The Application of a SaCoVLMTM Visual Intubation Laryngeal Mask for the Management of Difficult Airways in Morbidly Obese Patients: Case Report

We report insertion of the SaCoVLMTM in three awake morbidly obese patients (BMI 46. 7–52.1 kg/m2). The patients were given intravenous atropine and midazolam injections after entering the operating room and then inhaled an anesthetic with 2% lidocaine atomization. After SaCoVLMTM insertion while patients were awake, when the vocal cords were visualized, controlled anesthetic induction commenced with spontaneous ventilation. The entire anesthesia induction and intubation process was completed under visualization, and no adverse events such as hypoxemia occurred. No patient had an unpleasant recall of the procedure. We conclude that the SaCoVLMTM is easy to use, well tolerated and suitable for awake orotracheal intubation in patients with known difficult airways.

Efficacy of transcutaneous cardiac pacing for transient asystole caused by trigeminocardiac reflex: illustrative case

BACKGROUND Trigeminocardiac reflex (TCR) is a brainstem reflex caused by stimulation of the trigeminal nerve, which results in bradycardia, hypotension, and asystole. TCR can occur during any neurosurgical procedure. Initially, it is managed via the immediate removal of the stimulus from the trigeminal nerve. If asystole persists after intravenous atropine or glycopyrrolate, chest compression or transcutaneous cardiac pacing may be considered. The authors present the first case of TCR that was successfully managed with transcutaneous cardiac pacing. OBSERVATIONS A 51-year-old man presented with aneurysmal subarachnoid hemorrhage. Although he had no history of cardiac disease and there were no abnormal findings on electrocardiography, transient asystole due to TCR occurred during craniotomy. The patient’s heart rate spontaneously recovered after the immediate discontinuation of the procedure. The authors completed aneurysm clipping with transcutaneous cardiac pacing because intravenous atropine was not effective in preventing TCR. There were no complications associated with intraoperative asystole or transcutaneous cardiac pacing, and the patient was discharged without neurological deficits. LESSONS TCR can be appropriately managed with the immediate discontinuation of intraoperative procedures. Furthermore, transcutaneous cardiac pacing may be considered for persistent TCR with poor response to intravenous atropine or glycopyrrolate.

Adverse Cardiovascular Effects of Phenylephrine Eye Drops Combined With Intravenous Atropine

Background: Phenylephrine and atropine can cause serious adverse effects when applied in combination. We investigated the effect of phenylephrine eye drops combined with intravenous atropine on the cardiovascular system in patients under general anesthesia undergoing intraocular surgery.Methods: The effects of the drugs were observed through clinical study. Thirteen patients undergoing intraocular surgery under general anesthesia were observed in this study; all were injected intravenously with atropine due to the oculocardiac reflex during surgery. To study the combination of drugs, an in vivo study was performed on rats. Seventy-two standard deviation rats that received phenylephrine eye drops and intravenous atropine treatment under general anesthesia were assessed, of which 18 treated with these drugs simultaneously were administered normal saline, neostigmine or esmolol. Blood pressure and heart rate were recorded and analyzed.Findings: The age of the patients ranged from seven to 14 years old with an average age of 10.7 years old, and 11 patients were male. In patients, 5% phenylephrine eye drops combined with intravenous atropine led to a significant heart rate increase and the increase lasted 20 min. The significant increase in diastolic blood pressure and systolic blood pressure lasted for 15 and 25 min, respectively. From five to 25 min after intravenous atropine treatment, the systolic blood pressure and diastolic blood pressure were both more than 20% higher than that at baseline. In rats, the changes in blood pressure and heart rate were independent of the phenylephrine and atropine administration sequence but were related to the administration time interval. The neostigmine group showed a significant decrease in blood pressure after the increase from the administration of phenylephrine and atropine.Interpretation: Phenylephrine eye drops combined with intravenous atropine have obvious cardiovascular effects that can be reversed by neostigmine. This drug combination should be used carefully for ophthalmic surgery, especially in patients with cardio-cerebrovascular diseases.

ST-Segment Elevation Associated with Mobitz II Atrioventricular Block During Transseptal Puncture for Atrial Fibrillation Ablation

Pulmonary veins electrical isolation as an invasive treatment of atrial fibrillation has been widely used in electrophysiology laboratories. This case report presents a rare and transient complication, during transseptal puncture for atrial fibrillation ablation. ST-segment elevation, hypotension and bradyarrhythmia related to catheterization were observed despite cineangiocoronariography without obstructive lesions. Clinical stability was achieved after administration of intravenous atropine and saline solution. It is speculated that the phenomenon is attributed to an increased vagal tone after the mechanical effect of transseptal puncture in the interatrial vagal network. The procedure was completed despite the phenomenon.

Peribulbar anesthesia for strabismus surgery in adult patients

Purpose: To evaluate the efficacy and safety of peribulbar anesthesia during strabismus surgery. Methods: Medical records of patients undergoing strabismus surgery and peribulbar anesthesia were reviewed. The overall efficacy of peribulbar anesthesia was evaluated as requirement of supplemental peribulbar anesthesia, impossibility to perform eye muscles surgery due to inadequate efficacy of the block and peribulbar block complications that occurred up to 6 weeks postoperatively. Presence of oculocardiac reflex (OCR) and presence of decreased visual acuity and afferent pupillary defect postoperatively were reported. Results: A total of 510 patients comprised our study group. The total amount of peribulbar injections was 717. Four patients (0.7%) required supplemental injection in the superonasal quadrant. Five of 510 (0.9%) required an anesthesiologic intervention with intravenous atropine. Eighty patients of 510 (15.6%) complained about transitory complete ptosis and/or amaurosis postoperatively. No complications were observed up to 6 weeks postoperatively. Conclusion: Peribulbar anesthesia was an effective and safe option during strabismus surgery in adult patients.

Case Series: Organophosphate Contamination of Camel’s Mammary Glands Affects Human Health

In this case series, we present 2 cases of previously healthy farmers, who presented with symptoms of a cholinergic crisis that developed several hours after ingestion of camel milk. The initial case was treated with supportive medical care without using antidote as no history of direct exposure to pesticides was available.The second case presented with symptoms of cholinergic crisis that developed several hours after the ingestion of camel milk. Clinical features included slurred speech, headache, vomiting, diarrhea, frequent ­micturition, muscle fasciculation, chest discomfort, and atrial fibrillation. The patient developed bradycardia that responded to intravenous atropine. Routine investigations were unremarkable, but acetylcholinesterase and pseudocholinesterase levels were both low. The patient was managed with intravenous fluids, analgesia, atropine, and pralidoxime, which were administered when he developed respiratory symptoms secondary to excessive secretions. The following day, the patient was asymptomatic and discharged. On the medical history, the patient denied any other ingestion including food and drink or potential organophosphate exposure on the day of symptom onset. Application of organophosphate pesticides to the mammary glands of camels has been used for many decades against <i>Sarcoptes scabei cameli</i>, a mite that causes a dermal infestation in camels similar to human scabies infections.

Haemodynamic effects of premedication for neonatal intubation: an observational study

ObjectiveTo examine changes in blood pressure (BP), cardiac output (CO) and cerebral regional oxygen saturation (rScO2) with administration of premedication for neonatal intubation.DesignPilot, prospective, observational study. Oxygen saturation, heart rate, CO, rScO2 and BP data were collected. Monitoring began 5 min prior to premedication and continued until spontaneous movement.SettingSingle-centre, level 3 neonatal intensive care unitPatients35 infants, all gestational ages. 81 eligible infants: 66 consented, 15 refused.InterventionsIntravenous atropine, fentanyl or morphine, ±cisatracuriumMain outcome measuresBP, CO, rScO2Resultsn=37 intubations. Mean gestational age and median birth weight were 31 4/7 weeks and 1511 g. After premedication, 10 episodes resulted in a BP increase from baseline and 27 in a BP decrease. Of those whose BP decreased, 17 had <20% decrease and 10 had ≥20% decrease. Those with <20% BP decrease took an average of 2.5 min to return to baseline while those with a ≥20% BP decline took an average of 15.2 min. Three did not return to baseline by 35 min. Following intubation, further declines in BP (21%–51%) were observed in eight additional cases. One infant required a bolus for persistently low BPs. CO and rScO2 changes were statistically similar between the two groups.ConclusionAbout 30% of infants dropped their BP by ≥20% after premedication for elective intubation. These BP changes were not associated with any significant change in rScO2 or CO. More data are needed to better characterise the immediate haemodynamic changes and clinical outcomes associated with premedication.