Volume 8 Number 1 Spring 2009 The International Student Journal of Nurse

TOPICS IN THIS ISSUE

MS & ECT

Cardioprotection of Volatile Agents

Hyperthermic Chemotherapy

Intubating LMA

Pierre Robin Syndrome

Alpha Thalassemia

Latex Allergy & Spina Bifida

Distorted Upper Airway

Volunteerism – Honduras

INTERNATIONAL STUDENT JOURNAL OF NURSE ANESTHESIA Vol. 8 No. 1 Spring 2009

Editor - in - Chief Ronald L. Van Nest, CRNA, JD

Associate Editors Vicki C. Coopmans, CRNA, PhD Julie A. Pearson, CRNA, PhD

EDITORIAL BOARD & SECTION EDITORS

Pediatrics Janet A. Dewan, CRNA, MS Northeastern University

Obstetrics Greg Nezat, CRNA, PhD Navy Nurse Corps Anesthesia Program

Research & Capstone Joseph E. Pellegrini, CRNA, University of Maryland PhD Regional / Pain Christopher Oudekerk, CRNA, Uniformed Services Universi- DNP ty of the Health Sciences

Cardiovascular Michele Gold, CRNA, PhD University of Southern Cali- fornia

Thoracic/ Fluid Balance Lori Ann Winner, CRNA, MSN University of Pennsylvania

Unique Patient Syndromes Kathleen R. Wren, CRNA, PhD Florida Hospital College of Health Sciences

Equipment Carrie C. Bowman Dalley, Georgetown University CRNA, MS

Pharmacology Maria Magro, CRNA, MS, University of Pennsylvania MSN

Pathophysiology JoAnn Platko, CRNA, MSN University of Scranton

Special Surgical Techniques Russell Lynn, CRNA, MSN University of Pennsylvania

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Airway & Respiration Michael Rieker, CRNA, DNP Wake Forest University Baptist Medical Center ,Nurse Anesthesia Program, Univer- sity of North Carolina at Greensboro

Neurology & Neurosurgery Edward Waters, CRNA, MN Kaiser School of Anesthesia, California State University, Fullerton

Contributing Editors For This Issue

Terrie Norris, CRNA, EdD University of Southern California Sharon Hadenfeldt, CRNA, PhD Bryan LGH Medical Center

Elizabeth Koop, CRNA, MS Georgetown University

Reviewers For This Issue

Candace Pratt MS CRNA, MS Jefferson University School of Nursing Johanna Newman MS,CRNA Florida Hospital College of Health Sciences

Connie Calvin, CRNA, MS Northeastern University

The opinions contained in this journal are those of the student and do not necessarily represent the opinions of the program or the University

Disclaimer for all articles authored by military personnel: The views expressed in this journal are those of the authors and do not necessarily reflect the official policy or position of their re- spective Military Department, Department of Defense, nor the U.S. Government. The work was prepared as part of the official duties of the military service member. Title 17 U.S.C. 105 pro- vides that ‘Copyright protection under this title is not available for any work of the United States Government’. Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that per- son’s official duties.

Front Cover: Kate Silver, BSN (left) and Andrea Atkins, BSN (right), graduate students enrolled in the Goldfarb School of Nursing at Barnes-Jewish College, practice an induction sequence in a simulated OR setting. (Photo by Chris Tobnick, BA)

Guide for Authors: can be found at www.aana.com > Professional Development > Nurse Anes- thesia Education > For Students (Scroll to the bottom of the page) > Guide for Authors

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Tab le of Contents

Multiple Sclerosis and Electroconvulsive Therapy ………………………………………. 4 Joanna Woersching, Duke University

Cardioprotection: The Role of Volatile Anesthetics ……………………………………… 7 Angela D. Liddell, Georgetown University

Hyperthermic Intraoperative Intraperitoneal Chemotherapy ………………………..... 11 Kelly S. Chambers, Georgetown University

The Role of the Intubating …………………………………… 14 Vonnett T. Seeger, Georgetown University

Airway Management in Pierre Robin Syndrome …………………………………….…. 17 Sheila T. Carbonell, University of Southern California

Alpha Thalassemia and General Anesthesia ……………………………………….……. 21 Katrina M. Longe, Bryan LGH Medical Center

Latex Allergy in the Spina Bifida Patient ……………………………………………….. 23 Tani a M. Roberts, Goldfarb School of Nursing at Barnes-Jewish College

Intubation of the Distorted Upper Airway ………………………………………...……. 26 Callie J. Fischer, Goldfarb School of Nursing at Barnes-Jewish College

LETTER TO THE EDITOR

Student Registered Volunteer Experience in Honduras ………. .… 30 Kelly S. Chambers, Georgetown University

Editorial ……………………………………………………………...…………………… 33 Ronald L. Van Nest

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Multiple Sclerosis and Electroconvulsive Therapy

Joanna Woersching, BSN Duke University

Key Words: Multiple Sclerosis, Electro- considerations of patients with MS requiring convulsive Therapy, Depression and Nerv- electroconvulsive therapy. ous System. Case Report Multiple sclerosis (MS) is a demyelinating, autoimmune disease which damages the A 47 year old, 97 kg, 64 in, ASA 3 Cauca- white matter of the brain and spinal cord and sian female presented for her first electro- can lead to chronic inflammation and neural convulsive therapy session. The patient’s scarring (gliosis).1, 2 MS is a progressive past medical history was significant for disease that affects people throughout their hypertension, fibromyalgia, obesity, depres- lives. Patients are predominantly women sion, diabetes, relapsing-remitting multiple (2:1) between 20 and 40 years of age.3 Mul- sclerosis (RRMS) and smoking with an tiple sclerosis affects Caucasians more than acute case of bronchitis two months prior. other ethnic groups and is more prevalent in The patient was admitted to the psychiatric populations living between the poles and 40 ward for an acute episode of major depres- degrees north or south latitude.4 In the Unit- sion. The patient had prior uneventful anes- ed States, at least 350,000 people have MS thetics. A drug allergy to penicillin was and 10,000 new cases are diagnosed every reported to cause hives. Current medications year.4 It is projected that 50% of patients included glipizide, hydrochlorothiazide, me- diagnosed with MS will be bedridden within thylprednisolone, sertraline, gabapentin and 15 years.5 Mood disorders have been asso- aspirin. A complete blood count and basic ciated with multiple sclerosis and may re- chemistry were normal. Her heart rate was quire treatment with electroconvulsive normal with a blood pressure of 140/80. Her therapy.6 In 1999, the U.S Department of lungs were clear, she had good neck exten- Health and Human Services estimated that sion, mouth opening and had a Mallampati 100,000 hospitalized Americans received class II airway exam. electroconvulsive therapy (ECT).7 Electro- convulsive therapy is most commonly used The patient was transferred from the psy- to treat unipolar depression, bipolar depres- chiatric ward to the postoperative unit where sion and mania.8 Small electrical stimuli are electroconvulsive therapy was performed in applied to the cerebrum eliciting generalized this institution. The postoperative unit was seizures. A good therapeutic effect is com- equipped with a mask and ambu-bag resus- monly achieved after 400 to 700 seconds of citation set, code cart, suction, oxygen and seizure.5 Patients are scheduled for a series for blood pressure, pulse, oxy- of treatments, usually two to three per week gen saturation and end tidal carbon dioxide. (six to ten treatments total). Although the The anesthesia interview revealed that over mechanism of action is not fully understood, the past week the patient developed symp- it is proposed that levels of certain neuro- toms of acute, relapsing MS.6 The patient transmitters are increased by direct stimula- reported new onset muscle weakness that led tion of certain areas of the brain.8 The to paralysis rendering the patient unable to following case report describes the unique ambulate with urinary incontinence, diplopia

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and generalized fatigue. The planned anes- blocking agent on a patient with muscu- thetic included Brevital® () and loskeletal paresis which may result in Anectine® (succinylcholine). In order to hyperkalemia. Due to unpredictable neuro- proceed with electroconvulsive therapy, the muscular blockade seen with alternative, anesthesia practitioners were prepared for non-depolarizing neuromuscular blocking possible intubation and mechanical ventila- agents and MS, prolonged mechanical venti- tion. This might have required a post- lation maybe required.6 This response can be procedural intensive care unit admission for attributed to the increase in extrajunctional monitoring and mechanical ventilation. Af- cholinergic receptors in upper motor neuron ter discussing the anesthesia risks and bene- lesions seen in advanced, MS.3 fits the proposed ECT was postponed to provide resolution of MS symptoms. Uncontrolled motor activity during ECT could result in musculoskeletal injury if Discussion general anesthesia is not used.5 and mask ventilation are re- Relapsing-remitting and primary-progres- quired throughout the treatment. The optim- sive are two of the most common forms of al anesthetic for ECT is a light, general MS.5 RRMS affects 80% of people diag- anesthetic providing amnesia for the period nosed with MS and is characterized by ex- of neuromuscular blockade that neither inhi- acerbations or attacks lasting one to three bits the seizure nor produces prolonged ap- months, followed by periods of remission nea. As previously mentioned methohexital lasting a year or longer. The remaining 20% is the agent of choice at this institution. Oth- of patients diagnosed with MS have pri- er induction agents such as propofol, benzo- mary-progressive MS which shows a steady diazepines, barbiturates and etomidate have increase in neurological symptoms without anticonvulsant properties.5 Alternatives to remission.5 The cause of multiple sclerosis depolarizing muscle relaxants could include is unknown with a genetic correlation of 3% a short acting non-depolarizing neuromuscu- to 4% to a first relative diagnosed with MS.4 lar relaxant (NDNMR) such as mivacurium Smoking and slow-acting viruses have also or combining an intermediate NDNMR with been correlated to MS.4 the rapid onset NDNMR antagonist sugam- madex. Currently neither mivacurium nor Major anesthetic considerations for multiple sugammadex are available in the United sclerosis include exacerbation of symptoms States. caused by temperature changes, autonomic instability and ventilatory compromise.1 An Electroconvulsive therapy has been shown increase in body temperature as small as one to cause mild neurological defects in all pa- degree Celsius can lead to an exacerbation tients.9 Evidence that electroconvulsive of MS symptoms.5 Temperature increases therapy instigates an increase in the size and may block demyelinated nerve conduction.5 number of plaques thus causing further dete- Also, patients with significant respiratory rioration of multiple sclerosis symptoms has compromise or muscle weakness (rendering been debated.10-12 Mattingly et al11 demon- them bedridden), are at significant risk for strated the possible value of gadolinium en- prolonged ventilation after anesthesia.1 In hanced MRI scanning of white matter on this case of acute MS exacerbation, anesthe- cranial MRI as a predictor of ECT induced sia professionals have to consider the risks neurological dysfunction in MS patients, of using a depolarizing neuromuscular however, this case study only considered

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one subject. Other case studies showed mild support staff available during electroconvul- retrograde and antegrade amnesia that is a sive treatment is important as it is common- common side effect of bipolar ECT pulsing ly performed as an outpatient procedure and as opposed to unipolar pulsing in all pa- in remote anesthetic areas outside of the tients.8 The majority of case reports of MS main operating room. patients undergoing unilateral and bilateral ECT pulsing showed minimal incidents of References short term deterioration.10, 13-16 However, the long term effects of ECT treatments on the 1. National Multiple Sclerosis Society. Li- neurological status of MS patients have yet brary & Literature: Anesthesia. 2004. to be determined.13 Available at: http://www.nationalmsssociety.org/Sour The systemic effects of electroconvulsive cebook-Anesthesia.asp. Accessed April therapy on an MS patient are unpredictable. 22, 2008. Patients with advanced MS disease may ex- 2. Pittock SJ, Lucchinetti CF. The pathol- hibit increased cardiovascular instability due ogy of MS: New insights and potential to autonomic dysfunction. ECT is a signifi- clinical applications. Neurologist. Mar cant hemodynamic stressor.3 In a grand mal 2007;13(2):45-56. seizure, parasympathetic centers are acti- 3. Stoelting RK, Dierdorf SF. Anesthesia vated, resulting in bradyarrhythmias and and co-existing disease. 4th ed. New brief sinus pauses. This is followed by a York: Churchill Livingstone; 2002:268- sympathetic discharge with heart rate and 289. blood pressure increasing up to 30% above 4. Courtney S, Burks J, Borkowski A, baseline.5 Because of the hemodynamic ef- Damiri P, Richman C. All About Mul- fects of ECT, contraindications include: re- tiple Sclerosis. Cherry Hill, NJ: Mul- cent myocardial infarction (less than three tiple Sclerosis Association of America; months ago), recent cerebrovascular acci- 2002. dent (less than three months ago), intra- 5. Morgan GE, Mikhail MS. Clinical cranial mass, or elevated intracranial . 2nd ed. Stamford, pressure, aortic aneurysm, angina, conges- Conn.: Appleton & Lange; 1996:587- tive heart failure, pheochromocytoma, recent 589, 659-660. intracranial surgery (less than three months 6. Schneider KM. AANA Journal course: ago) and retinal detachment.8 Update for nurse anesthetists--an over- view of multiple sclerosis and implica- Multiple Sclerosis is multifaceted disease tions for anesthesia. AANA J. process with symptoms ranging from muscle 2005;73(3):217-224. spasticity, fatigue, sensory disorders, bladder 7. U.S. Department of Health and Human and bowel dysfunction to significant motor Services. Mental Health: A Report of disorders, paresis, cerebellar demyelination the Surgeon General—Executive Sum- and ventilatory compromise.6 When caring mary. Rockville, MD: U.S. Department for patient with MS review any acute symp- of Health and Human Services, Sub- tom changes and medical history that may stance Abuse and Mental Health Servic- put a patient at risk for neurological com- es Administration, Center for Mental promise, prolonged mechanical ventilation Health Services, National Institutes of and autonomic disturbances. Careful as- Health, National Institute of Mental sessment of the resources of the setting and Health; 1999:258-261.

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8. Pandya MM, Pozuelo LL, Malone DD. tiple sclerosis. J Neuropsychiatry Clin Electroconvulsive therapy: what the in- Neurosci. 1995;7(1):90-92. ternist needs to know.Cleve Clin J Med. 13. Corruble E, Awad H, Chouinard G, 2007;74(9):679-685. Hardy P. ECT in delusional depression 9. Greenberg RMRM, Kellner CHCH. with multiple sclerosis. Am J Psychia- Electroconvulsive therapy: a selected try. 2004;161(9):1715. review. Am J Geriatr Psychiatry. 14. Pittock SJ, Rodriguez M, Wijdicks EF. 2005;13(4):268-281. Rapid weaning from mechanical venti- 10. Coffey CE, Weiner RD, McCall WV, lator in acute cervical cord multiple Heinz ER. Electroconvulsive Therapy sclerosis lesion after steroids. Anesth in Multiple Sclerosis: A Magnetic Re- Analg. 2001;93(6):1550-1551, table of sonance Imaging Study of the Brain. contents. Convuls Ther. 1987;3(2):137-144. 15. Rasmussen KGKG, Keegan BMBM. 11. Mattingly G, Baker K, Zorumski CF, Electroconvulsive therapy in patients Figiel GS. Multiple sclerosis and ECT: with multiple sclerosis. J ECT. possible value of gadolinium-enhanced 2007;23(3):179-180. magnetic resonance scans for identify- 16. Savitsky N, Karliner W. Electroshock ing high-risk patients. J Neuropsychia- therapy and multiple sclerosis. N Y State try Clin Neurosci. 1992;4(2):145-151. J Med. 1951;51(6):788. 12. Scott TF, Lang D, Girgis RM, Price T. Prolonged akinetic mutism due to mul- Mentor: Julie Pearson CRNA, PhD

Cardioprotection: The Role of Volatile Anesthetics

Angela D. Liddell, BN Georgetown University

Key Words: volatile agents, cardioprotec- tection when utilized. Conclusive studies tion, total esophagectomy, non-cardiac sur- find these agents to have cardioprotective gery, myocardial ischemia effects that decrease morbidity and mortali- ty. 2 Anesthetic management for high risk sur- gery can be challenging, especially when a Case Report patient presents with significant cardiac risk factors. Ischemic heart disease is present in A 56 year old, 107kg male, scheduled for a an estimated 30% of patients who undergo total esophagectomy presented with distal surgery annually in the United States.1 A esophageal cancer. Past medical history in- thorough history is essential in the detection cluded; hypertension, hypercholesterolemia, of diseases that would place the patient in a sleep apnea, depression, gastroesophageal high surgical risk category. Once significant reflux, obesity, and a smoking history of one cardiac risk has been established preopera- pack per day for 45 years. The patient could tively, certain cardioprotective actions can perform activities of approximately 5 meta- be taken to prevent ischemia. bolic equivalent tasks. An electocardiogram Recent data imply volatile agents such as on the day of surgery revealed normal sinus sevoflurane and desflurane offer cardiopro- rhythm, a rate of seventy-five beats per

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minute, and a possible old inferior wall intravenous and ephedrine 20mg intravenous myocardial infarct. The patient denied chest were administered without return to baseline pain or shortness of breath on exertion. blood pressure levels. Epinephrine 85mcg Heart tones were normal and regular in rate IV was then administered, and the blood and rhythm. Current medications included pressure then returned to within 20% of escitalopram 20mg once daily, atorvastatin baseline and remained adequate throughout 10mg once daily, and metoprolol 100mg the case. twice daily. The last dose of metroprolol was taken on the morning of surgery. Anesthesia was maintained with sevoflurane at an end tidal concentration of 1.6-2.4% A few days prior, this patient was scheduled and 1.0 liter/min flow of air and oxygen. for a total esophagectomy. However, the Fentanyl was utilized throughout the case, anesthesia team recommended the surgery totaling 800mcg IV. A peripheral nerve sti- be cancelled, and the patient see a cardiolo- mulator was utilized to titrate pancuronium gist for further cardiac evaluation and thal- in 2mg IV boluses to maintain adequate lium imaging and stress testing. A muscle relaxation. Estimated blood loss to- cardiologist evaluated the patient and denied taled 650mls. Fresh frozen plasma 480ml the need for further testing. The cardiologist and homologous red blood cells 700mls report claimed the patient only required beta were administered for a drop in hematocrit blockade at this time, and no further testing (hct) level from an initial 38.8% to 33%, re- was needed for this surgery. The decision spectively. Fluid replacement was based on was made to proceed with the surgery with urine output, blood pressure, and estimated general anesthesia at that time. The patient third space loss. A total of 7500mls crystal- was not given the option of an epidural due loid was administered, and urine output to- to initial abnormal PT/PTT results, which taled 1125mls. The patient was taken to the were later refuted by repeat testing which intensive care unit and mechanical ventila- indicated normal PT/PTT values. tion was maintained. The patient’s trachea was extubated on postoperative day one, and After pre-oxygenation, induction was per- he was discharged on postoperative day four formed utilizing lidocaine 50mg intraven- without cardiac complications. ous, fentanyl 250mcg intravenous, propofol 160mg intravenous, and rocuronium 50mg Discussion intravenous. The trachea was intubated uti- lizing the GlideScope® video laryngoscope The two most important risk factors for de- for proficiency purposes. Bilateral breath velopment of atherosclerosis involving the sounds were confirmed, and continuous end coronary arteries are male gender and in- tidal carbon dioxide was confirmed present. creasing age. Additional risk factors are A left radial arterial line and right internal hypercholesterolemia, systemic hyperten- jugular central line with central venous pres- sion, and smoking.1 This patient’s preopera- sure monitoring capabilities were placed tive risk factors suggest he may have without complications. The patient had an significant coronary artery disease and may initial drop in blood pressure after induction be at risk for myocardial ischemia. to a low of 65/40 mmHg. Incremental ad- Since the patient was already taking metro- ministration of phenylephrine 100mcg intra- prolol for his hypertension, beta blockade venous and ephedrine 10mg intravenous therapy, a significant cardioprotective inter- were administered. Phenylephrine 400mcg vention, was already in place preoperatively.

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The American Heart Association (AHA) re- resistance and enhance coronary, hepatic, commends beta blockade for patients in intestinal, and skeletal muscle blood flow, whom preoperative assessment identifies whereas halothane and isoflurane decrease coronary heart disease or high cardiac risk, regional tissue perfusion in these vascular as defined by the presence of more than one beds to varying degrees during systemic hy- clinical risk factor, who are undergoing in- potension.2 One study compared the effects termediate-risk or vascular surgery.3 Beta- of sevoflurane and propofol on myocardial blockers reduce cardiovascular morbidity function during and after coronary artery and mortality in patients with hypertension, surgery. Before coronary pulmonary bypass heart failure, and post-myocardial infarc- (CPB), all hemodynamics were similar be- tion.4 However, despite the help of beta tween the two groups. However, after CPB, blockade in preventing ischemia, recent data patients who had received sevoflurane had suggest beta blockade alone is not enough preserved cardiac performance, and the need for adequate cardioprotection.5 for inotropic support in the postoperative period was significantly less. This was con- The AHA recommends using volatile agents firmed in a subsequent study in a group of during non-cardiac surgery for maintenance elderly high-risk patients with documented of general anesthesia in hemodynamically impaired myocardial function. Sevoflurane stable patients at risk for myocardial ische- and desflurane preserved myocardial func- mia.3 Volatile anesthetics produce a precon- tion after CPB with less evidence of myo- ditioning-like effect, short periods of cardial damage and better postoperative transient myocardial ischemia which appear myocardial function compared with an to protect the heart from subsequent longer intravenous regimen.6 periods of myocardial ischemia.6 Many stu- dies indicate Sevoflurane and Desflurane Non-cardiac surgery, in this patient’s case, a allow better control of hemodynamic and total esophagectomy, is also associated with sympathetic response to stimuli than isoflu- risk of perioperative cardiac morbid events. rane and other agents. One study reports a The observation that anesthetic cardiopro- lower incidence of myocardial ischemia in tection with sevoflurane and desflurane is patients anesthetized with sevoflurane than also observed during off pump coronary isoflurane while undergoing cardiac sur- surgery may suggest this phenomenon is al- gery.2 so present in patients at risk for myocardial events undergoing non-cardiac surgery.6 The A meta-analysis of pooled data from several AHA practice guidelines identify a number studies was performed and showed desflu- of procedures with a more than 5% risk of rane and sevoflurane significantly decreased perioperative cardiac morbidity; such as the rate of myocardial ischemia and death in procedures associated with large fluid shifts patients undergoing cardiac surgery. Since or blood loss, as in a total esophagectomy.6 the mechanisms of anesthetic precondition- Overall, physiologic considerations and con- ing are not fully understood, it cannot be siderable clinical data argue for the use of excluded that the protective effects of sevof- volatile agents in patients at risk for cardiac lurane and desflurane observed may be events.2 caused by properties other than precondi- Considering the increased risk for cardiac tioning alone.2 events due to both the patient’s risk factors and the surgical procedure, sevoflurane was Desflurane and sevoflurane reduce vascular chosen for use of maintenance anesthesia.

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Hemodynamic parameters remained stable analysis of randomized clinical trials. J throughout the procedure, despite large fluid Cardiothorac Vasc Anesth. 2007;4:502- shifts and considerable blood loss. The post 11. induction hypotension could have been re- 3. Fleisher FA, et al: ACC/AHA 2007 lated to the chosen induction agent, propo- Guidelines on perioperative cardiovas- fol. Etomidate 0.3mg/kg for induction of cular evaluation and care for noncardiac general anesthesia is a viable option to pre- surgery: executive summary: a report of vent this phenomenon due to the fact intra- the American college of cardiolo- venous administration of up to 0.6mg/kg of gy/American heart association task etomidate to patients with severe cardiovas- force on practice guidelines. Circula- cular disease has little or no effect on myo- tion. 2007;116;1971-1996. cardial metabolism, cardiac output, 4. Egan BM, Basile J, Chilton RJ, Cohen peripheral circulation or pulmonary circula- JD. Cardioprotection: the role of beta tion.7 blocker therapy. J Clin HTN. 2005;7:409-16. The choice of a volatile agent may be anoth- 5. Licker M, Niaper J, Ellenberger C. Pe- er factor that assists in protecting the myo- rioperative beta blockade – still not cardium. This in combination with strong enough for adequate cardioprotection. fluid management, maintaining hemody- Anesth Analg. 2007;105:278-279. namic stability, and pre/ perioperative beta 6. De Hert SG, Turani F, Mathur S, et al: blockade may decrease the incidence of a Cardioprotection with volatile anesthet- cardiac event. ics: mechanisms and clinical implica- tions. Anesth Analg. 2005;100: 1584- References 1593 7. Bedford Laboratories. (2004). Etomi- 1. Stoelting RK, Dierdorf, SF. Anesthesia date injection. [Package Insert]. Bed- and Co-Existing Disease. 4th ed. Phila- ford, OH: Author delphia, PA: Churchill Livingstone; 2003;1. Mentor: Carrie C. Bowman Dalley, CRNA, 2. Landoni G, et al: Desflurane and sevof- MS lurane in cardiac surgery: a meta-

Hyperthermic Intraoperative Intraperitoneal Chemotherapy

Kelly S. Chambers, BSN Georgetown University

Key words: mesothelioma, cytoreductive associated with exposure to asbestos.1 Ap- surgery, hyperthermic intraoperative intrape- proximately 2500 patients are diagnosed ritoneal chemotherapy, chemotherapy, anes- with malignant mesothelioma each year.2-3 thesia Malignant mesothelioma is generally diffuse Malignant mesothelioma is a rare form of and can progress asymptomatically for sev- cancer originating from the serosal lining of eral months. The median survival rate from cavities such as the pleural, pericardial, or the time of malignant mesothelioma diagno- peritoneal cavities and is most frequently sis is one year with current treatment involv-

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ing surgery, chemotherapy, radiation, radio- maintained with end tidal isoflurane, 1- therapy, immunotherapy, gene therapy, and 1.3%, oxygen, 1 liter, and air, 1 liter. Vecu- palliative care.4 In order to decrease morbid- ronium was administered throughout the ity and mortality, multimodal treatment ap- case (23 mg total). A total of fentanyl 600 proaches are increasingly being sought. One mcg and hydromorphone 2mg were given such treatment is cytoreductive surgery with throughout the case. hyperthermic intraoperative intraperitoneal chemotherapy.5 Prior to the administration of HIIC, the pa- tient received diphenhydramine 50mg , on- Case Report dansetron 4mg, famotidine 20mg, and an infusion of dopamine at 3 mcg/kg/min was A 53 year old male with diffuse malignant initiated to maintain urine output. The room peritoneal mesothelioma (DMPM) was temperature was placed at 55°C, the thermal scheduled for exploratory laparotomy with blanket and fluid warmers were discontin- lysis of adhesions, cytoreductive surgery, ued. The patient’s temperature prior to HIIC and hyperthermic intraoperative intraperito- administration was 36.3°C. The patient’s neal chemotherapy (HIIC). The patient’s International Normalized Ratio (INR) was surgical history included a previous cytore- 1.2 and partial thromboplastin time (PTT) ductive surgery in 2006 with HIIC with was 33.4. HIIC with melphalan 138mg at doxorubicin and cisplatin and early post- 42.5°C was initiated 4 ½ hours into the op- operative intraperitoneal paclitaxel. The pa- eration. Personal protective equipment for tient’s medical history was otherwise chemotherapy administration was donned. negative. The patient’s admission height was During the HIIC, the patient’s urine output 5’11 and weight 234 pounds. The patient’s was maintained at 150 ml per 15 minutes. preoperative assessment including electro- Urine and blood samples were collected cardiogram and pulmonary function was every 15 minutes. Ringer’s Lactate was in- normal. The patient’s preoperative hemog- fused at approximately 1,500 ml/ hour. The lobin and hematocrit were 13.8 g/dL and patient received 200 ml of 25% albumin. 41.4%. Platelets were 374,000 mm3, serum Arterial blood gases were obtained through- creatinine was 1.0 mg/dL, and potassium out the procedure. The patient was repleted was 4.1 meq/L. with potassium 50 meq throughout the case. Magnesium 2 gms HIIC was terminated af- Anesthesia was induced through an 18- ter 90 minutes. Dopamine was discontinued. gauge peripheral intravenous catheter (PIV) The patient’s maximum temperature reached with 2mg, fentanyl 100 mcg, ro- 38.5°C, vital signs remained stable. The pa- curonium 5mg, propofol 200mg, and succi- tient was taken, intubated and sedated with nylcholine 120mg. An 8.0 mmID midazolam 2 mg, to the post anesthesia care endotracheal tube (ETT) was inserted into unit 1 hour later. the trachea. A right radial arterial line, second PIV (16-gauge), and a right internal Discussion jugular central catheter were inserted. A na- sogastric tube and an esophageal tempera- Current treatment of DMPM involves sur- ture probe were inserted. A thermal blanket gery, chemotherapy, radiation, radiotherapy, was placed on the upper body and initiated immunotherapy, gene therapy, and palliative at 43°C. Intravenous fluids were warmed care.4 To decrease the morbidity and mortali- with fluid warmers. Anesthetic depth was ty associated with this disease a combination

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of treatments may be utilized.5 Cytoreduc- nium throughout the cytoreduction and HIIC tive surgery with hyperthermic intraopera- administration. tive intraperitoneal chemotherapy (HIIC) is one of the combined treatment options for During the cytoreductive portion of the pro- those diagnosed with diffuse malignant peri- cedure the patient may encounter fluid toneal mesothelioma. The anesthesia practi- shifts, blood loss, coagulopathies, and elec- tioner must be aware of the unique trolyte imbalances. These parameters, espe- considerations for anesthetic management cially coagulation panels, must be evaluated for the cytoreductive surgery as well as and corrected prior to the administration of HIIC, including blood loss, fluid shifts, elec- HIIC. Intravascular volume should be opti- trolyte imbalances, coagulation abnormali- mized prior to the initiation of HIIC, as dur- ties, and heat related problems.6 ing the administration of HIIC, urine output Additionally, the anesthesia practitioner is maintained at 400cc per hour during HIIC must be aware of safety precautions during and for 1 hour afterwards.6 Urine output chemotherapy administration. Other than the may be maintained by fluid bolus, furose- DMPM, this patient was relatively healthy. mide, mannitol, and/or a renal dose dopa- This allowed for adherence to these consid- mine infusion. Additionally, intravascular erations and the standards of care. volume should be maintained to offset heat related problems associated with hyperther- Patients with DMPM may have been ma- mia. Intravascular volume may be main- naged in the past with chemotherapy, sur- tained with crystalloids, blood products, or gery, and/or radiation. A thorough review of albumin. Hespan is strongly contraindicated past treatments, particularly chemotherapy in this procedure due to associated dose re- agents, should take place preoperatively. The lated coagulopathies.6 These parameters for anesthesia professional needs to be aware of monitoring and care were met during this possible organ damage associated with che- case with pre HIIC electrolyte and coagula- motherapeutic agents such as anthracyclines tion evaluation, adequate intravenous fluids, (doxorubicin) and cardiotoxicity, bleomycin and a dopamine infusion throughout HIIC. and pulmonary toxicity, and cisplatin and renal toxicity.7 The patient in this case was Prior to the administration of HIIC, cooling treated with doxorubicin and cisplatin; how- measures must be taken to offset the hyper- ever, the patient’s cardiac and renal func- thermia encountered with HIIC. These cool- tions were normal preoperatively. ing measures include reducing the room thermostat to the lowest setting and discon- In the case of DMPM with HIIC, cytoreduc- tinuing all heating devices including thermal tive surgery is followed by the administra- blankets and fluid warmers, as was per- tion of HIIC. Muscle relaxant was utilized to formed in this case. Problems associated keep the patient fully relaxed. This patient with hyperthermia include primarily peri- had a BMI of 32.6. A modified rapid se- pheral vasodilatation, followed by hypoten- quence induction was performed to avoid sion, decreased urine output, and prolonged muscle relaxation should the pa- tachycardia.6,8 These issues may develop tient have a difficult airway. A defasciculat- into a heat stroke like syndrome in which the ing dose of rocuronium was utilized prior to patient’s temperature could remain elevated succinylcholine administration. The patient even after cessation of HIIC. Treatment for was maintained fully relaxed with vecuro- this heat stroke like syndrome include admi- nistering cool saline irrigation to the abdo-

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minopelvic cavity and surrounding the pa- 2. Price B. Analysis of current trends in tient’s head with ice.6 the United States mesothelioma inci- dence. Am J Epidemiol (1997) 145:211– Safe handling of blood and body fluids 218. should be enforced during administration of 3. Price B, Ware A. Mesothelioma trends chemotherapy and for 48 hours following in the Unites States: an update based on chemotherapy administration.5 The basic surveillance, epidemiology and end re- principle of safe handling of blood and body sults program data from 1973 through fluids contaminated with cytotoxic agents is 2003. Am J Epidemiol (2004) 159:107– Universal Precautions including gowns, 112. gloves, masks and eye shields when the pos- 4. Robinson BWS, Lake RA. Advances in sibility of contact with contaminated blood malignant mesothelioma. N Engl J Med and body fluids is present. The anesthesia (2005) 353:1591–1603. practitioner should double glove to provide a 5. White SK, Stephens AD, Sugarbaker better barrier against contact with cytotoxic PH: Hyperthermic intraoperative intra- agents.9 In addition to wearing 2 pairs of peritoneal chemotherapy safety consid- gloves, the gloves should be changed every erations, AORN 63:716-724, 1996. 30 minutes and powderless latex gloves 6. Stephens AD, White SK, Esquivel J, should be utilized as they are less permeable Stuart OA, Sugarbaker PH. Hyperther- and provide a better barrier.6 Additionally, a mic intraoperative intraperitoneal che- smoke evacuator should be used to remove motherapy tutorial. Available at vapors, a chemotherapy spill kit should be http://www.surgicaloncology.com/hiicm available, and all waste accumulated after an.htm. Accessed August 18, 2007. the initiation of chemotherapy should be 7. Maracic L, Van Nostrand, J: AANA specially labeled and stored for 48 hours journal course; anesthetic implications prior to disposal to an appropriate hazardous for cancer chemotherapy, AANA Jour- waste facility.5- 6, 9-10 During this case, these nal 75 (3): 219-226, 2007. guidelines were strictly utilized. 8. Esquivel J, Angulo F, Bland RK, Ste- phens AD, Sugarbaker PH: Hemody- In addition to anesthetic implications regard- namic and cardiac function parameters ing cytoreductive surgery, management of a during heated intraoperative intraperito- patient receiving HIIC following cytoreduc- neal chemotherapy using the open "Co- tive surgery requires a unique knowledge of liseum Technique" Ann Surg Oncol chemotherapy administration, hyperthermia, 7(4):296-300, 2000. and safety precautions. 9. OSHA Technical Manual. Section VI: Chapter 2. Controlling occupational ex- References posure to hazardous drugs. Occupation- al Safety and Health Administration. 1. National Cancer Institute Fact Sheet. Available at Mesothelioma: Questions and Answers. http://www.osha.gov/dts/osta/otm/otm_ National Cancer Institute. May 13, vi/otm_vi_2.html . Accessed February 2002. Available at 18, 2008. http://www.cancer.gov/cancertopics/fact 10. NIOSH alert. Preventing occupational sheet/Sites-Typers/mesothelioma Ac- exposure to antineoplastic and other ha- cessed February 17, 2008. zardous drugs in health care settings. January 21, 2005. Available at http://0-

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www.cdc.gov.library.lausys.georgetown Mentor: Carrie C. Bowman Dalley, CRNA, .edu/niosh/docs/2004-165/pdfs/2004- MS 165.pdf . Accessed February 18, 2008.

The Role of the Intubating Laryngeal Mask Airway

Von nett T. Seeger, BSN Georgetown University

Keywords: Difficult airway, laryngeal mask by mouth for 12 hours prior. Her preopera- airway, alternatives, intubation. tive labs, electrocardiogram and chest radio- graph were unremarkable. Practice guidelines are established by the American Society of Anesthesiologist’s Airway evaluation revealed a mouth open- (ASA) Task Force for the management of ing of 3 cm and a Mallampati classification the difficult airway. Revisions occur with the of III. The traction device rendered the c- development of new technology, research, spine immobile. Based on her evaluation, a and clinical practice. Components of the difficult airway was anticipated. The patient airway evaluation and the patient’s past strongly opposed awake . medical and surgical history may be indica- tive of a difficult airway. While the compar- Two large bore intravenous (IV) lines and ative benefit of a particular approach is arterial line were placed prior to induction. difficult to conclusively establish, the con- The room was equipped with an sensus is that a systematic approach may AIRTRAQ® Laryngoscope, an Air-Q Intu- lead to improved patient outcomes.1 bating Laryngeal Airway (ILA), fiberoptic scope, and a cart with additional adjuncts. Case Report The surgical team was present at induction and prepared to place an emergency surgical A 75 year old female presented for revision airway if needed. of an occipital cervical fusion. Past surgical history included an anterior cervical fusion In the operating room, midazolam 1 mg IV for C1-C2 subluxation and posterior cervical and fentanyl 25 mcg IV were given while fusion of C2-C4. She recently began to ex- standard monitors were placed. After 3 mi- perience increased neck pain without neuro- nutes of preoxygenation with 100% FIO2, logical deficit. Radiograph of the c-spine induction consisted of lidocaine 40 mg and revealed unstable hardware at C1-C2. She propofol 40 mg IV. With loss of conscious- was placed in Halo traction for stabilization ness and successful mask ventilation, rocu- and scheduled for surgery the following day. ronium 30 mg IV was administered and ventilation was assisted for 90 seconds. Ini- The patient had a past medical history of tial attempt at tracheal intubation (TI) was osteoarthritis, cervical stenosis, and hyper- unsuccessful with an AIRTRAQ®. Mask tension. Routine medications consisted of ventilation was resumed to optimize oxyge- Candesartan and Oxycodone. At 62 inches nation before a subsequent attempt. An Air- she weighed 52 kilograms and had nothing Q ILA size 2.5 was then inserted with ease.

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The cuff was inflated and connected to the avoided, as well as compromise of blood circuit, placement confirmed with ventila- flow to the spinal cord.3 The difficult airway tion that produced chest rise and an end tidal algorithm can provide a safe approach to carbon dioxide (ETCO2) tracing. The circuit airway control. The choice of device lies was then disconnected and a 6.5mmID en- with the anesthesia practitioner’s preference, dotracheal tube (ETT) was blindly passed experience level, and comfort. Anesthesia through the ILA conduit. The ILA was re- professionals agree that the focus lies on li- moved after cuff deflation. The ETT cuff miting injury, rather than the use of any par- was inflated, chest excursion and appropri- ticular device.4 Each technique has ate ETCO2 were noted, and equal breath disadvantages or contraindications. One ex- sounds heard. ample, the flexible fiberoptic scope cannot be utilized if the patient is uncooperative or Fentanyl infusion at 25 micrograms/hour refuses. Blind nasotracheal intubation is and 0.6% Isoflurane were used for mainten- contraindicated if basal skull fracture is sus- ance of general anesthesia. At the conclusion pected.4 Laryngeal Mask Airway (LMA) is of the case, the trachea was extubated after contraindicated whenever there is a risk of adequate tidal volumes and a regular respira- aspiration of gastric contents, whether due to tory rate and pattern were noted. The patient gastroesophageal reflux disease, inappro- was able to follow commands with equal priate fasting times, gastroparesis or morbid strength in the upper extremities. She was obesity. Other contraindications include low awake, without deficit and at baseline he- pulmonary compliance requiring peak inspi- modynamics. She was discharged on the ratory pressures greater than 20 cm H20. fifth post operative day following an un- The LMA was selected as the patient had no eventful hospital course. contraindications and she refused awake fi- beroptic intubation. The 2003 ASA algo- Discussion rithm suggests several non invasive alternatives if face mask ventilation is ade- When evaluating the airway, limited mouth quate and the non emergent pathway is fol- opening may alter visualization during la- lowed. Among these are the LMA as an ryngoscopy.2 Airway difficulties have been intubation conduit with or without fiberoptic associated with a Mallampati classification guidance.1 The LMA is also a primary con- greater than II. While no single component sideration under the emergency pathway if of the airway evaluation is a sole predictor, mask ventilation is inadequate. suspicion should arise if multiple indicators are noted. Formulation of alternative plans Although inexperienced operators using the can improve success and reduce patient risk. ILA achieve a lower intubation success rate than skilled clinicians performing direct la- Surgical history of prior cervical fusion in- ryngoscopy and TI, patients can be venti- dicates profound limitation of extension in lated between intubation attempts.5 One the c-spine, therefore making laryngoscopy study proposed that ILA could be safely extremely challenging. The use of traction used after induction of general anesthesia. by halo-thoracic fixator is most effective for All patients were successfully ventilated short term stabilization, but presents an ob- with the ILA. Blind TI was accomplished in vious challenge, making airway instrumen- 50%, and an additional 25% with Fiber Op- tation and TI cumbersome.2 By minimizing tic (FO) guidance with the initial ILA. With neck flexion; mechanical insult may be reinsertion of the ILA another 15% were in-

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tubated with FO assistance. The remaining References 10% could not be intubated by the primary anesthesia professional but intubation was 1. Developed by the American Society of successful by another anesthesia profession- Anesthesiologist Task Force on Diffi- al.6 Of important note is that the primary cult Airway Management. Practice anesthesiologist had significantly more ex- guidelines for the management of the perience with AFOI compared to ILA. Min- difficult airway. Anesthesiology imum oxygen saturation was higher in the 2003;98:1269-1277. ILA group at 97.5% compared to 94.5%. 2. Gal, TJ. Airway management. In: Miller Oxygen saturation dropped to 62% and 84% RD, ed. Anesthesia. 6th ed. Philadelphia: in two patients in the AFOI group.6 Both Churchill Livingstone; 2005:1617-1652. methods of TI were highly successful and 3. Hastings RH, Marks JD. Airway man- there were no adverse events with partici- agement for trauma patients with cer- pants. It concluded that ILA is a suitable al- vical spine injuries. Anesth Analg ternative, especially when AFOI is not 1991;73:471-482. possible.6 In this case study, oxygen satura- 4. Ghafoor AU, Martin TW, Gopalakrish- tion decreased from 99% to 98%, correlating nan, et al. Caring for the patient with with the findings of Joo, et al. cervical spine injuries: what we have learned. J Clin Anesth 2005;17:640- Securing the airway, assuring adequate gas 649. exchange, and stabilizing circulation are ini- 5. Manoach S, Paladino L. Manual in-line tial priorities in anesthetic management. Vi- stabilization for acute airway manage- gilant practitioners must have the ability to ment of suspected cervical spine injury: recognize a potentially difficult airway, an- historical review and current questions. ticipate the problem and have alternative Ann Emerg Med 2007;50:236-245. plans in place. The purpose of this case 6. Joo HS, Kapoor S, Rose DK, et al. The study was to explore the ILA as a reasonable intubating laryngeal mask airway after approach to TI in the face of patient refusal induction of general anesthesia versus of AFOI. The ASA recognizes the LMA as a awake fiberoptic intubation in patients primary airway management device in an with difficult airways. Anesth Analg emergency situation and the ILA as a con- 2001;92:1342-1346. duit to blind TI. Further research is needed to explore this approach as a reasonable al- Mentor: Carrie C. Bowman Dalley, CRNA, ternative to AFOI in difficult airway man- MS agement.

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Airway Management in Pierre Robin Syndrome

Sheila T. Carbonell, BSN University of Southern California

Keywords: Pierre Robin syndrome, laryn- On arrival to the operating room, intraopera- geal mask airway, tracheal intubation, child- tive monitors were placed and the patient ren, fiberoptic intubation was pre-oxygenated via facemask. Inhala- tional induction was initiated with nitrous Pierre Robin anomaly is a congenital mal- oxide at 6 L/min and oxygen at 4 L/min, formation of craniofacial development while sevoflurane was rapidly titrated to 8%. which may present challenging airway man- Spontaneous ventilation was maintained. A agement issues throughout the perioperative 70millimeter oropharyngeal airway was in- period. This birth defect is a relatively rare serted to avoid airway obstruction. After condition with an incidence of 1 in 50,000 reaching a sufficient depth of anesthesia, births.1 Pierre Robin syndrome is characte- direct laryngoscopy was attempted twice rized by an unusually small jaw (microgna- with cricoid pressure, first using a size 1 thia), posterior displacement or retraction of Miller blade and a second attempt with a the tongue (glossoptosis), and upper airway size 1.5 Wisconsin blade. The vocal cords obstruction. Incomplete closure of the roof could not be easily visualized under laryn- of the mouth (cleft palate), is present in the goscopy. Both Miller and Wisconsin blades majority of patients, and is commonly U- provided views of the epiglottis only. After shaped.2 This case presentation describes the an unsuccessful attempt at blind endotra- anesthetic and airway management of a pa- cheal intubation to secure control of the air- tient with Pierre Robin syndrome under- way, a #2 disposable Laryngeal Mask going cleft palate repair. Airway (LMA) was placed. Effective venti- lation was verified by adequate chest expan- Case Report sion and . An Omeda 2.2 mm fiberoptic bronchoscope was inserted A 2.5 year-old boy, weighing 12 kilograms, through the lumen of the LMA and we were diagnosed with Pierre Robin syndrome pre- able to visualize the vocal cords. The fibe- sented for cleft palate repair. The patient’s roptic bronchoscope was removed and an history of sleeping on two pillows and snor- uncuffed 4.0 oral RAE tracheal tube was ing was suggestive of upper airway obstruc- threaded over the bronchoscope. The bron- tion during sleep. On physical examination, choscope was then reinserted through the he appeared to be in no acute distress. His LMA. After the vocal cords were visualized, airway exam showed a complete cleft palate, the endotracheal tube was inserted without mouth opening of three centimeters, and full difficulty through the vocal cords and into range of motion of his neck. Other physical the trachea. The position of the tube above findings included a thyromental distance of the carina was fiberoptically verified. The two centimeters consistent with microgna- LMA was gently removed with long tipped thia, and glossoptosis associated with cleft forceps holding the oral RAE tube in place. palate. All other physical findings, laborato- The endotracheal tube position was again ry results, and anesthetic history were unre- verified with capnography, bilateral breath markable. sounds, and condensation seen in the endo- tracheal tube.

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General anesthesia was maintained with neuvers encourage slightly forward move- nitrous oxide at 2 L/min, oxygen at 1 L/min ment of the tongue in response to gravity and sevoflurane at 3%. Intravenous dexame- which improves the obstruction. thasone 6.5milligrams was given after intu- bation to prevent airway edema. Vital signs Anesthetic management for patients with remained stable throughout the case. At the Pierre Robin should begin with a thorough end of the case, the neuromuscular blocker preoperative history, with special attention was antagonized. When the patient was to the cardiac and respiratory systems and awake and met extubation criteria , the tra- associated congenital anomalies. Sleep ap- chea was extubated. The patient was placed nea, snoring, and/or inspiratory stridor may in a sitting position where he was breathing be present. Feeding difficulties, obstructive without signs of respiratory distress or ob- symptoms, and congenital heart defects may struction. The child was observed for post- also complicate the clinical presentation of operative respiratory complications in the these patients.2 A careful review of the pa- recovery room before he was discharged to tient’s medical and anesthetic records is ex- the ward. tremely helpful in assessing the patient’s risk for a difficult intubation. Discussion Physical examination should include a care- Patients with Pierre Robin syndrome may ful evaluation of the child’s airway. Nasal present to the anesthetist for a variety of flaring, accessory muscle retractions, stridor, procedures from infancy to childhood. The dyspnea, and an increased anterior-posterior airway problems are less likely to be life diameter of the chest would suggest the threatening with increasing age and usually, presence of significant upper airway ob- after six months of age, are not a cause of struction. Chest auscultation may reveal car- significant concern.3 Although the upper diac murmurs, pulmonary rhonchi or airway obstruction in these patients im- wheezing. Preoperative sedatives should not proves as they grow, they may be difficult to be given to patients who have symptoms of mask ventilate at any stage of their devel- significant airway compromise. opment and may be impossible to intubate by direct laryngoscopy.4 During intubation, multiple attempts at di- rect laryngoscopy may cause edema and The pathophysiology of airway obstruction bleeding with subsequent difficult mask in patients with Pierre Robin is primarily ventilation. When faced with a difficult air- due to a posteriorly situated tongue which way, an alternative technique to achieve significantly reduces the size of the posterior successful placement of a tracheal tube pharyngeal area. Each time the infant in- without traumatizing the larynx should be hales, the tongue is drawn more posteriorly sought. According to Rasch et al, awake in- and downward by the force of negative in- tubation would be the safest method for se- trapharyngeal pressures generated by respi- curing the airway.2 This may be possible in a ration.5 This “ball and valve” effect of the smaller infant, but may be difficult to ac- tongue produces inspiratory obstruction of complish in the older infant or child in the airway which, according to Mallory et whom an inhalational induction may be pre- al., can usually be improved by placing the ferred. With the child breathing sponta- infant prone, in a head down position, or in a neously, breath sounds and air bubbles in the sitting position leaning forward.4 These ma- pharynx could be a useful guide to intuba-

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tion. Use of muscle relaxants should be LMA to manage difficult intubations in avoided as airway obstruction is more likely children.6,11 to occur when soft tissues are relaxed.6 At the conclusion of surgery, a decision Several effective techniques for the man- must be made regarding the feasibility of agement of difficult airways in adults and extubation. This depends largely on the children have been reported. One example is operative site and any trauma occurring to using an LMA to facilitate a fiberoptic intu- the airway during intubation. If the trachea bation. Patel et al. intubated the trachea of is extubated, the patient should be closely an infant with Pierre Robin using a pediatric observed for postoperative complications of fiberscope, OD 2.2mm, mounted with a 3.0 airway obstruction. Use of a nasal trumpet endotracheal tube through a #1 LMA.7 The can help avoid postoperative airway obstruc- use of an LMA allows control of the airway tion. One should be cautious of administer- before and during placement and manipula- ing postoperative analgesia because of the tion of the fiberoptic scope.8 Osses et al. re- potential for respiratory depression. ported successful endotracheal intubation through an LMA in 6 children with cra- Children born with craniofacial anomalies niofacial malformations undergoing head such as Pierre Robin syndrome often have and neck reconstructive plastic surgery. In- anesthetic airway management difficulties. stead of using a fiberoptic scope to intubate, If tolerated, an awake intubation would be they passed an endotracheal tube blindly via the safest method of securing the airway.2 the LMA and, after confirming placement, Based on current literature review, the use of maintained the tube in position with the aid an LMA for managing difficult airways in of an adult stylet. The LMA was then gently children has proven to be reliable. Fiberop- removed while holding the endotracheal tic-guided endotracheal intubation via the tube in place with the stylet.9 A case report LMA can successfully be used to secure the by Ofer et al. demonstrated using an LMA to airway of a child with Pierre Robin syn- intubate a 6 year-old child with Pierre Robin drome. Recent case reports have demon- syndrome by placing a normal stylet guide strated that the use of an adult intubating into the tube to remove the LMA.10 Mullick stylet to maintain the endotracheal tube in et al. reported the case of a twenty-one- place while the LMA is removed enables month-old boy with Pierre Robin syndrome this technique to be used on children. The who was intubated through an LMA. The use of the intubating “Fastrach” LMA, endotracheal tube was held in place with the which has facilitated difficult airway intuba- use of an adult intubating stylet modified tion in adults may be another option for with a thick band of leucoplast applied to the children in the future. middle of the stylet. The leucoplast pre- vented tracheal injury that could have been Important aspects in the anesthetic manage- caused by the stylet migrating beyond the tip ment of patients with Pierre Robin include a of the endotracheal tube at the time of re- thorough preoperative evaluation of their moval of the LMA.6 An intubating “Fa- medical conditions and physical evidence of strach” LMA has been used successfully to airway obstruction, and close postoperative facilitate difficult airway intubation in observation for late complications of airway adults. Currently there are no case reports of obstruction. In addition, safe and effective using a pediatric size intubating “Fastrach” methods using an LMA for facilitating endo- tracheal intubation in the Pierre Robin popu-

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lation have been illustrated. In this case, our 5. Mullick P, Talwar V. The laryngeal findings suggest that the LMA was a valua- mask: an aid for difficult intubation in a ble device to assist in the tracheal intubation. child with Pierre-Robin Syndrome-a When a potentially difficult airway presents case report. Indian J Anaesth. in a pediatric patient, the fiberoptic intuba- 2005;49:51-3. tion via an LMA has demonstrated to be an 6. Patel A, Venn PJ, Barham CJ. Fiberop- efficacious first line technique for airway tic intubation through a laryngeal mask management. airway in an infant with Robin se- quence. Eur J Anaesth. 1998;15:237-9. References 7. Heard CM, Caldicott LD, Fletcher JE, Selsby DS. Fiberoptic-guided endotra- 1. Fletcher MM, Blum SL, Blanchard CL. cheal intubation via the laryngeal mask Pierre Robin Syndrome: pathophysiolo- airway in pediatric patients: a report of gy of obstructive episodes. Laryngos- a series of cases. Anesth Analg. cope. 1969;79:547. 1996;82:1287-9. 2. Rasch DM, Browder F, Barr M, Greer 8. Osses H, Poblete M, Asenjo F. Laryn- D. Clinical reports: anesthesia for geal mask for difficult intubation in Treacher Collins and Pierre Robin Syn- children. Paediatr Anaesth. 1999;9:399- dromes: a report of three cases. Can 401. Anesth Soc J. 1986;33:364-70. 9. Ofer R, Dworzak H. The laryngeal 3. Motoyama EK, Davis PJ. Smith’s anes- mask-a valuable instrument for cases of thesia for infants and children. 7th ed. difficult intubation in children. Anesthe- Philadelphia: Elsevier; 2006. siologic management in the presence of 1. 4) Mallory SB, Paradise JL. Glossopto- Pierre-Robin Syndrome. Anaesthetist. sis revisted: on the development and 1996;45:268-70. resolution of airway obstruction in 10. Joo H, Rose K. Fastrach-a new intubat- Pierre Robin Syndrome. Pediatrics. ing laryngeal mask airway: successful 1979; 64:946-8. use in patients with difficult airways. 4. Stoelting R, Dierdorf S. Anesthesia and Can J Anaesth. 1998;45:253-6. co-existing disease. 4th ed. New York: Churchill Livingstone; 2002. Mentor: Terrie Norris, CRNA, EdD

Alpha Thalassemia and General Anesthesia

Katrina M. Longe, B.S.N. Bryan LGH Medical Center

Keywords: altered hemoglobin, anemia, the alpha chains of the hemoglobin mole- dental restoration, erythropoesis, thalasse- cule. It is reported that more than 15 million mia, people worldwide have clinically apparent thalassemias.1 Alpha thalassemia is most There are several forms of thalassemia, all frequently seen in the Southeast Asian, affecting the normal production of hemog- southern Chinese, Middle Eastern, and Me- lobin. Alpha thalassemia is a genetic disord- diterranean populations.2 Anesthetic impli- er caused by mutations in any, or all four of cations for patients with alpha thalassemia

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are guided by the severity of the disorde r. was continued with end-tidal sevoflurane at Thorough airway assessment, evaluation of 2.3% to 3.7%. Dexamethasone 9 mg and preoperative hemoglobin levels, and as- ondansetron 4 mg were administered intra- sessment of any additional physiologic operatively. A lactated Ringers microdrip anomalies or potential risk factors are indi- was utilized to give a total of 350 mL cated. throughout the case.

Case Report The dental restoration was completed in 48 minutes. The patient’s oxygen saturation A 21 month old, 9 kg, American Society of was maintained at 100% with spontaneous Anesthesiologists (ASA) Class 1 African ventilation and the endotracheal tube re- American female was admitted for outpa- moved without any adverse events. The pa- tient dental restoration under general anes- tient was taken to the recovery room and a thesia. Review of her history and physical unit dose albuterol nebulizer treatment or- revealed a diagnosis of alpha thalassemia dered and administered for coarse lung trait with no other significant medical histo- sounds upon auscultation. After a routine ry noted. The patient was receiving no rou- recovery course the patient returned to the tine medications and had no known medical outpatient surgery area and was discharged allergies or previous surgeries. Family to home that same day. members did smoke in the patient’s home. A preoperative blood cell count revealed a Discussion: mild anemia with a hemoglobin of 10.2 g/dL and hematocrit 32.9%. The patient was There are several known classifications of asymptomatic despite this anemia with all thalassemia with varying degrees of symp- vital signs within normal limits. The airway toms. These include alpha, beta, and sickle assessment revealed dental decay, but no cell thalassemias. Alpha thalassemia is a de- other significant airway abnormalities. No letion or mutation in the alpha chain of the preoperative medication was administered. hemoglobin molecule. The alpha gene is lo- cated on chromosome #16 and the number In the operating room, pulse oximetry, non- of genes altered determines the severity and invasive blood pressure, and electrocardio- type of anemia.3 The patient in this case re- gram monitors were applied and port had alpha thalassemia trait, or a hetero- preoxygenation was followed by an inhala- zygous form where two alpha chain genes tion induction with 8% sevoflurane. A 22 are deleted and two are present. The most gauge IV catheter was placed in the left an- common symptom of this form of alpha tha- tecubital vein with fentanyl 30 mcg adminis- lassemia is mild anemia unresponsive to iron tered IV. The right nare was prepped with therapy with microcytosis. When all four neosynephrine nasal spray and 1% lidocaine alpha chains are deleted, the homozygous jelly. Visualization of the vocal cords was form, or alpha thalassemia major is present. obtained with a Robert Shaw laryngoscope This form is incompatible with life and re- blade and a 3.5 mm nasal Rae tube was uti- sults in hydrops fetalis. Beta thalassemia lized for intubation. The endotracheal tube occurs when there is an excess of alpha was inserted into the trachea with the assis- chains, and usually presents with elevated 4 tance of Magill forceps. The patient’s head levels of hemoglobin A2. Symptoms can was placed in a gel donut headrest and the range from mild anemia to the need for eyes covered. Maintenance of anesthesia chronic blood transfusions or splenectomy.

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These two types of thalassemia are differen- taken.6 The anesthesia practitioner should tiated only through laboratory tests. consider diseases associated with anemia, especially in African-American patients. A concern for patients with thalassemia is Pallor and cyanosis are difficult to detect facial deformity from ineffective erythro- with dark skin tones, and many times the poesis due to the genetic disability to pro- color of the mucous membranes is obscured duce useful hemoglobin.4 Additional airway by the dental pack. If the preoperative he- anomalies may also be unseen and only evi- moglobin is unknown, diligent observation dent upon laryngoscopy. Careful airway as- should be maintained. sessment is necessary in patients with known thalassemia. Some alpha thalasse- This case is an example of a type of proce- mias are associated with an X-linked mental dure common among patients with thalas- retardation with vertebral and upper airway semia. It has been found that dental caries anomalies. These anomalies can include are more common in thalassemic patients. In many causes for airway obstruction such as a 2006 study by Gomber and Dewan, it was an enlarged tongue.5 Of most concern with suggested that patients with beta thalassemia these patients is airway obstruction or air- will require restorative dental care more of- way management issues that may compro- ten than the healthy patient.7 The anesthesia mise ventilation.5 Careful positioning of the practitioner may also encounter a thalassem- airway during, and after intubation is impor- ic patient undergoing a splenectomy, as this tant to prevent possible nerve injury or is one of the treatments for thalassemia ma- movement of the endotracheal tube. In addi- jor, a form of beta thalassemia. tion, renal disorders secondary to agenesis can be present in these patients and should Careful preoperative assessment for possible be monitored and closely followed.5 A renal airway complications and anemia should be function test was not done preoperatively on done when caring for a patient with known this patient, but could be a consideration in thalassemia. An understanding of the type of future procedures. thalassemia and changes associated with the disorder are important when providing anes- A preoperative hemoglobin in this patient thesia care. In this case report, general anes- was obtained secondary to the thalassemia thesia was appropriate with careful diagnosis, as hemoglobin levels are not rou- assessment of the airway and observation of tinely obtained, especially in minor proce- possible complications related to chronic dures for healthy patients. The patient’s anemia. history did not state how the diagnosis of alpha thalassemia was made, but it is often References: found by chance during evaluation for another procedure.1 Due to the changing 1. Yaish HM. Thalassemia. Available at demographics related to immigration, the http://www.emedicine.com/ped/topic22 incidence of alpha thalassemia has increased 29.htm. Accessed August 20, 2008. in California and is now included in new- 2. Cohen AR, Galanello R, Pennell DJ, born screening in the state.2 Though it has Cunningham MJ, Vichinsky E. Thalas- been determined that preoperative hemoglo- semia. Hematology 2004:14-34. bin testing in healthy pediatric patients un- 3. Hematology and blood disorders: Alpha dergoing minor procedures is not needed, thalassemia. Available at careful pre-operative assessment should be http://www.lpch.org/DiseaseHealthInfo/

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HealthLi- 6. Roy WL, Lerman J, McIntyre BG. brary/hematology/thalapth.html. Preoperative hemoglobin value in minor Accessed August 20, 2008. paediatric surgery. Can J Anaesth 4. Roizen MF, Fleisher LA. Anesthetic 1990;37:4:S7. implications of concurrent diseases. In: 7. Gomber S, Dewan P. Physical growth Miller RD, ed. Millers anesthesia. 6th patterns and dental caries in thalasse- ed. Pennsylvania: Elsevier; 2005:1113. mia. Indian Pediatr 2006;43:1064- 5. Butler MG, Hayes BG, Hathaway MM, 1069. Begleiter ML. Specific genetic diseases at risk for sedation/anesthesia complica- Mentor: Sharon Hadenfeldt, CRNA, PhD tions. Anesth Analg 2000;91:837-855.

Latex Allergy in the Spina Bifida Patient

Tania M. Roberts, BSN Goldfarb School of Nursing at Barnes-Jewish College

Key Words: Latex allergy, spina bifida, takedown, bladder reconstruction, and ileal neural tube defects, anaphylaxis, anesthesia conduit formation. Other history included renal insufficiency with atrophic kidneys, The prevalence of spina bifida in the United frequent urinary tract infections, cesarean States is one out of every 1,000 live births, section, morbid obesity, and seasonal aller- making the condition the most common gic asthma. Her only medication was an al- neural tube defect.1 First reported in 1979, buterol inhaler used intermittently. latex sensitization is currently on the rise, Preoperative laboratory values were within accounting for 6% of the general population normal limits except an elevated creatinine and as high as 67% of spina bifida pa- at 2.0mg/dL consistent with her renal insuf- tients.1,2 Latex allergy is the second most ficiency. Allergies included latex and suprax. common cause of anaphylaxis in anesthesia, Past reactions to latex included a systemic accounting for 16.6% of cases.2 Early preo- red rash with hives. Her reaction to suprax, a perative identification and prevention of la- cephalosporin, was a generalized rash. tex exposure in high risk patients can lead to a reduction in the overall morbidity and Upon review of the patient’s medical infor- mortality associated with latex anaphylaxis. mation, latex allergy precautions were taken in the set up of anesthesia for the case. A Case Report latex-free head strap was obtained, and all anesthesia supplies including the reservoir A 24 year old, 61.5”, 135 kg, female patient bag, circuit, mask, endotracheal tube, and presented for a laparoscopic cholecystecto- monitoring equipment were checked for la- my for a two month history of right upper tex content and replaced if necessary. Addi- quadrant pain associated with eating fatty tionally, non-latex examination gloves foods. Her past medical history consisted of replaced the gloves normally stocked on the spina bifida with spine closure as an infant , and all medications were and multiple other surgeries throughout her drawn up after removal of the rubber stop- lifetime including; colostomy, colostomy

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pers and lids. Emergency medications were consistent throughout the case. Emergence also readily available. from anesthesia was smooth, and the patient transferred to the post anesthesia care unit Physical examination revealed an obese fe- (PACU) with oxygen delivered by face male with a Mallampati I classification, nat- mask. Report was given to the PACU RN, ural dentition, greater than 6cm thyromental and the patient’s latex allergy was relayed distance, and full cervical range of motion. immediately. The patient was discharged to Vital signs were 109/68, 79, 14, and 98% home later that day with no symptoms of an saturation on room air. Breath sounds were allergic reaction. clear to auscultation in all lung fields. The cardiac exam revealed a regular rate and Discussion rhythm with no murmurs, rubs, or gallops noted. An ileal conduit stoma was appre- Spina bifida is a condition associated with ciated on the left abdomen, and the patient the failure of spine closure during the first last catheterized herself at 5:30 am that two months of gestation. It is thought to be morning. Non-latex examination gloves due to a genetic predisposition or a deficien- were used for the exam, and a latex-free cy of folic acid in the first six weeks of tourniquet was used for intravenous access. pregnancy and may result in a range of ab- Lactated ringers solution was started, and normalities including; paralysis, hydroce- midazolam 2mg IV was given upon transfer phalus, scoliosis, or bowel and bladder to the operating room. A general endotra- problems.1 Children with spina bifida have a cheal anesthesia was planned for this pa- great degree of exposure to natural rubber tient. latex due to repeated surgical procedures, implanted latex-containing materials, and After transferring to the operating table, catheterizations.3 This can lead to a latex standard monitors and oxygen at 10 L/min sensitization and allergy, which may worsen by face mask were applied. Intravenous in- with age. Survival into adulthood is less duction consisted of fentanyl 150mcg, lido- common in spina bifida, with only a 50% caine 100mg, propofol 150mg. Mask survival rate at 30 years of age predominant- ventilation was attempted and successful ly due to renal failure.4 It is common to treat with an oral airway and two-handed tech- any patient with spina bifida as latex sensi- nique. Rocuronium 50mg was given and af- tive due to the high correlation of latex sen- ter 60 seconds and 0/4 train-of-four, a sitization and development of a life- 7.0mm endotracheal tube was inserted into threatening latex allergy at any time. the trachea by direct laryngoscopy. Place- ment was confirmed by bilateral equal In latex sensitization, there is a presence of breath sounds and ETCO2, mechanical ven- immunoglobulin E (IgE) antibodies to latex tilation was started, and anesthesia was with a lack of clinical manifestations, whe- maintained with desflurane, rocuronium reas, latex allergy is an immune-mediated 5mg, and morphine sulfate 10mg throughout reaction to latex with clinical manifesta- the case. Ciprofloxacin 400mg and metron- tions.2 The two types of latex allergy are diazole 500mg were given intravenously for Type IV cell-mediated hypersensitivity reac- prophylactic antibiotics. tion and Type I IgE mediated hypersensitivi- ty reaction. A Type IV response is a 48 to 96 The case was uneventful without incidence hour delayed reaction to latex exposure of anaphylaxis. Hemodynamic stability was causing contact dermatitis with no systemic

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symptoms, while a Type I response is an ry on previous sensitivity, skin testing for immediate sensitization and interaction of latex sensitivity, and a positive radioallergo- IgE with the allergen leading to an allergic sorbent test (RAST).7 The anesthetic prepa- response ranging from mild to severe.5 Clin- ration and plan can be altered to take ical manifestations may range from contact precautions for the patient with a confirmed dermatitis, itching, uticaria, rhinitis, con- latex allergy. Avoidance of latex is the best junctivitis, bronchoconstriction, dyspnea, or prevention against anaphylaxis. One of the anaphylactic shock leading to bronchos- most important items to replace is latex ex- pasm, laryngeal edema, circulatory collapse, amination gloves due to the frequent contact hypotension, tachycardia, arrhythmias, or with the skin and mucous membranes.5 In cardiac arrest.5 addition, the operating room should be latex free and all medical equipment should con- Latex allergy as a causative agent for ana- sist of latex-free materials. A latex allergy phylaxis during anesthesia is second only to protocol, emergency medications, and neuromuscular blockers.6 The most common equipment should also be readily available.2 features of anaphylaxis under anesthesia are cardiovascular symptoms such as hypoten- In this particular case study, the patient had sion and tachycardia, cutaneous symptoms, an uncomplicated surgical intervention laryngeal edema and bronchospasm which without incidence of latex anaphylaxis. usually occur within 30 minutes of induction Without the proper precautions to provide a of anesthesia.2 These symptoms may be due latex-free environment, the outcome may to other conditions that resemble anaphylax- have turned out differently. Understanding is or by the anesthesia and medications giv- the correlation between spina bifida and la- en during the procedure; therefore, careful tex allergy and the prevalence of latex aller- assessment and timing of symptoms must be gy to anaphylaxis is of great value to the considered. Latex should always be included anesthesia practitioners. Performing a tho- in the differential diagnosis of anaphylaxis rough preoperative assessment and institut- during anesthesia.2 Treatment of latex ana- ing prophylactic measures to prevent latex phylaxis consists of maintaining the pa- anaphylaxis is vital to providing quality tient’s airway, breathing, and circulation. anesthesia care for the latex allergy patient. Instituting oxygen, IV fluids, removal of la- tex containing products and agents, discon- References tinuation of all anesthetics and non- emergency medications, and administering 1. Hudson ME. Dental surgery in pediatric resuscitative medications such as epineph- patients with spina bifida and latex al- rine, antihistamines, bronchodilators, H-2 lergy. AORN J. 2001;74:57-72. blockers, and corticosteroids as needed are 2. Hepner DL, Castells MC. Latex allergy: various interventions for anaphylaxis.1,2 an update. Anesth Analg. 2003;96:1219- 1229. Prevention is the best management for ana- 3. Rendeli C, Nucera E, Ausili E, et al. La- phylaxis. The potential severity of anaphy- tex sensitization and allergy in children laxis during anesthesia necessitates a with myelomeningocele. Childs Nerv reduction in incidence by performing a tho- Syst. 2006;22:28-32. rough preoperative assessment.6 Confirming 4. Alderson JD. About spina bifida. Anaes- a latex allergy can be accomplished by a thesia. 2000;55:695-730. comprehensive interview and focused histo-

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5. Garcia-Miguel JF, Galindo-Menendez occurring during anesthesia in France in S. Anesthesia in pediatric patients with 1999-2000. Anesthesiology. allergy to latex: report of three cases. 2003;99:536-545. Internet J Anesthesiology [serial on- 7. Watts JC. Latex allergy and anesthesia. line]. 2001;5:1092-406X. Accessed Anesth Analg. 1998;86:919. April 24, 2008. 6. Mertes PM, Laxenaire M, Alla F. Ana- Mentor: Vicki Coopmans, CRNA, PhD phylactic and anaphylactoid reactions

Intubation of the Distorted Upper Airway

Callie J. Fischer, BSN Goldfarb School of Nursing at Barnes-Jewish College

Key words: tracheal mass, difficult airway, was classified as a 3, with significant medi- difficult intubation, airway assessment, gum cal history including coronary artery disease elastic bougie requiring placement of three coronary stents, hypertension, dyslipidemia, gastroesopha- A large thyroid mass can cause significant geal reflux disease, obesity (BMI 41 kg/m2), tracheal deviation and compression render- and cervical spine osteoarthritis. Her medi- ing perioperative airway management diffi- cations included metroprolol, quinapril, dil- cult. A thorough preoperative airway tiazem, hydralazine, acetylsalicylic acid, evaluation and review of the patient’s histo- alprazolam, and acetaminophen. Recent ry must be completed prior to administration chest radiography revealed a large right neck of anesthesia to decrease the risk of mortali- mass protruding into the mediastinum with ty and morbidity. Critical airway incidents trachea displacement to the left and narrow- are responsible for 50% of anesthesia- ing of the trachea at the level of the thoracic related deaths.1 When upper airway distor- inlet. tions cause difficult direct laryngoscopy, other non-invasive airway techniques should Physical examination revealed an obese be utilized.2 A gum elastic bougie-assisted woman with a large right neck mass appear- intubation is a simple technique that can be ing slightly smaller than a baseball. The pa- particularly useful for patients with upper tient had a Mallampati class III airway with airway abnormalities, such as those occur- a thyromental distance of 3 cm. She had li- ring in the presence of a large thyroid goi- mited cervical spine range of motion with ter.2,3 decreased neck flexion and extension. The patient was unable to touch the tip of her Case Report chin to her chest. Her trachea was palpated and clearly deviated to the left. She had noi- A 77-year-old, 109-kilogram, 64-inch fe- sy respirations at rest, but denied shortness male patient with a large right thyroid goiter of breath or sleep apnea. Her oxygen satura- presented to the preoperative area for a right tion on room air was 96%, and breath thyroidectomy. She was euthyroid at the sounds were clear to auscultation in all lung time, but had a long medical history of fields. Her heart was in normal sinus rhythm hyperthyroidism. Her ASA physical status with no murmurs or rubs noted.

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An 18-gauge peripheral IV was inserted, and performed using a #3 Miller blade. Again, a lactated Ringers was started. The patient grade 3 glottic view was obtained. A gum was premedicated with midazolam 2 mg IV elastic bougie was used to guide a 7 mm oral and glycopyrrolate 0.1 mg IV in the preo- endotracheal tube through the glottic open- perative area and then transferred to the op- ing. erating room suite. A rapid sequence induction with Sellick’s maneuver was Endotracheal intubation was successful and planned. A fiberoptic bronchoscope was placement was confirmed by bilateral equal ready for use and the difficult airway cart breath sounds and ETCO2. General anesthe- was present in the operating room. Anesthe- sia was maintained with desflurane in oxy- sia practitioners present included an SRNA, gen at 2L/minute flows. Dexamethasone 10 CRNA, and attending anesthesiologist. mg IV and ketorolac 30 mg IV were given during the case as it continued uneventfully. In the operating room, the patient moved herself to the table. While standard monitors Emergence was smooth, and extubation oc- were being applied, the patient received curred without difficulty. The patient was oxygen at 10L/minute via facemask. The transferred to the post-anesthesia care unit patient was instructed to breathe deeply and with an oxygen saturation of 96% on 6 slowly. After approximately five minutes of L/min oxygen via nasal cannula. This pa- pre-oxygenation, her oxygen saturation was tient was discharged the following day. 99% and a rapid sequence induction was performed by administration of fentanyl 100 Discussion mcg IV, followed by lidocaine 100 mg IV, propofol 150 mg IV, and succinylcholine 80 Patients with large thyroid goiters often mg IV. When fasciculations stopped, laryn- present with distorted upper airways. Large goscopy was attempted using a #3 Miller upper airway masses with tracheal compres- blade. A Cormack and Lehane grade 3 glot- sion and deviation are predictive of a diffi- tic view was obtained. Despite visualization cult intubation requiring alternative airway of the epiglottis, intubation was unsuccess- management strategies.4 The American So- ful, with three failed attempts to pass the ciety of Anesthesiologists (ASA) defines a endotracheal tube through the vocal cords. difficult airway as “the clinical situation in Within 60 seconds, the patient’s oxygen sa- which a conventionally trained anesthesiol- turation decreased to 85%, the blade was ogist experiences difficulty with face mask removed and manual mask ventilation with ventilation of the upper airway, difficulty oxygen at 10L/min was attempted. Mask with tracheal intubation, or both.”2 Several ventilation was initially unsuccessful with preoperative findings, in addition to the oxygen saturations continuing to decrease to presence of a large tracheal mass, were pre- 80%. After prompt head repositioning and dictive of a difficult intubation in this pa- insertion of an oral airway, successful mask tient. Although the predictive value of any ventilation was achieved. Chest rise and single component of an airway assessment is positive end-tidal carbon dioxide (ETCO2) uncertain, multiple assessment components were noted, and oxygen saturation began considered collectively improve prediction increasing. Rocuronium 30 mg IV and an of the difficult airway. Preoperative assess- additional dose of propofol 100 mg were ments that may be associated with difficult administered. When oxygen saturations in- intubation include a Mallampati classifica- creased to 96%, a second laryngoscopy was tion greater than II, thyromental distance

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less than 6 cm, sternomental distance less in this patient. This allowed time to attempt than 12.5, and mouth opening of less than 5 non-invasive approaches to tracheal intuba- cm. It is suggested that Mallampati classifi- tion. cation and thyromental distance may be the most accurate combination of factors useful Non-invasive approaches to difficult intuba- for predicting difficult intubation.5 All of tion with adequate ventilation include use of these components were addressed preopera- different laryngoscope blades, a laryngeal tively as indicated, and confirmed the anes- mask airway as an intubation conduit, fibe- thesia practitioner’s suspicion of a roptic intubation, intubating stylet or tube potentially difficult intubation in this patient. changer, light wand, retrograde intubation, The patient’s previous anesthetic records and blind oral or nasal intubation.2 In this were obtained, and information about prior case, a gum elastic bougie was chosen first. airway management was reviewed. Upon With the second attempt at laryngoscopy, the review, they were devoid of prior intubation bougie was inserted just under the epiglottis difficulty. until resistance was met. The tracheal tube was easily threaded over the bougie and en- In congruence with the ASA practice guide- dotracheal intubation was successful. lines of difficult airway management, sever- al basic preparation steps were taken prior to Gum elastic bougie-assisted intubation was transfer of the patient to the operative suite.2 helpful in this patient because the airway First, the patient was informed of the special anatomy was abnormal and laryngoscopy risks and procedures that may have occurred provided a limited view. The gum elastic with her potentially difficult airway. Next, it bougie is one of several non-invasive alter- was ensured that multiple anesthesia practi- native approaches described within the diffi- tioners were immediately available during cult airway algorithm recommended by the induction and intubation. Finally, a difficult ASA.2 It has been used for a significant pe- airway cart was placed in the operating riod of time as a common tool when direct room and supplies within were prepared for laryngoscopy is difficult. A review of the immediate use. literature reveals successful use of the gum elastic bougie in cases when anatomical In this case, rapid sequence induction of landmarks of the upper airway are not re- general anesthesia with administration of a cognizable due to significant upper airway low dose of succinylcholine was chosen, as distortion.3 it would have quickly allowed the patient to return to spontaneous ventilation if needed The presence of a thyroid goiter predicts the after failed initial intubation attempts. Ac- possibility of a difficult patient intubation. A cording to the ASA difficult intubation thorough preoperative airway physical as- guidelines, after induction of general anes- sessment and review of the patient’s history thesia fails and initial intubation attempts are is crucial in determining the appropriate unsuccessful, face mask ventilation should technique for airway management. If intuba- be attempted. If face mask ventilation is tion is unsuccessful after induction of gener- adequate, anesthesia practitioners should al anesthesia, but face mask ventilation is attempt one of a variety of non-invasive ap- adequate, many alternatives can be consi- proaches to successfully intubate the pa- dered as non-invasive approaches to tracheal tient.2 Face mask ventilation with insertion intubation. A gum elastic bougie is one that of an oral airway was ultimately successful may be considered if upper trachea distor-

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tion and compression results in a limited di- 3. Combes X, Dumerat M, Dhonner G. rect laryngoscopy as in the case of a signifi- Emergency gum elastic bougie-assisted cant tracheal goiter. tracheal intubation in four patients with upper airway distortion. Can J Anaesth. References 2004;51:1022-1024. 4. Wakeling H, Ody H, Ball A. Large goiter 1. Ezri T, Szmuk P. Recent trends in tra- causing difficult intubation and failure to cheal intubation: emphasis on the diffi- intubate using the intubating laryngeal cult airway. Curr Opin Anaesthesiol. mask airway: lessons for the next time. 2004;17:487-490. Br J Anaesth. 1998;81:979-981. 2. Practice guidelines for management of 5. Shiga T, Wajima Z, Inoue T, Sakamoto A. the difficult airway: an updated report by Predicting difficult intubation in appar- the American Society of Anesthesiologist ently normal patients: a meta-analysis of Task Force on Management of the Diffi- bedside screening test performance. cult Airway. Anesthesiology. Anesthesiology. 2005;103:429-437. 2003;98:1269-1267. Mentor: Vicki Coopmans, CRNA, PhD

LETTER TO THE EDITOR

Student Registered Nurse Anesthetist Volunteer Experience in Honduras

Kelly S. Chambers, BSN Georgetown University

Key words: volunteer, Honduras, anesthe- on technology). Additionally, this experience sia, limited resources, problem solving taught me the balance of administering a safe, quality anesthetic while preserving re- Through my 27 months as a nurse anesthesia sources. student, much of my time was spent on basic science, anesthesia fundamentals, and clini- The Virginia Hospital Center Medical Bri- cal skills. In the final month of my education gade has traveled to Honduras for one week at Georgetown University, I had the unique every year since 1999 (with the exception of opportunity to spend a week in Honduras 2001), focusing not only on delivery of med- with the Virginia Hospital Center Medical ical and surgical services, but also on pro- Brigade. This volunteer opportunity not only viding education and supervision for allowed me to help in an underserved com- Honduran community health workers in ru- munity, but was also a practical culmination ral villages. This past year, members of the of my nurse anesthesia education. I was able brigade worked with community members to assess the tools necessary for anesthesia to build a water system, which now provides administration, apply problem-solving skills clean water for 1,800 members of a remote to my knowledge of the anesthesia machine, mountain village.1 I was able to work on the and improve clinical focus on the patient surgical team administering general and re- (while gaining perspective on my reliance gional anesthesia with a group of three sea-

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soned certified registered nurse anesthetists and use the parts to fix the OR machine. For (CRNAs) and an anesthesiologist. Almost all one fix in particular, the CRNA called on the of the anesthetics were performed by the services of the local auto mechanic, who had CRNAs. We managed anesthesia for 78 pa- the only tools available to fix the machine. tients with primary surgeries including stra- For scavenging, we ran a scavenging hose to bismus correction, hernia repair, chole- an outside hallway or did without and tried cystectomy, hysterectomy and caesarean to minimize exposure with a tight mask fit section. for inhalation inductions. For cases with the scavenging hose running to the hallway, I Prior to arriving in Honduras, there was a continuously made sure that the hose did not coordinated effort by Betsy Koop, CRNA to become kinked or stuck in the door to avoid obtain and organize the anesthesia supplies. barotrauma to the patient. These were sent by ship to our destination two months before the trip. Anesthesia ma- We primarily utilized manual blood pressure chines were donated and available for each cuffs or store bought automatic cuffs for of the operating rooms (ORs). There was blood pressure readings. Inaccurate gas con- one extra machine in the supply warehouse. centration monitoring was the most chal- Upon arrival to Santa Teresa Regional Hos- lenging situation for me. We used pital, we began to assess the equipment in- sevoflurane, isoflurane and enflurane; how- cluding the anesthesia machines, supplies, ever, at times the gas monitoring would read and gas supply. The machines were older the primary gas and also halothane and/or than I expected to see and included some nitrous oxide (neither of which was availa- settings that I had not worked with in the ble). To obtain the appropriate depth of past. For example, one of the ventilators re- anesthesia, instead of reading my end tidal quired a setting of the respiratory rate and gas or calculated minimal alveolar concen- the minute ventilation (as opposed to tidal tration (MAC) from a monitor the method volume). I enjoyed calculating the settings that I had been so reliant on in the past, I had in a new way. Instead of the machine giving to keep in mind the dialed concentration, me the calculated numbers, I was able to flow rate, respiratory rate, and carefully utilize calculations had I learned from my monitor vital signs. I quickly found that I anesthesia courses. stopped relying on monitors and numbers; instead, I really started to focus more on my The anesthesia machinery was mostly in patient. working condition and every room had a working pulse oximeter; however, there I began to realize the extent to which I rely were issues such as ventilator malfunction, on monitors. Part of this, I attribute to study- machine alarm malfunction, unavailable ing anesthesia now, in a time of technologi- scavenging, inaccurate gas monitoring and cal dependence and advancement. I firmly malfunctioning blood pressure monitoring. believe in utilizing technology as an adjunct to the clinical picture, indeed, technology We were able to circumvent the ventilator has made anesthesia safer for patients.2 malfunction by utilizing laryngeal mask However, in Santa Teresa Regional Hospital, airways (LMAs), regional anesthesia, or by where access to state of the art equipment manually ventilating the patient. The solu- was not available, I found I was more at- tion for fixing a malfunctioning OR machine tuned to the patient’s condition. For in- alarm was to disassemble the extra machine stance, at the start of a procedure in which

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an LMA was used, I noticed that the pa- less and little thought is given to the fact that tient’s chest was rising inconsistently. The we might run out of a necessary supply. LMA needed to be repositioned. In the US, I more than likely would have noticed a drop I went into this experience hoping to help in in my end tidal carbon dioxide (EtCO2) first, an underserved community, and indeed the rather than the chest rise. services were needed and the patients were grateful. I did not expect that this opportuni- An additional lesson learned was the balance ty would enhance my anesthesia education of giving a safe and quality anesthetic while as much as it did. The CRNA professionals, keeping in mind the necessity of preserving Betsy Koop CRNA, MS, Donna Jasinski limited anesthesia resources. As expected, in CRNA, PhD, and Tracy Coverdale CRNA, Honduras, the standards of giving anesthesia MS, were instrumental in mentoring me not are different from in the United States. only with volunteering and anesthesia, but Many supplies, such as LMAs, breathing also with professional development. They circuits, and oxygen delivery supplies are really helped me to build my anesthetic reused. The anesthesia practitioners in this technique from the ground up; to assess the hospital sometimes performed as circulators tools necessary to provide a safe, quality or scrub technicians. Also, they sometimes anesthetic, to problem solve the anesthesia left the rooms during the anesthetic! We machine, and to maintain focus on the pa- strived to provide anesthesia to our Ameri- tient, while preserving resources. This expe- can Association of Nurse Anesthetists rience allowed me to pool my anesthesia (AANA) standards.3 The trip anesthesia knowledge and problem solve, both of coordinator was able to secure needed medi- which are important for developing a more cations and anesthesia supplies. We did not in-depth scope of knowledge. I highly rec- reuse endotracheal tubes, breathing circuits, ommend this type of opportunity to anyone syringes, and/or needles. However, there who is interested. were some supply limitations. We did need to reuse LMAs (after thoroughly cleaning) References and we did draw medications more than once from single dose vials (using aseptic 1. Virginia Hospital Center Medical Bri- technique). gade. (2007). Providing humanitarian healthcare to the underserved of Hondu- There were a few technical limitations, par- ras. Retrieved December 10, 2008, from ticularly with oxygen supply. Oxygen was http://www.vhcmedicalbrigade.org/inde supplied from an H cylinder in each room. I x.html had to be vigilant about turning my flow 2. American Association of Nurse Anes- rates down in a timely manner and remem- thetists. (2008). Introduction to Quality bering to turn the oxygen off at the end of of Care in Anesthesia. Retrieved De- the case. I was mindful of using resources cember 10, 2008, from only when needed i.e. not every patient went http://www.aana.com/Resources.aspx?u to the post-anesthesia care unit (PACU) with cNavMe- a nasal cannula or facemask. This practice nu_TSMenuTargetID=51&ucNavMenu was a deviation from my clinical expe- _TSMenuTargetType=4&ucNavMenu_ riences at large teaching facilities in the TSMenu- United States, where resources appear limit- ID=6&id=667&terms=safer+anesthesia

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3. American Association of Nurse Anes- low the local embassy to know you are thetists. (2008). Scope and Standards in the country; any assistance you might for Nurse Anesthesia Practice. Re- need will be facilitated if they know you trieved December 10, 2008, from are there (lost passport, need to leave http://www.aana.com/Resources.aspx?u country emergently, etc.). cNavMe- 4. Learn about the location where you will nu_TSMenuTargetID=51&ucNavMenu travel- safety of water and food, lodg- _TSMenuTargetType=4&ucNavMenu_ ing, local customs, acceptable dress, TSMenuID=6&id=783 personal security issues, etc. 5. Extensively review the anesthesia ma- Recommendations for Student Registered chine inner workings. 6. Review or have a resource for inhaled Nurse Anesthetists Volunteering agents not commonly used. 7. Bring your own stethoscope, scrubs, 1. Obtain all of the information you can and monitor devices when possible. from the organization you are traveling (Portable automatic/manual blood pres- with including trip details and details sure monitoring and pulse oximeter de- about the anesthesia supplies/equipment vices are especially useful.) available. If there are supplies, such as 8. Bring small anesthesia reference books. clipboards, tape, baskets for organiza- 9. Bring hand sanitizer. tion, etc. that are not available, consider 10. Consider bringing donated toys for pe- bringing these items. diatric patients. 2. Visit the Centers for Disease Control 11. Consider bringing OR shoes that you and Prevention website to determine can leave/ donate to the hospital. what vaccinations you will need for tra- 12. Keep a cheat sheet of a few common vel. anesthesia phrases in the language of 3. Register with the US Department of the location in which you will be volun- State prior to your trip. Know the loca- teering. tion of the local embassy in the country to which you are traveling. Registering Mentor: Elizabeth Koop, CRNA, MS with the US Department of State will al-

EDITORIAL

Bon Voyage

When my daughter was very young I remember the emotion I had when I set her on the floor and instead of sitting, she stood and walked away from me without my assistance. It is with a similar, albeit not as intense emotion that I set the Student Journal down and let it walk away into new hands.

The Student Journal started more than eight years ago as a case report writing assignment for Georgetown students during the clinical phase of their anesthesia program. Their case reports were so interesting that instead of putting them in a filing cabinet I had them copied for every student in the class to read each other’s work. The moment I stapled them together it dawned on me that we had a little “journal”. My office-mate, Julie Pearson, subsequently showed this to our

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Dean and she had the foresight see its potential. She funded a graphic artist for a cover design and formal publication of the first year’s work. We sent it to every program in the country and invited them to join us in this endeavor. We had a slow beginning and then Baxter Healthcare, Inc. saw it and decided to fund it as an educational grant. We then printed copies and mailed them to every SRNA in the country – free. For economic reasons, Baxter had to end that support after a few years but AANA graciously allowed us to use space on its website. We have been there ever since, and very timely as many journals are going paperless.

Despite being online, which may give the impression of being less than a quality journal, every article of The International Student Journal of Nurse Anesthesia is given two blind reviews by experienced CRNAs, most of whom are program faculty members and many are Program Direc- tors. We have also contracted for the Indexing of the articles so they should soon be searchable on Medline and other major database search engines.

The Editorial Board now has almost as many members as the first issue had authors. Since the cost of printing and mailing paper journals is not of concern, the Journal can look to publishing research abstracts, capstone papers and other scholarly writings, but this is for the new Editor and Editorial Board to nurture.

I am confident that this Journal will not just continue to walk but will run smoothly with Vicki Coopmans, CRNA, PhD as the new Editor in Chief and Julie Pearson, CRNA, PhD remaining as an active Associate Editor. Many thanks to each of you dedicated Editorial Board members who have willingly taken on more work from you own program responsibilities by not only reviewing articles for the Journal, but mentoring your own faculty into a reviewer role while also mentoring articles from students in your own programs.

Many thanks to so many of you who patiently mentored articles for your students and did so sel- flessly, without the recognition and credit as a co-author.

Thank you to all student authors whose enthusiasm for this great profession has been jumping off of every page of every article since the first of the 286 we have published to date.

I wish the Journal a successful voyage into the future.

Ron Van Nest, CRNA, JD

Editor-in-Chief

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