised in wards and emergency departments for central venous pressure monitoring, administration of ionotropes, hyperosmolar drugs, parenteral nutrition and chemotherapy. Ultrasonographic (USG) guidance and therapeutic beds for achieving Trendelenburg position provide valuable help in vessel access and performing this procedure safely. But at many locations and institutions these facilities may not be available, and use of the blind technique in supine position becomes mandatory. Blind technique is associated with significantly higher complication rate and a lower success rate. On the basis of normal human physiology, we opine that in such situations, the use of Valsalva maneuver (VM) to aid CVC increases the success rate. We illustrate this by two cases, where expected difficult CVC was simplified using VM.

Case 1: A 15 years old male, diagnosed with aplastic anemia, required CVC for antithymocyte globulin administration. He had a cyst on left side of the neck and right sided skin excoriation due to a previously placed CVC in the right internal jugular vein (IJV). A platelet count of 20,000/mm³ in the patient prevented us from trying the blind subclavian approach. IJV cannulation on the right side was not attempted due to previous scar. USG machine and therapeutic bed were not available. After aseptic preparation and local anesthetic infiltration, the patient was asked to perform VM which made the external jugular vein (EJV) prominent. While the patient maintained VM, the EJV was punctured and the guidewire was threaded effortlessly through the EJV. A repeat VM helped guide the CVC over the guidewire.

Case 2: A 48 years old, obese, female patient of enterocutaneous fistula, with short neck required CVC for parenteral nutrition. In the absence of USG, a therapeutic bed and prominent anatomical landmarks, we anticipated difficulty. After aseptic preparation and local anesthetic infiltration, the patient was asked to perform VM. After a test puncture with a pilot needle, the needle for passage of guidewire was inserted into right IJV just lateral to carotid pulsation, followed by successful guide wire placement. The central catheter was then placed following a repeat VM.

IJV cannulation is a common technique for blind external landmark guided CVC, wherein inadvertent carotid artery puncture, nerve injury and airway compromise are frequently encountered complications. Trendelenburg position, hepatic compression, positive intra thoracic pressure and VM^1,2  increase the cross sectional area of central veins significantly (>20% ) and reduce their collapsibility in spontaneously breathing patients³ as shown in Figure 1 and 2. Moreover, VM opens the valves in the larger veins (especially EJV) by distending them. Increased diameter of IJV and EJV combined with opening of the venous valves makes needle placement, passage of guidewire and catheter easier,⁴ thereby reducing the complications. Feasibility of performing VM in both intubated and ventilated patients (passive VM), as well as in spontaneously breathing patients (active VM) allows this technique to be used in a wide range of patients. Clinicians should thus be aware of this simple technique to enhance the success rates of CVC in wards and emergency settings.

References:

1. Lobato EB, Florete OG Jr, Paige GB, Morey TE. Cross sectional area and intravascular pressure of the right internal jugular vein during anesthesia.effect of Trendelenburg position, positive intrathoracic pressure, and hepatic compression. J Clin Anesth 1998; 10:1-5.

[Medline]

2.  P. Cowlishaw, P. Ballard. Valsalva Manoeuvre For Central Venous Cannulation Anesthesia 2007;62:640

3. Bellazzini MA, Rankin PM, Gangnon RE, Bjoernsen LP. Ultrasound validation of maneuvers to increased internal jugular vein cross section area and decreased compressibility. Am J Emerg Med. 2009 May;27(4):454-9. doi: 10.1016/j.ajem.2008.03.034.

[Medline]

4. Suzuki T, Takeyama K, Hasegawa J, Nishiyama J, Takiguchi M. Valsalva maneuver prevents guide wire trouble associated with 22-g safe guide. Tokai J Exp Clin Med. 2001;26(3):113-8.

[UnboundMedline] [Medline]

Figure 1: IJV cross section before VM.

Figure 2: IJV cross section after VM.

Sukhen Samanta, MD^* andRudrashish Haldar, MD, PDCC^**

*Department of Critical Care Medicine, **Department of Anesthesiology

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, 226014

Correspondence:  Dr. Rudrashish Haldar, Old PG Hostel, Room No. 2, SGPGI, Lucknow, India, 226014; Email: rudrashish@yahoo.com; Mobile: 08004904625

Citation: Samanta S, Haldar R. Valsalva maneuver aids blind central venous catheterization. Anaesth Pain & Intensive Care 2013;17(1):—

*Associate Professor; **Lecturer; ***MD Student; ****Professor & Head

Department of Anesthesiology, King George’s Medical University, Chowk, Lucknow U.P.  (India).

Correspondence: Dr. Sulekha Saxena, MD Student, Department of Anesthesiology, King George’s Medical University, Chowk, Lucknow U.P. (India); Cell: 09359618480; E-mail: dr.sulekha2008@rediffmail.com

ABSTRACT

Airway management is one of the most important routine tasks performed by an anesthesiologist. Adept airway management is an essential skill for an anesthesiologist. Although practice guidelines and algorithms may help in such situations, but vigilance and a timely decision remain all important in such a situation. We encountered a patient with a rapidly enlarging subscapular mass due to which maintenance of supine position on the operating table for laryngoscopy and intubation was almost impossible. We had little options for airway management during general anesthesia in this patient. We present our method of successful management in this case and reiterate the role of different methods of correct positioning and intubation in such circumstances.

Key words: Airway management; Laryngoscopy; Difficult airway; Fibreoptic intubation; LMA

Citation: Abbas H, Arshad Z, Saxena S, Bogra JS. Airway management in a patient with a large mass in scapular region: A case report. Anaesth Pain & Intensive Care 2013;17(1):97-99

INTRODUCTION

Management of the difficult airway presents a great challenge for the anesthesiologist. Practice guidelines and algorithms are useful in such circumstances. However, the anesthesiologist’s judgment and vigilance remain the primary means to save airway management. There are few options for securing the airway during induction of general anesthesia in supine position, in a patient with a large mass on the back, which can be enumerated as follows. Placement of a proper wedge on the opposite side of the tumor to make the patient level in supine position without putting weight on the mass or to intubate patient in a lateral position may require some experience and skill. Fibreoptic intubation is the other option available but it is not usually available in the hospitals of the third world countries.

We present here a case of large mass in scapular region which posed anticipated difficulty in maintaining supine position for intubation. The authors tried an alternate scheme to intubate this patient. Patient was taken on the edge of the table with the mass hanging between the edge of the table and the arm rest. By this way we were able to maintain the desired position for laryngoscopy and intubation and the airway was managed successfully.

CASE REPORT

A  55 yr old male presented with a large mass in scapular region posted for wide local excision and split thickness grafting in the Department of Surgery, King George’s Medical University Hospital, Chowk, Lucknow (Figures 1-A & 1-B).

Figure 1-A: Large mass in right scapular region

Figure 1-B: The lateral patient position on the edge of the table, before placing him supine

Figure 2: Patient on the edge of the table with mass hanging between the edge of the table and the arm rest

Patient was declared physically fit and ASA grade-1 on preanesthetic checkup. He had a short receding jaw and loose upper incisors, hence was anticipated to be a candidate for difficult laryngoscopy and intubation. Written consent was obtained and standard monitoring devices e.g. electrocardiogram, pulse oximetry, noninvasive blood pressure, and end-tidal carbon dioxide monitors, were attached to the patient in the operating room in the sitting position. An intravenous line with 18G cannula was passed.

The mass was assessed and it was felt that the supine position would be difficult to obtain by using large cushions and pillows. The lateral position was an option but intubation in this position was felt to be particularly difficult in view of his short receding jaw and loose upper incisors. Due to same reasons LMA insertion was also felt to be difficult in the lateral position. We placed the patient in the lateral position, facing towards opposite direction to his mass, on the extreme edge of the table. An arm rest was attached at the most cephaled end of the operating table. Then the patient was asked to roll over to a supine position so that the mass was hanging between the edge of the table and the arm rest (Figure 2). The right arm was supported over his chest and an assistant held the patient in position. Patient was given inj. glycopyrrolate 0.2 mg, inj. fentanyl 100mcg and inj. midazolam 1 mg IV. Anesthesia was induced with inj. propofol 120 mg and intubation was facilitated with inj succinyl choline 100 mg. Laryngoscopy was performed and endotracheal tube size 8.5 mm was placed successfully and secured. The patient was then paralyzed with inj. tracrium, ventilated and placed in lateral position for the surgery. He was extubated uneventfully at the end of the surgery in the lateral position.

DISCUSSION

Awake fibreoptic intubation remains the gold standard for anticipated difficult intubation.¹ Blind nasal or oral intubation is a simple technique, but it is associated with two major drawbacks: infrequent success on the first pass, and increased trauma with repeated attempts. We could not risk precipitating complete airway obstruction that necessitated emergent cricothyrotomy.^2-6 Also, insertion of the endotracheal tube via the nasal passage has a risk of nasal bleeding. This can result in an inability to visualize subsequent fibreoptic attempts due to both tissue edema and bleeding. Previous studies indicated fibreoptic nasotracheal intubations is associated with frequent failure (66% in some studies).⁶ However, there are reports of a greater success rate with this procedure, attributed to a well-organized approach, and expertise in flexible bronchoscopy.^1,6 Unluckily, this procedure demands high level of expertise and skill for its success. The fiberscopes may not be available at all centers. Sitting fiberoptic bronchoscopic intubation can be life-saving, therefore, we suggest that anesthesiologists occasionally practice this technique so that it may be used when confronted with a patient requiring awake urgent intubation who cannot tolerate the supine position.

Elective tracheostomy using local anesthesia has been considered the ‘definitive’ modality of airway management in difficult situations such as deep neck infections^6–8. Nevertheless, it may be difficult or impossible in advanced cases such as in our case because of the supine position needed for tracheostomy, or due to the anatomical distortion of the anterior neck. In our case, surgeons were reluctant to perform tracheostomy using local anesthesia without a secure airway^1,5,8.

Intubation in lateral position is requires experience and skill. In our case, we felt it particularly difficult due to features of difficult airway present in this patient. Due to same reasons, the use of LMA or i-gel was thought to be impractical.^9,10

We performed the laryngoscopy and intubation in the usual way, except that the position of the patient was adjusted according to the mass on the back to make patient supine to maintain suitable position for laryngoscopy and intubation.

REFERENCES

1. Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway. 2nd ed. Philadelphia: Lippincott-Raven Press, 1996
2. Belmont MJ, Wax MK, DeSouza FN. The difficult airway: cardiopulmonary bypass—the ultimate solution. Head Neck 1998;20:266–9 [Medline]
3. Hariprasad M, Smurthwaite GJ. Management of a known difficult airway in a morbidly obese patient with gross supraglottic oedema secondary to thyroid disease. Br J Anaesth 2002;89:927–30 [Medline] [Free Full Article] doi: 10.1093/bja/aef274
4. Huitink JM, Balm AJ, Keijzer C, Buitelaar DR. Awake fibrecapnic intubation in head and neck cancer patients with difficult airways: new findings and refinements to the technique. Anaesthesia 2007;62:214–9 [Medline]
5. Oka Y, Nishijima J, Azuma T, Inada K, Miyazaki S, Nakano H, et al. Blunt thyroid trauma with acute hemorrhage and respiratory distress. J Emerg Med 2007;32:381–5 [Medline]
6. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 2005;100:585–9 [Medline] [Free Full Article]
7. Tsilchorozidou T, Vagropoulos I, Karagianidou C, Grigoriadis N. Huge intrathyroidal hematoma causing airway obstruction: a multidisciplinary challenge. Thyroid 2006;16:795–9 [Medline]
8. Heidegger T, Gerig HJ. Algorithms for management of the difficult airway. Curr Opin Anaesthesiol 2004;17:483–4 [Medline]
9. Ramachandran K, Kannan S. Laryngeal mask airway and the difficult airway. Curr Opin Anaesthesiol. 2004 Dec;17(6):491-3.
10. Drolet P. Management of the anticipated difficult airway–a systematic approach: continuing Professional Development. Can J Anaesth. 2009 Sep;56(9):683-701. doi: 10.1007/s12630-009-9144-4. Epub 2009 Jul 28.

*Professor of Anesthesiology; ***P.G. Student

Department of Anesthesiology and Critical Care

**Professor of ENT

Department of Ear, Nose & Throat

Pt. B.D. Sharma PGIMS, Rohtak, Haryana (India) 124001

Correspondence: Dr. Anju Ghai, 19/9 J, Medical Enclave, Pt. B.D. Sharma, PGIMS, Rohtak (India); E-mail: dr.wadhera@yahoo.com

ABSTRACT

Patients with sleep apnea syndrome (SAS) have excessive adipose tissue in oropharynx which can obstruct the airway. A high prevalence of difficult intubation has been reported in these patients and an association between the severity of SAS and difficult intubation has been suggested. LMA Proseal^® (LMA Company, USA) has been launched as a better alternative to LMA classic, as it provides good airway seal due to its modified cuff. The improved seal of LMA Proseal^® (PLMA^®) has an advantage in obese patients where higher airway pressures are required for positive pressure ventilation. We found that LMA Classic^® provided better airway management than PLMA^® in one of our obese patients with SAS.

Key Words:   LMA Proseal^® (PLMA^®); LMA Classic^®; Sleep apnea syndrome; Positive pressure ventilation; Supraglottic device

Citation: Ghai A, Hooda S, Wadhera R, Kad N, Garg N.Failed ventilation with LMA Proseal® in a patient with sleep apnea syndrome. Anaesth Pain & Intensive Care 2013;17(1):94-96

INTRODUCTION

Obstructive sleep apnea is a syndrome, characterised by partial or complete obstruction of the upper airway during sleep due to inadequate pharyngeal muscle tone. These patients may have a compromised airway due to oropharyngeal narrowing as there is deposition of fat in collapsible segments of the airway.¹ SAS severity is measured by the apnea hypoapnea index (AHI) which is defined as number of apnea / hypoapnea events per hour of sleep and the lowest oxygen saturation associated with an abnormal respiratory events during sleep. Theoretically, the larger the pharyngeal tissue, the higher the AHI will be. Patients with SAS have many implications for anesthesia. These patients usually pose a problem of difficult intubation as they have abnormal facial and upper airway morphology, e.g. retrognathia, short and thick neck and a large tongue.² Hiremath et al found a high prevalence of SAS in patients with difficult intubation retrospectively.³ Sleep apnea results in fragmented sleep, hypoxemia, day time somnolence and altered cardiopulmonary functions.

PLMA^® is a modification of classic^® LMA. It has a larger and deeper bowl with no grille and cuff extends posteriorly to give a more effective seal around the glottis. It has a drainage tube running parallel to the airway tube which provides a bypass channel for regurgitated gastric contents and allows rapid diagnosis of mask misplacement. Since the airway tube of PLMA^® is shorter than LMA Classic^® and of similar calibre, airway resistance is 20% more than LMA Classic^®. The PLMA^® is superior to LMA Classic^® for providing positive pressure ventilation and at a given cuff pressure, provides twice the seal pressure of the LMA Classic^®. The improved seal is of advantage in obese patients where higher airway pressure are required for positive pressure ventilation.⁴

A patient of obstructive sleep apnea is reported where PLMA^® failed to provide adequate airway approach as compared to conventional LMA Classic^®.

CASE REPORT

A 51 year old male, weighing 90 kg, ASA grade II, with the diagnosis of gall stones and paraumbilical hernia was posted for cholecystectomy. He was a known case of SAS for 2 years. He also suffered from hypertension for two months and was on tab atenolol 50 mg and tab amlodipine 5 mg. His ECG showed ST segment flattening with T-wave inversion in V2-V5 leads. Chest x-ray revealed cardiomegaly. On general physical examination, he was found to have a short thick neck with a pulse rate of 80/min and  B.P. 130/80 mmHg.  Echocardiography revealed concentric left ventricular hypertrophy with ejection fraction of 54%. Symptoms of SAS were relieved with exercise and weight reduction. Pulmonary function tests revealed  FEV1 3.5 L, FVC 4.04L, FEV1/FVC 86%, PEFR 297L/min and oxygen saturation 93% on room air. Polysomnographic studies revealed  moderate  apnea / hypoapnea episodes. A high risk informed consent was obtained. Antihypertensive drugs were ordered to be continued but no sedative drugs. Standard monitoring e.g. electrocardiography, SpO₂ and non-invasive blood pressure, was applied. Preoxygenation was carried out with 100% oxygen for 6 minutes. Routine induction protocol was followed. Direct laryngoscopy revealed Cormack and Lehane grade 4 view. Intubation could not be achieved despite two attempts. Fibroptic bronchoscope was not available to help intubation. Further attempts on intubation were abandoned to avoid airway trauma and sympathetic stimulation leading to surges in blood pressure in this patient. PLMA^® size 4 was inserted and correct placement was confirmed by gentle inflation. An orogastric tube could be passed through the drain tube and a drop of gel placed over the proximal end of drain tube ruled out mask malposition. Airway pressures and end tidal CO₂ were within normal limits. The surgery was started. Patient was ventilated by IPPV.

After about five minutes of placement, an increased resistance to ventilation was felt. Patient could not be ventilated adequately. EtCO₂ rose to 60-70 mmHg. Airway pressure increased to 40 cmH₂O. We considered it to be suboptimal positioning or an inappropriate size. An attempt at repositioning did not succeed in lowering the airway resistance. We replaced PLMA^® size 4 with size 5. Gas leakage and resistance to ventilation was still noted. It was then replaced with LMA Classic^® size 4. Fibroptic assessment could have been helpful, but it was not available. To our relief, the patient could now be ventilated adequately. Airway pressure dropped down and end tidal CO₂ also lowered down to 40 mmHg. Rest of intraoperative period was uneventful. Surgery lasted for one hour. At the end of surgery, when patient was fully awake, LMA was taken out. Nasopharyngeal airway was placed for 24 hours postoperatively so as to avoid obstruction.

DISCUSSION

Controlled ventilation with tracheal intubation is the choice if general anesthesia with relaxation is the only available option. Nasal continuous positive airway pressure may be applied if airway obstruction persists, and it should be started before surgery and resumed immediately after extubation in cases of SAS.⁵

The cause of increased resistance to ventilation in our patient could be malpositioning, infolding of epiglottis or improper size. PLMA^® provides more effective seal than LMA Classic^® at same airway pressure⁴ due to the broader proximal cuff plugging the oropharynx  more effectively and also the ventral cuff pressing the dorsal cuff firmly into periglottic tissues.^6-8

The difficulty in ventilation with PLMA^® in our case could be explained due to epiglottis impinging in the lumen of the airway tube during insertion causing obstruction. This is not seen with LMA Classic^® as it has aperture bars. Though downfolded epiglottis does not impede airflow with PLMA^® due to presence of accessory vent, but in this case impediment could be significant due to excessive perilaryngeal tissues. In addition any supraglottic airway device (SGD) with a large inflatable hypopharyngeal component can cause mechanical airway obstruction by vocal cord closure secondary to glottic compression.⁸ Stacy et al have reported 20% incidence of airway obstruction with these airway management devices. They hypothesized epiglottic downfolding or mechanical cord closure.⁹ In its resting state, the hypopharynx is usually closed. Any device occupying the hypopharynx sufficiently to form a seal must open it and push the glottis anteriorly. This will inevitably cause glottic compression in patients with unfavourable anatomy. The incidence of mechanical cord closure is 0.4%.¹⁰ Over-enthusiastic insertion and inflation of the PLMA^® cuff beyond its optimal position results in near complete airway obstruction, presumably because of forward displacement of the glottic inlet. Application of cricoid pressure with the LMA Classic^® may also simulate the same condition.¹¹ Another cause of impaired ventilation could be infolding of the aryepiglottic folds.¹² We could not perform a fiberoptic assessment, though it would have provided important clues about the etiology of the obstruction. It is strongly recommended in the assessment of airway obstruction with SGD’s whenever clinical circumstances allow. The best options in case of inadequate ventilation after insertion of a SGD are to remove and reinsert it, or to opt for a different size. We exercised both of these options but failed. However, the change of SGD (LMA Classic^® for PLMA^®) resulted in successful ventilation.

Sedation and narcotic based analgesia was avoided in postoperative period in our patient as it could exacerbate symptoms of sleep apnea. NSAID’s and local infiltration at incision site is preferred.

CONCLUSION

PLMA^® has specially developed to improve the seal and ensure effective ventilation, but in our patient with SAS, it failed in its stated purpose. The cause of its failure cannot be ascertained with certainty. In case of failure, either the size or type of the SGD should be changed.

REFERENCES

1. Jonathan L. Benumof. Obesity, sleep apnea, the airway and anesthesia. Curr Opin Anaesthesiol. 2004 Feb;17(1):21-30. [Medline]
2. Siyam M.A., Benhamou D. Difficult Endotracheal Intubation in patients with  Sleep Apnea Syndrome. Anaesth Analg 2002;95:1098-102. [Medline]
3. Hiremath AS, Hillman DR, James AL et al. Relationship between different tracheal intubation and obstructive sleep apnea. Br J Anaesthesia 1998;80:606-11. [Medline]
4. Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the Proseal versus the Classic laryngeal mask airway in anaesthetized paralysed patients. Br J Anaesth 2000;85:262-6. [Medline]
5. Anaesthesia and sleep apnea. Br J Anaesth 2001;86(2):254-66. [Medline]
6. Brain AIJ, Verghese C, Strube PJ. The LMA ‘Proseal’- a laryngeal mask with an oesophageal vent. Br J Anaesth 2000;84:650-4  [Medline]
7. Brimacombe J, Keller C. The Proseal laryngeal mask airway: Randomised crossover study with the standard laryngeal mask airway in paralyzed, anaesthetised patients. Anesthesiology 2000;93:104-9 [Medline]
8. Yanagimoto M: Effect of position of the epiglottis on volume-pressure curve during use of the LMA. J Jpn Soc Clin Anesth 1992;12:738-41 [Medline]
9. Stacey MR, Sivasankar R, Bahlmann UB, Hughes RC, Hall JE. Mechanical closure of the vocal cords with the airway management device. Br J Anaesth 2003;91:299-03 [Medline]
10. Brimacombe J, Richardson C, Keller C, Donald S. Mechanical closure of the vocal cords with Proseal laryngeal mask airway. Br J Anaesth 2002;89:296-7 [Medline]
11. Brimacombe J, Berry A. Mechanical airway obstruction following cricoid pressure with the laryngeal mask airway. Anaesth Analg 2001;78:604-5 [Medline]
12. Dubreuil M, Janvier G, Dugrais G, Berthoud MC. Uncommon laryngeal mask obstruction. Can J Anaesth 1992;39:517-8 [Medline]

Masood Ur Rahman, MD****

*Chairman; **** Deputy Chairman, Department of Critical Care Medicine

**Resident, Department of Internal Medicine

*** Department of Pharmacy

Tawam Hospital, P.O.Box 15258 Al Ain (United Arab Emirates)

Correspondence: Said Abuhasna, MD., Chairman, Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Abu Dhabi, UAE

Email: sabuhasna@tawamhospital.ae ; sabuhasna@gmail.com

ABSTRACT

Self-strangulation is an important cause of homicidal and suicidal injury, leading to death due to asphyxia and may be accidental or suicidal. Accidental strangulation is rare, and to be strangulated by a scarf is even less common. We report a 19-year-old male who was accidentally strangulated by his own scarf or ‘ghutra’ (a traditional cotton headdress worn by Arab males), while working on his idle vehicle engine, resulting in anoxic brain encephalopathy. The patient remained in a persistent vegetative state and ventilator dependent.

Because this was previously an unrecognized hazard of ‘ghutra’ as well as the unique mode of injury, it prompted us to report this case to highlight the circumstances surrounding the event in order to minimize similar.

Key words:  Headscarf; Ghutra; Strangulation; Anoxic brain encephalopathy

Citation: Abuhasna SD, Ebaid MA, Qadoom EDM, Rahman MU. Accidental asphyxiation by an Arabic headscarf. Anaesth Pain & Intensive Care 2013;17(1):91-93

INTRODUCTION

Accidental strangulation is rare, and to be strangulated by a scarf is even less common. The traditional Arabic headdress goes by several names. It is called a ‘keffiyeh’, ‘shmagh’, ‘ghutra’ or a scarf. It can be worn in several different ways, either by itself or with a cap (‘igal’) and wreath (‘tagiyyah’) to keep it in place. The scarf was initially used by the dwellers of the desert  to protect them  from the harsh rays of the sun and the whipping sands of the desert. It still serves that purpose, but now it has become a symbol of Arab culture. It is also worn at weddings and by heads of state, when it serves a purely decorative function. The ‘shmargh’ is a large square piece of cotton cloth that is woven in a distinctive checkered design. It is usually red and white, or black and white.¹

We present a case of a 19 years old male who was accidentally strangled by his own scarf, while he was working on his idle running vehicle. The scarf was accidentally tangled into the fan of the engine and tightened around his neck leading to asphyxiation and brain death, which left the patient in a persistent vegetative state.

CASE REPORT

A 19 years old healthy male (weight 66 kg, height 155 cm) was admitted to our intensive care unit (ICU), comatosed with multiple facial abrasions and a fresh injury mark around his neck. The history was provided by the front seat passenger who was patient’s first cousin. The patient and his cousin were driving to report as newly inducted recruits to the police academy for training on a chilly morning. The patient was wearing the traditional scarf around his head and neck to keep him warm. On their way to the academy, the vehicle engine stalled. The patient reportedly exited the vehicle and opened the hood to check the engine.  He was able to restart the engine while his head was still under the hood. Evidently, the fan of the engine started abruptly, catching his scarf in the fan belt, and tightening it progressively more and more around his neck leading to asphyxiation with loss of consciousness. The passenger, who saw that his cousin head slammed on the engine, immediately turned off the engine and called Emergency Medical Service 911. Subsequently, he attempted to untangle the scarf and get it released from the fan, but he was not successful. The victim sustained asphyxiation and quickly became unconscious.  The Emergency Medical Service transported the patient to the hospital on oxygen supplementation and monitoring. He was resuscitated at the trauma centre. Upon arrival to the ICU the patient was on a ventilator and was flaccid with a Glasgow coma scale of 3/15 and with decerebrate posture. The oxyhemoglobin saturation was 97% on FiO₂ 45%. The ventilatory rate was 12 in the assist control mode with a tidal volume of 6 ml/kg and a positive end-expiratory pressure (PEEP) of 5 cmH₂O. The heart rate was 75 bpm in normal sinus rhythm, the temperture was 37.1° C and the BP was 100/58 mmHg. The pupils were fixed and dilated at 7 mm. There was a ligature mark over the anterior neck (Figure 1). No other injuries were found. Rest of his examination was unremarkable.

In the subsequent few days, he suffered from episodes of generalized tonic-clonic convulsions and ARDS, probably due to aspiration pneumonia. Arterial blood gas analysis showed PO₂ of 56 mmHg on FiO₂ 90% and the chest radiograph showed bilateral infiltrates. The plain radiograph of the neck did not reveal any hyoid or cervical vertebral fractures and a computerized tomography (CT) scan of cranium showed skull fracture with moderate subdural hematoma on the right parietal area which was surgically evacuated. CT scan of the neck was unremarkable. Patient was treated with intravenous phenytoin for seizures; on 5th day of ICU admission, he developed diabetes insipidus (DI) and was treated with desmopressin infusion.

Due to his deep coma and vegetative state, tracheostomy was performed and he was placed on long term ventilation.

DISCUSSION

In different types of strangulation, the initially applied ligature causes venous congestion with stasis of cerebral blood leading to unconsciousness. After the person is limp, the ligature can tighten, progressing to complete arterial occlusion. Vagal reflexes from pressure on the carotid bodies can lead to dysrhythmias. Airway compression does not play an important role in the pathophysiology of strangulation injuries. Laryngeal fractures have been reported in hanging deaths but are rare in survivors.

The clinical features of strangulation can include indentation of the neck in the course of the ligature or other signs of trauma to the neck, such as scratches, abrasions or lacerated wounds (Figure 1).

Tardieu spots are petechial hemorrhages in the conjunctiva, mucous membranes, and skin cephalad to the ligature marks.^2,3 Strangulation is a common method of homicide, but accidental ones like our case are rare. Accidental strangulation is a potentially fatal injury and only two cases similar to ours have been reported.⁴ In strangulation, and in some suicidal hangings where the individual is “saved” before death, there may be a variable period of survival, but with brain damage, followed by death. This delay is the effect of loss of blood flow to the brain, with partial asphyxiation of the brain. A decrease in blood flow to the brain will produce a pathologic change called anoxic encephalopathy. In our case there was strangulation with the headscarf, that resulted in anoxic encephalopathy and a vegetative state. The process of strangulation, whether by hand (manual) or by a ligature, results in blunt injury of the soft tissues of the neck. The pattern of these injuries allows us to recognize strangulation as a mechanism, and to distinguish strangulation from other blunt injuries including hanging, traumatic blows to the neck, and artifacts of decomposition.^2,3 Fatal anoxic encephalopathy results in clinical “brain death” where the body functions of the heart and internal organs can be maintained by medical life support, but all hope of meaningful recovery is lost. Complications may include persistent vegetative coma, cerebral edema, and herniation of the brain. Apparently this is not the first case to die from strangulation of own headscarf. Searching the internet, we found two cases only reported in the news and information sites, but not in medical literature. The first case was of a well known American dancer named Angela Isadora Duncan, who died in a car accident in 1931. Her silk scarf, draped around her neck, became entangled around the open-spoked wheels and rear axle, breaking her neck.⁴ The second case was of a teenager girl Suzanne Cornwell, 18. She was strangled to death by her scarf in a freak go-karting accident when the garment got caught in the engine the first time she had ever tried the sport. Accidental strangulation of this variety is under-reported in the third world countries and is preventable if the public follows safety recommendations. Since the occurrence of this case we have started short courses of instructions to primary care physicians to provide anticipatory guidance to the public of the United Arab Emirates, and to explain to their patients and their families the dangers and the potential strangulation by a headscarf in certain situations such as inspection of a vehicle under the hood while the engine is running.

REFERENCES

1. How to Wear an Arabic Headdress: Available on http://www.ehow.com/how_6046805_wear-arabic-headdress.html. (Accessed on 10 March 2013).

2.  Kelly M: Trauma to the neck and larynx [Review]. CRNA 1997 Feb;8(1):22-30. [PubMed]

3. Missliwetz J, Vycudilik W: Homicide by strangling or dumping with postmortem injuries   after heroin poisoning? Am J Forensic Med Pathol. 1997 Jun;18(2):211-4. [PubMed]

4. Craine, Debra and Mackrell J. The Oxford Dictionary of Dance. Oxford University  Press, Oxford. 2000; p152. ISBN 0-19-860106-9

*Department of Intensive Care Unit, **Department of Anesthesiology & Reanimatology,

University of Fukui, Faculty of Medicine Sciences, Fukui (Japan)

Correspondence: Yasunari Matsuki, MD, Department of Intensive Care Unit, University of Fukui, Faculty of Medicine Sciences, 23-3 Shimoaizuki, Matsuoka, Eiheijicho, Yoshidagun, Fukui 910-1193 (Japan); Tel: +81-776-61-8391; Fax: +81-776-61-8116; E-mail: tainobu@u-fukui.ac.jp

ABSTRACT

Legionella pneumonia is often complicated by multiple organ failure. Although acute kidney injury is relatively rare in the context of Legionella pneumonia, it is associated with an increase in mortality rate. This report describes a case of a patient with Legionella pneumonia and acute kidney injury who was successfully treated with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). We conclude that PMX-DHP may be a useful therapeutic modality in patients with Legionella infection and acute kidney injury.

Key words: Legionella pneumonia; Polymyxin B-immobilized fiber column direct hemoperfusion; Acute kidney injury

Citation: Matsuki Y, Matsuki Y, Yasuda Y, Mizogami M, Takakura K, Shigemi K. Successful treatment of severe Legionella pneumonia and acute kidney injury with polymyxin B-immobilized fiber column direct hemoperfusion. Anaesth Pain & Intensive Care 2013;17(1):88-90

INTRODUCTION

Legionella pneumonia was first described following an outbreak of pneumonia among army veterans attending an American Legion convention in Philadelphia in 1976.¹ This pneumonia is often complicated by multiple organ failure, including acute kidney injury and hepatic dysfunction, that is associated with an increase in mortality rate.^2-3 Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is a useful treatment modality for patients with organ dysfunction due to severe sepsis.⁴ We describe a case of a patient with severe Legionella pneumonia and acute kidney injury who was successfully treated with PMX-DHP.

CASE REPORT

A 70 years old man was admitted to our hospital with diarrhea, high-grade fever and dyspnea. He had been on treatment for malignant lymphoma, and had mitral valvuloplasty in the past. Physical examination on admission to our hospital revealed a temperature of 38.8°C, blood pressure of 65/40mmHg, heart rate of 89/min, SpO₂ of 80% (on 15 L/min of O₂ via reservoir mask) and a respiratory rate of 35/min. Glasgow coma scale was 9/15. Fine crackles were audible in the upper lung fields bilaterally. Laboratory tests showed elevations in leukocytes and C-reactive protein at 13,100/μl and 35.20mg/100 ml respectively. BUN (28 mg/100 ml), Creatinine (1.64 mg/100 ml), AST (1019iu/L), ALT (677iu/L) and LDH (1756iu/L) were also elevated, and the Na level (127 mEq/L) was low. Arterial blood gas analysis (taken while O₂ was being administered at 15 L/min via reservoir mask) showed severe hypoxemia, and metabolic acidosis (pH of 7.06, PaCO₂ of 54 mmHg, PaO₂ of 52 mmHg, HCO₃^- of 14.5 mmol/L). Chest x-ray film showed infiltrative shadows in the left upper lung fields, and a chest CT revealed consolidation and ground-glass opacity in the left upper lung field (Fig 1-A&B).

Fig 1-A: Chest radiograph on admission. There is an infiltrative shadow in the left upper lung field.

Fig 1-B: Chest computed tomography on admission showing consolidation with ground-glass opacities in the left lung field

The patient’s clinical course is summarized in Fig 2. He was admitted to the intensive care unit (ICU) with a blood pressure of 78/42 mmHg despite administration of 5 μg/kg/min of dopamine hydrochloride and 0.1 μg/kg/min of noradrenaline. He was immediately intubated and ventilated with 100% oxygen and was treated with sivelestat sodium hydrate, intravenous fluids of volume and antibiotics (tazobactam/piperacillin, pazufloxacin). A diagnosis of legionellosis was made on the basis of positive specific urinary antigen. Antibiotics were switched to erythromycin, but blood pressure and the PaO₂/FiO₂ (P/F) ratio continued to decrease. He became anuric, and continuous hemodiafiltration (CHDF) (CH-1.0^®; Toray Medical Co., Tokyo, Japan) was started to maintain body water balance. In addition, PMX-DHP (Toraymyxin 20R^®; Toray Medical Co., Tokyo, Japan) was performed for 4 hours on days 1 and 2 to adsorb endotoxin. After the introduction of PMX-DHP, blood pressure and urinary output were gradually increased, and catecholamines were tapered off. The P/F ratio improved from 173 to 386 on day 3, and CHDF was terminated on day 8. The patient was extubated on day 9 after careful weaning from mechanical ventilation.

Fig 2: Clinical course after initiation of PMX-DHP. Catecholamines (noradrenaline and dopamine) were tapered off, and blood pressure and the PaO₂/FiO₂ (P/F) ratio gradually improved.

(Legend: NA: noradrenaline, DOA: dopamine, CHDF: continuous hemodiafiltration, PMX-DHP: polymyxin B-immobilized fiber column direct hemoperfusion, sBP: systolic blood pressure, dBP: diastolic blood pressure)

DISCUSSION

The bacterium, Legionella, got its name after a 1976 outbreak, when many people who went to a Philadelphia convention of the American Legion suffered from this disease, a type of pneumonia (lung infection). Although this type of bacterium was around before 1976, more illness from Legionnaires’ disease is being detected now. The report describes the case of a patient with Legionella pneumonia and acute kidney injury who was successfully treated with PMX-DHP. Legionella pneumophila is one of the three most common causes of severe community-acquired acute pneumonia and comprises 3-6% of all cases of community-acquired pneumonias.^5,6 Although radiologic and clinical findings alone are not sufficient to establish a diagnosis of Legionella pneumonia, if these are accompanied by diarrhea, neurological signs, a temperature >39°C, hyponatremia and hepatic dysfunction, these are strongly suggestive of legionellosis.^7-9 Diarrhea, hyponatremia and hepatic dysfunction were noted in our present case. The patient was ultimately diagnosed with legionellosis on the basis of positive specific urinary antigen.

Although Legionella pneumonia complicated by acute kidney injury is a rare disease, it is associated with a mortality rate greater than 50%.^2,3 In our case, rhabdomyolysis was not observed, and we speculated that direct microbial toxicity,¹⁰ endotoxemia, inflammatory cytokines¹¹ and/or hypotension was the cause of acute kidney injury. L. pneumophila is a Gram-negative aerobic bacterium that is an intracellular parasite, and produces beta-lactamase and many other potential endotoxins.

PMX-DHP can lower the plasma level of endotoxin and inflammatory cytokines,^12,13 and can significantly improve hemodynamics and organ function in patients with severe sepsis and/or septic shock arising from Gram-negative bacterial infections.^4,14 In the present case, early use of PMX-DHP resulted in improved hemodynamics and kidney function. PMX-DHP exerts a therapeutic effect in patients with pneumonia by absorbing cytokines (e.g. IL-8) and neutrophil elastase produced by activated neutrophils PMX-DHP,^15,16 and this was the likely mechanism of therapeutic action in our patient.

CONCLUSION

We conclude that PMX-DHP may be a useful therapeutic modality in patients with Legionella infection and acute kidney injury.

REFERENCES

1. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, et al. Legionnaires’ disease. Description of an epidemic of pneumonia. N Engl J Med. 1977;297(22):1189-97. [PubMed]
2. Harvey M, Quirke P, Warren D. Acute renal failure complicating Legionnaires’ disease. Postgrad Med J. 1980 Sep;56(659):672-4. [PubMed] [Free full article]
3. Lin SL, Chen HS, Yu CJ, Yen TS. Legionnaires’ disease with acute renal failure: report of two cases. J Formos Med Assoc. 1995 Mar;94(3):123-6. [PubMed]
4. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009 Jun 17;301(23):2445-52. doi: 10.1001/jama.2009.856. [PubMed] [Free full article]

5. Mundy LM, Auwaerter PG, Oldach D, Warner ML, Burton A, Vance E, et al. Community-acquired pneumonia: impact of immune status. Am J Respir Crit Care Med. 1995 Oct;152(4 Pt 1):1309-15. [PubMed]
6. Marston BJ, Plouffe JF, File TM Jr, Hackman BA, Salstrom SJ, Lipman HB, et al. Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch Intern Med. 1997 Aug 11-25;157(15):1709-18. [PubMed]
7. Stout JE, Yu VL. Legionellosis. N Engl J Med. 1997 Sep 4;337(10):682-7. [PubMed]
8. Katz DS, Leung AN. Radiology of pneumonia. Clin Chest Med. 1999 Sep;20(3):549-62. [PubMed]
9. Mulazimoglu L, Yu VL. Can Legionnaires disease be diagnosed by clinical criteria? A critical review. Chest. 2001 Oct;120(4):1049-53. [PubMed]
10. Wong KH, Moss CW, Hochstein DH, Arko RJ, Schalla WO. “Endotoxicity” of the Legionnaires’ disease bacterium. Ann Intern Med 1979; 90: 624-627. [PubMed]
11. Remick DG, Kunkel SL. Toxic effects of cytokines in vivo. Lab Invest. 1989 Mar;60(3):317-9. [PubMed]
12. Kushi H, Miki T, Okamaoto K, Nakahara J, Saito T, Tanjoh K. Early hemoperfusion with an immobilized polymyxin B fiber column eliminates humoral mediators and improves pulmonary oxygenation. Crit Care 2005; 9: 653-661. [PubMed] [Free full article]
13. Seo Y, Abe S, Kurahara M, Okada D, Saito Y, Usuki J, et al. Beneficial effect of polymyxin B-immobilized fiber column (PMX) hemoperfusion treatment on acute exacerbation of idiopathic pulmonary fibrosis. Intern Med. 2006;45(18):1033-8. Epub 2006 Oct 16. [PubMed] [Free full article]
14. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009 ;301:2445-2452. [PubMed] [Free full article]
15. Abe S, Seo Y, Hayashi H. Neutrophil adsorption by polymyxin B-immobilized fiber column(PMX) for acute exacerbation in patients with interstitial pneumonia: a pilot study. Blood Purif. 2010;29(4):321-6. doi: 10.1159/000287232. Epub 2010 Feb 24. [PubMed] [Free full article]
16. Kawagishi N, Ohkohchi N, Fujimori K, Orii T, Koyamada N, Kikuchi H, Satomi S. The effect of continuous veno-venous hemofiltration or direct hemoperfusion with polymyxin B-immobilized fiber on neutrophil respiratory oxidative burst in patients with sepsis and septic shock. Ther Apher. 2001 Feb;5(1):7-11. [PubMed]

*The Ohio State School of Medicine, Columbus, Ohio (USA)

**Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University, Columbus, Ohio (USA)

Correspondence: David Martin, MD, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio 43205 (USA); Phone: (614) 722-4200; FAX: (614) 722-4203; E-mail: 

ABSTRACT

Familial dysautonomia (FD), also known as Riley-Day syndrome, is a disorder of the autonomic nervous system that results in loss of demyelinated nerve fibers of sensory, sympathetic and parasympathetic neurons.  Individuals with FD have variable clinical symptoms that may include insensitivity to pain, inability to produce tears, poor oral intake during infancy, repeated vomiting, failure to thrive, wide fluctuations in body temperature, and episodic hypertension and hypotension. These paroxysmal crises are due to dysfunction of the autonomic system with an elevation of both norepinephrine and dopamine levels. Clonidine, an α₂-adrenergic agonist, has been previously demonstrated to be an effective pharmacological agent in the treatment of dysautonomic crises related to FD. Dexmedetomidine is an α₂-adrenergic agonist with an α₂:α₁specificity that is almost 8 times that of clonidine. The authors present the perioperative use of dexmedetomidine in a patient with FD.  Previous reports of the use of dexmedetomidine in patients with FD are reviewed and the beneficial physiologic effects discussed.

Key words: Familial dysautonomia; Riley-Day syndrome; Clonidine; Dexmedetomidine;  Autonomic nervous system dysfunction; Hereditary sensory and autonomic neuropathies; Paroxysmal autonomic instability with dystonia; PAID

Citation:  DiGiusto M, Martin D, Tobias JD. Dexmedetomidine and the perioperative care in Riley-Day syndrome: a case report and literature review. Anaesth Pain & Intensive Care 2013; 17(1):83-87

INTRODUCTION

Familial dysautonomia (FD), originally known as Riley-Day syndrome, was first described by Riley and Day after a constellation of unique findings were noted in a group of patients who were Ashkenazi Jews.¹  This original report included five children, whose clinical presentation included hypertension, erythematous cutaneous eruptions, excessive sweating, and defective lacrimation in response to anxiety.  Today FD is recognized as one of a group of genetically distinct disorders known as Hereditary Sensory and Autonomic Neuropathies (HSAN). FD is a disorder of the autonomic nervous system that results in loss of demyelinated nerve fibers of sensory, sympathetic, and parasympathetic neurons.  FD displays an autosomal recessive mode of inheritance from a single mutation on chromosome 9q31 in the gene coding inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase associated protein complex (IKBKAP).²

Infants with FD have variable symptoms including insensitivity to pain, inability to produce tears, poor oral intake, repeated vomiting, failure to thrive, wide fluctuations in body temperature, and episodic hypertension and hypotension.³ Given their multiple medical problems including poor oral intake, feeding intolerance and repeated episodes of vomiting, surgical interventions may be required in these patients. Perioperatively, patients with FD may manifest paroxysmal crises, most often attributed to emotional distress or pain, which include hypertension, tachycardia, vomiting, fever, diaphoresis, and erythematous cutaneous eruptions.³ During these paroxysmal events, norepinephrine (NE) and dopamine levels are increased.⁴ It has been hypothesized that the hypertension occurring during these crises is due to the increased vascular sensitivity to released catecholamines as the blood vessels in patients with FD show an exaggerated response to NE.⁵ One of the goals of perioperative care is to limit the sympathetic stress response and blunt the release of endogenous catecholamines.

Dexmedetomidine is an α₂-adrenergic agonist approved for sedation of adults during mechanical ventilation and for monitored anesthesia care (MAC) of adults. Although FDA approved it only for use in adults, it has been used successfully in several different clinical scenarios in infants and children including sedation during mechanical ventilation, procedural sedation, supplementation of postoperative analgesia, prevention of emergence delirium, control of post-anesthesia shivering, and the treatment of withdrawal.⁶ Several potential perioperative benefits of dexmedetomidine have been demonstrated including a decreased requirement for inhalational and intravenous anesthetic agents, blunting of the sympathetic stress response, decreased postoperative opioid requirements, and the prevention of postoperative shivering.^6-8  The authors report the perioperative use of dexmedetomidine in a 28-year-old patient with Riley-Day syndrome. Previous reports of the perioperative use of dexmedetomidine in patients with FD are reviewed and its effects on the sympathetic nervous system discussed.

CASE REPORT

Institutional Review Board approval for case reports involving one or two patients is not required by Nationwide Children’s Hospital (Columbus, Ohio). The patient was a 28-year old, 22.5 kg female with a past medical history significant for Riley-Day syndrome, delayed psychomotor development, mental retardation, unspecified osteoporosis, and severe gastric reflux. She had a long history of breath holding spells and self-mutilation behaviors. She appeared to be approximately 7-8 years of age and was non-verbal. In May 2007 she had undergone a Nissen fundoplication with placement of a jejunostomy feeding tube to allow for enteral nutrition. A few months prior to this encounter, she was tolerating her feedings well through the gastrostomy tube, which had been placed prior to the Nissen/jejunostomy tube in 2006. She no longer required the jejunostomy tube.  Therefore, the decision was made in March of 2012 to close the jejunostomy as it resulted in severe irritation of her skin.  After an uneventful standard general anesthetic, the jejunostomy was closed and ultimately healed after a superficial wound infection. In the ensuing months following this procedure, the patient had significant bloating with feedings and it was decided that the best course of management was replacement of the jejunostomy tube. A review of the patient’s previous anesthetics showed no prior exposure to dexmedetomidine and the clinicians used typical opiate dosing for an opiate-tolerant patient.  Her long history of agitation was treated on the inpatient wards with nurse-controlled opiate analgesic strategies. On 7th postoperative day after the proximal gastrojejunostomy, an evisceration of the intra-abdominal contents was noted secondary to fascial dehiscence, necessitating a return to the operating room for exploratory laparotomy and wound closure.

Preoperative medications included dicyclomine, ranitidine, lansoprazole, inhaled budesonide and nystatin.  The patient was held nil per os for 6 hours and was transported to the operating room where routine monitors were placed.  Following pre-oxygenation, a modified rapid sequence intubation using cricoid pressure was performed with the administration of propofol 3 mg/kg, fentanyl 2.5 µg/kg and rocuronium 0.8 mg/kg. Maintenance anesthesia consisted of desflurane with an exhaled concentration of 3-5% and morphine (0.1 mg/kg).  Surgical exploration revealed that the fascia on the patient’s right side had failed.  The remainder of the bowel was intact.  The fascia was re-approximated and an nasogastric tube was placed in the gastric pouch.  The surgical procedure lasted approximately 90 minutes. Intraoperative fluids included 800 mL of lactated Ringer’s solution and 100 mL of normal saline.  Following completion of the surgical procedure, residual neuromuscular blockade was reversed with neostigmine, administered with glycopyrrolate, and the patient’s trachea was extubated. The patient was transported to the postoperative anesthesia care unit (PACU) where there were multiple episodes of breath holding resulting in decrease of the oxygen saturation measured by pulse oximetry to 50% range.  These breath holding spells were self-limited with the addition of facemask oxygen support but were accompanied by significant agitation. She appeared to be at her reported baseline and therefore no additional laboratory analysis was deemed warranted at that time.  Along with these episodes of oxygen desaturation, the patient had hypertension (144/91 mmHg), tachycardia (heart rate 140-160 beats/minute), diaphoresis and agitation. There was minimal change following the administration of hydromorphone (0.005mg/kg) and the initiation of a hydromophone-NCA (nurse controlled analgesia). A bolus dose of dexmedetomidine (0.4 µg/kg) was administered which resulted in a decrease of her BP to 118/80 mmHg, cessation of the diaphoresis, control of agitation, and a decrease of the heart rate to 100-120 beats/minute.  She maintained her oxygen saturations >95% with a nasal cannula at 2 L/min of oxygen flow with a respiratory rate of 20-24 breaths/min.  The patient was admitted to the Pediatric ICU and a dexmedetomidine infusion at 0.3µg/kg/hr was started, in addition to the hydromorphone-NCA. The dexmedetomidine infusion was continued for 60 hours.  There were no additional episodes of hypertension, tachycardia, and agitation; she was able to be easily weaned from dexmedetomidine at the conclusion of therapy.  The remainder of her postoperative course was unremarkable and she was discharged home on postoperative day 11.

DISCUSSION

Individuals with FD present multiple intraoperative anesthetic challenges across many organ systems. Dysautonomic crisis are a common perioperative problem manifested by vomiting, diaphoresis, hemodynamic lability, bradycardia, and tachycardia. These problems can be precipitated by emotional stress, anxiety and/or pain.³ Patients with FD have a reduction in the number of peripheral neurons in the sympathetic gangliaand a loss of sympathetic innervation of blood vessels.^9,10 Orthostatic hypotension without reflex tachycardia is common in these patients and this abnormal baroreflex may be due to a dysfunctional parasympathetic system.¹¹ Additional evidence for autonomic dysfunction is the presence of a prolonged QT interval in these patients.¹² Issues related to increased sympathetic outflow in patients with FD include hyperhidrosis which may result in perioperative hypovolemia and hyponatremia.¹³ As such, perioperative management and control of the labile autonomic system is of utmost importance.^13,14

Historically, diazepam has been used to control the autonomic crises of FD while more recently clonidine, an α₂-adrenergic, has been shown to be effective for refractory cases especially those manifesting hypertension.^13,14 Like clonidine, dexmedetomidine is in the imidazole subclass of the an α₂-adrenergic agonists. The α₂:α₁ specificity of clonidine is 220:1, while that of dexmedetomidine is 1620:1, making dexmedetomidine a complete α₂-agonist.¹⁵ Additionally, dexmedetomidine has a shorter half-life (2-3 hours) compared to clonidine (12-24 hours) and is available for intravenous administration. Given its shorter half-life, it can be easily titrated by intravenous infusion while its effects dissipate more rapidly in the event of adverse effects. Additionally, there is significant experience with its perioperative use in infants and children.^6,7

Centrally acting α₂-adrenergic agonists reduce norepinephrine release through central effects on receptors in the medullary vasomotor center. Biochemical data from a cohort of 8 adult postoperative patients demonstrate the sympatholytic effects of dexmedetomidine.⁷ Following a 60 minute dexmedetomidine infusion to achieve a therapeutic plasma concentration of 600 pg/mL, the plasma norepinephrine concentration decreased from 2.1 ± 0.8 to 0.7 ± 0.3 nmol/L, the plasma epinephrine concentration decreased from 0.7 ± 0.5 to 0.2 ± 0.2 nmol/L, HR decreased from 76 ± 15 to 64 ± 11 beats/min; and systolic BP decreased from 158 ± 23 to 140 ± 23 mmHg. The same investigators evaluated changes in plasma and urinary catecholamines in 41 adult patients undergoing vascular surgery.¹⁶ When compared to patients receiving dexmedetomidine, plasma norepinephrine concentrations were 2-3 times higher at the time of tracheal extubation and at 60 minutes after arrival in the post-anesthesia care unit in the control group. Urinary normetanephrine levels increased significantly in the placebo group, while no change was noted in patients receiving dexmedetomidine. A similar sympatholytic effect has been demonstrated following the intraoperative administration of dexmedetomidine to pediatric patients undergoing cardiopulmonary bypass and surgery for congenital heart disease.¹⁷

Given that autonomic dysfunction with hyperactivity of the sympathetic nervous system may result in perioperative problems in patients with FD, there is sound physiologic rationale for the use of an agent like dexmedetomidine that effectively blunts this response.¹⁸  Dexmedetomidine has been used effectively to control the sympathetic nervous system in other disorders of autonomic dysfunction including withdrawal from alcohol as well as iatrogenic opiate or benzodiazepine use.^19-24 Anecdotal experience has also demonstrated the efficacy of dexmedetomidine to treat paroxysmal autonomic instability with dystonia (PAID). PAID, sometimes referred to as “sympathetic storms” or “dysautonomia,” is most often seen in patients with traumatic brain injury, tumor, and acute hydrocephalus.²⁵ The tachycardia, hypertension, hyperprexia, tachypenea, and diaphoresis seen in PAID patients may be due to a loss of inhibitory input to sympathetic feedback loops.²⁴  Goddeau et al reported their experience with a 38-year-old patient suffering from PAID after traumatic brain injury, who did not respond to the standard treatment including morphine, fentanyl, labetalol, lorazepam, metoprolol and clonidine.  Following the institution of a dexmedetomidine infusion which was titrated to 0.7 µg/kg/hr and continued for 72 hours, all other medications were able to be discontinued and the PAID was well controlled.

There is additional anecdotal experience with the use of dexmedetomidine in patients with FD (Table 1).^26-28 These cases demonstrate the potential utility of using dexmedetomidine as part of a balanced anesthetic technique during intraoperative care. In the first two cases, the dexmedetomidine was discontinued intraoperatively while Koshibe and Lee continued the infusion at a decreased dose of 0.2µg/kg/hr into the recovery phase until the PCA device was started. In our patient, a bolus dose of dexmedetomidine (0.4µg/kg) effectively controlled the postoperative hypertension, tachycardia, and agitation. Our patient’s agitation and hemodynamic status was not affected by the use of narcotics especially with the coexistent breath holding spells. She responded well clinically in the immediate postoperative period and into the next few days of dexmedetomidine therapy.  She was easily weaned off dexmedetomidine therapy at the conclusion of her 60 hour course.

In addition to controlling the sympathetic nervous system and potentially preventing the hemodynamic lability, that may occur in patients with FD, dexmedetomidine may also facilitate the emergence process by preventing emergence delirium, decreasing shivering, and potentiation

Table 1: Anecdotal experience with dexmedetomidine in patients with familial dysautonomia

PACU = post-anesthesia care unit; BP = blood pressure; SNP = sodium nitroprusside

of the opioid analgesia.^6,8,29  The opioid sparing effect of dexmedetomidine may be particularly important in patients with FD. Axelrod et al noted the frequent need for postoperative ventilation with the use of opioids following abdominal surgery in patients with FD.³⁰

CONCLUSION

Despite relatively limited anecdotal experience, the physiologic basis of FD and the pharmacologic mechanisms of dexmedetomidine provide a sound physiologic rationale suggesting that it should be considered as a valuable agent in the perioperative management of familial dysautonomia (FD), also known as Riley-Day syndrome.

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