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References [1] Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978; 49:399-406. [2] Desmeules H, Tremblay PR. Laryngoscope blade breakage during intubation. Can J Anaesth 1988;35:202-3. [3] Paterson JG. Laryngoscope breakage. Can J Anaesth 2000;47:927.
Fig. 2
Lateral view of misplaced light source.
Paralyzed by beauty
Fig. 3 View of sidewall hole and groove where the light source should have been assembled.
In the current case, the laryngoscope (fiberoptic Macintosh 4; Welch Allyn, Skaneateles Falls, NY, USA) was engaged to illuminate the light and was functional. The patient was brought to the operating room and general anesthesia was induced. Bag ventilation was easy and after adequate relaxation, direct laryngoscopy was performed. On insertion of the laryngoscope into the patient’s mouth, no pharyngeal illumination was obtained and no anatomical landmarks could be seen. The laryngoscope was removed and found to have a functioning light source. A second insertion again showed darkness of the hypophaynx. An additional laryngoscope blade (fiberoptic Miller 2, Welch Allyn) was inserted and successful intubation was performed. Further analysis of the Macintosh 4 blade showed that the fiberoptic light source had been placed on the wrong side of the flange [Figs. 1, 2, and 3]. The individual responsible for cleaning the blade frequently removes the fiberoptic channel and, in this case, he screwed the fiberoptic bundle back on the blade incorrectly. The fiberoptic bundle was not passed through the sidewall to the right side of the blade. The light source was misplaced on the left side of the flange, which is used to sweep the tongue to the left during direct laryngoscopy. Therefore, the light shone only onto the patient’s tongue and did not illuminate the airway. Thomas E. Schulte MD (Assistant Professor of Anesthesiology) Ankit Agrawal (Clinical Researcher) Department of Anesthesiology University of Nebraska Medical Center Omaha, NE 68198-4455, USA E-mail address:
[email protected] doi:10.1016/j.jclinane.2011.02.012
To the Editor: A 46 year old woman, who appeared younger than her stated age, presented for a general anesthetic to rule out ovarian cancer. She had normal laboratory values and she denied medical or surgical history other than one diagnostic laparoscopy. The patient denied plastic surgery in front of her husband, but a chin implant surgery was noted in her chart. On the way to the operating room, she again denied any surgeries. We noted that she had chin implant, breast implant, blepharoplasty, and rhinoplasty scars. After preoxygenation of the patient, fentanyl, propofol, and rocuronium 0.6 mg/kg were given, followed by an easy intubation. The procedure was over within 75 minutes. Trainof-four stimulation of the facial nerve at 10 mA was checked, with no visual or tactile twitches elicited. We checked the nerve stimulator on ourselves with effect at 3.0 mA. Using the same nerve stimulator, 4 strong twitches were then elicited at the ulnar nerve with 10 mA. A repeated stimulus at the facial nerve yielded no twitches. The skin was cleaned and the electrodes were moved further apart to attempt to capture the facial nerve. Four strong sternocleidomastoid muscular contractions occurred during stimulation, with her head vigorously turning down and to the right. Reversal was then administered. In the recovery room, she confirmed all suspected cosmetic procedures and multiple recent “heavy botox” treatments. She made an uneventful recovery. Botox may prohibit the ability of a nerve stimulator from eliciting a response along the facial nerve [1]. Furthermore, history of a chin implant could obfuscate thyromental distance evaluation, leading to difficult mask ventilation [2] or unanticipated difficult intubation [3,4]. Patients with a cosmetic surgery history, those who appear to have undergone cosmetic procedures, or those who appear younger than their stated age should be asked if they have had Botox injections or other cosmetic surgeries. Failure to do so may delay anesthesia reversal, with safety and financial implications. Carlos Brun MD (Staff Anesthesiologist and Intensivist) John G. Brock-Utne MD, PhD, FFA(SA) (Professor of Anesthesia) Department of Anesthesia Stanford University School of Medicine Stanford, CA, USA
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Correspondence Veterans Affairs Palo Alto Medical Center Palo Alto, CA 94304, USA E-mail address:
[email protected]
doi:10.1016/j.jclinane.2011.09.002
References [1] Ward SJ, Harrop-Griffiths W. Botox injections and monitoring neuromuscular blockade. Anaesthesia 2006;61:726. [2] Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006;105:885-91. [3] Haddow GR, Brodsky JB, Brock-Utne JG, Azar DR, Kaye B. Difficult laryngoscopy masked by previous cosmetic surgery. Plast Reconstr Surg 1991;87:1143-4. [4] Boorin MR. Unanticipated difficult endotracheal intubation related to preexisting chin implant and mandibular condylar resorption. Anesth Analg 1997;84:686-9.
Intractable neuropathic pain due to ulnar nerve entrapment treated with cannabis and ketamine 10% To the Editor: Since 1994, various case reports, pilot studies, and clinical trials have documented the efficacy and safety of ketamine in the treatment of chronic neuropathic pain [1]. Due to its unique mechanism of action, ketamine is a highly interesting drug for the treatment of therapy-resistant chronic pain syndromes, and it may be administered in various ways, such as via oral, sublingual, intranasal, rectal, and transdermal routes. Long periods of decreased pain may be induced by relatively short courses of ketamine intravenously (IV). Complex Regional Pain Syndrome Type 1 patients suffering from severe pain were successfully treated for 4 days with a continuous infusion of low-dose S-ketamine over 11 weeks, without a reemergence of their pain. However, one of the troublesome clinical aspects of (IV) ketamine is the reemergence of pain after some weeks, and thus the necessity to re-administer ketamine infusions [2]. Cannabis has been used to treat pain for thousands of years [3]. It is considered by pain specialists a viable treatment option for patients suffering from neuropathic pain, based on a great variety of preclinical and clinical findings [4]. In our clinic, we gained experience prescribing 10% racemic ketamine cream in patients with refractory pain in combination with cannabis. A 56 year old woman suffered from severe chronic neuropathic pain due to entrapment of the nervus ulnaris dextra, leading to cubital tunnel syndrome. She had a long and complicated medical history. At the age of 7 she had a traumatic fracture of the radius, which was surgically broken after 6 weeks to optimize healing. In 1966, a new accident led to a second fracture of the same radius; three years later, a third fracture occurred in which a bone chip could not be realigned with the caput radii. In 1972, she suffered the first episode of elbow immobility due to a wandering bone chip. During
surgical extirpation of the bone chip, the ulnar nerve was damaged. Postoperatively, she had no movement of the pinky and ring fingers for two weeks. In 1977, her elbow was traumatized due to a bicycle accident, and painful tingling irradiation at the ulnar side of the arm emerged, accompanied by muscle weakness and cramps. In 1996, pain intensified in the innervation area of the nervus ulnaris; the neurosurgeon moved the ulnar nerve to the radial side of the elbow, which resulted in profound pain reduction. In 2004, the pain intensified again. Diclofenac 75 mg combined with misoprostol 200 μg, ibuprofen 400 mg, acetaminophen, physical therapy, and acupuncture had only a moderate effect; the pain decreased from 8 to 6 on an 11-point numerical rating scale (NRS). In 2006, the orthopedic surgeon concluded that the elbow joint was severely arthritic; very little cartilage remained; and the joint was filled with debris. In 2006, the elbow, immobile once more, was surgically re-explored to extirpate the caput radii and to clean the joint of all debris, resulting in more mobility of the joint but no effect on the pain. In 2008, magnetic resonance imaging showed impingement of the ulnar nerve due to several adhesions. New surgical exploration showed adhesions of approximately 12 cm and adhesiolysis followed, without any clinical benefits. In January 2009, the patient's pain was again severe, NRS 9. This time she received acetaminophen/codeine 500 mg/ 10 mg three times daily, pregabalin 75 mg three times daily, and oxycodone 10 mg, which reduced the pain to NRS 7, though she suffered considerable side effects. One month later, she consulted our clinic. On the NRS she scored 8. She also scored 8 on the Douleur Neuropathique 4 questionnaire (DN-4; total score 10), which corresponded to severe neuropathic pain. The pain was characterized as burning, tingling, stinging, a painful cold sensation, and itching. At the same time, numbness and hypoesthesia, as tested by slight pressure and a pinprick in the innervation area of the ulnar nerve, were present. Transcutaneous electrical nerve stimulation reduced her pain from NRS 8 to 5, but it lasted only for an hour. She stopped the medication due to severe side effects and started our prescribed treatment: oral cannabis ingested in the form of homemade cookies consisting of 10 grams of Dutch government-grown, prescription cannabis – 20 cookies. Each cookie weighed 10 g, and the patient ate one third of a cookie three times daily, or a total of a half a g of cannabis per day. The patient preferred this regimen to smoking or herbal cannabis tea. The latter form of ingestion of cannabis is suboptimal due to the erratic resorption of the lipophilic cannabinoids. The cookies were made in such a way that homogeneity of the cannabinoids in the dough was guaranteed. Pain scores subsequently decreased from NRS 8 to 5. Adding amitriptyline 5% cream twice daily did not lower pain intensity, though the patient slept better and had no more depressive feelings due to the pain. Adding a racemic ketamine cream 10% twice daily, 2.0 to 4.0 mL per application, further reduced the pain (NRS 2 to 3). In the morning, she no longer experienced pain. But if she