Epidural abscess complicating insertion of epidural catheters

We present three cases of epidural abscess, all in patientsin whom an epidural catheter had been inserted for postoperativepain management. In all three cases the infecting organism wasStaphylococcus aureus and two patients had diabetes. The diagnosiswas made within 3 days of epidural catheter removal in two cases,but in one the abscess did not present until after the patienthad been discharged from hospital. We have retrospectively calculatedthe incidence of epidural abscess in our hospital over the 5-yrperiod 1993–98 to be 1 in 800 (0.12%). We emphasize theimportance of using techniques that minimize the risk of bacterialcontamination during both catheter placement and the managementof infusion, and seek to raise awareness of this relativelyrare but significant condition. Br J Anaesth 2002; 89: 778–82     

Anaesthesia for caesarean section in a patient with dopa-responsive dystonia or Segawa’s syndrome

Dopa-responsive dystonia, also known as hereditary progressive dystonia with diurnal fluctuation or Segawa’s syndrome, is a rare hereditary progressive dystonia with two striking clinical features: a marked diurnal fluctuation of symptoms with symptoms worsening throughout the day and improving after sleep, and a dramatic response to levodopa therapy. Whilst rare, it is treatable, with function being normal or near normal after levodopa therapy. We present our experience of providing anaesthesia for caesarean section in a patient with dopa-responsive dystonia and discuss the safety of levodopa therapy during pregnancy and the anaesthetic management of these patients.     

Acute airway obstruction in a child with acute lymphoblastic leukaemia during central venous catheterization

We report the case of a seven-year-old girl with recently diagnosed acute lymphoblastic leukaemia (ALL) who suffered acute airway obstruction during insertion of a central venous catheter under general anaesthesia. The central airway obstruction was due to a mixture of leukaemic cells, blood clot and fibrin. There is discussion about airway obstruction both as a complication of central line insertion and secondary to ALL. The pulmonary complications of ALL, with particular reference to pulmonary haemorrhage, are detailed. The management of blood clot obstructing the central airway is discussed.     

Airway obstruction with cricoid pressure

Cricoid pressure may cause airway obstruction. We investigated whether this is related to the force applied and to the technique of application. We recorded expired tidal volumes and inflation pressures during ventilation via a face-mask and oral airway in 52 female patients who were anaesthetised and about to undergo elective surgery. An inspired tidal volume of 900 ml was delivered using a ventilator. Ventilation was assessed under five different conditions: no cricoid pressure, backwards cricoid pressure applied with a force of 30 N, cricoid pressure applied in an upward and backward direction with a force of 30 N, backwards cricoid pressure with a force of 44 N and through a tracheal tube. An expired tidal volume of < 200 ml was taken to indicate airway obstruction. Airway obstruction did not occur without cricoid pressure, but did occur in one patient (2%) with cricoid pressure at 30 N, in 29 patients (56%) with 30 N applied in an upward and backward direction and in 18 (35%) patients with cricoid pressure at 44 N. Cricoid pressure applied with a force of 44 N can cause airway obstruction but if cricoid pressure is applied with a force of 30 N, airway obstruction occurs less frequently (p = 0.0001) unless the force is applied in an upward and backward direction.     

Gastric pressure during emergency caesarean section under general anaesthesia

Gastric pressure and volume were measured in 20 pregnant women during emergency Caesarean section under general anaesthesia with neuromuscular block. Mean gastric pressure was 11 (range 4-19) mm Hg and we can predict that 99% of women undergoing emergency Caesarean section with neuromuscular block are likely to have gastric pressures of less than 25 mm Hg (mean + 3 SD). This has implications for the amount of cricoid pressure required during induction of anaesthesia. Gastric pressure increased during delivery to 19 mm Hg and fundal pressure caused a gastric pressure of 65 mm Hg in one woman. Gastric pressure decreased significantly after delivery (P < 0.001) to 8 mm Hg. Although we measured large gastric volumes (mean 112 (range 20-350) ml), there was no correlation between gastric volume and gastric pressure.