J Neurosurg Anesthesiol
Volume 27, Number 3, July 2015
lower lobe (marked at 54 cm). A necrotic-looking lesion with blood trace elements was plugging up the lateral basal segment of the right lower lobe. Because the tracheal lumen of the DLT could not accommodate both the BB and the adult fiberoptic bronchoscope, a 7-Fr Arndt BB was introduced blindly through the blocker port of the adapter and advanced down the tracheal lumen until 53 cm, at which point there was slight resistance. The balloon of the BB was inflated (Fig. 1C). An indirect confirmation for lobar exclusion was achieved on auscultation of the chest fields. No chest x-ray was taken because of the surgical patient’s positioning with the head fixed in pins. Anesthetic and surgical courses were uneventful. Intraoperative arterial blood gases showed a PaCO2 level within normal range (35 to 40 mm Hg) with normal oxygenation (PaO2 range, 110 to 205 mm Hg) and good brain relaxation. At the end of the case, the patient was gradually weaned off from the ventilator, the BB was removed, and he was transferred extubated to the ICU in stable conditions.
RECOMMENDATIONS AND CONCLUSIONS This patient’s pathology required balancing our neuroanesthetic and thoracic concerns, such as, avoidance of OLV, selective isolation of the diseased lobe, and maintenance of CO2 clearance to control intracranial pressure. The use of a single-lumen endotracheal tube plus BB was considered. However, BBs perform better when positioned in the left mainstem broncus versus the right broncus and have a greater incidence of intraoperative malposition compared with DLT.5 Thus, the malpositioning of a BB or a pulmonary hemorrhage would have posed an increased risk and challenge in comparison with thoracic surgery as the accessibility to the patient’s airway is limited and restricted by the surgical field and the fixed head position. In this case, blind insertion of the BB through a DLT proved a useful technique for isolation of the right lower lobe improving surgical conditions while optimizing neuroanesthetic management and providing safe anesthetic care. Copyright
r
Marco M. Garavaglia, MD* Sunit Das, MD, PhDw Gregory M. T. Hare, MD, PhD*z *Department of Anesthesia wDepartment of Surgery Division of Neurosurgery St Michael’s Hospital, Li Ka Shing Knowledge Institute zDepartment of Physiology University of Toronto, Toronto, ON, Canada
ACKNOWLEDGMENTS The authors would like to thank for their support during the procedure: Dr. Melinda Li (Department of Anesthesia, University of Toronto) and Mrs. Pamela McLachlan (Respiratory Therapy Department, St. Michael’s Hospital). REFERENCES 1. Kazan R, Bracco D, Hemmerling TM. Reduced cerebral oxygen saturation measured by absolute cerebral oximetry during thoracic surgery correlates with postoperative complications. Br J Anaesth. 2009;103:811–816. 2. Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology. 2009;110:1402–1411. 3. Ruiz P, Kovarik G. Lung mechanics and gas exchange in one-lung ventilation following contralateral resection. Can J Anaesth. 2005;52:986–989. 4. Gelb AW, Craen RA, Rao GS, et al. Does hyperventilation improve operating condition during supratentorial craniotomy? A multicenter randomized crossover trial. Anesth Analg. 2008;106:585–594. table of contents. 5. Narayanaswamy M, McRae K, Slinger P, et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes. Anesth Analg. 2009;108:1097–1101.
Anesthetic Management of a Child With Severe Dystonia and G6PD Deficiency for Deep Brain Stimulation To JNA Readers: Glucose 6-phosphate dehydrogenase (G6PD) deficiency is a rare The authors have no funding or conflicts of interest to disclose.
2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Correspondence
enzyme disorder which clinically manifests as acute hemolytic syndrome, generally triggered by oxidative drugs or certain foodstuffs.1 We report successful deep brain stimulation (DBS) in a child with severe dystonia and G6PD deficiency with bispectral index (BIS)guided anesthetic titration and discuss anesthetic concerns in such patients. A 10-year-old male child weighing 23 kg was referred for surgical treatment of primary generalized dystonia. He had worsening of symptoms (dysphagia and continuous painful dystonic movements) for the last 4 years despite intensive medical treatment. He was diagnosed with G6PD deficiency at 3 years. His medication (Levodopa) was continued on the morning of surgery. In the magnetic resonance imaging suite, anesthesia was induced with propofol and intubation was facilitated with vecuronium. Fentanyl was administered during application of stereotactic frame. Anesthesia was maintained with 40% O2 in air and propofol infusion. During surgery, propofol was continued at 80 to 100 mg/h to maintain BIS of 50 to 60. For microelectrode recording (MER), propofol was reduced to 40 to 50 mg/h to maintain BIS value at 70 to 75. MER along with sterotactically obtained imaging input was used for electrode implantation in globus palladium interna for DBS. Propofol was discontinued after surgery and trachea was extubated. The anesthetic management of a patient with G6PD deficiency and severe dystonia presenting for functional neurosurgery has not been reported in literature previously. The presence of dual pathology of G6PD deficiency and dystonia poses independent challenges to the anesthesiologist. Ketamine, fentanyl, propofol, thiopentone, succinylcholine, and bupivacaine are considered safe to use in patients with G6PD deficiency. However, sevoflurane, lignocaine, metoclopramide, penicillin, and sulfonamide are to be avoided.2 The ideal anesthetic management for patients with G6PD requiring MER was not possible in our patient who also had severe dystonia. In our patient with G6PD and dystonia, we believed the best technique was to provide a propofol-based www.jnsa.com |
271
J Neurosurg Anesthesiol
Correspondence
anesthetic with BIS monitoring of anesthetic depth with spontaneous breathing. This was achieved by not administering vecuronium after the initial bolus used during intubation. This technique facilitated neurological assessment during MER and assessment of clinical signs of hemolysis like dyspnea. Our management goal was to eliminate risk factors and provide supportive treatment as required, specifically; we avoided the drugs mentioned above and avoided hypothermia, metabolic stress, and infection. We monitored the patient for any evidence of hemolysis, like decreased hemoglobin and elevated reticulocytes, lactate dehydrogenase, and unconjugated bilirubin. Multichannel MER facilitates precise electrode placement by identifying the target and its borders during DBS. Anesthesia reduces spontaneous neuronal activity, including MER and hence is avoided or used in low concentrations. However, in this pediatric dystonic patient, adequate titration of propofol using BIS facilitated MER recordings and also avoided discomfort and movement. Although dexmedetomidine would have been an effective alternative,3 its safety in G6PD-deficient patient is unknown. Although in 1 study, propofol decreased subthalamic neuronal activity and interfered with MER at high dose (50 mg/kg/min),4 another study did not observe negative effect of propofol on MER when BIS was maintained at 60.5 To conclude, this report demonstrates that BIS-guided propofol infusion is suitable and safe for both MER during DBS and in children with G6PD deficiency.
2.
3.
4.
5.
ase-deficient patient. Case report. Rev Bras Anestesiol. 2002;52:707–711. Elyassi AR, Rowshan HH. Perioperative management of the glucose-6-phosphate dehydrogenase deficient patient: a review of literature. Anesth Prog. 2009;56:86–91. Sebeo J, Deiner SG, Alterman RL, et al. Anesthesia for pediatric deep brain stimulation. Anesthesiol Res Pract. 2010; pii: 401419. DOI:10.1155/2010/401419. [Epub ahead of Print]. Raz A, Eimerl D, Zaidel A, et al. Propofol decreases neuronal population spiking activity in the subthalamic nucleus of parkinsonian patients. Anesth Analg. 2010;111:1285–1289. Lefaucheur JP, Gurruchaga JM, Pollin B, et al. Outcome of bilateral subthalamic nucleus stimulation in the treatment of Parkinson’s disease: correlation with intraoperative multi-unit recordings but not with the type of anaesthesia. Eur Neurol. 2008; 60:186–199.
Transesophageal Echocardiography as a Guide to Central Venous Catheter Placement in a Patient With Functional Ventriculo-atrial CSF Shunt To JNA Readers: Accurate positioning of central venous catheter (CVC) is important in certain situations, and there are limited options available in the operating
Volume 27, Number 3, July 2015
room. We describe a case in which positioning of CVC was done with transesophageal echo (TEE) and its implications in neurosurgery. A 10-year-old female child was diagnosed as having optico-chiasmatic glioma at 2 years of age and was on regular follow-up. At 7 years of age she underwent ventriculo-peritoneal shunt and after 1 year it was replaced with right-sided ventriculo-atrial (VA) shunt as she developed shunt ascitis. Now the child was scheduled to undergo decompression of the lesion. On the day of surgery, under standard monitoring, anesthesia was induced and intubated. Under standard precaution, a pediatric TEE (GE Vivid 7, GE Healthcare) probe was introduced. Using a midesophageal bicaval position, patency in foramen ovale was ruled out and VA catheter tip was identified. Under aseptic precaution, the left subclavian vein was punctured and the straight end of the guide wire was advanced into the right atrium under continuous TEE monitoring. Multiorifice CVC was advanced over the guide wire. The catheter was identified as 2 closely spaced, parallel, bright echo dense lines surrounding the darker fluid-filled lumen. The catheter was positioned parallel to the VA catheter (Fig. 1). The distal tip of the CVC was confirmed with use of heparinized saline flush. TEE-guided CVC placement is described in neurosurgical anesthesia management wherein there were high
Kamath Sriganesh, DM* Sethuraman Manikandan, MDw *Department of Neuroanaesthesia NIMHANS, Bangalore wDepartment of Anesthesia Division of Neuroanesthesia SCTIMST, Trivandrum, India
REFERENCES 1. Abreu MP, Freire CCS, Miura RS. Anesthesia in glucose 6-phosphate dehydrogen-
FIGURE 1. Mid-esophageal bicaval plane showing a ventriculo-atrial catheter and a central venous catheter in the right atrium. The authors have no funding or conflicts of interest to disclose.
272 | www.jnsa.com
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Volume 27, Number 3, July 2015
lower lobe (marked at 54 cm). A necrotic-looking lesion with blood trace elements was plugging up the lateral basal segment of the right lower lobe. Because the tracheal lumen of the DLT could not accommodate both the BB and the adult fiberoptic bronchoscope, a 7-Fr Arndt BB was introduced blindly through the blocker port of the adapter and advanced down the tracheal lumen until 53 cm, at which point there was slight resistance. The balloon of the BB was inflated (Fig. 1C). An indirect confirmation for lobar exclusion was achieved on auscultation of the chest fields. No chest x-ray was taken because of the surgical patient’s positioning with the head fixed in pins. Anesthetic and surgical courses were uneventful. Intraoperative arterial blood gases showed a PaCO2 level within normal range (35 to 40 mm Hg) with normal oxygenation (PaO2 range, 110 to 205 mm Hg) and good brain relaxation. At the end of the case, the patient was gradually weaned off from the ventilator, the BB was removed, and he was transferred extubated to the ICU in stable conditions.
RECOMMENDATIONS AND CONCLUSIONS This patient’s pathology required balancing our neuroanesthetic and thoracic concerns, such as, avoidance of OLV, selective isolation of the diseased lobe, and maintenance of CO2 clearance to control intracranial pressure. The use of a single-lumen endotracheal tube plus BB was considered. However, BBs perform better when positioned in the left mainstem broncus versus the right broncus and have a greater incidence of intraoperative malposition compared with DLT.5 Thus, the malpositioning of a BB or a pulmonary hemorrhage would have posed an increased risk and challenge in comparison with thoracic surgery as the accessibility to the patient’s airway is limited and restricted by the surgical field and the fixed head position. In this case, blind insertion of the BB through a DLT proved a useful technique for isolation of the right lower lobe improving surgical conditions while optimizing neuroanesthetic management and providing safe anesthetic care. Copyright
r
Marco M. Garavaglia, MD* Sunit Das, MD, PhDw Gregory M. T. Hare, MD, PhD*z *Department of Anesthesia wDepartment of Surgery Division of Neurosurgery St Michael’s Hospital, Li Ka Shing Knowledge Institute zDepartment of Physiology University of Toronto, Toronto, ON, Canada
ACKNOWLEDGMENTS The authors would like to thank for their support during the procedure: Dr. Melinda Li (Department of Anesthesia, University of Toronto) and Mrs. Pamela McLachlan (Respiratory Therapy Department, St. Michael’s Hospital). REFERENCES 1. Kazan R, Bracco D, Hemmerling TM. Reduced cerebral oxygen saturation measured by absolute cerebral oximetry during thoracic surgery correlates with postoperative complications. Br J Anaesth. 2009;103:811–816. 2. Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology. 2009;110:1402–1411. 3. Ruiz P, Kovarik G. Lung mechanics and gas exchange in one-lung ventilation following contralateral resection. Can J Anaesth. 2005;52:986–989. 4. Gelb AW, Craen RA, Rao GS, et al. Does hyperventilation improve operating condition during supratentorial craniotomy? A multicenter randomized crossover trial. Anesth Analg. 2008;106:585–594. table of contents. 5. Narayanaswamy M, McRae K, Slinger P, et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes. Anesth Analg. 2009;108:1097–1101.
Anesthetic Management of a Child With Severe Dystonia and G6PD Deficiency for Deep Brain Stimulation To JNA Readers: Glucose 6-phosphate dehydrogenase (G6PD) deficiency is a rare The authors have no funding or conflicts of interest to disclose.
2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Correspondence
enzyme disorder which clinically manifests as acute hemolytic syndrome, generally triggered by oxidative drugs or certain foodstuffs.1 We report successful deep brain stimulation (DBS) in a child with severe dystonia and G6PD deficiency with bispectral index (BIS)guided anesthetic titration and discuss anesthetic concerns in such patients. A 10-year-old male child weighing 23 kg was referred for surgical treatment of primary generalized dystonia. He had worsening of symptoms (dysphagia and continuous painful dystonic movements) for the last 4 years despite intensive medical treatment. He was diagnosed with G6PD deficiency at 3 years. His medication (Levodopa) was continued on the morning of surgery. In the magnetic resonance imaging suite, anesthesia was induced with propofol and intubation was facilitated with vecuronium. Fentanyl was administered during application of stereotactic frame. Anesthesia was maintained with 40% O2 in air and propofol infusion. During surgery, propofol was continued at 80 to 100 mg/h to maintain BIS of 50 to 60. For microelectrode recording (MER), propofol was reduced to 40 to 50 mg/h to maintain BIS value at 70 to 75. MER along with sterotactically obtained imaging input was used for electrode implantation in globus palladium interna for DBS. Propofol was discontinued after surgery and trachea was extubated. The anesthetic management of a patient with G6PD deficiency and severe dystonia presenting for functional neurosurgery has not been reported in literature previously. The presence of dual pathology of G6PD deficiency and dystonia poses independent challenges to the anesthesiologist. Ketamine, fentanyl, propofol, thiopentone, succinylcholine, and bupivacaine are considered safe to use in patients with G6PD deficiency. However, sevoflurane, lignocaine, metoclopramide, penicillin, and sulfonamide are to be avoided.2 The ideal anesthetic management for patients with G6PD requiring MER was not possible in our patient who also had severe dystonia. In our patient with G6PD and dystonia, we believed the best technique was to provide a propofol-based www.jnsa.com |
271
J Neurosurg Anesthesiol
Correspondence
anesthetic with BIS monitoring of anesthetic depth with spontaneous breathing. This was achieved by not administering vecuronium after the initial bolus used during intubation. This technique facilitated neurological assessment during MER and assessment of clinical signs of hemolysis like dyspnea. Our management goal was to eliminate risk factors and provide supportive treatment as required, specifically; we avoided the drugs mentioned above and avoided hypothermia, metabolic stress, and infection. We monitored the patient for any evidence of hemolysis, like decreased hemoglobin and elevated reticulocytes, lactate dehydrogenase, and unconjugated bilirubin. Multichannel MER facilitates precise electrode placement by identifying the target and its borders during DBS. Anesthesia reduces spontaneous neuronal activity, including MER and hence is avoided or used in low concentrations. However, in this pediatric dystonic patient, adequate titration of propofol using BIS facilitated MER recordings and also avoided discomfort and movement. Although dexmedetomidine would have been an effective alternative,3 its safety in G6PD-deficient patient is unknown. Although in 1 study, propofol decreased subthalamic neuronal activity and interfered with MER at high dose (50 mg/kg/min),4 another study did not observe negative effect of propofol on MER when BIS was maintained at 60.5 To conclude, this report demonstrates that BIS-guided propofol infusion is suitable and safe for both MER during DBS and in children with G6PD deficiency.
2.
3.
4.
5.
ase-deficient patient. Case report. Rev Bras Anestesiol. 2002;52:707–711. Elyassi AR, Rowshan HH. Perioperative management of the glucose-6-phosphate dehydrogenase deficient patient: a review of literature. Anesth Prog. 2009;56:86–91. Sebeo J, Deiner SG, Alterman RL, et al. Anesthesia for pediatric deep brain stimulation. Anesthesiol Res Pract. 2010; pii: 401419. DOI:10.1155/2010/401419. [Epub ahead of Print]. Raz A, Eimerl D, Zaidel A, et al. Propofol decreases neuronal population spiking activity in the subthalamic nucleus of parkinsonian patients. Anesth Analg. 2010;111:1285–1289. Lefaucheur JP, Gurruchaga JM, Pollin B, et al. Outcome of bilateral subthalamic nucleus stimulation in the treatment of Parkinson’s disease: correlation with intraoperative multi-unit recordings but not with the type of anaesthesia. Eur Neurol. 2008; 60:186–199.
Transesophageal Echocardiography as a Guide to Central Venous Catheter Placement in a Patient With Functional Ventriculo-atrial CSF Shunt To JNA Readers: Accurate positioning of central venous catheter (CVC) is important in certain situations, and there are limited options available in the operating
Volume 27, Number 3, July 2015
room. We describe a case in which positioning of CVC was done with transesophageal echo (TEE) and its implications in neurosurgery. A 10-year-old female child was diagnosed as having optico-chiasmatic glioma at 2 years of age and was on regular follow-up. At 7 years of age she underwent ventriculo-peritoneal shunt and after 1 year it was replaced with right-sided ventriculo-atrial (VA) shunt as she developed shunt ascitis. Now the child was scheduled to undergo decompression of the lesion. On the day of surgery, under standard monitoring, anesthesia was induced and intubated. Under standard precaution, a pediatric TEE (GE Vivid 7, GE Healthcare) probe was introduced. Using a midesophageal bicaval position, patency in foramen ovale was ruled out and VA catheter tip was identified. Under aseptic precaution, the left subclavian vein was punctured and the straight end of the guide wire was advanced into the right atrium under continuous TEE monitoring. Multiorifice CVC was advanced over the guide wire. The catheter was identified as 2 closely spaced, parallel, bright echo dense lines surrounding the darker fluid-filled lumen. The catheter was positioned parallel to the VA catheter (Fig. 1). The distal tip of the CVC was confirmed with use of heparinized saline flush. TEE-guided CVC placement is described in neurosurgical anesthesia management wherein there were high
Kamath Sriganesh, DM* Sethuraman Manikandan, MDw *Department of Neuroanaesthesia NIMHANS, Bangalore wDepartment of Anesthesia Division of Neuroanesthesia SCTIMST, Trivandrum, India
REFERENCES 1. Abreu MP, Freire CCS, Miura RS. Anesthesia in glucose 6-phosphate dehydrogen-
FIGURE 1. Mid-esophageal bicaval plane showing a ventriculo-atrial catheter and a central venous catheter in the right atrium. The authors have no funding or conflicts of interest to disclose.
272 | www.jnsa.com
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
