Saudi Journal of Anaesthesia最新文献

A 29-year-old lady was referred to us with a rare complication of scoliosis correction surgery. She had two of the screws migrated and penetrated the descending thoracic aorta. She came to theater to have the screws removed and the aorta repaired endovascularly. The successful intervention needed a multidisciplinary team planning, coordinated work, and communication between the four involved teams: anesthesia, vascular surgery, interventional radiology, and spine surgery. There was a lot of anesthetic challenges that were new to us because of the rarity of that complication. In addition, it was another situation where the trans-esophageal echocardiography was found very useful and affected the decision making by visualizing the screws inside the aorta. The outcome was successful, and the patient was discharged home safely, hence, we would like to share our experience in managing this difficult case to help others who might find themselves in a similar situation.

Post-traumatic trigeminal neuropathic pain is one of the rare complications that could follow orofacial procedures such as dental extraction. The incidence of this type of pain following craniofacial trauma ranges between 3% and 13% depending on the type of surgery. The inferior alveolar and lingual nerves are commonly affected following molar tooth extraction. Pain usually differs from one patient to another concerning intensity and distribution. Pulsed radiofrequency treatment is one of the most widely used techniques in chronic pain management. It focuses on generating heat using radiofrequency waves at higher voltages than conventional radiofrequency while keeping tissue temperature below the neuro-destructive range. This report aims to highlight the benefit of using trigeminal ganglion pulsed radiofrequency to manage neuropathic pain following molar extraction.

Background: Efficient analgesia is the cornerstone in multiple rib fractures (MRFs) management. The serratus anterior plane block (SAPB) shows promising outcomes. However, it is still provocative whether the superficial or deep approach is more effective in the SAPB procedure. We hypothesized that the deep approach of ultrasound (US)-guided continuous SAPB could be superior for MRFs pain management.

Methods: Sixty-two adult patients having unilateral MRFs, were randomized into two groups to receive continuous superficial SAPB (group S, n = 31) or continuous deep SAPB (group D, n = 31). As a primary outcome, we compared pain numeric rating scale (NRS), while total analgesic consumption, incentive spirometer volume (IS-V), lung ultrasound score (LUSS), basal and 24-h serum beta-endorphin (BE) levels, and any adverse events were secondary outcomes.

Results: There was a significant reduction in NRS in favor of group D when compared to group S at 30 minutes (P = 0.001) until 12 hours (P = 0.029); total analgesic consumption was significantly lower in group D (P = 0.005). A significant increase in the median IS-V in group D compared to group S at 90 minutes (P = 0.02) and 12h postblock (P = 0.004) LUSS was significantly lower in D group at 90 min, 12 h, and 24 h (P = 0.04, 0.001, 0.031). No significant differences as regards serum BE levels. No adverse events were noted.

Conclusion: Either superficial or deep continuous SAPB can be used safely and effectively in managing pain related to MRFs. Notably, the deep approach offered superior analgesia and improved deep breathing compared to the superficial.

Background and aims: Priming the breathing circuit with a volatile agent plays a major role in inhalational induction. It depends on the fresh gas flow rate (FGF), concentration setting of the volatile agent, and time taken to attain the desired end-tidal concentration. The aim of the study is to compare ventilator-assisted priming (VAP) and a passive priming technique using different fresh gas flows (FGFs) in neonatal, pediatric, and adult anesthetic circuits with sevoflurane vaporizer.

Methodology: An exploratory study was conducted on a single Datex ohmeda GE Inc. workstation using three different circuits. In both techniques, FGF with 100% oxygen and 8% sevoflurane vaporizer concentration was set at 2 L/min, 4 L/min, and 8 L/min corresponding to their three groups FGF-2, FGF-4, and FGF-8, respectively. The time taken to achieve 6% sevoflurane concentration at the patient end of the circuit was measured. In this study, we have explored various combinations of tidal volumes, respiratory rates with three different fresh gas flows, and their priming time with sevoflurane consumption.

Results: The minimum time required to prime neonate, pediatric, and adult circuits using the ventilator-assisted technique to attain end-tidal sevoflurane 6% is 29 seconds, 39 seconds, and 61 seconds with 2 L/min FGF. Their corresponding sevoflurane consumptions are 0.25 ml for the neonate circuit, 0.78 ml for the pediatric circuit, and 2 ml for the adult circuit.

Conclusion: The ventilator-assisted priming technique is an effective and quick method to attain end-tidal sevoflurane 6% with low FGF (2 L/min), low tidal volume (100 ml), maximum respiratory rate (20), and minimal sevoflurane consumption when compared to the passive priming technique.

Background: The pneumoperitoneum in laparoscopic surgeries elevates intracranial ICP because of the increased abdominal pressure, and ICP increases even further in the Trendelenburg position. A new noninvasive method to measure optic nerve sheath diameter (ONSD) via ultrasonography detects the raised ICP is reliable and inexpensive and can be repeated many times.

Methods: In this prospective observational study, 23 pediatric patients aged between 5 and 16 years, undergoing elective laparoscopic procedures under general anesthesia, were included. After endotracheal intubation with proper aseptic precautions, ocular ultrasound was performed to measure baseline ONSD in both eyes. Later, pneumoperitoneum was established by maintaining the intra-abdominal pressure (IAP) at 12 cmH2O. Again, ONSD was estimated at 15 minutes of pneumoperitoneum and observed for any variation from the previous readings. The cutoff considered for ONSD was 5 mm, above which the intracranial pressure (ICP) was regarded as increased.

Results: In our study, the mean age of subjects was 9.67 ± 5.18 years. The majority were males (60.9%). The subjects showed an increase in ONSD at the 15^th minute after inducing pneumoperitoneum using abdominal CO₂ insufflation, in comparison with the baseline values, in the left eye [4.67 ± 0.48, P 0.016] and the right eye [4.63 ± 0.43]. The readings of ONSD were observed to be <5 mm, not statistically significant.

Conclusion: USG-guided ONSD measurements serve as a valuable tool in ensuring optimal intra-abdominal pressures and safe administration of anesthesia for patients undergoing laparoscopic surgery, particularly those vulnerable to an increase in ICP.

Background: Patients with multiple co-morbidities undergoing cataract surgery are at risk of hypoxia and hypercarbia secondary to the rebreathing of the accumulated carbon dioxide under the surgical drapes. They are also at risk of fire accidents due to the hyperoxic condition secondary to oxygen supplementation.

Objectives: The main aim of the study was to determine the lowest level of hemoglobin oxygen saturation while providing medical air in comparison with oxygen. Our hypothesis is that providing medical air will be non-inferior to oxygen administration in preventing hypoxia and rebreathing in these patients.

Methods: This randomized non-inferiority trial was conducted in a single center Tertiary care hospital, over a study period of March 2020 to February 2021. Fifty-six adult patients with equal gender distribution undergoing cataract surgery with multiple comorbid conditions without sedative premedications were included in the study and randomized into either Group "O" (n = 28) who received oxygen @ 4 l min^-1 through a nasal cannula with suction, and Group "A" (n = 28) who received medical air @10 l min^-1 through the circle breathing system under the drapes. The main outcome measured was the lowest hemoglobin oxygen saturation (SPO₂), the highest end-tidal carbon dioxide (hETCO₂), and the highest fraction of inspired carbon dioxide levels (hFiCO₂).

Results: The lowest mean SPO₂ measured was found to be similar between Group O and Group A with 98.8 ± 0.7 and 98.4 ± 0.9 (P = 0.081), respectively. The highest mean ETCO₂ and mean FiCO₂ values were also comparable between the Group O versus Group A with 32.8 ± 2.1 versus 33.3 ± 2.2 (P = 0.464), and 4.5 ± 1.4 versus 4.8 ± 1.8 (P = 0.464) respectively.

Conclusion: We conclude that the supplementation of compressed medical air under surgical drapes is non-inferior to nasal oxygen supplementation under regional anesthesia without causing hypoxia and hypercarbia by conserving valuable hospital resources.

Massive hemoptysis is a life-threatening pathology requiring emergent intervention to prevent airway obstruction and hypovolemic shock. Intubation followed by lung isolation should be urgently performed. We elected to place Fuji Uniblocker (Fuji Systems Corporation, Tokyo, Japan) through an endotracheal tube to isolate a hemorrhage secondary to a cavitary lung lesion caused by a large pulmonary embolus. This article examines lung isolation strategies and addresses the advantages and disadvantages in patients with massive hemoptysis.

Intraoperative tracheobronchial injury is one of the most serious complications of any thoracic surgery. Its management is really challenging both for the surgeons as well as for the anesthesiologists. We present a rare case of intraoperative tracheobronchial injury during esophagectomy and the management of the ventilation by intermittent manual occlusion of the rent as a rescue method. The left-sided bronchus got injured near the carina, while the patient was on one-lung ventilation in a lateral position and the left lung was being ventilated with a left-sided double-lumen tube (DLT). Surgeons decided to repair it in a lateral position and required the right lung to be deflated for surgical access. The endobronchial part of the tube was taken out in the trachea, and the patient was intermittently ventilated by occlusion of tracheal rent by the surgeon as a rescue measure. Intermittent apnea and ventilation were conducted, and the repair of tracheal rent was conducted in the apnea period. A negligible air leak was present after the repair. Manual occlusion of the rent can help restore ventilation in an emergency situation when other options are technically difficult.

Background and aims: Temporomandibular Joint (TMJ) ankylosis patients pose serious anesthetic challenges due to difficult airway and obstructive sleep apnoea (OSA). However, data are sparse on anesthetic management and perioperative outcomes of such patients. This study aimed to identify the anesthetic and airway management techniques in children and adolescents with TMJ ankylosis and whether the presence of retrognathia and OSA increases the risk of airway-related complications.

Materials and methods: A retrospective anesthetic chart review of TMJ ankylosis patients undergoing maxillo-facial surgery from 2008 to 2018 in a tertiary care teaching hospital in India was performed. Available anesthetic data were tabulated and analyzed. Difficult mask ventilation, use of nasopharyngeal airway (NPA), difficult intubation, desaturation at induction and extubation, maneuvers to open the airway at extubation, and any post-operative anesthetic complications were noted.

Results: Three hundred seventy-two children including 85 patients of OSA were available for analysis. All patients with OSA had retrognathia. Fiber-optic bronchoscopy (FOB) guided intubation was performed in 362 (97.3%) patients. Desflurane and fentanyl were common anesthetics used for the maintenance of anesthesia. Difficult mask ventilation, use of nasopharyngeal airway (NPA) and requirement of airway maneuvers were more common in OSA patients than in non-OSA patients. Difficult mask ventilation was observed in 18.0% and difficult intubation in 12.9% of patients. Desaturation at induction was noted in 5.1% of patients but none required emergency surgical airway access. Maneuvres to open the airway at extubation were required in 24.5% of patients and the incidence of desaturation at extubation was 7.2%. However, no serious adverse event was noted and only one patient required reintubation.

Conclusion: FOB-guided intubation should be considered the technique of choice in TMJ ankylosis patients. In the presence of retrognathia and OSA chance of difficult mask ventilation, requirement of NPA and difficulty in maintaining the airway after extubation increase significantly.