- Email: [email protected]
Follow-up to ‘Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open?’
Correspondence / Journal of Clinical Anesthesia 25 (2013) 240-246
Chih-Hung Wang MD, PhD (Associate Professor of Otolaryngology) Department of Otolaryngology-Head and Neck Surgery Tri-Service General Hospital and National Defense Medical Center Neihu 114, Taipei, Taiwan
This “180° upside down maneuver” is easy to perform and improves the success rate in patients with limited mouth opening.
Manpreet Singh MD, FCCP, FIMSA, FACEE, FCCS (Assistant Professor) Kamlesh Kumari MBBS (Postgraduate Resident in Anaesthesia) Dheeraj Kapoor MD, FCCP, FCCS, FACEE (Assistant Professor) Jasveer Singh MD (Assistant Professor) Department of Anaesthesia and Intensive Care Govt. Medical College and Hospital Chandigarh 160030, India E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2012.11.005
References [1] Stoneham MD. The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy. Anaesthesia 1993;48:575–80. [2] Han DW, Shim YH, Shin CS, Lee YW, Lee JS, Ahn SW. Estimation of the length of the nares-vocal cord. Anesth Analg 2005;100:1533–5. [3] Hwang CL, Luu KC, Wu TJ, et al. Estimation of the length of nasopharyngeal airway in Chinese adults. Ma Zui Xue Za Zhi (Acta Anaesthesiol Taiwan) 1990;28:49–54. [4] Roberts K, Whalley H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J 2005;22:394–6. [5] Milam MG, Miller KS. Aspiration of an artificial nasopharyngeal airway. Chest 1988;93:223–4. [6] Yokoyama T, Yamashita K, Manabe M. Airway obstruction caused by nasal airway. Anesth Analg 2006;103:508–9. [7] Mahajan R, Bassi R, Mehta S. Retrieval of aspirated nasopharyngeal airway using Foley catheter. Anesth Analg 2010;110:1245–6. [8] Bajaj Y, Gadepalli C, Knight LC. Securing a nasopharyngeal airway. J Laryngol Otol 2008;122:733–4. [9] Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg 2007;104:1313.
“180° upside down maneuver” for ease of endotracheal tube insertion with the GlideScope in patients with limited mouth opening
243
http://dx.doi.org/10.1016/j.jclinane.2012.12.006
References [1] Sakles JC, Brown CA. Videolaryngoscopy. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 168–82. [2] Walls RM, Samuels-Kalow M, Perkins A. A new maneuver for endotracheal tube insertion during difficult GlideScope intubation. J Emerg Med 2010;39:86–8.
Follow-up to ‘Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open?’
To the Editor: To the Editor: The GlideScope (Verathon, Bothell, WA, USA) videolaryngoscope is widely used in the management of a difficult or failed airway in elective and emergency situations [1]. Intubation of the trachea in patients with reduced mouth opening presents a challenge for anesthesiologists. Optimal mouth opening is one of the critical determinants in the selection of an airway device or technique, and insertion of an endotracheal tube (ETT) is always difficult when the GlideScope blade is in situ, particularly with limited mouth opening and a small oral orifice. We routinely follow the recommended maneuver that was described by Walls et al for ease of ETT insertion when using the GlideScope [2]. Yet even with this maneuver, we have encountered numerous problems when introducing the tip of the ETT in those patients with limited mouth opening. We describe a method that improves the ease of insertion and success rate. The steps of the troubleshooting maneuver are: 1. Insert the GlideScope blade in the midline and try to visualize the epiglottis and the “target”, ie, the glottic aperture. 2. Insert the ETT into the mouth (premounted with the manufacturer’s stylet, with stylet tip just behind the ETT’s distal end) with convexity anteriorly until the tip touches the hard palate. 3. Rotate the ETT 180° counterclockwise, gently advancing the ETT such that the curvature follows the contour of the floor of the mouth, until it reaches the glottic aperture. Counterclockwise rotation may easily avoid the blade, which may act as an obstacle to ETT insertion. 4. Withdraw the stylet 2.5 - 5 cm (1 to 2 inches) outside and slide the ETT further into trachea. 5. Withdraw the stylet completely, followed by the GlideScope blade, and secure the ETT with tape.
We previously reported an obese patient with cholelithiasis and acute cholecystitis, who was scheduled to undergo an emergency laparoscopic cholecystectomy, but was recognized preoperatively to have a large patent foramen ovale (PFO) with a right-to-left shunt that was open at rest [1]. She also had concomitant choledocholithiasis, and she underwent an endoscopic sphincterotomy with prompt resolution of her fever and abdominal pain. At the time, the benefits of laparoscopy were weighed against the risk of paradoxical emboli and stroke, and the choice of either a laparoscopic or open cholecystectomy was discussed carefully with the patient and her family. The patient chose to return home, and she declined surgical intervention. Five years after this initial evaluation in 2007, the patient returned to the Emergency Department with right upper quadrant pain, fever, and symptoms of recurrent biliary tract disease. A computed tomography scan and ultrasound confirmed acute cholecystitis and were suspicious for gallbladder perforation, with the possibility of an underlying malignancy. The General Surgery service was consulted, and the patient was admitted to the hospital. The risk of a paradoxical embolus was revisited perioperatively [1], but because of the refractory symptoms, concern for worsening sepsis, and the suspicion of malignancy, the patient was counseled to undergo surgical intervention. Laparoscopy was attempted initially and the patient tolerated pneumoperitoneum with no cardiovascular events. However, because dense pericholecystic adhesions were severe, the case was converted to an open approach for safety. There was no gross or microscopic evidence of malignancy. The procedure was otherwise uncomplicated and the patient made a full recovery without any neurologic events. The decision not to operate in 2007 was made primarily by the patient on the grounds that the combined risks of surgery with her patent foramen ovale (PFO) were greater than the future risks of
244
Correspondence / Journal of Clinical Anesthesia 25 (2013) 240–246
recurrent biliary tract disease. Ultimately, she required an open cholecystectomy, but it is unclear whether this procedure would have been necessary 5 years earlier. The severity of her inflammation in 2012 may have resulted from a low-grade chronic inflammation that evolved into chronic cholecystitis and scarring. The consensus in the surgical literature strongly recommends earlier over delayed cholecystectomy, though the rate of conversion to an open procedure is higher than in the setting of an uninflamed gallbladder [2]. New approaches to close the PFO preoperatively were discussed in 2012, but the state of the technology has not advanced to the point that an effective and standardized intervention would have been indicated. In addition, the prevalence of an undiagnosed PFO in the general population is not insignificant, yet the incidence of perioperative paradoxical embolism after laparoscopy remains low. Based on the current literature and the current case, we conclude that 1) acute cholecystitis is best treated early, preferably during the initial presentation, as the likelihood of recurrent cholecystitis is significant; 2) maintaining a low threshold for converting to an open cholecystectomy is advised; 3) patients with PFO may tolerate pneumoperitoneum without increased risk of neurologic events; and 4) vigilance for perioperative events should be maintained at a high level.
Pringl L. Miller MD (Clinical Instructor UCSF) Division of General Surgery, Department of Surgery University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA Larry Litt MD (Professor of Anesthesia UCSF) Department of Anesthesia and Perioperative Care University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA Nelson Schiller MD (Professor of Cardiology UCSF) Division of Cardiology, Department of Medicine University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA
A healthy, 14 year old, 50 kg girl who presented with a diagnosis of cervical spinal tumor (C4, intradural extramedullar), was scheduled to undergo tumor resection. No remarkable medical history was noted preoperatively, and routine blood coagulation tests were normal. Anesthesia induction was performed with intravenous (IV) midazolam 1 mg, sulfentanil 20 μg, propofol 100 mg, and cisatracurium 10 mg. Tracheal intubation was achieved using a 6.5-mm inner diameter, cuffed endotracheal tube during direct laryngoscopy. Intravenous balanced general anesthesia was maintained with propofol 5~10 mg/ kg/hr (adjusted according to bispectral index values), and IV sulfentanil 10 μg or IV cisatracurium 5 mg injected intermittently. Systolic blood pressure was controlled in the range of 80 - 140 mmHg during the threehour surgery. The tumor was resected following laminectomy and durotomy, and the surgery was completed successfully. However, the patient presented with significantly delayed emergence from anesthesia. The patient was unconscious and needed assisted ventilation due to weak spontaneous respiratory efforts during the first hour after surgery. The result of arterial blood gas analysis indicated carbon dioxide retention (PaCO2 50 mmHg). Pupils were equal (to 4 mm), bilateral pupillary light reflexes were absent, and bilateral Babinski signs were positive. From these findings, the consultant neurologist felt the diagnosis was the residual effect of the anesthetics and suggested that conservative care be maintained. Because the clinical signs showed no improvement after 30 minutes, brain computed tomography (CT) was performed, showing bilateral epidural hemorrhages (Fig. 1). The patient rapidly underwent bilateral epidural hematoma evacuation. She recovered well and was discharged two weeks later without any neurological deficits. Intracranial hemorrhage is an unpredictable and rare complication of spine surgery, and most reported cases are associated with cerebellar hemorrhage. Though the mechanism of such complications in spine surgery remains unclear, loss of cerebrospinal fluid (CSF) may play an important role [5,6,9]. In the present case, the pathogenesis of bilateral epidural hemorrhages may have shared similar mechanisms for the following reasons. First, no bleeding propensity was noted preoperatively and routine blood coagulation tests were normal.
John Maa MD (Assistant Professor of Surgery UCSF) Division of General Surgery, Department of Surgery University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2012.12.003
References [1] Thoma MS, Maa J, Schiller NB, Litt L. Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open? J Clin Anesth 2010;22:553–6. [2] Chong CC, Chiu PW, Lee KF, Lai PB. Timing of laparoscopic cholecystectomy in acute cholecystitis: any controversy? Surg Pract 2012;16:22–7.
Delayed emergence from anesthesia resulting from bilateral epidural hemorrhages during cervical spine surgery To the Editor: Intracranial hemorrhage is a rare complication of spine surgery and most reported cases are associated with cerebellar hemorrhage [1-11]. A case of bilateral epidural hemorrhages during cervical spine surgery is presented.
Fig. 1. Plain computed tomographic image of the head 2.5 hours after surgery. Note the bilateral epidural hemorrhages.
Chih-Hung Wang MD, PhD (Associate Professor of Otolaryngology) Department of Otolaryngology-Head and Neck Surgery Tri-Service General Hospital and National Defense Medical Center Neihu 114, Taipei, Taiwan
This “180° upside down maneuver” is easy to perform and improves the success rate in patients with limited mouth opening.
Manpreet Singh MD, FCCP, FIMSA, FACEE, FCCS (Assistant Professor) Kamlesh Kumari MBBS (Postgraduate Resident in Anaesthesia) Dheeraj Kapoor MD, FCCP, FCCS, FACEE (Assistant Professor) Jasveer Singh MD (Assistant Professor) Department of Anaesthesia and Intensive Care Govt. Medical College and Hospital Chandigarh 160030, India E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2012.11.005
References [1] Stoneham MD. The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy. Anaesthesia 1993;48:575–80. [2] Han DW, Shim YH, Shin CS, Lee YW, Lee JS, Ahn SW. Estimation of the length of the nares-vocal cord. Anesth Analg 2005;100:1533–5. [3] Hwang CL, Luu KC, Wu TJ, et al. Estimation of the length of nasopharyngeal airway in Chinese adults. Ma Zui Xue Za Zhi (Acta Anaesthesiol Taiwan) 1990;28:49–54. [4] Roberts K, Whalley H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J 2005;22:394–6. [5] Milam MG, Miller KS. Aspiration of an artificial nasopharyngeal airway. Chest 1988;93:223–4. [6] Yokoyama T, Yamashita K, Manabe M. Airway obstruction caused by nasal airway. Anesth Analg 2006;103:508–9. [7] Mahajan R, Bassi R, Mehta S. Retrieval of aspirated nasopharyngeal airway using Foley catheter. Anesth Analg 2010;110:1245–6. [8] Bajaj Y, Gadepalli C, Knight LC. Securing a nasopharyngeal airway. J Laryngol Otol 2008;122:733–4. [9] Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg 2007;104:1313.
“180° upside down maneuver” for ease of endotracheal tube insertion with the GlideScope in patients with limited mouth opening
243
http://dx.doi.org/10.1016/j.jclinane.2012.12.006
References [1] Sakles JC, Brown CA. Videolaryngoscopy. In: Walls RM, Murphy MF, editors. Manual of emergency airway management. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 168–82. [2] Walls RM, Samuels-Kalow M, Perkins A. A new maneuver for endotracheal tube insertion during difficult GlideScope intubation. J Emerg Med 2010;39:86–8.
Follow-up to ‘Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open?’
To the Editor: To the Editor: The GlideScope (Verathon, Bothell, WA, USA) videolaryngoscope is widely used in the management of a difficult or failed airway in elective and emergency situations [1]. Intubation of the trachea in patients with reduced mouth opening presents a challenge for anesthesiologists. Optimal mouth opening is one of the critical determinants in the selection of an airway device or technique, and insertion of an endotracheal tube (ETT) is always difficult when the GlideScope blade is in situ, particularly with limited mouth opening and a small oral orifice. We routinely follow the recommended maneuver that was described by Walls et al for ease of ETT insertion when using the GlideScope [2]. Yet even with this maneuver, we have encountered numerous problems when introducing the tip of the ETT in those patients with limited mouth opening. We describe a method that improves the ease of insertion and success rate. The steps of the troubleshooting maneuver are: 1. Insert the GlideScope blade in the midline and try to visualize the epiglottis and the “target”, ie, the glottic aperture. 2. Insert the ETT into the mouth (premounted with the manufacturer’s stylet, with stylet tip just behind the ETT’s distal end) with convexity anteriorly until the tip touches the hard palate. 3. Rotate the ETT 180° counterclockwise, gently advancing the ETT such that the curvature follows the contour of the floor of the mouth, until it reaches the glottic aperture. Counterclockwise rotation may easily avoid the blade, which may act as an obstacle to ETT insertion. 4. Withdraw the stylet 2.5 - 5 cm (1 to 2 inches) outside and slide the ETT further into trachea. 5. Withdraw the stylet completely, followed by the GlideScope blade, and secure the ETT with tape.
We previously reported an obese patient with cholelithiasis and acute cholecystitis, who was scheduled to undergo an emergency laparoscopic cholecystectomy, but was recognized preoperatively to have a large patent foramen ovale (PFO) with a right-to-left shunt that was open at rest [1]. She also had concomitant choledocholithiasis, and she underwent an endoscopic sphincterotomy with prompt resolution of her fever and abdominal pain. At the time, the benefits of laparoscopy were weighed against the risk of paradoxical emboli and stroke, and the choice of either a laparoscopic or open cholecystectomy was discussed carefully with the patient and her family. The patient chose to return home, and she declined surgical intervention. Five years after this initial evaluation in 2007, the patient returned to the Emergency Department with right upper quadrant pain, fever, and symptoms of recurrent biliary tract disease. A computed tomography scan and ultrasound confirmed acute cholecystitis and were suspicious for gallbladder perforation, with the possibility of an underlying malignancy. The General Surgery service was consulted, and the patient was admitted to the hospital. The risk of a paradoxical embolus was revisited perioperatively [1], but because of the refractory symptoms, concern for worsening sepsis, and the suspicion of malignancy, the patient was counseled to undergo surgical intervention. Laparoscopy was attempted initially and the patient tolerated pneumoperitoneum with no cardiovascular events. However, because dense pericholecystic adhesions were severe, the case was converted to an open approach for safety. There was no gross or microscopic evidence of malignancy. The procedure was otherwise uncomplicated and the patient made a full recovery without any neurologic events. The decision not to operate in 2007 was made primarily by the patient on the grounds that the combined risks of surgery with her patent foramen ovale (PFO) were greater than the future risks of
244
Correspondence / Journal of Clinical Anesthesia 25 (2013) 240–246
recurrent biliary tract disease. Ultimately, she required an open cholecystectomy, but it is unclear whether this procedure would have been necessary 5 years earlier. The severity of her inflammation in 2012 may have resulted from a low-grade chronic inflammation that evolved into chronic cholecystitis and scarring. The consensus in the surgical literature strongly recommends earlier over delayed cholecystectomy, though the rate of conversion to an open procedure is higher than in the setting of an uninflamed gallbladder [2]. New approaches to close the PFO preoperatively were discussed in 2012, but the state of the technology has not advanced to the point that an effective and standardized intervention would have been indicated. In addition, the prevalence of an undiagnosed PFO in the general population is not insignificant, yet the incidence of perioperative paradoxical embolism after laparoscopy remains low. Based on the current literature and the current case, we conclude that 1) acute cholecystitis is best treated early, preferably during the initial presentation, as the likelihood of recurrent cholecystitis is significant; 2) maintaining a low threshold for converting to an open cholecystectomy is advised; 3) patients with PFO may tolerate pneumoperitoneum without increased risk of neurologic events; and 4) vigilance for perioperative events should be maintained at a high level.
Pringl L. Miller MD (Clinical Instructor UCSF) Division of General Surgery, Department of Surgery University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA Larry Litt MD (Professor of Anesthesia UCSF) Department of Anesthesia and Perioperative Care University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA Nelson Schiller MD (Professor of Cardiology UCSF) Division of Cardiology, Department of Medicine University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA
A healthy, 14 year old, 50 kg girl who presented with a diagnosis of cervical spinal tumor (C4, intradural extramedullar), was scheduled to undergo tumor resection. No remarkable medical history was noted preoperatively, and routine blood coagulation tests were normal. Anesthesia induction was performed with intravenous (IV) midazolam 1 mg, sulfentanil 20 μg, propofol 100 mg, and cisatracurium 10 mg. Tracheal intubation was achieved using a 6.5-mm inner diameter, cuffed endotracheal tube during direct laryngoscopy. Intravenous balanced general anesthesia was maintained with propofol 5~10 mg/ kg/hr (adjusted according to bispectral index values), and IV sulfentanil 10 μg or IV cisatracurium 5 mg injected intermittently. Systolic blood pressure was controlled in the range of 80 - 140 mmHg during the threehour surgery. The tumor was resected following laminectomy and durotomy, and the surgery was completed successfully. However, the patient presented with significantly delayed emergence from anesthesia. The patient was unconscious and needed assisted ventilation due to weak spontaneous respiratory efforts during the first hour after surgery. The result of arterial blood gas analysis indicated carbon dioxide retention (PaCO2 50 mmHg). Pupils were equal (to 4 mm), bilateral pupillary light reflexes were absent, and bilateral Babinski signs were positive. From these findings, the consultant neurologist felt the diagnosis was the residual effect of the anesthetics and suggested that conservative care be maintained. Because the clinical signs showed no improvement after 30 minutes, brain computed tomography (CT) was performed, showing bilateral epidural hemorrhages (Fig. 1). The patient rapidly underwent bilateral epidural hematoma evacuation. She recovered well and was discharged two weeks later without any neurological deficits. Intracranial hemorrhage is an unpredictable and rare complication of spine surgery, and most reported cases are associated with cerebellar hemorrhage. Though the mechanism of such complications in spine surgery remains unclear, loss of cerebrospinal fluid (CSF) may play an important role [5,6,9]. In the present case, the pathogenesis of bilateral epidural hemorrhages may have shared similar mechanisms for the following reasons. First, no bleeding propensity was noted preoperatively and routine blood coagulation tests were normal.
John Maa MD (Assistant Professor of Surgery UCSF) Division of General Surgery, Department of Surgery University of California, San Francisco UCSF Hospital, San Francisco, CA 94143-0790, USA E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2012.12.003
References [1] Thoma MS, Maa J, Schiller NB, Litt L. Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open? J Clin Anesth 2010;22:553–6. [2] Chong CC, Chiu PW, Lee KF, Lai PB. Timing of laparoscopic cholecystectomy in acute cholecystitis: any controversy? Surg Pract 2012;16:22–7.
Delayed emergence from anesthesia resulting from bilateral epidural hemorrhages during cervical spine surgery To the Editor: Intracranial hemorrhage is a rare complication of spine surgery and most reported cases are associated with cerebellar hemorrhage [1-11]. A case of bilateral epidural hemorrhages during cervical spine surgery is presented.
Fig. 1. Plain computed tomographic image of the head 2.5 hours after surgery. Note the bilateral epidural hemorrhages.