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 Click here to view

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

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 Click here to view

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

p. 78
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.
https://plus.google.com/u/0/+AlexandrosGSfakianakis/posts/DbhmnVsxE6j

The use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided.Clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension

Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension p. 63

Hiroyuki Oshika, Yukihide Koyama, Yutaka Usuda, Tomio Andoh

DOI:10.4103/sja.SJA_367_18  

We report a case of intravenous ephedrine administration that abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension and who was subsequently diagnosed postoperatively as having bronchial asthma. A 54-year-old man who had childhood asthma was scheduled for laparoscopic cholecystectomy at our institution. The preanesthetic interview suggested full resolution of his childhood asthma. His capnogram showed an airway obstructive pattern immediately after the initiation of mechanical ventilation. However, after administration of ephedrine due to low blood pressure during surgery, his obstructive capnogram reverted to normal. On postoperative day 3, he was diagnosed as having bronchial asthma. Furthermore, we found that small airway obstruction as indicated in his preoperative pulmonary function test (PFT) had been overlooked. Two important points arise from this case. First, the use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided. Second, clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate

Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias

DOI:10.4103/sja.SJA_413_18  

Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of Postoperative acute kidney injury (AKI) : Hydroxyethyl starch (HES) solutions,Stroke volume variation-guided tetrastarch,Ringer's lactate

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate 

Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi

DOI:10.4103/sja.SJA_410_18  

Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. 

Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.