Anaesthesia and the Kearns-Sayre syndrome

A six-month-old infant presented for anaesthesia with, unbeknown to us, some of the manifestations of the Kearns-Sayre Syndrome. This syndrome is one of the clinical presentations in patients with mitochondral myopathy. The anaesthetic related events and aspects of mitochondral myopathy are described and caveats are suggested for the management of anaesthesia for patients with this type of myopathy.     

Sick sinus syndrome manifest after spinal anaesthesia

A case of sick sinus syndrome which presented as a cardiac arrest following spinal anaesthesia is reported. The diagnosis of sick sinus syndrome, the cardiovascular effects of spinal anaesthesia and the anaesthetic management of patients with the syndrome are discussed.     

ANAESTHESIA FOR SHEEHAN'S SYNDROME

A case is presented of a 35-year-old woman with proven Sheehan'ssyndrome requiring anaesthesia for Caesarean section at theend of a second pregnancy. She showed signs of adrenocorticalinsufficiency before anaesthesia. Sheehan's syndrome is brieflyreviewed and the management of anaesthesia in patients withthis condition is discussed.     

Peri‐operative management of the obese surgical patient 2015

Guidelines are presented for the organisational and clinical peri‐operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri‐operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.     

Anaesthetic management of posterior lumbar osteotomy

Sixty-four cases of posterior lumbar extension osteotomy performed at the Toronto East General Hospital between 1969 and 1983 are reviewed. The anaesthetic management is presented. The procedure was performed with local infiltration anaesthesia, heavy sedation and a brief period of general anaesthesia induced with nitrous oxide, halothane or ketamine. Five stages in the anaesthetic management are distinguished, each in relation to a phase of the surgical procedure and drug usage. A method of supporting these deformed patients in the prone position in moulded plaster casts is described. Anaesthetic and surgical complications and postoperative psychological disturbances are described and discussed. It is suggested that caudal epidural opioid or local anaesthetic analgesia be explored as an aid in the management of these patients.     

Acute epiglottitis: current management and review

Forty-seven patients treated for acute epiglottitis by nasotracheal intubation under general anaesthesia following a preset protocol are presented. The results are compared with 61 cases treated by tracheostomy following induction of general anaesthesia and intubation in the same institution. Both groups were followed clinically, and 13 of the children treated by nasotracheal intubation alone had a follow-up endoscopic examination of the larynx. There was no mortality in either group, but the morbidity was significantly higher in the children who had tracheostomy. Details of the management protocol are presented. Only inhalation anaesthetic agents are recommended and it is concluded that children with acute epiglottitis should always have an artificial airway inserted. Nasotracheal intubation seems to be associated with less morbidity than tracheostomy in experienced hands.     

Anaesthesia for amiodarone-induced thyrotoxicosis: a case review

Amiodarone-induced thyrotoxicosis is a life-threatening problem that is very effectively managed by total thyroidectomy, although often many of these patients are considered "too unfit" for anaesthesia. The aim of this study was to review the safety of anaesthesia for total thyroidectomy in the acute management of amiodarone-induced thyrotoxicosis. Information was obtained retrospectively from a prospective endocrine surgical database and from hospital records. Data, including outcomes and morbidity, are presented from 12 patients who underwent anaesthesia for total thyroidectomy as an urgent procedure for amiodarone-induced thyrotoxicosis. Despite the fact that these patients had uncontrolled thyrotoxicosis and marked cardiac failure at the time of anaesthesia, no anaesthetic or surgical mortality was seen. We conclude that a challenging patient with amiodarone-induced thyrotoxicosis that has not responded to conservative measures may be considered for total thyroidectomy early in their management. Total thyroidectomy can be performed under general or local anaesthesia with apparent relative safety.     

Complete failure of spinal anaesthesia in obstetrics

Intrathecal anaesthesia, either as a single shot-spinal or as part of a combined spinal-epidural technique, is now widely accepted as the management of choice for caesarean section. It generally produces rapid and predictable anaesthesia, yet occasionally fails for no apparent reason. Four case reports of seemingly inexplicable complete failure of intrathecal anaesthesia are presented, together with a literature review of other cases and possible causes of the failure, which include anatomical abnormality, drug failure and management failure.     

Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers

A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management.     

Spinal anaesthesia for caesarean section in a patient with cervical cord compression

The anaesthetic management a of 42-year-old woman with significant symptomatic cervical cord compression, who presented for emergency caesarean section, is presented. She declined to have general anaesthesia in any circumstance and had the surgery conducted under spinal anaesthesia, without developing any postoperative neurological deterioration. The implications of various anaesthetic options are discussed along with the role of patient's wishes in anaesthetic decision-making.     

Isolated lung transplantation for pulmonary fibrosis

The peri-operative anaesthetic management of 11 patients with pulmonary fibrosis undergoing single-lung transplantation is presented. Intra-operative problems, the early postoperative phase of recovery and intensive care, and other incidents in which general anaesthesia was required for the management of complications, are featured. Results, both short- and long-term, are mentioned. Major intra-operative events that cause concern appear to be related to the severity of the presenting illness and the development of respiratory failure. Others have reported the development of intra-operative cardiac failure. All cases were successfully managed operatively using conventional one-lung anaesthesia, although resort to partial cardiopulmonary bypass may have been indicated in some. The indications and attitudes to utilising cardiopulmonary bypass in the evolution of techniques for facilitating single-lung transplantation are reviewed.     

McArdle''s disease

A case is presented of the anaesthetic management of a patient with McArdle's disease who required Caesarean section. The pathology of the condition is considered together with the clinical features and treatment. The problems of anaesthesia in patients with this inherited disease are discussed with particular reference to the use of muscle relaxant drugs.     

Anesthesia for section caesarean with aortic dissection in Marfan Syndrome

Marfan Syndrome (MFS) is associated with an increased anaesthesia risk because of the pathological manifestations in anaesthesia-relevant organ systems. If, in addition, a typical MFS complication - acute aortic dissection - presents and this in pregnant patients, a high-risk anaesthesia must be assumed. In the case reported, a 30 year old woman in the 35 th week of gestation presented with an acute aortic dissection, initially in the region of the descending aorta and later, in the course of the ascending aorta. An urgent Caesarean section was indicated in order to perform the equally urgent vascular surgery as quickly as possible. The most important goal of the anaesthesia management is to determine an anaesthesia procedure which addresses the combination of aorta dissection, gestation and MFS. On the one hand, the risk of an aorta rupture needs to be kept as low as possible and on the other hand, the vital functions of the baby have to be maintained. A general anaesthesia procedure under mild controlled hypotension was selected. Optimal monitoring and absolute freedom from pain were the prerequisites both for the anaesthesia management of the Caesarean section as well as for the immediate transport to a clinic for further treatment after completion of anaesthesia.     

Haemodynamic monitoring in the management of severe pre-eclampsia and eclampsia

Four case histories are presented to illustrate that haemodynamic monitoring is a useful guide in the acute management of severe pre-eclampsia and eclampsia. The application of intensive monitoring and therapy to patients in the delivery room is both feasible and of great help to the clinician managing fluid therapy and/or anaesthesia.     

Local anaesthetic thoracoscopy for intractable pneumothorax in a high-risk patient

The management of high-operative-risk patients with a pneumothorax is complicated. The case of a 79-year old man with an intractable secondary pneumothorax, who had taken oral steroids to control asthma, is presented. Since the patient could not tolerate general anaesthesia because of poor cardiac function, thoracoscopic surgery was performed under local anaesthesia. A successful lung fistula closure was achieved and the continuous air leakage disappeared immediately after the surgery.     

Computerized anaesthesia information management systems: are we on the threshold of widespread use?

Despite a recognition that they are essential for the future progress of anaesthesia, computerized anaesthesia information management systems are not in widespread use. In this article, relevant recent publications are summarized with a view to identifying the reasons for the current situation. Several developments which might promote the wider use of such systems in the near future are also presented.     

Hypertension pulmonaire et fracture du col fémoral : intérêt de la rachianesthésie continue

Anaesthetic management of patients with pulmonary hypertension is challenging and alternatives to general anaesthesia are encouraged. We report anaesthetic management of two patients with pulmonary hypertension admitted for femoral neck fracture. In order to reduce the risk of right-sided heart failure and systemic hypotension, it was decided to operate the patients under continuous spinal anaesthesia. Anaesthesia was induced with excellent hemodynamic tolerance. Quality and extension of the block was correct and allowed surgery. No postoperative complication was observed. These cases suggest that continuous spinal anaesthesia may be considered for the management of patients with pulmonary hypertension undergoing femoral neck fracture surgery.     

Guidelines for day-case surgery 2019

Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.     

Anaesthesia for major orthopaedic surgery in the elderly

This article addresses three specific issues related to major hip and knee surgery in the elderly. Firstly, the importance of thorough pre-operative evaluation is discussed. Secondly, the pros and cons in the immediate peri-operative period of major regional (spinal or epidural) anaesthesia versus general anaesthesia are reviewed with respect to blood loss, cardiovascular and respiratory function and immunological and metabolic responses to surgery. Finally, the evidence for an anaesthetic technique effect on outcome parameters, especially thromboembolism, cognitive function and mortality, is presented. Regional anaesthesia is the method of choice for most patients undergoing elective hip surgery since it results in reduced blood loss and transfusion needs, modification of the neuro-endocrine stress response, improved early postoperative oxygenation, and a reduced incidence of deep vein thrombosis (DVT) postoperatively. In the surgery of fractures of the neck of femur, outcome with regional anaesthesia is at least comparable to that with general anaesthesia, but with improved early postoperative oxygenation and a smoother emergence from anaesthesia making initial nursing management easier. Comparative data in other forms of orthopaedic surgery in the elderly are few, but also support the use of regional techniques.     

Safety and efficacy of target controlled infusion (Diprifusor) vs manually controlled infusion of propofol for anaesthesia.

In this multi-centre, randomized trial, we compared the safety and efficacy of Diprifusor TCI with manually controlled infusion (MCI) of propofol for anaesthesia. With approval, 123 adult male and female patients were studied. Firstly, each investigator anaesthetized five patients to familiarize themselves with Diprifusor TCI. In Stage 2, 98 patients were randomized to receive propofol-based anaesthesia via TCI or MCI. Adjuvant drugs, airway management and monitoring were managed at the discretion of the anaesthetist. Results are presented as mean (SD). Induction times were significantly longer [67 (32) vs 54 (17)s] and induction doses were significantly lower [14 (5) vs 16 (4) ml] in the TCI vs the MCI group. Recovery times and total doses were not significantly different. There were statistically but not clinically significant differences in mean arterial blood pressure and heart rate. Quality of anaesthesia and ease of control of anaesthesia were similar. We conclude that Diprifusor TCI and MCI are similar in terms of safety and efficacy.