| Unfractionated heparin |
| Known allergy |
| History of HITs |
| Low-molecular-weight heparin |
| Known allergy |
| History of HITs |
| Invasive procedure within the previous 24 h |
| Systemic TPA |
| Known allergy |
| Active bleeding |
| Central nervous system ischemia/hemorrhage/surgery within the previous 10 d (includes birth asphyxia) |
| Surgery within the previous 7 d |
| Invasive procedure within the previous 3 d |
| Seizures within the previous 48 h |
| Thrombolysis by interventional radiology |
| Known allergy |
| In cases where needed, inability to place a vena cava filter |
| Limitations are size of involved vessels and experience of interventionalists |
Thursday, January 3, 2019
How I treat venous thrombosis in children Contraindications to specific antithrombotic therapies in infants and children
Beware of upper airway obstruction in warfarinized patients : Initial management included nursing the patient upright and administration of oxygen through a non-rebreath mask, at a flow rate of 15 L/min. Intravenous vitamin K was administered immediately. After a hematology consult, four-factor prothrombin complex concentrate (Beriplex P/N; CSL Behring UK, West Sussex, UK) was administered as a rapid reversal of anticoagulation. Once stabilized, she was transferred to theater for fibreoptic intubation, with an ENT team available to establish a surgical airway. The patient was successfully intubated through the oral route and was transferred to the intensive care unit for further support.
Beware of upper airway obstruction in warfarinized patients
Tiarnan Magos, Martyn Barnes
Department of Otolaryngology and Head and Neck Surgery, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea SS0 0RY, UK
| Date of Web Publication | 3-Jan-2019 |
     |
Correspondence Address:
Tiarnan Magos
Department of Otolaryngology and Head and Neck Surgery, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea SS0 0RY
UK
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joacp.JOACP_116_16
| How to cite this article: Magos T, Barnes M. Beware of upper airway obstruction in warfarinized patients. J Anaesthesiol Clin Pharmacol 2018;34:550-2 |
| How to cite this URL: Magos T, Barnes M. Beware of upper airway obstruction in warfarinized patients. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2019 Jan 4];34:550-2. Available from: http://www.joacp.org/text.asp?2018/34/4/550/249286 |
Madam,
We would like to draw attention to the airway risks of anticoagulation with coumarins. Patients on a coumarin are at risk of spontaneous upper airway obstruction secondary to hematoma if anticoagulation is poorly controlled. Treatment in these instances needs to be prompt and includes medical, anesthetic, and potentially surgical intervention. We recently encountered a patient with acute airway obstruction secondary to spontaneous lingual, sublingual, and supraglottic hematoma while on warfarin.
An 86-year-old woman was admitted under the care of the medical team and treated for a community-acquired pneumonia and pulmonary edema. On day 3 of her admission, she was noted to have malar, chin, and submental ecchymosis [Figure 1]. Within 24 h, it was noted that she was in respiratory distress with clearly audible stertor and a subtle inspiratory stridor. Her respiratory rate was noted to have increased and her oxygen saturations dropped from 96% to 90% on room air. This was accompanied by significant chin, submental, neck, and upper chest ecchymosis [Figure 1] and [Figure 2] post intubation]. Oral examination revealed a swollen and purple tongue and floor of mouth, consistent with lingual and sublingual hamatomas. Flexible nasoendoscopy revealed diffuse submucosal supraglottic hematoma with a narrowed laryngeal inlet. Blood screening demonstrated an international normalized ratio of 4 and a stable hemoglobin and platelet count. Initial management included nursing the patient upright and administration of oxygen through a non-rebreath mask, at a flow rate of 15 L/min. Intravenous vitamin K was administered immediately. After a hematology consult, four-factor prothrombin complex concentrate (Beriplex P/N; CSL Behring UK, West Sussex, UK) was administered as a rapid reversal of anticoagulation. Once stabilized, she was transferred to theater for fibreoptic intubation, with an ENT team available to establish a surgical airway. The patient was successfully intubated through the oral route and was transferred to the intensive care unit for further support. Subsequently respiratory failure after 24 h of ventilation in the ICU led to unfortunate demise of the patient.
 | Figure 1: Malar, chin, and submental ecchymosis seen on day 3 Click here to view |
 | Figure 2: Chin, submental, neck, and upper chest ecchymosis seen post intubation on day 5 Click here to view |
It is well known that patients on coumarins are at higher risk of significant spontaneous hemorrhage, both intracranially and extracranially.[1] Spontaneous hemorrhage and hematoma formation have been reported in the upper airway, including in sublingual, submandibular, and laryngeal submucosal spaces.[2],[3],[4] Quick recognition of these potentially life-threatening presentations is necessary to ensure timely reversal of anticoagulation and placement of a definitive airway if necessary. The initial management of these patients should include oxygen therapy, upper airway evaluation with flexible laryngoscopy, reversal of anticoagulation, and close monitoring.[4] The timing and mode of securing the airway remain controversial and without consensus.[5] Uppal et al. state that cricothyroidotomy may be preferable to surgical tracheostomy in such cases, as dissection inevitably involves less blood loss given the avascular nature of the overlying tissues, and the patient's requirement for a surgical airway is likely to be brief.[6]From the literature, it appears that discrete laryngeal hematomas are less likely to require a definitive airway intervention than diffuse lingual, sublingual, retropharyngeal, and submucosal haematomas.[7]
Upper airway hematomas are rare but potentially life-threatening complications of anticoagulation. Awareness of their occasionally unprecipitated nature is important. In such cases, we recommend timely reversal of anticoagulation, close airway monitoring with serial flexible endoscopy, and early consideration of intubation in theater, with ENT team prepared to immediately secure a surgical airway in case of failed intubation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Videolaryngoscope-assisted nasotracheal intubation
: Another option!
Nishkarsh Gupta1, Anju Gupta2
1 Department of Onco Anesthesia and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India
2 Department of Anesthesiology and Intensive Care, VMMC and Associated Safdarjung Hospital, New Delhi, India
| Date of Web Publication | 3-Jan-2019 |
| |
Correspondence Address:
Nishkarsh Gupta
437 Pocket A, Sarita Vihar, New Delhi
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joacp.JOACP_183_16
| How to cite this article: Gupta N, Gupta A. Videolaryngoscope-assisted nasotracheal intubation: Another option!. J Anaesthesiol Clin Pharmacol 2018;34:554-5 |
| How to cite this URL: Gupta N, Gupta A. Videolaryngoscope-assisted nasotracheal intubation: Another option!. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2019 Jan 4];34:554-5. Available from: http://www.joacp.org/text.asp?2018/34/4/554/249295 |
Madam,
We read with interest the article on Truview PCD-video laryngoscope (VL) aided nasotracheal intubation (NTI) in cases series of orofacial malignancy with limited mouth opening by Patil et al.[1] We appreciate their use of Truview PCD VL for NTI in orofacial malignancy.
Despite the recent advances in airway management, NTI in oral and maxillofacial surgeries remains challenging. Submandibular stiffness, decreased mouth opening, and associated deformities of facial structures limit the available choices for airway management.[2] Traditionally, NTI was done blindly, with the assistance of conventional laryngoscope or through fiberoptic bronchoscope. All these have their own problems as mentioned by the author.[2] VL (Truview, Glidescope, etc.) have been recently described for NTI.[1],[3] However, a good glottic view with VL does not guarantee an easy intubation.
These patients may have a large mass or raw area which may be traumatized with the use of equipments such as Magill's forceps and bougie (used by author).[2] We have done more than 30 Glidescope-assisted NTI in such patients with cuff inflation technique. We inflate the cuff of endotracheal tube with 15–20 mL of air as soon as it crosses the nasopharynx to guide its tip toward glottis [Figure 1].[3],[4] We could intubate all our patients in a single attempt (even with 1.6 cm mouth opening) and believe that use of cuff inflation can be a good adjunct to VL for NTI in patients with orofacial malignancy.[3] The only limitation of NTI with VL is that mouth opening of the patient should be at least 1.5 cm (but definitely less than conventional laryngoscopy) for insertion of VL blade.
 | Figure 1: The cuff inflation guides the endotracheal tube into glottis Click here to view |
Venous air/oxygen embolism due to hydrogen peroxide in anal fistulectomy : uddenly the patient developed respiratory distress with the respiratory rate at 40/min and started coughing. He started complaining of chest pain which was crushing in character. Heart rate increased from 80/min to 140/min and blood pressure fell to 90/60 mm Hg. EtCO2 decreased from 35 to 20 mm Hg and oxygen saturation fell to 85%. Chest auscultation revealed bilateral bronchospasm. The operative procedure was deferred and the patient was put in the Trendelenburg position with 100% oxygen. Sublingual sorbitrate was given and hydrocortisone 100 mg and deriphyllin were administered intravenously. In view of non-return of hydrogen peroxide from the fistula tract, the possibility of air/oxygen embolism was considered. Within 15 minutes, urgent transthoracic echocardiography using a portable ultrasound machine was done which showed air in the right atrium confirming the diagnosis of embolism [Figure 1]. PA pressure
Shashi Kiran1, Sanjay Marwah2, Teena Bansal1, Neha Gupta3
1 Department of Anaesthesiology and Critical Care, University of Health Sciences, Rohtak, Haryana, India
2 Department of Surgery, University of Health Sciences, Rohtak, Haryana, India
3 Department of Anaesthesia, KGMC, Lucknow, Uttar Pradesh, India
| Date of Web Publication | 3-Jan-2019 |
| |
Correspondence Address:
Teena Bansal
Department of Anaesthesiology and Critical Care, University of Health Sciences, Rohtak - 124 001, Haryana
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joacp.JOACP_11_18
| How to cite this article: Kiran S, Marwah S, Bansal T, Gupta N. Venous air/oxygen embolism due to hydrogen peroxide in anal fistulectomy. J Anaesthesiol Clin Pharmacol 2018;34:555-7 |
| How to cite this URL: Kiran S, Marwah S, Bansal T, Gupta N. Venous air/oxygen embolism due to hydrogen peroxide in anal fistulectomy. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2019 Jan 4];34:555-7. Available from: http://www.joacp.org/text.asp?2018/34/4/555/249285 |
Hydrogen peroxide, an oxidizing agent, is frequently used in the cleansing of wound due to its germicidal properties. It is also used by surgeons in anal fistulectomy to locate the internal opening of the fistula in addition to its action in bubbling out foreign materials and debris. However, it may lead to air/oxygen embolism when irrigated into a closed body cavity.[1] Here, we present a case of air/oxygen embolism due to hydrogen peroxide in anal fistulectomy that was managed successfully.
A 39-year-old male ASA 1 was scheduled to undergo anal fistulectomy. Saddle block anesthesia was provided using 1.2 ml of 0.5% hyperbaric bupivacaine. After 15 minutes of saddle block, the patient was put in the lithotomy position. Per rectal examination was done by the surgeons. The external opening was at six o' clock position and the internal opening could not be felt. The external fistula opening was probed with a lubricated blunt malleable fistula probe that could be pushed up to 2 cm in intersphincteric plane. He remained hemodynamically stable. The probe was removed and a 6 FG feeding tube was inserted through the external opening into the tract and 10 ml of 1.5% hydrogen peroxide was pushed with the aim to locate the internal opening. The internal opening could not be located and hydrogen peroxide did not return from the external opening as well.
At this time, suddenly the patient developed respiratory distress with the respiratory rate at 40/min and started coughing. He started complaining of chest pain which was crushing in character. Heart rate increased from 80/min to 140/min and blood pressure fell to 90/60 mm Hg. EtCO2 decreased from 35 to 20 mm Hg and oxygen saturation fell to 85%. Chest auscultation revealed bilateral bronchospasm. The operative procedure was deferred and the patient was put in the Trendelenburg position with 100% oxygen. Sublingual sorbitrate was given and hydrocortisone 100 mg and deriphyllin were administered intravenously. In view of non-return of hydrogen peroxide from the fistula tract, the possibility of air/oxygen embolism was considered. Within 15 minutes, urgent transthoracic echocardiography using a portable ultrasound machine was done which showed air in the right atrium confirming the diagnosis of embolism [Figure 1]. PA pressure was 56 mm Hg and the right atrium and the right ventricle were dilated. The patient was treated symptomatically. A repeat echocardiography after half an hour showed no air in the right atrium. The patient was kept under observation for 24 hours and then discharged from the hospital.
 | Figure 1: Transthoracic echocardiography showing air in right atrium subcostal four chamber view Click here to view |
Administration of hydrogen peroxide into closed space or body cavities from which the release of oxygen has no egress can lead to catastrophic complications.[2] Each ml of 3% hydrogen peroxide produces 10 ml of oxygen. The possible mechanism of embolism is likely to be perforation of a plexus vein and injection of bubbles into plexus vein leading to a decrease in the cardiac output. Bubbles can traverse the lungs to cause systemic embolization including embolism to the coronary and cerebral arteries. The classic signs of air embolism are hypotension, precordial mill wheel murmur, and decrease in EtCO2 along with a decrease in the oxygen saturation. Precordial auscultation for mill wheel murmur, transoesophageal echocardiography, transthoracic echocardiography, and the measurement of pulmonary artery pressure and right ventricular output can be used for diagnosis. We suspected air embolism due to sudden alteration in the hemodynamic variables, decrease in EtCO2, and oxygen saturation, further confirmed by transthoracic echocardiography which showed air in right atrium. There were no signs and symptoms of systemic embolization.
The management of air embolism includes rinsing the point of gas entry with saline, placing the patient in the Trendelenburg and left lateral position to trap gas in the apex of the ventricle, administration of 100% oxygen, and maintaining hemodynamic stability along with symptomatic management.[1] We managed the patient successfully using these measures.
Gas embolism produced by hydrogen peroxide irrigation of an anal fistula during anesthesia has been reported in an 8-month-old infant by Tsai et al.[2] In addition, gas embolism has been reported during irrigation of surgical field with hydrogen peroxide in cervical spine surgery and enterocutaneous fistula.[3],[4] However, in these, undiluted hydrogen peroxide was used. Although we used diluted hydrogen peroxide, still gas embolism occurred.
This case highlights the catastrophic complication of using diluted hydrogen peroxide in a closed cavity like anal fistula and that the team working in the operating room should be aware of this potential fatal complication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References |  |
| 1. | Sastre JA, Prieto MA, Garzon JC, Muriel C. Left-sided cardiac gas embolism produced by hydrogen peroxide: Intraoperative diagnosis using transesophageal echocardiography. Anesth Analg 2001;93:1132-4.  |
| 2. | Tsai S, Lee T, Mok MS. Gas embolism produced by hydrogen peroxide irrigation of an anal fistula during anesthesia. Anesthesiology 1985;63:316-7. |
| 3. | Morikawa H, Mima H, Fujita H, Mishima S. Oxygen embolism due to hydrogen peroxide irrigation during cervical spine surgery. Can J Annaesth 1995;42:231-3. |
| 4. | Jones PM, Segal SH, Gelb AW. Venous oxygen embolism produced by injection of hydrogen peroxide into an enterocutaneous fistula. Anesth Analg 2004;99:1861-3. |
Continuous PECS block for anterior shoulder surgery
Matteo Bossolasco, Lucia Maria Fenoglio
Department of Anesthesiology and Intensive Care, ASL CN1, Savigliano, Cuneo, Italy
| Date of Web Publication | 3-Jan-2019 |
| |
Correspondence Address:
Matteo Bossolasco
Department of Anesthesiology and Intensive Care, ASL CN1, Via Ospedali 14, Savigliano, Cuneo
Italy
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joacp.JOACP_12_18
| How to cite this article: Bossolasco M, Fenoglio LM. Yet another PECS usage: A continuous PECS block for anterior shoulder surgery. J Anaesthesiol Clin Pharmacol 2018;34:569-70 |
| How to cite this URL: Bossolasco M, Fenoglio LM. Yet another PECS usage: A continuous PECS block for anterior shoulder surgery. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2019 Jan 4];34:569-70. Available from: http://www.joacp.org/text.asp?2018/34/4/569/249287 |
Madam,
Though often used in shoulder surgery, interscalene nerve blockade (INB) carries a high risk of transient complications, due to phrenic nerve block with homolateral diaphragmatic paralysis,[1] and also long-term complications such as permanent neurological deficit and brachial plexus palsy.[2]
Borgeat et al.[3] reported a 13% incidence of neurological complications, whereas Urmey et al.[4] reported a 100% incidence of hemidiaphragmatic paralysis after INB, as well as a 27% decrease in forced vital capacity and forced expiratory volume at 1 second. Although INB can be well tolerated in young healthy patients, it may be deleterious for frail patients with lung disease.
Recent research for less potentially dangerous analgesic techniques has identified the suprascapular nerve block[5] (SSB) as safe and easy to perform under ultrasound guidance during arthroscopic procedures or surgical access to the posterior aspect of the shoulder. Even more recently, Blanco[6] described the PECS block principally used to provide analgesia for procedures involving the anterolateral chest wall.
Since the anterosuperior part of the shoulder is innervated by the articular branch of the lateral pectoral nerve[7] that runs parallel to the thoraco-acromial artery on the undersurface of the upper portion of the pectoralis major muscle, this can be easily reached with a PECS block.
In our search for a continuous, easy-to-perform block that can provide postoperative analgesia and facilitate early mobilization, we recently used a PECS continuous block in a heavy smoker with severe chronic obstructive pulmonary disease (COPD) who underwent open shoulder surgery for proximal humeral fracture.
A 74-year-old woman heavy smoker (BMI 31 kg/m,[2] ASA-PS III) suffered a right humeral head fracture [Figure 1] was scheduled for open surgery reduction. The past medical history included severe COPD, metabolic syndrome, and anxiety. At current presentation, the functional status was 3 MET and the baseline peripheral oxygen saturation was between 88% and 95% on 2 L/min O2 with nasal cannula.
 | Figure 1: X-ray showing right proximal humeral fracture Click here to view |
Anesthetic options were discussed with the patient and the risks/benefit explained. To minimize potential issues with hemidiaphragmatic paralysis, we decided not to perform an INB but rather general anesthesia plus a single-shot SSB with PECS continuous block as postoperative analgesia. On the day of surgery, a single-shot ultrasound-guided SSB (ropivacaine 0.25% 10 mL) was administered, then general anesthesia induced and maintained with desflurane and remifentanil. On completion of surgery, sonographic evaluation of the right subclavicular region was performed; the two pectoralis major and minor muscles identified along with the pectoral branch of the thoraco-acromial artery that runs between them. Once identified, with maximum barrier precautions, a 19-gauge 10-cm Tuohy needle was advanced from medial to lateral using an in-plane approach under ultrasound guidance until the needle tip was close to the neurovascular bundle, where 20 mL of ropivacaine 0.25% were injected. Hydrodissection between the two pectoralis muscles was obtained, a catheter was inserted and secured [Figure 2] and connected to an elastomeric pump infusing 7 mL/h of ropivacaine 0.25%. General anesthesia was discontinued; the patient was fully cooperative and able to perform gentle movements with the operated limb without pain. The postoperative analgesic regimen was paracetamol 1 g every 8 h plus ketoprofen as a rescue dose for pain if the numerical rating scale (NRS) score was 1–3, or 5 mg i. v. morphine if the NRS score was ≥4.
 | Figure 2: In-situ PECS catheter and dressing using a Pajunk™ SonoLong Sono catheter secured with a Stat-Locki securement device (Stat-Lock, Salt Lake City, UT, USA) Click here to view |
Continuous infusion was maintained for 48 h, two rescue doses (ketoprofen 160 mg) were requested during the first 24-h postoperative; opioids were not required. She was discharged from hospital 72 h after surgery and was able to start physical therapy without major functional limitations and without exacerbation of baseline COPD.
Traditional techniques for postoperative analgesia in shoulder surgery rely on INB and SSB with noted side effects; classical regional anesthesia tecnique could have increased the risk of potential respiratory decompensation in this patient, especially because of the diminished vital capacity. Furthermore, INB and SSB catheter placement for continuous postoperative analgesia are cumbersome to perform, with risk of catheter displacement during mobilization.
PECS is a relatively novel, simple, and easy-to-perform interfascial plane block. When surgery is limited to the anterior aspect of the shoulder, we believe that it could be considered a potentially useful technique for achieving analgesia, especially in patients with impaired pulmonary function. Although promising, further studies are needed to support our findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |
| 1. | Robaux S, Bouaziz H, Boisseau N, Raucoules-Aimé M, Laxenaire MC; S.O.S. Regional Hot Line Service, et al. Persistent phrenic nerve paralysis following interscalene brachial plexus block. Anesthesiology 2001;95:1519-21. |
| 2. | Walton JS, Folk JW, Friedman RJ, Dorman BH. Complete brachial plexus palsy after total shoulder arthroplasty done with interscalene block anesthesia. Reg Anesth Pain Med 2000;25:318-21. |
| 3. | Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 2003;99:436-42. |
| 4. | Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72:498-503. |
| 5. | Raj PP. Suprascapular nerve block. In: Waldman SD, editor. Pain Management. Philadelphia: W.B. Saunders; 2007. p. 1239-42. |
| 6. | Blanco R. The 'pecs block': A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66:847-8. |
| 7. | Nam YS, Panchal K, Kim IB, Ji JH, Park MG, Park SR, et al. Anatomical study of the articular branch of the lateral pectoral nerve to the shoulder joint. Knee Surg Sports Traumatol Arthrosc 2016;24:3820-7. |
| Figures |
[Figure 1], [Figure 2]
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