Case Communications IMAJ • VOL 13 • october 2011

Awake Fiberoptic Intubation and General Anesthesia in a Parturient with Mirror Syndrome and a Predicted Difficult Airway Alexander Zlotnik MD PhD1, Shaun E. Gruenbaum MD3, Benjamin F. Gruenbaum BS1, Arie Koifman MD2 and Efim Rusabrov MD1

Departments of 1Anesthesiology and Critical Care and 2Obstetrics and Gynecology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel 3Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA

for seizure prophylaxis. The delivered The chest X-ray findings were suggestive Key words: mirror syndrome, anesthetic male fetus weighed 830 g and had hydrops of pulmonary congestion. Laboratory management, awake fiberoptic fetalis, with severe total body edema and tests showed the following: hemoglobin intubation accumulation of a large amount of exudate 9.5 g/dl, hematocrit 28%, platelets 106 x IMAJ 2011; 13: 640–642 in both the abdominal and pleural cavities 109/L, creatinine 0.63 mg/dl, magnesium [Figure]. The third stage of the delivery 5.5 mg/dl, aspartate aminotransferase was complicated by an undelivered pla- 97 U/L, alanine aminotransferase 50 centa retained in the uterus, which neces- U/L, lactate dehydrogenase 1134 U/L, sitated manual revision of the uterus and sodium 138 mEq/L and potassium 3.5 n 1892, John William Ballantyne des- lysis under anesthesia. The patient had no mEq/L. Evaluation of the airway pre- I cribed a rare condition during preg- epidural catheter in situ. dicted a potentially difficult intubation: nancy, characterized by massive edema- Pre-anesthetic evaluation showed Mallampaty score III, micrognathia, tous swelling of the fetus (fetal hydrops), morbid obesity (body mass index 34) and moderately prominent incisors, and short placentomegaly, and maternal edema significant anasarca including the neck thyromental distance (3 cm). There was [1]. The term “Mirror syndrome” reflects and face. The patient had dyspnea, orthop- no visible edema of the upper airway. The the maternal edema that “mirrors” the nea, and a respiratory rate of 22/min. patient had fasted for more than 8 hours. hydropic fetus and placenta. We discuss Auscultation revealed diffuse crepitations The decision was made to establish the pathophysiology of mirror syndrome at the base of both lungs. Blood pressure a definitive airway prior to induction and the anesthesiological considerations. was 145/95, heart rate 110/min, and blood of anesthesia using awake fiberoptic oxygen saturation 90% on room air that intubation. An arterial line was placed rose to 97% with a non-rebreathing mask. prior to induction. Local anesthesia for Patient Description A 26 year old woman, gravida 1 para 0, presented at 25 weeks gestation with fetal The delivered male fetus. The fetus meconium ileus, echogenic dilated bowel, weighed 830 g and intrauterine growth restriction, right had , persistent umbilical vein oligohydram- with severe total nios and hydrops fetalis, and fetal ascites body edema and consistent with mirror syndrome. The accumulation of a large amount of patient was admitted to the hospital at 27 exudate in both weeks gestation because of elevated blood the abdominal and pressure (150–170/100–110 mmHg), pro- pleural cavities teinuria, headache, diffuse edema and features of HELLP syndrome. She elected to terminate the . Induction of labor was initiated, her blood pressure was aggressively controlled with labetalol, and she was treated with magnesium sulfate

640 IMAJ • VOL 13 • october 2011 Case Communications

AFOI included oral and pharyngeal was discharged from the hospital in good Because mirror syndrome is rare, there topical irrigation with lidocaine spray condition after 2 days. is little in the literature relating to anes- 10%, a bilateral superior laryngeal nerve thesiological considerations in these block with 3 ml of 2% lidocaine, and patients. McCann et al. [3] reported the percutaneous transtracheal irrigation Comment successful use of an epidural in a patient with 4 ml of 2% lidocaine. Oxygen was Mirror syndrome shares many character- with mirror syndrome in whom labor delivered continuously via a face mask. istics with preeclampsia, including edema, was induced. It is clear that the anesthetic The patient could not tolerate the supine proteinuria and hypertension, and despite management of patients needs to be care- position because of respiratory failure, varying criteria in the literature to differ- fully planned because mirror syndrome and AFOI was performed while the entiate between the two syndromes, it is involves multiple maternal organ systems, patient was in the sitting position and the often difficult to make the distinction [1]. including the respiratory, cardiovascular, anesthesiologist performing the AFOI Additionally, it is believed that preeclamp- renal and neurological systems. The was behind the patient and standing on sia coexists in as many as 50% of patients multi-organ involvement in mirror syn- a high stool. Visualization of the land- presenting with mirror syndrome [2]. It drome mandates that the anesthesiologist marks of the upper airway was achieved has been suggested that hemodilution is obtain a detailed history, review relevant without difficulty, and no significant a distinct pathophysiological feature of laboratory values and radiologic studies, edema interfering with intubation was the syndrome, although hemoconcentra- and examine the airway and cardiopul- noted. A cuffed endotracheal tube with tion has been seen in preeclampsia [1,3]. monary status. In our patient several internal diameter of 6.5 mm was easily Other important clinical features of mir- anestheisiological considerations warrant slid down over the fiberoptic scope into ror syndrome are pruritus, formation of special mention. Because the patient had the trachea and the endotracheal tube abdominal blebs, progressive dyspnea, an increased risk of bleeding due to sus- cuff was immediately inflated. General elevated uric acid, and high plasma so- picion of placenta accreta, which might anesthesia was induced with propofol dium and chloride levels [1]. necessitate an emergent airway under bolus at a dose of 1.5 mg/kg. No muscle The exact mechanism of mirror suboptimal conditions, she required relaxant was used. Maintenance of anes- syndrome is unknown, but the fetus is general anesthesia for the procedure. She thesia was accomplished with isoflurane believed to play an important role in the also had a predicted difficult intubation, at 0.5% in 100% oxygen. Mechanical ven- pathogenesis. The mechanism is attrib- which necessitated the use of AFOI. This tilation was initiated with the following uted to alloimmunization or non-immu- was further complicated by her significant parameters: volume control ventilation, nological fetal hydrops. The development respiratory compromise and inability to tidal volume 500 ml, respiratory rate 12 of fetal hydrops is preceded by an initial tolerate lying flat. Therefore, the AFOI breaths/min, and positive end-expiratory insult to the placenta or fetus that has been was performed while the patient was in pressure 7 cm H2O. With the initiation described in the context of cytomegalovi- a sitting position. Many anesthesiologists of mechanical ventilation, the patient’s rus and parvovirus B19 infections, alpha- prefer AFOI to regional anesthesia in the blood oxygen saturation reached 100%. thalassemia, , pla- parturient with a predicted difficult air- Manual revision of the uterus was cental chorioangioma, Ebstein’s anomaly, way. They argue that the use of regional achieved uneventfully in approximately aneurysm of the vein of Galen, and fetal anesthesia in a patient with an expected 10 minutes. After cessation of the revi- supraventricular tachycardia [1,3]. The difficult airway does not solve the airway sion, the isoflurane was turned off, and placenta or fetus releases angiogenic fac- problem, and regional anesthesia-related the patient was woken up and extubated tors, including soluble endothelial growth complications may result in a difficult when she was fully awake. factor receptor-1, which in turn leads to airway emergency situation [4]. The early postoperative period in the endothelial cell dysfunction and maternal Alternative airway devices have been post-anesthesia care unit was unevent- edema. The important role of the fetus in described for managing the parturient ful. The patient remained moderately mirror syndrome was further supported with a predicted difficult airway, includ- hypertensive (140–150/80–90 mmHg), by the amelioration of maternal symp- ing video laryngoscopes such as Pentax, and the blood oxygen saturation was 98% toms when the cause of the fetal hydrops Airtraq, Bullard, and Glidescope [5] and with oxygen delivered via a nasal cannula. was corrected in utero [2]. video stylets such as Bonfils, Shikani, Arterial blood gases analysis revealed the In view of the patient’s generalized Levitan, and SensaScope. With proper following: pH 7.45, PaO2 140 mmHg, edema, hypertension and , as well topical anesthesia of airway and explana- hemoglobin 8.2 g/dl, HCO3 19.5 mM/L, as fetal hydrops, we felt that our patient tion to the patient, these airway devices base excess -3 mM/L, FiO2 0.4. The patient probably had features consistent with can be used in an awake patient as an both mirror syndrome and preeclamp- alternative to AFOI. It should be noted AFOI = awake fiberoptic intubation sia complicated by HELLP syndrome. that every airway device requires some

641 Case Communications IMAJ • VOL 13 • october 2011

degree of skill, and the choice of airway the surgery did not require any muscle tions should be implemented for manag- management should be based on the relaxation. ing a predicted difficult airway. operator’s preference and experience. Although it is thought that seizures Thus, any of these airway devices could are very rare in patients with mirror syn- Corresponding author: have been considered in our patient, drome [1], the patient’s clinical features of Dr. A. Zlotnik subject to its availability and proper preeclampsia prompted treatment with Dept. of Anesthesiology, Soroka University training in its use. When preparing to magnesium sulfate for seizure prophy- Medical Center, Beer Sheva 84105, Israel email: [email protected] manage these patients’ airways, supra- laxis. It is well known that magnesium glottic airway devices such as the I-gel prolongs the effects of non-depolarizing References and laryngeal mask airway should be neuromuscular relaxants by increasing 1. van Selm M, Kanhai HH, Gravenhorst JB. Maternal readily available in the event that a secure the sensitivity of the motor end-plate to hydrops syndrome: a review. Obstet Gynecol Surv airway cannot be established. Supraglottic relaxants. Muscle relaxants can be used 1991; 46: 785-8. airways are inserted blindly and allow for with caution in patients who have received 2. Midgley DY, Harding K. The mirror syndrome. ventilatory support until spontaneous magnesium treatment, in smaller doses Eur J Obstet Gynecol Reprod Biol 2000; 88: 201-2. breathing resumes and the patient can be and with reduced frequency. The use of 3. McCann SM, Emery SP, Vallejo MC. Anesthetic management of a parturient with fetal sacrococcy- woken. Lastly, the anesthesiologist should neuromuscular monitoring with a nerve geal teratoma and mirror syndrome complicated be prepared for the rare “cannot intubate, stimulator is mandatory in such cases. by elevated hCG and subsequent hyperthyroidism. cannot ventilate” scenario, in which case In conclusion, general anesthesia may J Clin Anesth 2009; 21: 521-4. emergent transtracheal ventilation must be safely administered to a parturient 4. Vasdev GM, Harrison BA, Keegan MT, Burkle CM. Management of the difficult and failed airway be established [5]. In our case, we decided with mirror syndrome, although it should in obstetric anesthesia. J Anesth 2008; 22: 38-48. not to use any muscle relaxant because we be carefully planned due to multisystem 5. Biro P. Difficult intubation in pregnancy. Curr chose AFOI, the procedure was short, and organ involvement, and special precau- Opin Anaesthesiol 2011; 24 (3): 249-54. Capsule

The diverse mutational etiology of head and neck squamous cell carcinoma Head and neck squamous cell carcinoma (HNSCC) affects about mutations in a diverse array of genes, including genes implicated 600,000 individuals each year and has a mortality rate of about in squamous differentiation such as NOTCH1. Notably, the 50%. Environmental factors such as tobacco and alcohol use and pattern of NOTCH1 mutations suggests that this gene acts as a human papillomavirus (HPV) infection are key participants. In tumor suppressor in HNSCC, in direct contrast to its role as an independent studies aimed at exploring the molecular genetics oncogene in other tumor types. The diverse mutational etiology of these tumors, Agrawal et al. (Science 2011; 333: 1154) and of HNSCC and the dearth of activating mutations in established Stransky et al. (p. 1157) sequenced the protein-coding genes of oncogenes suggest that targeted therapies for the disease will multiple tumors. Tumors from smokers had more mutations than be especially challenging, which emphasizes the importance of those from non-smokers, and tumors that were HPV-positive had prevention and early detection. fewer mutations than HPV-negative tumors. HNSCCs harbored Eitan Israel

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Microfluidics-based diagnostics of infectious diseases in the developing world One of the great challenges in science and engineering today μl of unprocessed whole blood and an ability to simultaneously is to develop technologies to improve the health of people diagnose HIV and syphilis with sensitivities and specificities that in the poorest regions of the world. Chin and collaborators rival those of reference benchtop assays. Unlike most current integrated new procedures for manufacturing, fluid handling rapid tests, the mChip test does not require user interpretation and signal detection in microfluidics into a single, easy-to-use of the signal. The authors demonstrate an integrated strategy for point-of-care (POC) assay that faithfully replicates all steps of miniaturizing complex laboratory assays using microfluidics and ELISA, at a lower total material cost. The researchers performed nanoparticles to enable POC diagnostics and early detection of this 'mChip' assay in Rwanda on hundreds of locally collected infectious diseases in remote settings. human samples. The chip had excellent performance in the Nature Med 2011; 17: 1015 diagnosis of human immunodeficiency virus (HIV) using only 1 Eitan Israeli

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