An anesthetic experience of hereditary angioedema type I patient undertook total laparoscopic hysterectomy - A case report -

Background: Hereditary angioedema (HAE) is an autosomal dominant disorder. The characteristic of HAE is recurrent angioedema episodes due to low C1 esterase inhibitor (C1-INH) level. HAE symptoms, especially those affecting oropharynx or larynx may develop respiratory distress syndrome due to impaired airway, which can be potentially fatal. Case: We report a clinical case of a 57 year-old woman, with type I HAE, scheduled for total laparoscopic hysterectomy under general endotracheal anesthesia, which was done successfully without inducing airway edema. Danazol, which increases liver synthesis of C1-INH, was administered and fresh frozen plasma (FFP), which contained C1-INH, was transfused after induction.Conclusions: For HAE patients, the greatest concern is that general anesthesia can induces upper airway edema by direct mucosal irritation by the endotracheal tube. The perioperative management should include both prophylactic increase of C1-INH production and on-demand administration of C1-INH or FFP.

The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position

Objective Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay. Materials and Methods Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18–60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients (n = 15) served as control group and received SFT intraoperatively, while patients in group G (n = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLVAI) and before extubation (CLVBE). Statistical Analysis and Results CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p-value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G (p-value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower (p-value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable. Conclusion GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Predictive Performance of Gargle Test in Prediction of Successful Extubation in Patients Undergoing Head and Neck Surgery in ICU

Background Improvement of predictive tools for recognition of airway edema is crucial for safe extubation and patient safety. This study aims to evaluate the efficacy of gargle test for assessment of airway edema and prediction of successful extubation in patients undergoing head and neck surgeries. Methods This is a prospective observational study on 118 patients that were undergone head and neck surgeries and been admitted to intensive care units. All the patients were weaned based on the same protocol. Initially, quantitative, and qualitative Cuff Leak Test were done and, the decision for extubation was made by employing them. Subsequently, gargling with purified water was implemented. Exclusion criteria were consisted of the impossibility of extubation due to reasons other than airway edema such as pneumonia. Independent sample t-test was applied to study the difference between quantitative variables between two groups, and Fisher’s exact test was used for categorical variables. P-value < 0.05 was determined as a significant difference between the variables. To investigate the relationship between these two tests, sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. Result One hundred eighteen were enrolled in this study. Sixty-seven patients (56.78%) male and 51 patients (43.22%) were female with a mean age of 54.7 ± 12.2 year. Due to surgical manipulations, and anatomical problems in the hypopharynx and larynx, 5 patients (4.2%) were not able to perform the gargle test. Six patients (5.1%) were facing extubation failure since they experienced respiratory distress and stridor. A measure of agreement (kappa) of gargle test with qualitative and quantitative CLT was low (K = 0.21, k = 0.07, respectively). The gargle test had higher specificity, negative predictive value (NPV), and accuracy compared to quantitative and qualitative CLT. Extubation failure in patients with positive gargle test was significantly lower than patients with negative gargle test (3.7% vs. 33.4 % respectively, P = 0.032). Conclusion The gargle test is simple, cheap, and does not require any equipment, and groups of nerves and muscles which control larynx function are being assessed in the gargle test. It provides better patients safety in difficult extubations.

A rare case of difficult airway management in a Klippel-Feil syndrome pediatric patient with osseous torticollis undergone orthopedic surgery

Background Orthopedic surgery for cervical torticollis poses potential threat to airway management both in tracheal intubation and extubation. Klippel-Feil syndrome (KFS) is a complex syndrome of osseous and visceral anomalies. The anatomical characteristics of KFS might have significant implications for airway management. Case presentation This is a rare case of an 8-year-old boy presenting with osseous torticollis, congenital occipito-atlantal deformity, congenital basilar invagination and KFS undergone elective torticollis correction surgery. Though with difficulty, tracheal intubation was successfully performed. Extubation failed twice on postoperative day 2 and 10, and required tracheostomy. Based on radiological findings, we speculated that prolonged airway edema accounted for the main reason of the failed extubation, the hypertrophic tonsil and occipito-cervical fusion resulted in reduced oropharyngeal space and limited cervical range of motion. Moreover, the Chiari malformation and KFS complicated the airway condition and lead to prolonged airway obstruction. The tracheostomy casing was removed 1 month later. Conclusions Cautions should be taken in extubation of pediatric patients undergone major osseous torticollis surgery. Reintubation should be prepared in case of failed extubation. Severe post-operative airway edema, complicated with hypertrophic tonsil, the structural abnormalities in the oropharyngeal cavity, and occipito-cervical deformities constituted the decreased oropharyngeal space and resulted in failed extubation. For severe airway compromise and prolonged intubation, tracheostomy should be considered.

Permanent Complete Heart Block After Kaala Pathar (Paraphenylene Diamine) Poisoning: A Case Report

Kaala Patthar, containing paraphenylene diamine (PPD) chemically, is used as a hair dye in South Punjab. Recent trends have shown its increasing use as a poison. The common manifestations of Kala Patthar poisoning include upper airway edema, rhabdomyolysis, and acute renal shutdown. However, cardiac toxicity is a rare complication and the conduction abnormalities are seldom reported. We are going to report a case of permanent complete heart block after Kaala Patthar poisoning where the patient needed permanent pacemaker to save his life.