Renal artery disease is the most common cause for surgically curable form of hypertension. In a small subset of patients with severe aortic disease where the aorta is not suitable for endovascular technique and to provide an arterial inflow, an extra-anatomic renal bypass surgery (EARBS) is an option. Anesthetic management of such procedures has not been described so far in the literature. We retrospectively analyzed the anesthetic techniques used in all patients who underwent EARBS between February 1998 and June 2008 at this institute. We also further analyzed data concerning blood pressure (BP) control and renal function response following surgery as outcome variable measures. A total of 11 patients underwent EARBS during this period. Five received oral clonidine with premedication. During laryngoscopy, esmolol was used in 4 patients, while lignocaine was used in remaining 7 patients. Of 11 patients, 7 showed significant hemodynamic response to laryngoscopy and intubation; among these, one had oral clonidine with premedicant, and 6 received lignocaine just before laryngoscopy. Intravenous vasodilators were used to maintain target BP within 20% of baseline during perioperative period. All patients received renal protective measures. During follow-up, 10% were considered cured, 70% had improved BP response, while 20% failed to show improvement in BP response. Renal functions improved in 54.5%, remain unchanged in 36.5%, and worsened in 9% of patients. Use of clonidine during premedication and esmolol before laryngoscopy were beneficial in attenuating hemodynamic response to laryngoscopy, while use of vasodilators to maintain target BP within 20% of baseline, and routine use of renal protective measures appear to be promising in patients undergoing EARBS.

Ebstein's anomaly (EA) is the most common cause of congenital tricuspid regurgitation. The associated anomalies commonly seen are atrial septal defect or patent foramen ovale and accessory conduction pathways. Its association with coexisting mitral stenosis (MS) has uncommonly been described. The hemodynamic consequences and anesthetic implications, of a combination of EA and rheumatic MS, have not so far been discussed in the literature. We report successful anesthetic management of a repair of EA and mitral valve replacement in a patient with coexisting Wolff-Parkinson-White (WPW) syndrome.

A 48-year-old man, weighing 60 kg, underwent mitral valve replacement for severe mitral stenosis with a 29-mm St. Jude bileaflet mechanical prosthesis (St. Jude Medical, St. Paul, MN). We present the case after obtaining his consent. Transesophageal echocardiography (TEE) revealed that the mechanical prosthesis was working well after separation from cardiopulmonary bypass with minimal gradients and good ventricular function.

Ultrasound (US) is used increasingly as an aid in the cannulation of the subclavian vein (SCV), which is the preferred site for long-term central venous catheter placement. Several methods are described for the differentiation of the SCV from the subclavian artery; they include nonpulsatility, position of the vein in relation to the artery, variation of lumen size with respiration, identification of confluence of the SCV and internal jugular vein, valves in the lumen of the vein, and Doppler interrogation of the flows.1Pirotte T. Veyckemans F. Ultrasound guided subclavian vein cannulation in infants and children: A novel approach.Br J Anaesth. 2007; 98: 509-514Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 2Braner D.A.V. Lai S. Eman S. et al.Central vein catheterization—Subclavian vein.N Engl J Med. 2007; 357: e26Crossref PubMed Scopus (34) Google Scholar However, imaging of the SCV can be difficult after multiple attempts (because of hematoma and compression of the lumen) and in patients who are obese with a short neck. Thus, the inability to properly identify subclavian vessels can be a major limitation to the usage of US. We describe a simple technique to immediately distinguish the SCV from the subclavian artery during US-guided cannulation. A peripheral large-bore venous access is obtained on the desired side of SCV cannulation, preferably in the cubital fossa. After the patient is positioned and draped for SCV cannulation, the US probe is positioned to obtain a cross-sectional view of the subclavian vessels (Fig 1A). Agitated saline (20 mL) is then injected rapidly through the peripheral venous access. SCV is easily identified by the appearance of microbubbles in its lumen (Fig 1B). Furthermore, any hematoma occurring because of multiple attempts to cannulate the vein tends to narrow the lumen. A continuously running intravenous drip in the ipsilateral peripheral vein will help in identification of the narrowed segment during longitudinal imaging of the SCV (the image is comparable to Doppler interrogation), which can be avoided in subsequent attempts. US-guided SCV cannulation can sometimes be challenging even for experienced anesthesiologists. Our technique, which is simple and reproducible, seems promising for easy identification of SCV and its differentiation from the artery even in cases in which hematoma formation has occurred.

(ECHOCARDIOGRAPHY, Volume 26, July 2009)

(ECHOCARDIOGRAPHY, Volume 26, July 2009).

A 34-year old woman with rheumatic mitral stenosis was found to have complete dual inferior venae cavae with bilateral infrarenal and suprarenal segments, on balloon mitral valvuloplasty. The bilateral, renal, and gonadal veins drained separately on the ipsilateral side. The left inferior vena cava was larger than the right, and the right inferior vena cava had an aneurysmal dilatation near its origin. The left inferior vena cava drained into the superior vena cava-right atrial junction.

Poliomyelitis remains endemic in many developing nations. Patients may develop residual muscle weakness in one or more limbs after an attack of poliomyelitis in childhood. We report an adult patient who presented for right temporal cortical grid placement. He had childhood poliomyelitis and, while showing no evidence of postpolio syndrome, demonstrated excessive sensitivity to nondepolarizing muscle relaxants and developed prolonged muscle weakness during the postoperative period.

Cannulation of the internal jugular vein is a standard practice during cardiac surgical procedures. Although complications are commonly described,1Sznajder J.I. Zveibil F.R. Bitterman H. et al.Central vein catheterization Failure and complication rates by three percutaneous approaches.Arch Int Med. 1986; 146: 259-261Crossref PubMed Scopus (629) Google Scholar, 2Paoletti F. Ripani U. Antonelli M. et al.Central venous catheters Observations on the implantation technique and its complications.Minerva Anesth. 2005; 71: 555-560PubMed Google Scholar properly executed it is a safe procedure.3Soltes G.D. Barth M.H. Roehm J.O. Preventing complications of central venous catheterization.N Engl J Med. 2003; 348: 2684-2686Crossref PubMed Scopus (20) Google Scholar Knotting of central catheters has also been described but most have been of pulmonary artery catheters or guidewires.4Bagul N.B. Menon N.J. Pathak R. et al.Knot in the cava—An unusual complication of Swan-Ganz catheters.Eur J Vasc Endovasc Surg. 2005; 29: 651-653Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Olsfanger D. Jedeiken R. Fredman B. et al.Intertwining and knotting of a guidewire with a central venous catheter.Chest. 1993; 104: 623-624Crossref PubMed Scopus (7) Google Scholar We describe an unusual case of looping of a central venous catheter in a patient undergoing cardiac surgery.A 28-year-old male, weighing 57 kg, height 167 cm, was scheduled for ostium secundum atrial septal defect closure on cardiopulmonary bypass. Anesthesia induction was smooth and uneventful. After induction, the right internal jugular vein was cannulated with a 7.0F triple-lumen central venous catheter (Arrow International, Inc, Reading, PA) by using the Seldinger technique. Cannulation of the vein was completed in one attempt, and the catheter was secured to the skin at the 15-cm mark. Free flow of blood was aspirated from all of the lumens. The central venous pressure (CVP) waveform was found to be normal on the monitor. During insertion of the guidewire, cardiac arrhythmias were noticed. Surgery proceeded with midsternotomy; however, during right atrium–superior vena cava (RA-SVC) cannulation, the surgeon remarked that there was some difficulty in negotiating the cannula into the superior vena cava (SVC). After some manipulation, the RA-SVC cannula was eventually negotiated into the SVC, and the patient was put on cardiopulmonary bypass. Soon after snugging down the RA-SVC cannula, the CVP trace became obliterated with a flat line, and there was great difficulty in aspirating blood from the distal port, whereas no aspiration of blood or forward fluid movement was possible from the 2 proximal ports. The surgery, subsequent weaning from bypass, and recovery in the intensive care unit were uneventful. A postextubation chest x-ray revealed knotting of the central venous catheter with the distal end forming a U-turn (Fig 1), which was repositioned with the help of a guidewire.In this case, we had elicited arrhythmias during guidewire insertion plus aspiration of blood from all the ports after placement of the catheter. The CVP trace on the monitor obtained after insertion further confirmed the correct placement of the catheter, which was lost during cannulation of the SVC. We believe that during attempted SVC cannulation, the SVC cannula might have pushed the CVP catheter upward, resulting in a U-turn and formation of a loop of the catheter. In such cases, if the surgeon ties down the SVC, the central catheter can be completely occluded from the venous system, which can result in the loss of CVP waveforms, difficulty in the transfusion of fluid/drugs, or sampling of blood as was evident from our case. We believe that the insertion length of the CVP cannula in our case was too long and could be a factor in causing this problem. Although many unique complications of central vein cannulation have been described,6Khan Z.H. Tabatabai S.A. Complication of catheter knotting after right cephalic vein cannulation.Anesth Analg. 1996; 82: 215-216PubMed Google Scholar, 7Cherian V. Faheem M. Knotting of a peripherally inserted central catheter.Can J Anaesth. 2004; 51: 1046-1047Crossref PubMed Scopus (5) Google Scholar the looping of a central venous catheter caused by the SVC cannula pushing the CVP catheter upward is an extremely rare and possibly a dangerous occurrence. It is generally recommended that the location of the tip of the CVP catheter should be at the RA-SVC junction for correct CVP measurement. However, we believe that especially where bicaval cannulation is desirable the length of the CVP cannula inside the SVC lumen should be kept to a minimum to avoid such complications. Cannulation of the internal jugular vein is a standard practice during cardiac surgical procedures. Although complications are commonly described,1Sznajder J.I. Zveibil F.R. Bitterman H. et al.Central vein catheterization Failure and complication rates by three percutaneous approaches.Arch Int Med. 1986; 146: 259-261Crossref PubMed Scopus (629) Google Scholar, 2Paoletti F. Ripani U. Antonelli M. et al.Central venous catheters Observations on the implantation technique and its complications.Minerva Anesth. 2005; 71: 555-560PubMed Google Scholar properly executed it is a safe procedure.3Soltes G.D. Barth M.H. Roehm J.O. Preventing complications of central venous catheterization.N Engl J Med. 2003; 348: 2684-2686Crossref PubMed Scopus (20) Google Scholar Knotting of central catheters has also been described but most have been of pulmonary artery catheters or guidewires.4Bagul N.B. Menon N.J. Pathak R. et al.Knot in the cava—An unusual complication of Swan-Ganz catheters.Eur J Vasc Endovasc Surg. 2005; 29: 651-653Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Olsfanger D. Jedeiken R. Fredman B. et al.Intertwining and knotting of a guidewire with a central venous catheter.Chest. 1993; 104: 623-624Crossref PubMed Scopus (7) Google Scholar We describe an unusual case of looping of a central venous catheter in a patient undergoing cardiac surgery. A 28-year-old male, weighing 57 kg, height 167 cm, was scheduled for ostium secundum atrial septal defect closure on cardiopulmonary bypass. Anesthesia induction was smooth and uneventful. After induction, the right internal jugular vein was cannulated with a 7.0F triple-lumen central venous catheter (Arrow International, Inc, Reading, PA) by using the Seldinger technique. Cannulation of the vein was completed in one attempt, and the catheter was secured to the skin at the 15-cm mark. Free flow of blood was aspirated from all of the lumens. The central venous pressure (CVP) waveform was found to be normal on the monitor. During insertion of the guidewire, cardiac arrhythmias were noticed. Surgery proceeded with midsternotomy; however, during right atrium–superior vena cava (RA-SVC) cannulation, the surgeon remarked that there was some difficulty in negotiating the cannula into the superior vena cava (SVC). After some manipulation, the RA-SVC cannula was eventually negotiated into the SVC, and the patient was put on cardiopulmonary bypass. Soon after snugging down the RA-SVC cannula, the CVP trace became obliterated with a flat line, and there was great difficulty in aspirating blood from the distal port, whereas no aspiration of blood or forward fluid movement was possible from the 2 proximal ports. The surgery, subsequent weaning from bypass, and recovery in the intensive care unit were uneventful. A postextubation chest x-ray revealed knotting of the central venous catheter with the distal end forming a U-turn (Fig 1), which was repositioned with the help of a guidewire. In this case, we had elicited arrhythmias during guidewire insertion plus aspiration of blood from all the ports after placement of the catheter. The CVP trace on the monitor obtained after insertion further confirmed the correct placement of the catheter, which was lost during cannulation of the SVC. We believe that during attempted SVC cannulation, the SVC cannula might have pushed the CVP catheter upward, resulting in a U-turn and formation of a loop of the catheter. In such cases, if the surgeon ties down the SVC, the central catheter can be completely occluded from the venous system, which can result in the loss of CVP waveforms, difficulty in the transfusion of fluid/drugs, or sampling of blood as was evident from our case. We believe that the insertion length of the CVP cannula in our case was too long and could be a factor in causing this problem. Although many unique complications of central vein cannulation have been described,6Khan Z.H. Tabatabai S.A. Complication of catheter knotting after right cephalic vein cannulation.Anesth Analg. 1996; 82: 215-216PubMed Google Scholar, 7Cherian V. Faheem M. Knotting of a peripherally inserted central catheter.Can J Anaesth. 2004; 51: 1046-1047Crossref PubMed Scopus (5) Google Scholar the looping of a central venous catheter caused by the SVC cannula pushing the CVP catheter upward is an extremely rare and possibly a dangerous occurrence. It is generally recommended that the location of the tip of the CVP catheter should be at the RA-SVC junction for correct CVP measurement. However, we believe that especially where bicaval cannulation is desirable the length of the CVP cannula inside the SVC lumen should be kept to a minimum to avoid such complications.

The radial artery is commonly cannulated percutaneously for invasive blood pressure monitoring because of its superficial location. The success of arterial cannulation is primarily dependent on the skill of the operator, which is acquired over a certain period of time. Despite this, failure to cannulate is not uncommon. This could either be because of the difficulty to enter the artery or because of the difficulty in threading the cannula into the artery once a flash of blood is seen on the hub of the cannula. “Over-the-needle” and “over-the-guidewire” (Seldinger technique) are the recommended techniques for threading the cannula inside the artery. Regardless of the technique, the success of cannulation is evident only at the end of the procedure after the needle or guidewire is removed by visualization of a return of pulsatile blood at the hub of the cannula. Any technique that hastens the appearance of blood in the hub of the cannula may prevent counterpuncture of the back wall of the artery. We have been using a modified “over-the-needle” technique that speeds up the appearance of blood in the hub during puncture and simultaneously lets us monitor the outflow of pulsatile blood continuously while threading without any spillage. In this technique, the hand is positioned in moderate dorsiflexion for radial artery cannulation. After removing the cap from the hub, the needle is filled with heparinized saline, and the hub end of the cannula is connected to the transparent cover of the cannula. Then, the whole assembly is used as a single unit to puncture the artery at an angle of 30° to 45° (Fig 1). As soon as the artery is punctured, a flash of blood appears at the hub of the cannula. The early appearance of blood in the hub is because of the heparinized flush inside the needle, which prevents the puncture of the back wall of the artery. Once the hub is full of blood, it continues to flow into the attached cover without spillage. The angle of puncture should then be decreased and the cannula advanced slightly further to ensure its position inside the artery. In case the needle tip punctures the posterior wall of the artery during this maneuver, there will be sudden cessation of rise of the blood column in the cannula cover. This allows the cannula to be slightly withdrawn, which will cause the blood column to rise again as the tip re-enters the arterial lumen. If the blood column fails to rise while advancing the cannula, it means that either the artery is in spasm or the tip of the cannula is bent. At this point, slight withdrawal of the cannula and/or a change in the angle of the cannula before further advancement may help, but a successful placement is always foretold by the rise in blood level in the cover (Fig 2). Before detaching the needle along with the cover from the cannula, the (radial) artery is compressed 2 to 3 cm proximal to the tip of the cannula to stop the outflow of blood to prevent its spillage during connection to the arterial extension tube. This method is superior to the conventional “over-the-needle” technique in many ways. The early appearance of blood in the hub of the needle facilitated by the heparinized flush in it might prevent a puncture of the posterior wall of the artery at the outset. Furthermore, it provides continuous evidence of the presence of a patent nondistorted cannula inside the artery from puncture to threading, as evidenced by a rising column of blood in the hub followed by the cover. Finally, the long length of the cover attached to the hub prevents the spillage of blood and may be particularly useful in infected individuals. The described technique is a no-hurry, no-spillage method of arterial cannulation that is very useful for teaching novices. The total volume of the cannula hub and cover is 2 mL, and most of the time the entire cannulation is over with a blood loss less than 1 mL, which is an important consideration in pediatric patients. The Seldinger technique is a 2-stage procedure requiring more skill, and it causes more spillage of blood while exchanging the needle with a guidewire. Gerber et al1Gerber D.R. Zeifman C.W. Khouli H.I. et al.Comparison of wire-guided and nonwire-guided radial artery catheters.Chest. 1996; 109: 761-764Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar prospectively compared wire-guided and conventional nonwire-guided arterial cannulation and did not find any superiority of the former technique, except in patients with absent or weak pulses. In the “over-the-wire” Seldinger technique, apart from the fact that intra-arterial positioning and patency of the cannula are not evident until the guidewire is removed, strict asepsis is also mandatory to prevent guidewire contamination. Therefore, the routine use of the Seldinger technique can significantly increase the cost and procedure time of arterial cannulation. Although our modified technique has been described before,2Mark J.B. Slaughter T.F. Reves J.G. Cardiovascular monitoring.in: Miller R.D. Anesthesia (vol 1). Churchill Livingstone, Philadelphia, PA2000: 1125-1127Google Scholar filling the cannula with saline to improve arterial puncture and its multiple advantages over the Seldinger technique have not been reported in the literature. We have been practicing this method for quite some time with a very high success rate. To the best of our knowledge, only 1 manufacturer (BD Insyte-W 20-G 48 mm and 22-G 25 mm; Becton Dickinson Infusion Therapy Systems Inc, Sandy, UT) supplies cannulas with a cover having both ends open and fitting properly with the hub. Therefore, we recommend that in view of its distinct advantages (this is the only technique that foretells the success of arterial cannulation without the need for observing the spurt of blood), all arterial cannulas should preferably have a transparent cover that can be fitted easily into the hub of the cannula or a long hub. In Response to “A Modified ‘Over-the-Needle' Technique for Arterial Cannulation”Journal of Cardiothoracic and Vascular AnesthesiaVol. 24Issue 2PreviewI would like to comment on the letter to the editor from Koshy et al1 regarding a technique for arterial puncture in adult patients. Full-Text PDF

THE ADEQUACY OF valve repair for regurgitation is commonly assessed intraoperatively by transesophageal echocardiography (TEE) after separation from cardiopulmonary bypass (CPB). 1 Gillam L.D. Intraoperative transesophageal echocardiography. Cardiol Rev. 2000; 8: 269-278 Crossref PubMed Scopus (5) Google Scholar , 2 Mochizuki Y. Patel A.K. Banerjee A. et al. Intraoperative transesophageal echocardiography: Correlation of echocardiographic findings and surgical pathology. Cardiol Rev. 1999; 7: 270-276 Crossref PubMed Scopus (10) Google Scholar However, the mitral valve (MV) can be assessed by injecting saline under pressure through the valve into the left ventricle (LV) before releasing the aortic cross-clamp (ACC). 3 Kouchoukos N.T. Blackstone E.H. Doty D.B. Mitral valve disease with or without tricuspid valve disease, in Kirklin/Barratt-Boyes Cardiac Surgery (vol 1). Churchill Livingstone, Philadelphia2005: 499 Google Scholar The technique of saline distention permits the identification and repair of residual areas of prolapse and regurgitation or replacement of the valve before initiating coronary perfusion. Unlike the MV, there is no reliable technique of confirming the adequacy of aortic valve (AV) repair before declamping the aorta. Unsuccessful repair may lead to LV distention and coronary hypoperfusion on removal of ACC. A novel technique of intraoperative assessment of adequacy of AV repair while the aorta is still cross-clamped is reported.

THE ASSOCIATION OF partial anomalous pulmonary venous return (PAPVR) with atrial septal defect (ASD) is not unusual. Rarely, PAPVR of the left side or right side is associated with an intact atrial septum (IAS). The combination of acquired rheumatic mitral stenosis (MS) with PAPVR and IAS is very rare, and its pathophysiology is complex. The successful anesthetic management of an adult who presented for surgery for rheumatic MS and was incidentally found to have PAPVR of the left side with an IAS is presented here. Anesthetic implications of such a rare combination of congenital and acquired heart disease are discussed.

1. Sanders JC, King MA, Mitchell RB, Kelly JP. Perioperative complications of adenotonsillectomy in children with obstructive sleep apnea. Anesth Analg 2006;103: 1115–21 2. Waters KA, McBrien F, Stewart P, Hinder M, Wharton S. Effects of OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children. J Appl Physiol 2002;92:1987–94 3. Brown KA, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology 2004;100:806–10 4. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg 1995;121:525–30 5. Brown KA, Laferrière A, Lakheeram I, Moss IR. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology 2006;105:665–9 6. Moss IR, Brown KA, Laferrière A. Recurrent hypoxia in the rat during development increases subsequent respiratory sensitivity to fentanyl. Anesthesiology 2006;105:715–18 7. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can Assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications? Anesthesiology 2002;96:313–22

Transesophageal echocardiographic (TEE) monitoring is increasingly used during cardiac surgery and has been shown to have a significant clinical impact.1Couture P. Denault A.Y. McKenty S. et al.Impact of routine use of intraoperative transesophageal echocardiography during cardiac surgery.Can J Anesth. 2000; 47: 20-26Crossref PubMed Scopus (95) Google Scholar However, the TEE probe and machine are expensive and are likely to get damaged if not used properly. There are several risk factors that can cause damage to the TEE probe; one is improper use of the TEE probe during difficult insertion. It has been found that on some occasions the insertion of the TEE probe may require some form of instrumentation (like laryngoscopy) for its correct placement, which can potentially cause damage to the probe. To avoid this, the TEE probe has to be placed into the patient’s esophagus (either orally or nasally) without much maneuvering or instrumentation. The difficulty occurs because of impaction of the TEE probe on the adjacent structures, ipsilateral piriform sinus, and arytenoid cartilages (Fig 1), which is also true for oro- (OGT) or nasogastric tube (NGT) insertion.2Ozer S. Benumof J.L. Oro- and nasogastric tube passage in intubated patients: Fibroptic description of where they go at the laryngeal level and how to make them enter the esophagus.Anesthesiology. 1999; 91: 137-143Crossref PubMed Scopus (83) Google Scholar We have found that during difficult insertion lifting the cricoid cartilage forward using the so-called “reverse Sellick’s maneuver” while the head is kept in a neutral position helps facilitate the easy insertion of the TEE probe, avoiding the need for instrumentation. Alternatively, external medially directed pressure can be applied to the ipsilateral lateral neck by multiple fingers at the level of the lateral border of the thyrohyoid membrane, the so-called “lateral neck pressure” as described by Ozer and Benumof2Ozer S. Benumof J.L. Oro- and nasogastric tube passage in intubated patients: Fibroptic description of where they go at the laryngeal level and how to make them enter the esophagus.Anesthesiology. 1999; 91: 137-143Crossref PubMed Scopus (83) Google Scholar for OGT or NGT insertion. This method is also useful for TEE probe insertion. We have used these techniques in both adults and children and found them to be very useful during difficult TEE probe placement. The probable mechanism by which the reverse Sellick’s maneuver facilitates the insertion of the TEE probe can be explained as follows: The inferior constrictor muscle forms the anatomic start of the esophagus, which is immediately posterior to the cricoid cartilage. Thus, anterior displacement of the cricoid cartilage may open the esophagus more widely (Fig 2) , making passage of a TEE probe easier in patients in whom initial TEE probe placement is difficult. The mechanism by which lateral neck pressure facilitates insertion of a TEE probe might be similar to that described for NGT insertion by Ozer et al2Ozer S. Benumof J.L. Oro- and nasogastric tube passage in intubated patients: Fibroptic description of where they go at the laryngeal level and how to make them enter the esophagus.Anesthesiology. 1999; 91: 137-143Crossref PubMed Scopus (83) Google Scholar in which lateral neck pressure causes compression of the piriform sinus and moves the arytenoid cartilage medially. The collapse of the piriform sinus eliminates this recess as a potential site of impaction and probably funnels a laterally oriented TEE probe toward the usual entry point into the hypopharynx, which is just lateral to the arytenoid cartilage,2Ozer S. Benumof J.L. Oro- and nasogastric tube passage in intubated patients: Fibroptic description of where they go at the laryngeal level and how to make them enter the esophagus.Anesthesiology. 1999; 91: 137-143Crossref PubMed Scopus (83) Google Scholar thus facilitating its easy entry into the esophagus.

Achieving adequate depth of anaesthesia during surgical procedures is desirable. Therefore, assessment and monitoring/measurement of the depth of anaesthesia are fundamental to anaesthetic practice. The purpose of this review is to identify the risk factors that may be associated with intraoperative awareness, provide decision tools that may enable the clinician to reduce the frequency of unintended intraoperative awareness, stimulate the pursuit and evaluation of strategies that may prevent or reduce the frequency of intraoperative awareness, different types of tools developed to date to monitor the depth of anaesthesia, provide guidance for the intraoperative use of different monitoring tools as they relate to intraoperative awareness and how to approach a patient when awareness is reported by the patient along with current guidelines in the use of current available monitors.

Context: Awake craniotomy is increasingly performed the world over. We share our experience of performing craniotomy awake with our anesthetic protocol. Aims: To evaluate and analyze the anesthesia records of the patients who underwent awake craniotomy at our institution. Settings and Design: University teaching hospital, Retrospective study. Materials and Methods: We reviewed records of the 42 consecutive patients who underwent awake craniotomy under conscious sedation using Fentanyl and Propofol infusion until December 2005. The drugs were titrated (Bispectral monitoring was used in 16 patients) to facilitate intermittent intraoperative neurological testing. All patients received scalp blocks with a mixture of bupivacaine and lignocaine with adrenaline. Haloperidol and ondansetron were administered in all patients at induction of anesthesia. Results: All patients completed the procedure. One patient each needed endotracheal intubation and LMA for airway control during closure, while another required CPAP perioperatively because of desaturation to <80%. There was significantly decreased use of anesthetics (P<0.001) and a trend towards reduction in complications (e.g. respiratory depression and deep sedation) (P>0.05) with the use of BIS as compared to without BIS. Intraoperative complications were hypertension (19%), tight brain (14.2%), focal seizure (9.5%) respiratory depression (7.1%), deep sedation (7.1%), tachycardia (7.1%) and bradycardia. Two patients desaturated to <95%. 23.8% patients developed transient neurological deficits. The most frequent postoperative complications were PONV (19%) and seizures (16.6%). Conclusions: With the use of advanced monitoring and newer anesthetics, awake craniotomy is a relatively safe procedure with an accepted rate of complications.

A 14-YEAR-OLD BOY, weighing 28 kg with a history of cough and purulent sputum for 1 month and breathlessness for 2 weeks, was referred to this center because of increasing shortness of breath. The patient was diagnosed with acute lymphoblastic leukemia (ALL) 2 months before admission and had received 3 cycles of chemotherapy with vincristine and dexamethasone. He developed pneumonia 1 month before this admission and the chest x-ray (CXR) showed consolidation of the entire left lung for which he was put on antibiotics. His repeat CXR showed clearing of the upper part of the left lung.