III. Preoperative assessment of the airway: should anaesthetists be making use of modern imaging techniques?

Preoperative assessment of the central airway is concerned primarilywith the detection and evaluation of laryngotracheal stenosis.There are many causes of laryngotracheal stenosis; however,stenosis secondary to a thyroid goitre is one of the more commontypes requiring evaluation prior to general anaesthetic. A postero-anteriorchest and lateral thoracic inlet radiograph have been the primaryinvestigative tools used to assess the degree of tracheal compressionand deviation in both the transverse and antero-posterior planes.¹In many patients this type of imaging will suffice; however,computed tomography (CT) will more comprehensively detail theextent of tracheal stenosis and the degree of retrosternal extension.Compression of other structures by retrosternal     

Postintubation tracheal stenosis

Postintubation tracheal stenosis is a clinical problem caused by regional ischemic necrosis of the airway. The incidence of postintubation tracheal stenosis has decreased with recognition of its etiology and modifications in the design and management endotracheal and tracheostomy tubes; however, it remains the most common indication for tracheal resection and reconstruction. Single-stage resection and reconstruction by a competent tracheal surgeon results in good or satisfactory results in 93.7% of patients, with a failure rate of 3.9% and a mortality rate of 2.4%. The intellect and skill of Dr. Grillo has made the etiology and management of postintubation stenosis obvious to us all.     

Anaesthesia and adrenocortical disease

The first 150 words of the full text of this article appear below. Key points Adrenocortical disease results in disturbances ofbody water volume and electrolyte concentrations; intra-cellularelectrolyte defects may be severe. Preoperative assessmentis of crucial importance in identifying the endocrine diseaseprocess and the severity of its effects. Preoperative preparationinvolves correction of volume deficit and electrolyte disturbances,and replacement of deficient hormones. Cardiovascular disturbanceand instability are particularly common and invasive cardiovascularmonitoring should be considered. Postoperative mineralocorticoidand glucocorticoid supplementation should be considered in Addison'sdisease and in steroid-induced hypoadrenalism.  

Ultrasonographic fata morgana.

Case A 35-year-old female with end-stage renal disease due to chronicglomerulonephritis received a cadaveric renal transplantationinto the right fossa iliaca. Her body mass index was 23 kg/m².The clinical course after transplantation was uneventful andgraft function was stable during follow-up. Ultrasonographicmonitoring of the renal transplant was performed regularly withB-scan, colour Duplex and Doppler ultrasonography using a 3.75MHz curved array transducer and sector transducer (SonolayerSSA 270A; Toshiba, Tokyo,     

Massive haemorrhage in pregnancy

The first 150 words of the full text of this article appear below. Key points Massive haemorrhage remains a significant causeof maternal mortality and morbidity. Clear and timely communicationbetween surgical, anaesthetic and haematology services is vitalto ensure optimal maternal and fetal outcome. Signs of hypovolaemiaoccur relatively late because of physiological changes in pregnancy. Theextent of intravascular volume deficit is not reflected by visualestimates of vaginal bleeding. The decision to perform a hysterectomyshould be made when other methods of haemostasis have failedand not delayed until control of maternal haemostasis and cardiovascularstability has been lost.   Massive haemorrhage is a major cause of maternal mortality.Life-threatening haemorrhage may occur as frequently as 6.7per 1000 deliveries.¹ This equates to 1400 cases yr ^–1in the UK or 33.5 yr ^–1 in an obstetric unit with 5000deliveries annually. Pregnancy-related conditions and complicationsaccount for 0.8% of intensive care admissions; 35% of thesearise from massive haemorrhage.^{1 2} Management of massive . . . [Full Text of this Article]

预防性横行气管切开在重症气管狭窄切除重建术中的应用

目的：探讨预防性横行气管切开对气管狭窄切除重建术后呼吸道管理及减小吻合口张力的价值。方法22例气管狭窄患者均施行气管病变段切除并对端吻合重建手术,根据是否手术同期接受横行切口气管切开,分为气管切开组10例和非气管切开组12例。分析比较两组患者临床资料。结果气管切开组患者术前CPIS评分（临床肺部感染评分）、声嘶、意识障碍比率均明显高于非气管切开组（P＜0．05）,全组患者无死亡,两组手术时间、手术出血量、术后呼吸机使用时间、ICU监护时间、抗生素使用时间以及术后ARDS、吻合口瘘等并发症发生率均无明显差异。术后随访22例,随访时间3～32个月,均日常活动正常,无呼吸困难症状,三维CT重建检查无气管狭窄。结论气管切除重建术后行预防性横行气管切开,简化了术后的气道管理,保证了气道的通畅与清洁,同时亦起到减小吻合口张力作用,有效地减少术后并发症,对于气管狭窄重症患者,推荐预防性气管切开。     

Atrial fibrillation

The first 150 words of the full text of this article appear below. Key points

• Atrial fibrillation (AF) is the commonest cardiacarrhythmia; its incidence increases with age.
• Diabetes mellitus,hypertension and ventricular hypertrophy are commonly associatedwith non-valvular atrial fibrillation.
• Primary aims of managementof AF are conversion to sinus rhythm, maintenance of sinus rhythmand prevention of thromboembolic complications.
• In elderlypatients who are asymptomatic, adequate rate control of AF appearsto offer the same benefits as rhythm control.
• Chronic AF carriesa high risk of ischaemic stroke from thromboembolism; all patientsat risk must receive adequate anticoagulation.
• Anticoagulationshould be continued in patients with risk factors despite successfulconversion to sinus rhythm.

  Atrial fibrillation (AF) is the commonest cardiac arrhythmia.The incidence increases with age and affects 5% of UK populationabove the age of 65 yr and 10% above 75 yr.^{1 2} In the UnitedStates, AF accounts for more than 35% of all admissions forcardiac arrhythmias.³ Men are . . . [Full Text of this Article]

Resection of the trachea for cicatrical stenosis

Tracheal stenosis represents a serious complication of tracheostomy or of endotracheal intubation. The objective of this article was to evaluate the results of resective therapy of patients with tracheal stenosis. METHODS: In 41 patients treated by tracheal resection for tracheal stenosis the diagnosis was established by bronchoscopy, tracheal tomography or CT. The following parameters were evaluated: the reasons for artificial pulmonary ventilation, basic parameters of stenosis (site of stenosis, length, diameter), the relationship between the duration of cannulation and asymptomatic interval, and postoperative complications. RESULTS: The most frequent reason for cannulation was trauma (n = 23), most patients were cannulated for 4-5 weeks (n = 16), the symptoms of stenosis appeared mostly within 4-5 weeks (n = 11) after decannulation. The asymptomatic interval was longer in patients with longer periods of cannulation (p < 0.01) than in patients with a shorter cannulation period. The most frequent site of stenoses was the medium third of the trachea (n = 22). The longest resected section measured 60 mm. In 3 patients (7.3 %) a tracheoesophageal fistula was found together with the stenosis. In 3 patients (7.3 %) restenosis appeared. Tracheocutaneous fistula with osteomyelitis of the sternum developed in one patient. Granulation tissue on the anastomosis site (n = 4, 9.7 %) was treated by laser or disappeared spontaneously. None of the patients died within 30 days after operation. CONCLUSION: Resection is the optimum therapeutic method for tracheal stenosis with low postoperative mortality and a small number of postoperative complications. Successful tracheal resection is a definitive solution in comparison with stent placement.     

Postintubation tracheal stenosis in an 11-year-old boy: a surgical and anaesthetic challenge

We present a case of postintubation tracheal stenosis in an 11-year-old boy occurring after a relatively short period of intubation. He had been intubated and ventilated in a paediatric intensive care unit after a road traffic accident. Clinical symptoms manifested by oxygen desaturation and wheeziness, finally leading to deterioration of the level of consciousness, occurred a few hours after the first attempt at extubation after 48 h requiring reintubation. Endoscopic examination performed a few weeks later revealed a tracheal stenosis. Consequently, he underwent an initial period of conservative treatment consisting of balloon dilatation and intralesional injection of steroids, followed by a tracheal resection and reconstruction. The anaesthetic management of patients with tracheal stenosis presenting for laryngo-tracheobronchoscopy and balloon dilatation is discussed.     

Fiberoptic Bronchoscopy-Assisted Endotracheal Intubation in a Patient With a Large Tracheal Tumor

In the event of a high degree of airway obstruction, endotracheal intubation can be impossible and even dangerous, because it can cause complete airway obstruction, especially in patients with high tracheal lesions. However, a smaller endotracheal tube under the guidance of a bronchoscope can be insinuated past obstructive tumor in most noncircumferential cases. Here we report a case of successful fiberoptic bronchoscopy-assisted endotracheal intubation in a patient undergoing surgical resection of a large, high tracheal tumor causing severe tracheal stenosis. A 42-year-old Chinese man presented with dyspnea, intermittent irritable cough, and sleep deprivation for one and a half years. X-rays and computed tomography scan of the chest revealed an irregular pedunculated soft tissue mass within the tracheal lumen. The mass occupied over 90% of the lumen and caused severe tracheal stenosis. Endotracheal intubation was done to perform tracheal tumor resection under general anesthesia. After several failed conventional endotracheal intubation attempts, fiberoptic bronchoscopy-assisted intubation was successful. The patient received mechanical ventilation and then underwent tumor resection and a permanent tracheostomy. This case provides evidence of the usefulness of the fiberoptic bronchoscopy-assisted intubation technique in management of an anticipated difficult airway and suggests that tracheal intubation can be performed directly in patients with a tracheal tumor who can sleep in the supine position, even if they have occasional sleep deprivation and severe tracheal obstruction as revealed by imaging techniques.Key words: Tracheal tumors, Fiberoptic bronchoscopy, Difficulty intubation, Difficult airwayPrimary tumors of the trachea, mostly malignant, are rare, accounting for fewer than 0.1% of all tumors.¹ Surgical resection is the major option that has the potential to cure all patients with benign and low-grade tumors and most patients with malignant tracheal tumors.¹ Since surgical procedure often requires the airway to be shared by the anesthetist and the surgeon, patients who undergo tracheal tumor resection often present with a considerable degree of airway obstruction, which makes anesthetic management during surgical resection challenging.² In the event of a high degree of airway obstruction, endotracheal intubation can be impossible and even dangerous because it can cause complete airway obstruction, especially in patients with high tracheal lesions.³ However, tumors are not circumferential in most cases, and a small endotracheal tube can be insinuated past a highly obstructive tumor under the guidance of bronchoscopy.³ Here we report a case of successful fiberoptic bronchoscopy-assisted endotracheal intubation in a patient undergoing surgical resection of a large, high tracheal tumor causing severe tracheal stenosis.     

CHANGES IN INTRAGASTRIC PRESSURE ON INDUCTION OF ANAESTHESIA

Intragastric pressure was measured in 20 patients before, andimmediately after, the induction of anaesthesia with thiopentone.Intragastric pressure decreased in patients whose weights werethe same as or less than expected, and increased in fire ofseven patients whose weights were greater than expected (P=0.0013). These findings suggest that the decrease in FRC knownto occur on the induction of anaesthesia is caused by a decreasein inspiratory muscle tone in the diapbragrn and other muscles Footnotes ^*Present address: Department of Anaesthesia, Adden-brookes Hospital,Hills Road, Cambridge CB2 2QQ     

Air entrainment during high-frequency jet ventilation

Editor—We read with great interest the article on ‘Airentrainment during high-frequency jet ventilation (HJFV) ina model of upper tracheal stenosis’.¹ The authors concludedthat ventilation delivered below the stenosis (BSV) is the safestoption from the point of view of low tracheal pressure and consistentoxygen concentrations of injected gas. We have several concernsabout the suggestions made by the authors. From our experience,the results of in vitro studies cannot always be transferredto patients. Transtracheal     

Two kidney-transplant women with therapy-resistant hypertension: diagnostic error of a renal artery stenosis.

Cases Patient 1 This was a 57-year-old woman with end-stage renal disease (ESRD)due to chronic pyelonephritis who had received a cadaver kidneygraft in July 1980 after 42 months of haemodialysis. Maintenanceimmunosuppression included azathioprine and prednisolone. Hypertensionappeared a few months after kidney transplantation (KT) andwas treated by methyldopa 250 mg three times a day. A systolo-diastolicmurmur was noticed 6 months after KT. A first graft arteriographywas performed in 1982. It revealed parietal irregularities witha <20% stenosis involving the first 2 cm of the transplantrenal artery stenosis (RAS). In 2000, hypertension became resistantto a treatment combining isradipine and atenolol. Cockroft creatinineclearance and 24 h proteinuria were 72 ml/min and 150 mg, respectively. A colour Doppler ultrasound (CDU) using a HDI 3000 machine witha 3.5 or 5 MHz sectorial transducer was performed. Peak systolicvelocity (PSV) was measured at 3.36     

分化型甲状腺癌侵入气管内的外科治疗及气道重建

目的探讨分化型甲状腺癌侵入气管内的外科治疗方法及效果。方法回顾性分析分化型甲状腺癌侵入气管内的患者行气管袖状切除术后的治疗结果。16例分化型甲状腺癌（均为乳头状癌）侵入气管内的患者进行了颈部淋巴结清扫术＋肿瘤整块切除术及气管袖状切除术,并一期行气管端端吻合术重建气道。结果16例患者手术均成功进行,术后并发症发生率为12．5％（2／16）,其中气管吻合口狭窄1例,CO：激光加浅层放疗治愈;双侧声带麻痹1例,CO2激光切除一侧声带后分治愈。平均随访时间23个月,1例患者术后3个月出现局部淋巴结复发,再次术后带瘤生存;1例局部复发死亡。结论气管袖状切除一拉拢缝合术能有效治疗分化型甲状腺癌侵犯气管内,而CO2激光与浅层放疗对术后双侧声带麻痹及吻合口瘢痕增生是有效的。     

Fibrosarcoma of the trachea with severe tracheal obstruction

Roncoroni, A. J., Puy, R. J. M., Goldman, E., Fonseca, R., and Olmedo, G. (1973).Thorax,28, 777-781. Fibrosarcoma of the trachea with severe tracheal obstruction. A patient with a tracheal fibrosarcoma is reported. The tumour was located just above the thoracic inlet and produced severe obstruction predominantly during expiration. An abnormal effort independent flow pattern was seen during inspiration in isovolume pressure-flow studies. Endoscopic resection induced temporary symptomatic remission, and airway resistance and expiratory flows became normal. Subsequently he required resection of eight tracheal rings with end-to-end tracheal anastomosis. Obstructive granulomata then developed at the suture sites, necessitating endoscopic removal. Later tracheal stenosis responded to periodic dilatation.     

The management of post-intubation tracheal stenoses with self-expandable stents: early and long-term results in 11 cases

Objective: The optimal management of post-intubation tracheal stenoses is surgical reconstruction of the airway. Stenting of the trachea using silastic T-tubes or one of the various types of tracheal stents are the alternative ways to surgical reconstruction for the management of post-intubation tracheal stenoses. The early and long-term results of 11 patients with post-intubation tracheal stenosis, who underwent tracheal stenting with self-expandable metallic stents (SEMSs), are presented. Methods: Twelve patients (10 men, mean age: 47.8 ± 20.4 years) with post-intubation tracheal stenosis were referred for tracheal stenting with SEMS (2000–2004). In three cases, the upper tracheal stenosis extended within the subglottic larynx. Stenting was successful in 11 patients, while, in one patient with involvement of the subglottic larynx, the attempt to insert the stent failed. Follow-up time varied from 6 to 96 months, and it was made with virtual and fiberoptic bronchoscopy. Results: Immediate relief of obstructive symptoms was observed in all the 11 patients, where an SEMS was successfully inserted. Stent dislodgement occurred shortly after the procedure in two patients, and it was treated with insertion of a new stent in the first case and a stent-on-stent insertion in the second. Good patency of the stent was observed in three patients for 60–96 months. Three patients with good patency of the stent died from other reasons 24–48 months after stent insertion. Four patients developed obstructive granulation tissue at the ends of the stent after 12–43 months, requiring further treatment with thermal lasers and/or tracheostomy. One patient underwent stent removal and successful laryngotracheal reconstruction 6 months after stent insertion. Conclusions: The application of SEMS in post-intubation tracheal stenoses results in immediate improvement of obstructive symptoms without significant perioperative complications. SEMSs have the potential risks of migration and of granulation tissue formation at the end of the stent. SEMS should be applied only in strictly selected patients with post-intubation tracheal stenosis, who are considered unfit for surgery and/or with limited life expectancy.     

Does successful segmental tracheal resection require releasing maneuvers?

OBJECTIVES: Tracheal resection is a well-established option for the management of airway stenosis. Releasing maneuvers have been described to reduce anastomotic tension. The aim of this study is to report on a series of tracheal resections performed without the use of these maneuvers. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary hospital. METHODS: All patients undergoing tracheal resection by the first author over a 6-year period were reviewed. RESULTS: Patients (n = 17; 7 men and 10 women, ages 23-76) were managed with tracheal resection and anastomosis without stenting or postoperative tracheotomy. 16/17 (94%) patients had successful treatment of their stenosis. 1/17 (6%) failed and 1/17 (6%) required dilation. There was no postoperative swallowing dysfunction. CONCLUSIONS: Segmental tracheal resection without releasing maneuvers was successful in 16/17 (94%) patients. SIGNIFICANCE: Though extrapolation from this series may be limited, future practitioners may consider forgoing additional releasing maneuvers for tracheal resection in many cases.     

Effect of remifentanil compared with fentanyl on intraocular pressure after succinylcholine and tracheal intubation

Rapid sequence induction using succinylcholine is associatedwith an increase in intraocular pressure (IOP). This may leadto loss of ocular contents in open globe injuries. No methodhas previously been shown to prevent this increase in IOP. Weinvestigated whether remifentanil, an ultra-short-acting opioid,could attenuate this increase in IOP during rapid sequence inductionof anaesthesia. Forty-five patients were randomized blindlyto receive remifentanil 1 µg kg^–1, fentanyl 2 µgkg^–1 or placebo 1 min before thiopental, succinylcholineand tracheal intubation. IOP and haemodynamic variables weremeasured before, 1 min after the test solution, 30 s after thiopental,30 s after succinylcholine, immediately after intubation andthen every 3 min for 9 min. Remifentanil obtunded the increasein IOP after succinylcholine and intubation, so it could besuitable for use in open globe injuries. Br J Anaesth 2000; 85: 785–7 Footnotes ^* Corresponding author     

Analysis of 40 patients who underwent tracheal resection due to benign complex tracheal stenosis

BackgroundBenign tracheal stenosis is a common complication in patients followed up in intensive care units. We aimed to analyze the etiology, diagnostic approaches, treatment methods for benign tracheal stenosis, and the predicting factors for complications after tracheal resection for benign stenosis.Material-methodForty patients who underwent tracheal resection reconstruction due to benign tracheal stenosis were analyzed retrospectively. Predictive factors for complications were determined by statistical analysis.ResultsThere were 23 patients (57.5%) in the intubation group, 11 patients (27.5%) in the tracheostomy group, and 6 patients (15%) in the subsequent tracheostomy group. Preoperatively, rigid dilatation was applied to all patients between 2 and 6 sessions (median = 3). Tracheal resections were performed in all patients after rigid dilatations. The mean of the resected segment lengths is 32.1 ± 8.8 mm. There was a statistically significant difference between preoperative bronchoscopic measurements, preoperative tomography measurements, and intraoperative measurements of the stenosis segment (?2 (2) = 71,500; p < 0.001). The patients' mean follow-up period was 27.4 ± 21.7 months (3–84). Mortality due to tracheal surgery and major anastomotic complications were not observed. The minor anastomotic complication rate was 12.5%, the non-anastomotic complication rate was 17.5%. The effect of resection length and surgical experience were found to be statistically significant risk factors for anastomotic complications.Conclusions: Rigid dilatation does not provide significant palliation in complex stenosis. Bronchoscopic measurements give closer results than CT measurements in the preoperative estimation of resection length. The risk of anastomotic complications increases when the length of the resection increases and when the surgical experience is less.     

Alcohol and anaesthesia

The first 150 words of the full text of this article appear below. Key points

Consumption of alcohol is widespread in British societyand a common co-factor in emergency hospital admissions.

Morbidityassociated with chronic alcohol abuse appears to be increasingand affecting younger patients.

Anaesthetists must considerthe acute and chronic effects of alcohol at all stages of thepatient pathway.

Alcohol withdrawal is a potentially life-threateningcomplication that must be diagnosed and actively managed.

Anaesthetistsare as susceptible to alcohol-related disease as others in thesame socio-economic group.

  Two-thirds of adults in England drink alcohol on a weekly basis,and 30% drink more than the recommended daily level.¹ Amongchildren, 46% of 15 yr olds and 3% of 11 yr olds admit to drinkingperiodically.² Alcohol misuse is estimated to cost the NHS £3 billionper year. Alcohol-related disease was the primary or secondarydiagnosis for over 180 000 NHS hospital admissions in 2004/2005.³This includes a doubling in the number . . . [Full Text of this Article]