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2008| July-December | Volume 2 | Issue 2
July 18, 2009
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Perioperative care of the child with guillain-barre syndrome
C Gipson, JD Tobias
July-December 2008, 2(2):67-73
The authors present 2 pediatric patients with acute Guillain-Barre syndrome (GBS) who required anesthetic care: one for diagnostic testing and another during a laparoscopic procedure to evaluate a possible intraabdominal process. Given the multi-system involvement of the disease, several concerns may arise in the perioperative period. Of primary concern is the potential for respiratory failure related either to upper airway control or skeletal muscle weakness. These issues may be made more problematic by aspiration risks and issues of a potential "full stomach" related to autonomic dysfunction and poor gastrointestinal (GI) motility. Autonomic involvement with cardiovascular dysfunction may manifest as abnormalities in the control of heart rate, systemic vascular resistance, and blood pressure. The potential perioperative implications of the disorder are discussed and its pathophysiology presented.
Contamination problems with reuse of laryngeal mask airways and laryngoscopes
LF Chu, P Mathur, JR Trudell, JG Brock-Utne
July-December 2008, 2(2):58-61
In many countries around the world reusable laryngeal mask airways (LMAs) are still in use despite the availability of cheap disposable LMAs. This study was designed to determine if the technique recommended in U.S. hospitals for cleaning of LMAs and laryngoscope blades is sufficient to prevent contamination.
Materials and Methods
. Previously used, cleaned, and autoclaved LMAs and laryngoscope blades were randomly collected from operating rooms and stained for 30 min at room temperature with erythrosinB dye. Two new and unused LMAs (negative controls) and two used and uncleaned LMAs (positive controls) were similarly stained. LMAs were rinsed with water and protein staining was evaluated by the investigators using specific criteria. In addition to the used and cleaned blades, an additional six used but not cleaned bladesacted as positive controls and two new blades were used as negative controls. Analysis of variance and two-tailed Fisher exact test were used to compare the difference in staining between various parts of the LMA.
Our data showed that 19/19 (100%) of the used LMAs had some degree of surface protein contamination, ranging from light to heavy staining. Moderate to heavy staining was present in 14/19 (74%) of these LMAs. The location of protein stains on the inner surface, compared to the outer surface or edgeswas statistically insignificant (P>0.05). For the laryngoscope blade portion of the study, the cleaned blades were statistically indistinguishable from the blades just removed from a patient's oropharynx.
Cleaned, autoclaved, reusable LMAs and laryngoscope blades at a U.S.-based University hospital contained significant surface protein contamination. These results demonstrated that current cleaning methods are ineffective at removing LMA and blade surface proteins and confirm similar evidence from European hospitals. Hence reusing LMAs is not recommended. In our hospital, we now only use disposable LMAs while the laryngoscope blades follow the same cleaning protocol as before. The use of the Slater laryngoscope blade sleeves has been recommended.
Pre-anaesthetic oral lansoprazole for the prophylaxis of
and impact of duodenogastric reflux on pH and volume of gastric contents
A Hussain, A Al-Saeed, S Habib
July-December 2008, 2(2):40-45
Lansoprazole, a proton pump inhibitor, is used in peptic ulcers and other acid dyspeptic disorders. The aim of this study is to determine whether a single oral dose of lansoprazole 30 mg, administered a night before surgery, is effective on pH and volume of gastric contents after excluding those samples contaminated with duodenogastric refluxate (DGR).
Patients and Methods.
This clinical trial was conducted in 112 adult patients of both sex, ASA physical status I-II, and aged 15-70 yr. The patients in group C (control) received placebo while group L (lansoprazole 30 mg) orally at 9.00 p.m., a night before elective surgery. On the next day, gastric contents were aspirated with a large bore, multi-orifices gastric tube passed through an endotracheal tube placed blindly in esophagus after tracheal intubation and analyzed for the presence of bile salts, pH and volume.
Thirty three samples (30 %) out of 110 were contaminated with duodenal contents. DGR significantly affected the pH and volume in both the groups. Lansoprazole, after excluding those samples contaminated either with duodenal fluid or blood, significantly increased pH (P<0.0001), decreased volume (P=0.0326) and the proportion of the patients (10.52 % versus 30.76%) considered" at risk" compared with Placebo (P=0.0475) according to the criteria defined (pH < 2.5 and volume > 25 ml).
Lansoprazole 30 mg given orally at 9.00 p.m., a night before surgery, significantly decreased the number of patients at risk of aspiration pneumonitis at the time of induction of anesthesia if the aspiration of gastric contents occurs.
Airway management outside the operating theatre
July-December 2008, 2(2):35-39
This review is intended to assist anesthesiologists in assessment and intubation of patients in venues other than the operating room (OR). Rapid assessment to identify patients at risk of failed intubation and oxygenation is essential to avoid a potentially disastrous emergency "Can't Intubate, Can't Ventilate" scenario. The equipment and drugs required for intubation may need to be taken to the venue where intubation is required as they may not be as freely available as in the OR. Extubation of the previously difficult airway needs to take place in a similar venue and with similar drugs and equipment available as when intubationwas performed.
Nosocomial pneumonia in mechanically ventilated patients : Prospective study in intensive care unit of Fez university hospital
B Bennani, R Selmani, M Mahmoud, C Nejjari, N Kanjaa
July-December 2008, 2(2):46-51
Nosocomial organisms remain the leading cause of infection in the intensive care units (ICU) in patients on mechanical ventilation (MV). The risk factors involved are poorly described in the literature. Therefore, we conducted this study to determine the risk factors and antimicrobial sensitivity of bacterial species responsible of nosocomial pneumonia in ICU of Fez University Hospital.
Patients and Methods.
Prospective study was conducted in this unit from February to Jun 2007. For bacteriological analysis, protected distal specimens were used from all mechanically ventilated patients within 48 hr. Clinical and epidemiologic data were collected for all patients and correlated to infection.
Statistical analysis showed that 68.8% of the 44 patients included in this study developed pneumonia. Etiology of infection was marked by the presence of two environmental species: acinobacter baumannii (44%) and pseudomonas aeruginosa (22%) with variable antibiotic sensitivity.
The study period was considered as epidemic for these two species. Data analysis showed that temperature, abnormal chest-x ray and bronchial expectoration can be used as pneumonia predictor in mechanically ventilated patients in ICU. Risk factors identified in this study were: prophylactic use of antibiotics, duration of ICU admission, environmental factor and patient's status.
Five hours of insufflation in a bad position: Anaesthetic implications
AA Shorrab, AD Demian, AM Shoma, SM Banoub
July-December 2008, 2(2):62-66
Laparoscopic radical cystectomy is a relatively new surgical procedure. Being a procedure of long duration, performed with pneumoperitoneum in exaggerated Trendlenberg position; it is expectedtopose unfavorable effects. We report pulmonary and haemodynamic changes in addition to postoperative outcome following laparoscopic radical cystectomy.
Patients and Methods.
The study was conducted on 31 patients anaesthetized with a combination of epidural and total intravenous anaesthesia (using midazolam, fentanyl, ketamine and vecuronium). Surgery wasdone while the patient in head down position (40
). Lungs were ventilated using air-oxygen (FiO2 = 0.35) with a tidal volume of 8 ml kg
at a rate of 12-14 min
. Lung mechanics and hemodynamic variables were recorded at different strategic points. Recovery and postoperative outcome were also evaluated.
Two patients were excluded due to conversion to open surgery and 29 completed the procedure. Fourteen of 29 patients (48.2%) had preoperative medical diseases and 11 patients (38%) received blood. There were significant decrease in lung compliance and significant increase in peak pressures after pneumoperitoneum and Trendlenberg position. Concomitantly, heart rate, arterial pressure and carbondioxide tension increased significantly. Three patients suffered post-extubation airway obstruction and the trachea was re-intubated. On the first postoperative day, one patient desaturated and one patient suffered severe nausea and vomiting.
Laparoscopic radical cystectomy in exaggerated head down position may be associated with harmful consequences and potential risks.
Patient satisfaction following awake craniotomy
N Khalifah, I Herrick, J Megyesi, A Parrent, D Steven, R Craen
July-December 2008, 2(2):52-56
Awake craniotomy using local anaesthesia and monitored conscious sedation is widely used for the excision of intracranial tumors or vascular abnormalities or for the management of refractory seizures. Propofol combined with remifentanil represents a popular technique for the provision of conscious sedation during these procedures. This study evaluated patient satisfaction following awake craniotomy performed under propofol-remifentanil sedation. The study also assessed the incidence of intraoperative and postoperative complications associated with this technique.
This prospective study evaluated the satisfaction of 25 adult patients undergoing awake craniotomy under propofol-remifentanil sedation. Evaluation involved interviewing patients at 1 hour, 24 hours, and 6 weeks postoperatively. Postoperative recall of pain, anxiety, and discomfort were assessed at 1 hour, 24 hours, and 6 weeks postoperatively. Surgeon and anesthesiologist satisfaction was also evaluated at the end of each procedure.
At 1 hour postoperative assessment, twenty-four patients (96%) were satisfied with the anesthetic technique. Patient satisfaction scores were similar at 1 hour, 24 hours and 6 weeks postoperatively. Twentyone of the twenty-four patients (84%) stated that they would choose the same anesthetic technique if they were to undergo the same procedure again. Surgeons and anesthesiologists were satisfied in twenty-three cases (92%).
This study confirms that monitored conscious sedation with propofol-remifentanil is a useful alternative technique for awake craniotomy with a high patient, surgeon and anesthetist satisfaction.
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