Letters to Editor Page | 307
A large obstructive hard palate teratoma in a baby: Challenges to the anesthesiologist Sir, A 5 months old baby weighing 7 kg presented with pedunculated palatal mass since birth. It was a full term normal delivery. Prenatal diagnosis was not done. At birth, the swelling was small approximately the size of a lemon which rapidly progressed to the present size (as big as it’s own head) within 5 months. The mother used to bottle-feed the baby by moving and holding the mass aside. CT scan revealed a large heterogeneous exophytic hypodense mass lesion arising from bony palate with fatty component and a tiny speck of calcification within suggestive of dermoid cyst/ teratoma. No other congenital anomalies were present. The size of the mass was 20 × 13 × 10 cm, which weighed 1000 g after excision. The patient was scheduled for resection of the pedunculated mass under general anesthesia. The baby was pale and hemoglobin was 8gm%. Other lab investigations were normal. On airway examination, the mouth opening was adequate with mass protruding out from the hard palate and adherent to the upper lip [Figure 1]. Difficult intubation was anticipated in view of large head, short neck and macroglossia in addition to the mass.[1] Tracheostomy tray was kept ready. Mask ventilation was impossible in this baby so oxygen was delivered by nasal canula. Laryngoscopy was very difficult as the mass was very heavy and it obstructed and compressed the airway in supine position so it was held up by an assistant. Hence we planned to excise the stalk of the mass under ketamine analgesia and immediately proceed with intubation. Precautions like
Figure 1: Photo of a large palatal teratoma
Saudi Journal of Anesthesia
continuous oxygenation, oral suctioning, head low position and monitoring of vital parameters were taken. The patient was premedicated with Inj Atropine 0.01 mg/kg, Inj Ondensetron 0.1 mg/kg. Paracetamol suppository 20 mg/ kg was kept. Induction was done with Inj Ketamine 1 mg/kg on spontaneous respiration. Oropharyngeal suctioning was done continuously and stalk was excised. Thus the mouth opened wide enough and laryngoscopy was possible. Inj Ketamine 10 mg IV was again repeated and the patient was intubated with a portex uncuffed 4.0 endotracheal tube in deep plane of anesthesia in the second attempt and throat was packed. Inj Atracurium 0.5 mg/kg was used as relaxant and the baby was maintained on O2, N2O and Sevoflurane 0.8%. Heart rate was 160-180/min and saturation was 100% throughout the surgery. IV Kidral P was given according to 4:2:1 formula. Surgery was completely successfully and the patient was extubated after thorough suctioning and throat pack removal. Reversal given was Inj Neostigmine 0.5 mg/ kg and Inj Glycopyrolate 8 mcg/kg. Extubation was smooth and recovery was uneventful. Post operatively, the patient was kept in lateral position. Palatal teratoma is a benign congenital tumor with an incidence of 1:4000.[2] It is less than 10% in head and neck region and can be associated with other congenital anomalies like cleft palate, cystic hygroma, and other multifocal teratomas. Thus it is very important to search for other anomalies in such patients. Airway control is most challenging in such patients. Upper airway difficulty causes anticipated functional problems at hypopharynx.[3] Hence anesthesia should be planned accordingly to first secure the airway. In this case, check laryngoscopy could not be performed as the mass occupied a major working place of laryngoscopy. Conventionally, fibreoptic nasal intubation would have been a better choice, but due to non-availability of a pediatric scope, preparations for surgical airway were kept ready.[4] Along with difficult airway management, the importance of proper suctioning should also be kept in mind. In cases of anticipated difficult intubation with intraoral tumor, our goals of management of such cases are careful assessment of airway, provision for alternative emergency surgical airway, exclusion of any congenital lesion, check Vol. 8, Issue 2, April-June 2014
Letters to Editor Page | 308
laryngoscopy if possible and establishment of reliable airway with appropriate induction agent.[2] Mugdha Markandeya, Rajesh Gore, Ujjwala Andurkar, Manisha Sapate Department of Anaesthesiology, YCM Hospital, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra, India Address for correspondence: Dr. Ujjwala S. Andurkar, YCM Hospital, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra, India. E-mail: [email protected]
REFERENCES 1.
Sharma SB, Nath MP, Pasari C, Chakrabarty A, Choudhury D. Hard palate tumor. Role of modified molar approach. Indian J Anaesth 2013;57:83-4.
2. 3. 4.
Ramani MN, Shah SK, Parikh U, Mehta P, Vakil SD. Infant with palatal swelling and anesthetic challenge. Indian J Anaesth 2002:46:217-8. Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthetic management of newborn for pedunculated teratoma of oral cavity. Anesth Essay Res 2010:4:124-5. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway Society guidelines for management of the unanticipated difficult intubation. Anesthesia 2004:59:675-94.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.130765
Amphetamine and atropine interaction: A reason for concern? Sir, Interactions between amphetamines and drugs used by anesthetists may be unpredictable and even lead to cardiovascular collapse.[1,2] Female, 18-year-old, body mass index of 39, scheduled for videolaparoscopic appendectomy. Laboratory examinations were normal. Anesthesia was inducted with propofol, fentanyl and atracurium, orotracheal intubation was performed. Anesthesia was maintained with isoflurane at 1.5% in nitrous oxide and oxygen (1:1). During the procedure, arterial pressure, oxygen saturation, end-tidal carbon dioxide pressure and endotracheal pressure have remained normal. At the end of the procedure, prostigmine (2 mg) and atropine (1 mg) have been administered. Afterwards, the patient presented supraventricular tachycardia (heart rate = 180 bpm) and arterial hypotension (arterial pressure = 73/28 mmHg). Acute lung edema developed rapidly eliminating a large amount of rosy frothy secretion through the tracheal tube associated to signs of decreased perfusion and SpO2 drop to 56%. Chest X-ray: Bilateral interstitial pulmonary infiltrates and arterial gasometry: Hypoxemia and hypocapnia. Then the patient was transferred to the intensive care unit and a catheter was placed into the pulmonary artery and showed a pattern of cardiogenic shock. Transesophageal echocardiogram: Diffuse hyperkinesia of the left ventricle, Vol. 8, Issue 2, April-June 2014
whose ejection fraction was equal to 30%. An intravenous infusion of noradrenaline and milrinone were initiated with a partial improvement of the clinical picture. The patient improved on the following days with the cessation of vasopressor support and of sedation. On the 4th post-operative day: Ejection fraction of 65% at the echocardiogram and on the 5th post-operative day tracheal extubation was performed, without sequelae. At hospital discharge, the patient’s relatives informed that she made chronic use of fenproporex without medical prescription, in order to lose weight. Amphetamines produce most of their effects by releasing biogenic amines, from their storage places in nerve endings. Its actions include: (1) Stimulating action in the central nervous system and (2) increasing alpha and beta peripheral sympathetic tones. The chronic use leads to central and peripheral depletion of catecholamines, mainly reducing noradrelanine reserves.[3,4] In this patient’s case, the interaction between amphetamine and atropine may have caused tachyarrhythmia, arterial hypotension and acute lung edema. After a complete depletion of endogenous catecholamines, hypotension and ventricular dysfunction refractory occurred. Experiments in rats have shown that administering doses of amphetamine successively followed by a dose of atropine may cause severe hypotension and even a cardiovascular collapse.[5] There is no pharmacological explanation for the interaction Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A large obstructive hard palate teratoma in a baby: Challenges to the anesthesiologist Sir, A 5 months old baby weighing 7 kg presented with pedunculated palatal mass since birth. It was a full term normal delivery. Prenatal diagnosis was not done. At birth, the swelling was small approximately the size of a lemon which rapidly progressed to the present size (as big as it’s own head) within 5 months. The mother used to bottle-feed the baby by moving and holding the mass aside. CT scan revealed a large heterogeneous exophytic hypodense mass lesion arising from bony palate with fatty component and a tiny speck of calcification within suggestive of dermoid cyst/ teratoma. No other congenital anomalies were present. The size of the mass was 20 × 13 × 10 cm, which weighed 1000 g after excision. The patient was scheduled for resection of the pedunculated mass under general anesthesia. The baby was pale and hemoglobin was 8gm%. Other lab investigations were normal. On airway examination, the mouth opening was adequate with mass protruding out from the hard palate and adherent to the upper lip [Figure 1]. Difficult intubation was anticipated in view of large head, short neck and macroglossia in addition to the mass.[1] Tracheostomy tray was kept ready. Mask ventilation was impossible in this baby so oxygen was delivered by nasal canula. Laryngoscopy was very difficult as the mass was very heavy and it obstructed and compressed the airway in supine position so it was held up by an assistant. Hence we planned to excise the stalk of the mass under ketamine analgesia and immediately proceed with intubation. Precautions like
Figure 1: Photo of a large palatal teratoma
Saudi Journal of Anesthesia
continuous oxygenation, oral suctioning, head low position and monitoring of vital parameters were taken. The patient was premedicated with Inj Atropine 0.01 mg/kg, Inj Ondensetron 0.1 mg/kg. Paracetamol suppository 20 mg/ kg was kept. Induction was done with Inj Ketamine 1 mg/kg on spontaneous respiration. Oropharyngeal suctioning was done continuously and stalk was excised. Thus the mouth opened wide enough and laryngoscopy was possible. Inj Ketamine 10 mg IV was again repeated and the patient was intubated with a portex uncuffed 4.0 endotracheal tube in deep plane of anesthesia in the second attempt and throat was packed. Inj Atracurium 0.5 mg/kg was used as relaxant and the baby was maintained on O2, N2O and Sevoflurane 0.8%. Heart rate was 160-180/min and saturation was 100% throughout the surgery. IV Kidral P was given according to 4:2:1 formula. Surgery was completely successfully and the patient was extubated after thorough suctioning and throat pack removal. Reversal given was Inj Neostigmine 0.5 mg/ kg and Inj Glycopyrolate 8 mcg/kg. Extubation was smooth and recovery was uneventful. Post operatively, the patient was kept in lateral position. Palatal teratoma is a benign congenital tumor with an incidence of 1:4000.[2] It is less than 10% in head and neck region and can be associated with other congenital anomalies like cleft palate, cystic hygroma, and other multifocal teratomas. Thus it is very important to search for other anomalies in such patients. Airway control is most challenging in such patients. Upper airway difficulty causes anticipated functional problems at hypopharynx.[3] Hence anesthesia should be planned accordingly to first secure the airway. In this case, check laryngoscopy could not be performed as the mass occupied a major working place of laryngoscopy. Conventionally, fibreoptic nasal intubation would have been a better choice, but due to non-availability of a pediatric scope, preparations for surgical airway were kept ready.[4] Along with difficult airway management, the importance of proper suctioning should also be kept in mind. In cases of anticipated difficult intubation with intraoral tumor, our goals of management of such cases are careful assessment of airway, provision for alternative emergency surgical airway, exclusion of any congenital lesion, check Vol. 8, Issue 2, April-June 2014
Letters to Editor Page | 308
laryngoscopy if possible and establishment of reliable airway with appropriate induction agent.[2] Mugdha Markandeya, Rajesh Gore, Ujjwala Andurkar, Manisha Sapate Department of Anaesthesiology, YCM Hospital, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra, India Address for correspondence: Dr. Ujjwala S. Andurkar, YCM Hospital, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra, India. E-mail: [email protected]
REFERENCES 1.
Sharma SB, Nath MP, Pasari C, Chakrabarty A, Choudhury D. Hard palate tumor. Role of modified molar approach. Indian J Anaesth 2013;57:83-4.
2. 3. 4.
Ramani MN, Shah SK, Parikh U, Mehta P, Vakil SD. Infant with palatal swelling and anesthetic challenge. Indian J Anaesth 2002:46:217-8. Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthetic management of newborn for pedunculated teratoma of oral cavity. Anesth Essay Res 2010:4:124-5. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway Society guidelines for management of the unanticipated difficult intubation. Anesthesia 2004:59:675-94.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.130765
Amphetamine and atropine interaction: A reason for concern? Sir, Interactions between amphetamines and drugs used by anesthetists may be unpredictable and even lead to cardiovascular collapse.[1,2] Female, 18-year-old, body mass index of 39, scheduled for videolaparoscopic appendectomy. Laboratory examinations were normal. Anesthesia was inducted with propofol, fentanyl and atracurium, orotracheal intubation was performed. Anesthesia was maintained with isoflurane at 1.5% in nitrous oxide and oxygen (1:1). During the procedure, arterial pressure, oxygen saturation, end-tidal carbon dioxide pressure and endotracheal pressure have remained normal. At the end of the procedure, prostigmine (2 mg) and atropine (1 mg) have been administered. Afterwards, the patient presented supraventricular tachycardia (heart rate = 180 bpm) and arterial hypotension (arterial pressure = 73/28 mmHg). Acute lung edema developed rapidly eliminating a large amount of rosy frothy secretion through the tracheal tube associated to signs of decreased perfusion and SpO2 drop to 56%. Chest X-ray: Bilateral interstitial pulmonary infiltrates and arterial gasometry: Hypoxemia and hypocapnia. Then the patient was transferred to the intensive care unit and a catheter was placed into the pulmonary artery and showed a pattern of cardiogenic shock. Transesophageal echocardiogram: Diffuse hyperkinesia of the left ventricle, Vol. 8, Issue 2, April-June 2014
whose ejection fraction was equal to 30%. An intravenous infusion of noradrenaline and milrinone were initiated with a partial improvement of the clinical picture. The patient improved on the following days with the cessation of vasopressor support and of sedation. On the 4th post-operative day: Ejection fraction of 65% at the echocardiogram and on the 5th post-operative day tracheal extubation was performed, without sequelae. At hospital discharge, the patient’s relatives informed that she made chronic use of fenproporex without medical prescription, in order to lose weight. Amphetamines produce most of their effects by releasing biogenic amines, from their storage places in nerve endings. Its actions include: (1) Stimulating action in the central nervous system and (2) increasing alpha and beta peripheral sympathetic tones. The chronic use leads to central and peripheral depletion of catecholamines, mainly reducing noradrelanine reserves.[3,4] In this patient’s case, the interaction between amphetamine and atropine may have caused tachyarrhythmia, arterial hypotension and acute lung edema. After a complete depletion of endogenous catecholamines, hypotension and ventricular dysfunction refractory occurred. Experiments in rats have shown that administering doses of amphetamine successively followed by a dose of atropine may cause severe hypotension and even a cardiovascular collapse.[5] There is no pharmacological explanation for the interaction Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
