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Saturday, December 29, 2018

Determination in hair samples by gas chromatography/mass spectrometry : 2-Ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), methadone (1,1-diphenyl-1-(2-dimethylaminopropyl)-2-butanone), cannabinol (6, 6, 9-trimethyl-3-pentyl-6H-dibenzo[b, d]pyran-1-ol), cannabidiol (2-[(1R,6R)-3-methyl-6-(prop-1-en-2-yl)cyclohex-2-en-1-yl]-5-pentylbenzene-1,3-diol), Δ9-tetrahydrocannabinol (THC), UR144 (1-pentyl-1H-indol-3-yl)(2, 2, 3, 3-tetramethylcyclopropyl)methanon), CP47497 (2-[(1R,3S)-3-hydroxycyclohexyl]-5-(2-methyl-2-octanyl)phenol) and its homolog CP47497-C7, 1-([5-fluoropentyl]-1H-indol-3-yl)-(naphthalen-1-yl)methanone (AM2201), (1-hexyl-1H-indol-3-yl)-1-naphthalenyl-methanone (JWH-019), (4-methoxy-1-naphthalenyl) (1-pentyl-1H-indol-3-yl)methanone (JWH-081), (4-methyl-1-naphthalenyl) (1-pentyl-1H-indol-3-yl)methanone (JWH-122), 1-(1-pentyl-1H-indol-3-yl)-2-(2-methoxyphenyl)-ethanone (JWH-250), tetrahydrocannabinol-D3 (THC-D3), EDDP-D3, and methadone-D3

http://www.jfsmonline.com/article.asp?issn=2349-5014;year=2018;volume=4;issue=4;spage=184;epage=191;aulast=Anzillotti

ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 4  |  Page : 184-191

Determination of methadone and eight new psychoactive substances in hair samples by gas chromatography/mass spectrometry


Department of Medicine and Surgery, Institute of Legal Medicine, University of Parma, Parma, Italy

Date of Web Publication27-Dec-2018

    

Correspondence Address:
Dr. Luca Anzillotti
Institute of Legal Medicine, University of Parma, Via A. Gramsci 14, Parma 43126 
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_22_18

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  Abstract 


Many new psychoactive substances (NPSs) with different chemical structures have emerged in the illicit drug market in the last decade. The present work was aimed at the development of a simple method in gas chromatography/mass spectrometry (MS) for the determination of NPS of different classes, the use of cannabinoids, and, at the same time, the evaluation of methadone therapy in hair matrix, within our routine analysis control for methadone treatment or from autopsy cases. The determination of synthetic cannabinoids and methadone therapy used an extraction method based on incubation in concentrated sodium hydroxide (NaOH) solution, providing a dissolution of the keratin matrix. The described method was applied on 15 authentic specimens from our cases: five showed the presence of methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers. The GC instrument was an Agilent 7820A (Agilent Technologies, Santa Clara, CA, USA), and the detection system was an Agilent 5977B single quadrupole MS operating in selective ion monitoring mode. Validation parameters such as limit of detections (LODs), limit of quantifications (LOQs), repeatability, accuracy, and linearity were satisfactory for its application on real specimens. LODs, LOQs, R%CV, standard deviation, and the mean concentration for the analyzed compounds are reported in Table 1b. Accuracy and repeatability were acceptable for all the analytes at their respective LOQs. Recovery experiments varied from 58.3% to 103.0%, thus allowing the application on authentic specimens. The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers, such as drivers.

Keywords: Drugs of abuse, forensic, gas chromatography/mass spectrometry, hair, new psychoactive substance, toxicology


How to cite this article:
Anzillotti L, Calò L, Giacalone M, Banchini A, Cecchi R. Determination of methadone and eight new psychoactive substances in hair samples by gas chromatography/mass spectrometry. J Forensic Sci Med 2018;4:184-91

How to cite this URL:
Anzillotti L, Calò L, Giacalone M, Banchini A, Cecchi R. Determination of methadone and eight new psychoactive substances in hair samples by gas chromatography/mass spectrometry. J Forensic Sci Med [serial online] 2018 [cited 2018 Dec 29];4:184-91. Available from: http://www.jfsmonline.com/text.asp?2018/4/4/184/248696




  Introduction Top


Many new psychoactive substances (NPSs) with different chemical structures have emerged in the illicit drug market in the last decade. NPSs are different chemical compounds sold online through the e-commerce and the deep web as legal substitutes for classical drugs of abuse, including synthetic cannabinoids, synthetic cathinones, phenethylamines, piperazines, or substances not relating to any of these groups and plant-based materials.[1] The ease of NPS distribution favored their quick spreading worldwide through different channels. However, as soon as NPSs are scheduled, new derivatives appear on the market; therefore, the number of NPS reported by the European Monitoring Centre for Drugs and Drug Addiction increases each year.[2] This rapid increase of NPS sets new challenges not only in drug prevention and legislation but also in clinical and forensic toxicology, as the acute and chronic toxicity of many of these compounds is still partially unknown. Hence, the identification in biological samples is of great concern for forensic and clinical toxicologists, to evaluate the spread of NPS among population. According to the 2016 European Early Warning System Report, the largest substance categories monitored are the synthetic cannabinoids (over 160 substances, including 11 new cannabinoids reported in 2016), followed by the synthetic cathinones (over 100 substances, 14 reported for the first time in 2016).[3] Even within the same class (i.e., synthetic cannabinoids), as soon as legislation is passed banning their use, different compounds show up in the next wave. These substances show different function group chemistry that dictates a sample extraction procedure that will capture the various chemical functionalities. Some NPSs are extremely potent in terms of dosage, so that they may only be present at trace levels. Hence, the necessity and the ability to analyze the complex chromatographic data in the presence of large amounts of coextractant material. These materials are also structurally similar in terms of chromatographic retention time (RT) and mass spectral appearance. Data analyses need to be able to identify the subtle differences in these species and be able to detect such substances in complex mixtures.[3],[4]

Many analytical methods were developed for NPS determination in biological fluids, such as oral fluid,[4],[5],[6] blood,[7],[8],[9] or urine.[10],[11]To date from a recent search in literature, only few studies deal with the determination of NPS in hair;[12],[13],[14],[15],[16],[17] to the best of our knowledge, no paperwork mentioned the determination of these classes of substances together. The present pilot study was aimed at the development of a simple method in gas chromatography/mass spectrometry (GC/MS) for the determination of eight NPSs of different classes (mainly synthetic cannabinoids), the use of cannabinoids, and, at the same time, the evaluation of methadone therapy in hair matrix, within our routine analyses control for patients with methadone treatment or from autopsy cases. The development of the method involved an extraction technique based on incubation in concentrated sodium hydroxide (NaOH) solution, providing a dissolution of the keratin matrix.[12],[13] Hair sampling is easy to perform, not invasive, and relatively stable, moreover less affected by adulterants.[18] Hair samples allow a retrospective determination of the drug use history depending basically on hair length due to their accumulation in keratin, taking into account that head hair grows at an average rate of 1 cm circa each month,[19] and being able to confirm long-term exposure: it is, therefore, a reliable and valuable tool to assess chronic use of drugs in a specific population.[18] Moreover, parent drugs prevalently accumulate in hair and keratinized matrices in general with respect to unmetabolized drugs,[20] avoiding hydrolysis steps for the determination of metabolites.


  Subjects and Methods Top


Reagents and standards

Water, sodium dodecyl sulfate (SDS), acetone, acetonitrile, formic acid, phosphate buffer and methanol, chloroform and isopropanol, NaOH, hexane, and ethyl acetate were purchased from Sigma Aldrich, Milano, Italy. 2-Ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), methadone (1,1-diphenyl-1-(2-dimethylaminopropyl)-2-butanone), cannabinol (6, 6, 9-trimethyl-3-pentyl-6H-dibenzo[b, d]pyran-1-ol), cannabidiol (2-[(1R,6R)-3-methyl-6-(prop-1-en-2-yl)cyclohex-2-en-1-yl]-5-pentylbenzene-1,3-diol), Δ9-tetrahydrocannabinol (THC), UR144 (1-pentyl-1H-indol-3-yl)(2, 23, 3-tetramethylcyclopropyl)methanon), CP47497 (2-[(1R,3S)-3-hydroxycyclohexyl]-5-(2-methyl-2-octanyl)phenol) and its homolog CP47497-C7, 1-([5-fluoropentyl]-1H-indol-3-yl)-(naphthalen-1-yl)methanone (AM2201), (1-hexyl-1H-indol-3-yl)-1-naphthalenyl-methanone (JWH-019), (4-methoxy-1-naphthalenyl) (1-pentyl-1H-indol-3-yl)methanone (JWH-081), (4-methyl-1-naphthalenyl) (1-pentyl-1H-indol-3-yl)methanone (JWH-122), 1-(1-pentyl-1H-indol-3-yl)-2-(2-methoxyphenyl)-ethanone (JWH-250), tetrahydrocannabinol-D3 (THC-D3), EDDP-D3, and methadone-D3 were supplied from LGC standards (Milan, Italy). Standard compounds were stored according to supplier recommendations until their use.

Calibration and sample preparation

Hair strands were collected either from routine analyses or from autopsies, cut from the posterior vertex region of the head, close to the scalp since this region is associated with least variation in growth rates (the amount required by SOHT guidelines is a pencil thickness.[18]) Hair sample aliquots were washed with 3 mL × 3 of a solution of SDS 1%, rinsed twice with 3 mL of distilled water, and then twice with 1 mL of acetone. After drying, each sample was segmented in samples of 1 cm each circa, then each one shred and grinded into small pieces of 1 mm circa (30 mg in weight).

A working solution mixture of deuterated drugs of abuse (mix drugs-Deut) containing EDDP D3, methadone D3, and THC D3 at 10 μg/mL was prepared by proper dilution of the standard solutions and stored at −20°C until use.

Individual methanolic stock solutions were used to prepare a working solution at a concentration of 10 μg/mL. Calibration curves were prepared by addition of the appropriate amount of cannabinoids to 30 mg of blank hair sample (collected from three different drug-free subjects) to obtain the following concentrations: 0.1, 0.5, 1, 2, 5, 10, and 20 ng/mg.

Thirty milligrams of hair samples was put in a vial and 3 μL mix drugs-Deut plus 500 μL of NaOH were added to digest hair sample at 90°C for 30 min. Then, the sample was extracted with 1.5 mL of a mixture composed by hexane: ethyl acetate (9:1) by automated shaking for 10 min and centrifuged for 5 min at 2000 rpm. The supernatant was then transferred into another vial and evaporated under a gentle stream of nitrogen to dryness. After the evaporation step, the sample was reconstituted with 100 μL of MeOH and 2 μL was injected in the GC/MS equipment.

Gas chromatography/mass spectroscopy equipment

The GC instrument was an Agilent 7820A (Agilent Technologies, Santa Clara, CA, USA), and the parameters chosen for optimization were the following: the liner temperature was held at 270°C; helium was used as a carrier gas at a constant flow of 40 mL/min. The oven temperature started from 100°C, then by 20°C/min was held at 250°C for 10 min, then at 20°C/min to 280°C and was held for 5 min and finally to 320°C for 4 min.

The detection system was an Agilent 5977B single quadrupole MS operating in selective ion monitoring (SIM) mode. The column was a J and W DB-5 (5% phenylmethyl silicone) capillary column (30 mm × 0.25 mm. i.d., 0.25 μm film thickness, Agilent Technologies). Characteristic ion fragments of investigated compounds were chosen and optimized injecting the individual methanolic solutions in scan mode before developing the analytical method in SIM [as reported in [Table 1]a. After pretreatment of the sample, 2 μL was injected into the instrument.


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Method validation

The method was validated according to the Food and Drug Administration guidelines[21] and was evaluated for linearity, limit of detection (LOD), limit of quantification (LOQ), lowest limit of quantitation (LLOQ), accuracy, and repeatability. The linearity of the assay was calculated by the method of least squares and expressed as coefficient of determination (R2). Calibration curves were prepared in triplicate in 3 different days by adding to blank hair samples a mixture of the commercially available standards at a concentration of 10 μg/mL in the proper amount to obtain the range of concentration and to determine the LOD and of quantification (LOQ). These parameters were studied using serial dilutions of the substances of interest in matrix in triplicate and analyzed in 5 different days. Repeatability and accuracy were assessed at three concentrations: low (quality control [QC] 1), medium (QC2), and high (QC3) injected in quintuplicate in 3 different days and were expressed, respectively, as CV% and E%. The parameters studied are listed below.

Specificity

Ten negative hair samples from voluntary subjects were collected and analyzed to determine specificity and verify, therefore, the absence of interfering peaks that could hinder the analytes. Specificity was also assessed by analyzing samples spiked with a sample at a concentration of 500 pg/mg of compounds with most common illicit or therapeutic drugs (such as cocaine and metabolites, opiates, benzodiazepines, and various antipsychotic drugs). Hence, satisfactory specificity was established if no interfering signals were found in terms of characteristic fragments and RT related to endogenous or exogenous compounds.

Limit of detection and limit of quantification

The LOD was calculated at a concentration value giving an S/N >3 for at least three ion fragments for each substance while the LOQ was considered the concentration value giving an S/N >10 for three ion fragments and acceptable accuracy and precision (%CV and %E <20%). LLOQ was calculated at the concentration value giving an S/N ratio >5. These parameters were studied using scalar dilutions of the substances of interest in hair in quintupled.

Linearity

The linearity of the method for each compound was studied in the range from the LLOQ of each substance to 20 ng/mg, performing triplicate analyses for each level. Calibration curves were built by linear regression of the area ratio of each substance with their internal standard (IS) versus the concentration of analyte.

Accuracy and precision

QC samples were prepared at three concentration levels: low (QC1), medium (QC2), and high concentrations (QC3). Accuracy and precision were assessed by analyzing the QCs in quintuplicate in three different days and were expressed respectively as %error (%E) and standard deviation (STD).

Memory effect

Memory effect, intended as carryover of analytes from sample to sample, was evaluated: two blank samples were injected after each run of spiked samples at 50 and 100 ng/mg and analyzed after positive samples.

Identification criteria

The criteria to be fulfilled for the identification of analytes were RT, the presence of three ion fragments, and their relative ion intensities. For the identification of an analyte, RT should not vary more than ±2.5%; relative ion intensities should not vary more than ±20% for ions with relative intensities >50%, ±25% for ions with relative intensities between 10% and 50%, and ±50% for ions with relative intensities <10%, with respect to a spiked control sample.

Recoveries

Recovery experiments were performed by comparing the analytical results for extracted samples at three concentrations (low 1 ng/mg, medium 10 ng/mg, and high 20 ng/mg) with samples spiked with standards after the extraction procedure that represent 100% recovery.


  Results Top


Specificity

The proposed method demonstrated its specificity for the detection and quantification of methadone and its main metabolite EDDP, including cannabinoids and the most common NPS in hair samples, verifying the absence of peaks that could interfere with the substances of interest.

Limit of detection and limit of quantification

All the analytes investigated were detectable in the range from 0.05 ng/mg to 0.5 ng/mg. The only exception was AM2201 which could be determined at 1 ng/mg [Table 1]b.

Linearity

From calibration curves, built by linear regression of the area ratio of each substance with their IS versus the concentration of analyte, the linearity of the assay was calculated by the method of least squares and expressed as coefficient of determination (R2). The method was linear in the range from LOQ to the highest concentration assessed with quadratic regression coefficients (R2) ranging from 0.9978 to 0.9997. R2 is reported for each analyzed substance in [Table 1]b.

Accuracy, precision, and recoveries

Accuracy and precision were expressed, respectively, as %CV and STD, and the results are shown in [Table 1]b. CV% values are lower than 20% for low concentrations and lower than 15% for high concentrations; therefore, according to the guidelines, the method showed acceptable accuracy and precision values. As expected after liquid/liquid extraction, a low matrix effect was observed: recovery percentages were very high (around 100%) for almost all the monitored compounds, except for JWH 019 and JWH 122, as shown in [Table 1]b.

In summary, validation parameters such as LODs, LOQs, repeatability, accuracy, and linearity were satisfactory for its application on real specimens. LODs, LOQs, R%CV, standard deviation, and the mean concentration for the analyzed compounds are reported in [Table 1]b (nominal values of QCs 1, 2, and 3 were 1 ng/mg, 5 ng/mg, and 20 ng/mg, respectively). Accuracy and repeatability were acceptable for all the analytes at their respective LOQs. Recovery experiments varied from 58.3% to 103.0%. [Figure 1] shows an extracted ion chromatogram of the quantifier ion for all the substances investigated.
Figure 1: Extracted ion chromatogram of the quantifier ion for all the substances investigated at a concentration of 20 ng/mg

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Application to real samples

Since the recent application of the protocol in our laboratory, the described method was applied on 15 authentic specimens from our cases: five showed the presence of methadone and EDDP: for example, the first analyzed hair sample's segments were from a female subject found dead in her apartment from which we were able to collect 15 cm of hair strand. Nine segments (S) of 1 cm circa were prepared and analyzed and showed the following results: the root was positive for methadone at 4.31 ng/mg, 6.42 ng/mg (S-1), 5.47 ng/mg (S-2), 2.51 ng/mg (S-3), 53.19 ng/mg (S-4), 129.57 ng/mg (S-5), 361.08 ng/mg (S-6), 86.87 ng/mg (S-7), and 149.80 ng/mg (S-8), including its metabolite EDDP at 7.98 ng/mg (root), 7.22 ng/mg (S-1), 10.23 ng/mg (S-2), 7.65 ng/mg (S-3), 38.93 ng/mg (S-4), 72.38 ng/mg (S-5), 5 ng/mg (S-6) 23.47 ng/mg (S-7), and 118.47 ng/mg, respectively (S-8). In [Figure 2], chromatogram of authentic postmortem hair sample (S-5) positive for methadone and EDDP is shown at 129.57 ng/mg and 72.38 ng/mg, respectively. The subject had a well-known history of substance abuse and resulted positive to many xenobiotics in biological fluids as well. Results obtained demonstrated the proficiency of the developed method to determine, with a satisfactory sensitivity and sensibility, the drugs of abuse in hair samples involved in the study rapidly and with a simple sample pretreatment.
Figure 2: Chromatograms of an authentic postmortem hair sample positive for methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine at 129.57 ng/mg and 72.38 ng/mg, respectively

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  Discussion Top


Although a few immunochemical rapid tests can detect few NPS, the gold standard for their detection is chromatography coupled to mass spectrometry. Drugs levels in hair are considerably lower than those found in matrices such as blood or urine; therefore, single or tandem mass spectrometry is employed for confirmation tests. Hair testing analysis provides a retrospective timeframe via segmental analysis, due to the larger detection window when compared with other specimens (up to months, depending on strands lengths); another advantage of hair sampling is low potential for donor manipulation. In the present work, we developed and validated an analytical method to employ either after autopsy or in a population of routine analysis for methadone treatment, showing a particularly high potential for the identification of NPS users. As our study confirms, the method is suitable for analyses of studied compounds; however, there are some limitations hereby discussed. The positivity rate obtained from the study is indeed influenced by the number of samples that we could be able to collect and analyze, although it has to be stressed that these are preliminary results and that more samplings and analyses will be performed; therefore, a significant greater number of authentic cases will be assayed.

In addition, since NPS comprehends a very wide range of substances with different chemical structures, it must be noticed that the application of our analytical procedure might not be suitable for other compounds (i.e., cathinones). In particular, heating the samples as a pretreatment procedure might affect and potentially have a destructive effect on the chemical stability of NPS with low boiling points or different structures, such as mephedrone or other synthetic derivatives.[22] For example, ester analogs (e.g., PB-22) decompose (or participates in the ester-exchange reactions) in the injection port; another example is that cyclopropyl urinary metabolites (e.g., UR-144) undergo a thermal degradation mainly in GC column.[23],[24],[25] To avoid such issues, when performing splitless injection, an injector temperature of 270°C and a surface deactivated injector liner without glass wool minimizes the degradation and enhances the sensitivity. These results indicate that special attention is required for GC-MS analysis of NPS.[23] Similar mass spectra are sometimes obtained by GC–MS analyses due to regio- and ring-substituted analogs available on the market: the misidentification of these analogs arises when comparing data only with the available mass spectra. When tandem and high-resolution MS are used to identify the conformational isomers or regioisomers, such misidentification does not occur. Moreover, compounds that are thermally unstable might decompose in the GC injection port, especially those with polar groups (i.e., amino or hydroxyl groups) that can cause a polar interaction with the column stationary phase, leading to poor detection of the analyte. To overcome these problems, derivatization step should be added onto the extraction method for these compounds; however, this step would be time-consuming and potentially toxic. From our validation study, satisfactory results on our set of analytes can be obtained overcoming the derivatization step.

Indeed, synthetic cannabinoids are not ideal compounds for GC-MS analysis because they are neutral to weakly acidic compounds and have high molecular weight. However, concerning the substances taken into consideration in the validation of the presented method, no destructive effect was noticed; therefore, the method is applicable only for the relevant compounds included in this study and more experiments will be performed when other NPS will be included in the procedure. The phenomenon might interest some metabolites that, however, are not the focus of our study, because the parent compounds are the main targets in hair analyses.

Hair analysis for NPS is still at an early stage of development, particularly on the toxicological screening side. The proposed method allows for the identification of synthetic cannabinoids, cannabinoids, and methadone (including its main metabolite) in hair samples with a simple sample pretreatment.


  Conclusions Top


The identification of NPS in biological samples is one of the emerging challenges for forensic laboratories due to the necessity of detection and confirmation of a very large class of substances, often not structurally correlated. Due to the reoccurring threat of synthetic cannabinoids to public health and their rapidly increasing abuse worldwide, it is necessary to develop reliable analytical methods for their detection in different biological matrices. SCs are constantly being modified and rapidly becoming widely available; therefore, laboratories should update their scope for detecting the most prevalent compounds at specific times.

Blood and urine are the first choice of sample for testing; however, hair is often used as an alternative matrix in repeated drug exposure. The method validation presented herein is a straightforward, selective, and accurate method for the determination of some drugs belonging to the CP and aminoalkylindole structural classes. The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers, such as drivers.

This study has been approved by the local ethics committee and the consent was exempted. 



 

Aspirated foreign body (FB),Point-of-care ultrasound (POCUS) of the upper airway

http://www.saudija.org/article.asp?issn=1658-354X;year=2019;volume=13;issue=1;spage=89;epage=90;aulast=Mohanty;type=3

Foreign bodies are common among the pediatric population. Plain radiograph AP view is the standard to diagnose and localize ingested or aspirated foreign body (FB). Most of the patients need either sedation or general anesthesia for FB removal depending on its position. Point-of-care ultrasound (POCUS) of the upper airway can be used for detection and also as a dynamic tool for monitoring the changes in the position of the FB during the attempt of its removal. It has been used for the localization and removal of soft tissue FB.[1] Here, we present a case of use of POCUS for upper esophageal FB removal.

A 3-year-old male child, 11 kg, presented to the emergency department with a history of ingestion of FB. The plan was to remove it under general anesthesia. Chest X-ray AP view confirmed a radio-opaque FB. He was premedicated with injection glycopyorrolate 0.1 μg, fentanyl 2 μg/kg, and inj. midazolam 0.5 mg iv. Ventilation was assisted with 50% oxygen and sevoflurane. Inj attracurium 0.5 mg/kg was administered, and trachea was intubated with cuffed size 4 endotracheal tube. The SonoSite M-Turbo ultrasound machine with linear 13--6 MHz transducer was used to confirm the location of FB [Figure 1]. It was removed with the help of esophagoscope. Initially, it was visible but was lost during manipulation. There was a doubt of the passage of FB down in the esophagus, but the ultrasound was suggesting its presence in the upper esophagus. Esophagoscope was repositioned and the FB was removed in the fourth attempt with minimal trauma. It is not rare to detect the FB in preprocedure X-ray, but finding nothing during exploration under anesthesia.
Figure 1: Radio-opaque foreign body (yellow arrow) inside esophagus (ESO); CCA: Common carotid artery; IJA: Internal jugular vein

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We suggest the use of POCUS before or after anesthesia, depending on the co-operation of the patient posted for FB removal. It will also avoid unnecessary radiation exposure in the pediatric population.[2] Further studies are needed to consider it as a part of FB management algorithm.  

Cannot intubate and cannot ventilate scenario in an infant for airway assessment

http://www.saudija.org/article.asp?issn=1658-354X;year=2019;volume=13;issue=1;spage=83;epage=84;aulast=Mahfouz

Cannot intubate and cannot ventilate scenario, in general, is rare, especially in infant age group, but results in calamitous events if it occurs. Here, we report the management of a case of cannot intubate and cannot ventilate in an infant with a history of stridor.


  Case Top


A 6-month-old girl was brought by an ambulance to our tertiary care hospital with difficulty in breathing and severe stridor. It was decided to perform airway assessment by ENT surgeon to determine the possible causes of stridor due to failure of improvement despite maximum medications given by pediatrician. Preoperative assessment showed an infant with mixed stridor requiring about 4 L of oxygen to maintain oxygen saturation above 90%. Suprasternal and intercostal recessions with conducted sounds could be heard on the chest. Chest X-ray was normal. No premedication was given and she was shifted to the operation theatre.

Supraglottic airway assessment was done awake with topical anesthesia using flexible fiberoptic endoscope which was normal. Subglottic endoscopic examination was decided under general anesthesia. She was induced with sevoflurane to maintain spontaneous ventilation for dynamic airway assessment. The spontaneous ventilation was assisted with great difficulty after loss of consciousness. The ENT surgeon used pediatric rigid endoscope. It revealed subglottic mass occluding 90% of the area, and it was not possible to bypass the mass with the smallest endoscope available (size 2.7 mm) [Figure 1]. The infant started to desaturate after endoscopic manipulations with difficulty to ventilate. Intubation failed with the smallest tube size 2. Ventilation was tried but was not effective. The saturation and heart rate started to drop with the scenario of cannot intubate and cannot ventilate. Atropine was given and external cardiac massage started as saturation dropped to less than 50% and heart rate fell to less than 60 beats per minute. Emergency tracheostomy was done successfully in 7 min and saturation improved to 99%. Infant regained consciousness and spontaneous breathing. Computed tomography was done which revealed a small hypodense area measuring 0.5 cm in diameter in the region of glottis. LASER marsupialization of the subglottic cyst was done successfully after 2 days from emergency tracheostomy.
Figure 1: Subglottic mass obstructing 90% of the airway

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Unfortunately, there is no definitive algorithm to follow for difficult airway in case of patients aged less than 1 year of age. Difficult airway society (DAS) published algorithm of cannot intubate and cannot ventilate in a paralyzed anesthetized child aged 1–8 years in 2015.[1]

In the present case, we skipped insertion of supraglottic devices, percutaneous transtracheal jet ventilation (PTJV), rigid bronchoscopy ventilation, and percutaneous cannula cricothyroidotomy (PCC) for different reasons. Supraglottic devices cannot be used due to distal mechanical obstruction. PTJV is relatively contraindicated due to near total airway obstruction below vocal cord.[2] In addition to risk of serious complications such as air embolism, extensive cervical emphysema, pneumothorax, and damage to the esophagus occur if jet ventilation is tried with misplaced cannula.[3]Rigid bronchoscopy ventilation was impossible as the smallest endoscope of size 2.7 mm could not bypass the mass. PCC is not easy in infants. Moreover, it is challenging to obtain a proper angle to insert PCC without the risk of perforation of posterior tracheal wall.[4] Emergent tracheostomy should be considered as the first step if an ENT surgeon is available.[5]

The management of cannot intubate, cannot ventilate scenario needs vast experience in airway assessment, unshaken confidence, with extreme cooperation between anesthetists and ENT surgeons.  

Difficult airway management and suspected malignant hyperthermia in a child with Cri Du Chat syndrome Amata AO - Saudi J Anaesth

http://www.saudija.org/article.asp?issn=1658-354X;year=2019;volume=13;issue=1;spage=81;epage=83;aulast=Amata

Cri du Chat Syndrome (CdCs) also known as Cat Cry syndrome, is a genetic disorder caused by the partial or total deletion of genetic material from the short arm of chromosome 5 (5p-, 5p minus syndrome) and was first described in 1963 by Lejeune et al.[1] The phenotypic manifestations are variable and often affect multiple organ systems with the most common features being the characteristic high-pitched cat-like cry (hence the name), dysmorphic features, and mental retardation.[2],[3] The reported incidence of CdCs is between 1 in 15,000 and 1 in 50,000 live births,[2],[3] and the children often require surgery for correctable anomalies.[3] Difficult airway management is a recognized challenge because of dysmorphic changes such as microcephaly, micrognathia, short neck, and the anatomical anomalies of the larynx.[2],[3] However, there have not been any reports of increased risk or susceptibility to malignant hyperthermia (MH) with this condition. I present a child that developed airway management challenge and possible MH during anesthetic induction.

A 2-year 5-month, 9.5 kg African male child with bilateral congenital talipes equinovarus congenital talipes equinovarus (CTEV) otherwise known as clubfoot, was scheduled for bilateral posteromedial release operation after minimal improvement with the conservative serial splinting, stretching, and bracing treatment known as the Ponseti method.

During the preoperative anesthetic assessment on the day before surgery, the child was noted to have an unusual facies, and he could not walk or talk. He had a peculiar high pitched cry that sounded cat-like that the mother said had been present since birth. He was the third in a family of three children, and he had been hospitalized twice in the past year for aspiration pneumonia. He was small for age and had a global developmental delay with significant hypotonia, gross motor and speech impairment, and severe bilateral CTEV. He had a microcephalic head with a round face, hypertelorism, depressed broad nasal bridge, low set ears, and micrognathia (head circumference 48 cm, height 79 cm). Clinical examination of the cardiorespiratory system was unremarkable. Hematologic examination indicated hypochromic microcytic anemia and thrombocytosis (hemoglobin - 10.5 g/dl, platelets - 513 × 109/L). Chest X-ray was unremarkable.

The anesthetic plan was to maintain the airway with a laryngeal mask airway (LMA) and perform a caudal epidural block for perioperative analgesia. On the operating table, routine monitors of noninvasive blood pressure (BP), electrocardiography, SpO2, and temperature were applied, and anesthesia was induced inhalationally with sevoflurane and nitrous oxide in oxygen. An intravenous (iv) access was secured once the child was unconscious. After the adequate depth of anesthesia, a size 2.0 LMA was inserted but ventilation through it was ineffective and it was removed with a plan to reinsert it properly. Morphine 1 mg iv was given. When attempting to reinsert the LMA, the child was noticed to have suddenly developed generalized muscle rigidity including trismus and laryngospasm. Mask ventilation became very difficult and ineffective, and the mouth could not be opened to insert an oropharyngeal airway. Propofol 20 mg iv was given to facilitate jaw relaxation but had no effect. At this point, the patient's oxygen saturation had begun to rapidly decrease. Succinylcholine, 20 mg iv was given, but it also had no effect. Attempts at laryngoscopy were impossible as the teeth were tightly clenched. The pulse rate was now >195/min and the immediate preinduction temperature of 35.7°C had gone up to 37.7°C. The capnograph tracing that initially indicated hypercarbia had progressed to almost baseline because of inability to ventilate the lungs. At this stage, the sevoflurane and nitrous oxide were turned off, and the patient was maintained on 100% oxygen through bag and mask. We were about to perform an emergency cricothyroidotomy when we noticed that the child that had been apneic during this period started making some respiratory efforts that rapidly got better and the oxygen saturation progressively improved with assisted respiration. About 10 min after the commencement of the incident, the child was breathing adequately spontaneously with SpO2 of 99%, and after close observation for about 15 min, he was transferred to the PACU for further monitoring. He was fully awake within 5 min of arrival in the PACU and was responding appropriately. The temperature and heart rate were still elevated (37.5°–377.7°C; 165–196/min) while his BP and oxygen saturation were normal during his 2 h stay in PACU. He was stable enough to be sent back to the high dependency unit of the ward and was closely observed by the ward doctor and reviewed by the pediatrician. The heart rate and temperature returned to preinduction levels about 4 h after the incident, and he was discharged from the hospital without any adverse effects or sequelae 96 h after the incident.

Children with CdCs have variable multiple phenotypical manifestations that predispose them to a greater likelihood of surgical intervention and also that have significant anesthetic implications.[2],[3] Diagnosis is clinical with confirmation by molecular cytogenetic tests such as fluorescent in situhybridization. With increasing and widespread availability of cytogenetic studies, the anesthesia care provider is likely to see increasing numbers of patients with this relatively common chromosomal condition.[2],[3] Up to two-thirds (75%) of patients with CdCs require general anesthesia for interventional procedures and parents felt that only about one-third (35%) of the anesthesiologists caring for their children were familiar with the condition.[3]

Previous studies have reported an increased risk of airway difficulty and inability to intubate the trachea.[2],[3] This is not surprising considering the orofacial anomalies these patients possess. MH risk or susceptibility has however not been associated with CdCs to our knowledge. We have a strong impression that our patient developed intraoperative MH because of the constellation of signs and symptoms. We initially assumed that the muscle rigidity and masseter spasm in a hypotonic child may have been opioid induced and/or due to a "light" plane of anesthesia, but when administration of propofol and then succinylcholine and maximum concentration of sevoflurane had no effect, coupled with the rapid development of hyperthermia, tachycardia, and hypercarbia, MH seemed the most likely diagnosis. In addition, discontinuation of the presumptive trigger, sevoflurane, led to improvement.

As early diagnosis and prompt treatment are vital in minimizing the high morbidity and mortality associated with MH, the diagnosis is usually clinical and requires a high index of suspicion and good clinical acumen.[4] This is especially important in resource-poor environments where medical record keeping is poor and necessary monitoring and laboratory facilities are not readily available. A clinical standardized and validated grading scale has been developed to help determine if an MH event has occurred.[5] The score ranges from 0 (almost never/very unlikely) to 6 (almost certain). Our patient scored 5, which indicates a "very likely" MH episode just short of the maximum 6, that indicates "almost certain" event in spite of our lack of relevant blood tests.

We did not use dantrolene, a specific drug indicated for MH because of nonavailability. However, patients have been shown to survive MH episodes even in the absence of dantrolene provided the diagnosis is considered early enough, and aggressive symptomatic treatment is carried out.[6] We were unable to confirm a definite diagnosis of MH because of unavailability of the "gold standard" confirmatory in vitro contracture test[4] however, pending future confirmatory studies it would be prudent to consider patients with CdCs as susceptible to MH and treated as such.  

Bronchial thermoplasty (BT) is an invasive procedure which carries a risk of coughing, wheezing, bronchospasm, and laryngospasm during and after the procedure.

Bronchial thermoplasty (BT) is an upcoming treatment for patients with asthma refractory to traditional pharmacotherapy

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Shilpi Agarwal, Wasimul Hoda, Saurbh Mittal, Karan Madan, Vijay Hadda, Anant Mohan, Sachidanand Jee Bharti
DOI:10.4103/sja.SJA_640_18  
Bronchial thermoplasty (BT) is an upcoming treatment for patients with asthma refractory to traditional pharmacotherapy. BT is an invasive procedure which carries a risk of coughing, wheezing, bronchospasm, and laryngospasm during and after the procedure. Some of these complications can be minimized using better anesthetic techniques during BT. We hereby report a case of a 63-year-old female with poorly controlled asthma posted for BT done under general anesthesia (GA) with supraglottic device. GA provides better working conditions for pulmonologists when compared with sedation. But still there is no consensus on what would be the ideal anesthetic technique for BT procedure. Till the time, considering anesthesiologist and pulmonologist's prospective, GA (total intravenous anesthesia) using supraglottic device would be a preferred choice for a safe and effective anesthetic strategy in BT.
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