CORRESPONDENCE
Anesthetic Management of a Paraparetic Patient With Multiple Lung Bullae To JNA Readers: A 60-year-old man presented with history of a fall 6 months back after which he developed neck pain, lower limb weakness, and urinary retention. There were no respiratory complaints. Medical history was not significant. Hypertonia was present in both the lower limbs with power of 3/5. The lungs were clear on auscultation. Magnetic resonance imaging of the spine revealed cord compression at the cervical (C3-C5) and thoracic (T10) levels. Laminectomy at T10T11 and excision of T10-T12 ossified ligamentum flavum were planned. X-ray reports of the chest showed bilateral upper-zone focal abnormalities with fibrotic bands and emphysematous changes. Computed tomography scan of the chest showed bilateral gross pleural thickening, upper-zone lesions with fibrotic strands, and calcified mediastinal lymph nodes (Fig. 1A). On the right side, multiple large emphysematous bullae were seen (Fig. 1B). Radiologic findings were suggestive of pulmonary
tuberculosis. Pulmonary function test revealed severe restriction. In view of emphysematous bullae, general anesthesia (GA) with spontaneous respiration was planned to avoid positive pressure ventilation (PPV). Patient was premedicated with 0.2 mg of glycopyrrolate and 1 mg of midazolam intravenously. Airway was anesthetized with 4% lignocaine nebulization, topical 10% spray, and transtracheal block. A dosage of 50 mg of propofol and a dosage of 40 mg IV fentanyl were given to facilitate intubation. Anesthesia was maintained using 1% to 2% sevoflurane and O2 with air (35:75). Analgesia was provided with fentanyl boluses. Throughout the procedure, spontaneous respiration was maintained (respiratory rate 8 to 12/min, end tidal carbon dioxide 40 to 42 mm Hg). Airway pressures and systemic parameters were monitored carefully to diagnose the occurrence of pneumothorax at the earliest. Postoperatively, patient was breathing comfortably with no new complications. Bulla is a pathologic entity caused by a confluence of 2 or more terminal elements of bronchial tree. It may get infected or enlarge progressively and may lead to pneumothorax. It exists frequently in conditions like tuberculosis. Various anesthetic techniques have been tried in patients with bullae
presenting for extrathoracic surgery such as GA with double-lumen tube,1 inhalational anesthetics and spontaneous ventilation,2 and awake craniotomy using dexmedetomidine sedation.3 Iwakura et al2 used spontaneous ventilation, although initially succinylcholine was used to facilitate intubation. Because of preoperative paraparesis, we avoided succinylcholine. To blunt airway reflexes, we used topical anesthesia and airway blocks. In another case report, authors have used laryngeal mask airway with epidural catheter in a spontaneously breathing patient.4 We did not consider regional anesthesia, despite being a good option in patients with lung bulla, in view of preoperative limb weakness. Placing a patient in prone position presents significant challenges to the anesthetist. A decrease in the mean arterial pressure, stroke volume, and the cardiac index can occur. Abdominal compression can worsen the obstruction to inferior vena cava leading to an increased surgical-site bleeding. Accidental extubation and endotracheal tube obstruction are other feared complications. Prone position increases functional residual capacity and improves oxygenation by reducing the ventilation perfusion mismatch. Spontaneous breathing can have synergistic effect with prone position. Active
FIGURE 1. Axial high-resolution computed tomography scan of the chest showing bilateral middle-zone lesions with surrounding fibrotic strands (shown by arrows) with evidence of emphysema in the surrounding lung (A) and multiple large emphysematous bullae [arrows in (B)]. The authors have no funding or conflicts of interest to disclose.
J Neurosurg Anesthesiol
Volume 26, Number 1, January 2014
www.jnsa.com |
85
Correspondence
contraction of the diaphragm during spontaneous breathing maintains ventilation to dependent lung preventing its collapse. Prone position enhances diaphragmatic movement during spontaneous breathing and redistributes ventilation to dorsobasal areas. The major problem associated with PPV is that it causes enlargement or rupture of bulla, especially with the use of nitrous oxide, whereas spontaneous unassisted respiration ensures safe levels of intrathoracic pressure. However, patients in whom GA is considered prudent and PPV is to be avoided, intubation can be achieved without using muscle relaxant by anesthetizing the airway with local anesthetics. Adequate airway anesthesia is an option that will minimize coughing with airway manipulation and in turn will prevent dynamic hyperinflation of the bullae. Further, a patient’s spontaneous respiration can be preserved intraoperatively using either inhalational or intravenous anesthesia. Most important is meticulous monitoring and vigilance to detect pneumothorax and be prepared to treat it promptly.
Sonia Bansal, MD, DNB, PDCC Rohini M. Surve, MD, PDCC Ramesh J. Venkatapura, MD Department of Neuroanaesthesia National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore, India
REFERENCES 1. Caseby NG. Anaesthesia for the patient with a coincidental giant lung bulla: a case report. Can Anaesth Soc J. 1981;28: 272–276. 2. Iwakura H, Kishimoto T, Takatori T, et al. Anesthetic management of a patient with abdominal aortic aneurysm (AAA) with giant bulla. Masui. 1994;43:116–118. 3. Kamath S, Bhadrinarayan V, Ranjan M, et al. Alternative approach for the anesthetic management of a patient with large pulmonary bulla presenting with an intracranial tumor for surgery. J Anaesthesiol Clin Pharmacol. 2012;28:272–273. 4. Nozaki K, Endou A, Sakurai K, et al. Anesthetic management of a patient with a giant bulla and liver cirrhosis using a laryngeal mask airway and epidural analgesia. Masui. 2001;50:639–641.
86 | www.jnsa.com
J Neurosurg Anesthesiol
Retrogasserian Glycerol Rhizolysis: First Description of Occurrence Trigeminocardiac Reflex To JNA Readers: Hemodynamic perturbations are commonly observed complications of ablative procedures for trigeminal neuralgia including retrogasserian glycerol rhizolysis, balloon decompression, and radiofrequency ablation.1 In anesthetized patient, it would be challenging to differentiate the various causes pertaining to these cardiovascular changes if they occur in the predilatation phase of the procedure. Therefore, we present here for the first time the occurrence of a trigeminal cardiac reflex (TCR) during retrogasserian glycerol rhizolysis. A middle-aged, otherwise healthy patient and known case of trigeminal neuralgia, was scheduled for retrogasserian glycerol rhizolysis under general anesthesia. All standard monitors were attached and baseline heart rate and blood pressure were recorded as 58 beats/min and 110/60 mm Hg, respectively. Patient was induced with intravenous fentanyl (2 mcg/kg), propofol (2 to 3 mg/kg), and rocuronium (0.7 mg/kg). Trachea was intubated and ventilated. For retrogasserian block, surgeon started to proceed with transovale placement of a spinal needle in the trigeminal cistern of Meckel cave under fluoroscopic guidance. When needle tip punctured the trigeminal cistern, egress of cerebrospinal fluid was noticed at hub of the spinal needle. At this time, surgeon planned for the contrast dye injection; however, sudden bradycardia (25 beats/min) was noted just before the injection. Surgeon was immediately notified and asked to hold the injection. In view of persistence of bradycardia (>30 s), intravenous glycopyrrolate (0.4 mg) was given and heart rate increased up to 84 beats/min without much significant increase in blood pressure (140/74 mm The authors have no funding or conflicts of interest to disclose.
Volume 26, Number 1, January 2014
Hg). Thereafter, surgeon performed the rest of the procedure (dye and glycerol injection) without any further changes in the hemodynamic parameters. At the conclusion of the surgery, anesthesia was reversed and the patient was extubated after ascertaining the full neurological recovery. Vasovagal reactions can be associated with any sharp noxious stimuli and it is usually observed during transovale passage of needle during percutaneous ablative procedures.2,3 The other possible differential diagnosis in this case can be stimulation of TCR which is usually triggered by the mechanical or chemical dilatation (due to dye/glycerol or balloon) or electrical stimulation (radiofrequency ablation).2 In our case, bradycardia is noted some time after the needle placement in trigeminal cistern thus possibility of vasovagal reaction is highly unlikely. Probably, sudden egress of cerebrospinal fluid could lead to sudden traction of dura and provoked TCR. The meningeal branch of maxillary nerve (second division of trigeminal nerve) innervates the middle fossa dura, which in this patient, may be considered to elicit the TCR.4 This patient had low baseline heart rate too. So probably, preexisting high vagotonicity coupled with mild stimulation of trigeminal nerve during dural traction could probably incite TCR and resulted in to severe bradycardia.5 Thus, preexisting high vagal tone may be a predisposing factor for intraoperative TCR. In conclusion, TCR can be provoked even during predilatation phase of trigeminal ablative procedures with catastrophic consequences and vigilant monitoring is warranted throughout the procedure in such cases. Tumul Chowdhury, MD, DM* Ronald B. Cappellani, MD, FRCPC* Bernhard Schaller, MD, PhD, DSCw for Trigeminocardiac Reflex Examination Group (TCREG) *Department of Neuroanesthesiology Health Sciences Center, University of Manitoba, Winnipeg, MB, Canada wDepartment of Research University of Southampton Southampton, UK r
2013 Lippincott Williams & Wilkins
Anesthetic Management of a Paraparetic Patient With Multiple Lung Bullae To JNA Readers: A 60-year-old man presented with history of a fall 6 months back after which he developed neck pain, lower limb weakness, and urinary retention. There were no respiratory complaints. Medical history was not significant. Hypertonia was present in both the lower limbs with power of 3/5. The lungs were clear on auscultation. Magnetic resonance imaging of the spine revealed cord compression at the cervical (C3-C5) and thoracic (T10) levels. Laminectomy at T10T11 and excision of T10-T12 ossified ligamentum flavum were planned. X-ray reports of the chest showed bilateral upper-zone focal abnormalities with fibrotic bands and emphysematous changes. Computed tomography scan of the chest showed bilateral gross pleural thickening, upper-zone lesions with fibrotic strands, and calcified mediastinal lymph nodes (Fig. 1A). On the right side, multiple large emphysematous bullae were seen (Fig. 1B). Radiologic findings were suggestive of pulmonary
tuberculosis. Pulmonary function test revealed severe restriction. In view of emphysematous bullae, general anesthesia (GA) with spontaneous respiration was planned to avoid positive pressure ventilation (PPV). Patient was premedicated with 0.2 mg of glycopyrrolate and 1 mg of midazolam intravenously. Airway was anesthetized with 4% lignocaine nebulization, topical 10% spray, and transtracheal block. A dosage of 50 mg of propofol and a dosage of 40 mg IV fentanyl were given to facilitate intubation. Anesthesia was maintained using 1% to 2% sevoflurane and O2 with air (35:75). Analgesia was provided with fentanyl boluses. Throughout the procedure, spontaneous respiration was maintained (respiratory rate 8 to 12/min, end tidal carbon dioxide 40 to 42 mm Hg). Airway pressures and systemic parameters were monitored carefully to diagnose the occurrence of pneumothorax at the earliest. Postoperatively, patient was breathing comfortably with no new complications. Bulla is a pathologic entity caused by a confluence of 2 or more terminal elements of bronchial tree. It may get infected or enlarge progressively and may lead to pneumothorax. It exists frequently in conditions like tuberculosis. Various anesthetic techniques have been tried in patients with bullae
presenting for extrathoracic surgery such as GA with double-lumen tube,1 inhalational anesthetics and spontaneous ventilation,2 and awake craniotomy using dexmedetomidine sedation.3 Iwakura et al2 used spontaneous ventilation, although initially succinylcholine was used to facilitate intubation. Because of preoperative paraparesis, we avoided succinylcholine. To blunt airway reflexes, we used topical anesthesia and airway blocks. In another case report, authors have used laryngeal mask airway with epidural catheter in a spontaneously breathing patient.4 We did not consider regional anesthesia, despite being a good option in patients with lung bulla, in view of preoperative limb weakness. Placing a patient in prone position presents significant challenges to the anesthetist. A decrease in the mean arterial pressure, stroke volume, and the cardiac index can occur. Abdominal compression can worsen the obstruction to inferior vena cava leading to an increased surgical-site bleeding. Accidental extubation and endotracheal tube obstruction are other feared complications. Prone position increases functional residual capacity and improves oxygenation by reducing the ventilation perfusion mismatch. Spontaneous breathing can have synergistic effect with prone position. Active
FIGURE 1. Axial high-resolution computed tomography scan of the chest showing bilateral middle-zone lesions with surrounding fibrotic strands (shown by arrows) with evidence of emphysema in the surrounding lung (A) and multiple large emphysematous bullae [arrows in (B)]. The authors have no funding or conflicts of interest to disclose.
J Neurosurg Anesthesiol
Volume 26, Number 1, January 2014
www.jnsa.com |
85
Correspondence
contraction of the diaphragm during spontaneous breathing maintains ventilation to dependent lung preventing its collapse. Prone position enhances diaphragmatic movement during spontaneous breathing and redistributes ventilation to dorsobasal areas. The major problem associated with PPV is that it causes enlargement or rupture of bulla, especially with the use of nitrous oxide, whereas spontaneous unassisted respiration ensures safe levels of intrathoracic pressure. However, patients in whom GA is considered prudent and PPV is to be avoided, intubation can be achieved without using muscle relaxant by anesthetizing the airway with local anesthetics. Adequate airway anesthesia is an option that will minimize coughing with airway manipulation and in turn will prevent dynamic hyperinflation of the bullae. Further, a patient’s spontaneous respiration can be preserved intraoperatively using either inhalational or intravenous anesthesia. Most important is meticulous monitoring and vigilance to detect pneumothorax and be prepared to treat it promptly.
Sonia Bansal, MD, DNB, PDCC Rohini M. Surve, MD, PDCC Ramesh J. Venkatapura, MD Department of Neuroanaesthesia National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore, India
REFERENCES 1. Caseby NG. Anaesthesia for the patient with a coincidental giant lung bulla: a case report. Can Anaesth Soc J. 1981;28: 272–276. 2. Iwakura H, Kishimoto T, Takatori T, et al. Anesthetic management of a patient with abdominal aortic aneurysm (AAA) with giant bulla. Masui. 1994;43:116–118. 3. Kamath S, Bhadrinarayan V, Ranjan M, et al. Alternative approach for the anesthetic management of a patient with large pulmonary bulla presenting with an intracranial tumor for surgery. J Anaesthesiol Clin Pharmacol. 2012;28:272–273. 4. Nozaki K, Endou A, Sakurai K, et al. Anesthetic management of a patient with a giant bulla and liver cirrhosis using a laryngeal mask airway and epidural analgesia. Masui. 2001;50:639–641.
86 | www.jnsa.com
J Neurosurg Anesthesiol
Retrogasserian Glycerol Rhizolysis: First Description of Occurrence Trigeminocardiac Reflex To JNA Readers: Hemodynamic perturbations are commonly observed complications of ablative procedures for trigeminal neuralgia including retrogasserian glycerol rhizolysis, balloon decompression, and radiofrequency ablation.1 In anesthetized patient, it would be challenging to differentiate the various causes pertaining to these cardiovascular changes if they occur in the predilatation phase of the procedure. Therefore, we present here for the first time the occurrence of a trigeminal cardiac reflex (TCR) during retrogasserian glycerol rhizolysis. A middle-aged, otherwise healthy patient and known case of trigeminal neuralgia, was scheduled for retrogasserian glycerol rhizolysis under general anesthesia. All standard monitors were attached and baseline heart rate and blood pressure were recorded as 58 beats/min and 110/60 mm Hg, respectively. Patient was induced with intravenous fentanyl (2 mcg/kg), propofol (2 to 3 mg/kg), and rocuronium (0.7 mg/kg). Trachea was intubated and ventilated. For retrogasserian block, surgeon started to proceed with transovale placement of a spinal needle in the trigeminal cistern of Meckel cave under fluoroscopic guidance. When needle tip punctured the trigeminal cistern, egress of cerebrospinal fluid was noticed at hub of the spinal needle. At this time, surgeon planned for the contrast dye injection; however, sudden bradycardia (25 beats/min) was noted just before the injection. Surgeon was immediately notified and asked to hold the injection. In view of persistence of bradycardia (>30 s), intravenous glycopyrrolate (0.4 mg) was given and heart rate increased up to 84 beats/min without much significant increase in blood pressure (140/74 mm The authors have no funding or conflicts of interest to disclose.
Volume 26, Number 1, January 2014
Hg). Thereafter, surgeon performed the rest of the procedure (dye and glycerol injection) without any further changes in the hemodynamic parameters. At the conclusion of the surgery, anesthesia was reversed and the patient was extubated after ascertaining the full neurological recovery. Vasovagal reactions can be associated with any sharp noxious stimuli and it is usually observed during transovale passage of needle during percutaneous ablative procedures.2,3 The other possible differential diagnosis in this case can be stimulation of TCR which is usually triggered by the mechanical or chemical dilatation (due to dye/glycerol or balloon) or electrical stimulation (radiofrequency ablation).2 In our case, bradycardia is noted some time after the needle placement in trigeminal cistern thus possibility of vasovagal reaction is highly unlikely. Probably, sudden egress of cerebrospinal fluid could lead to sudden traction of dura and provoked TCR. The meningeal branch of maxillary nerve (second division of trigeminal nerve) innervates the middle fossa dura, which in this patient, may be considered to elicit the TCR.4 This patient had low baseline heart rate too. So probably, preexisting high vagotonicity coupled with mild stimulation of trigeminal nerve during dural traction could probably incite TCR and resulted in to severe bradycardia.5 Thus, preexisting high vagal tone may be a predisposing factor for intraoperative TCR. In conclusion, TCR can be provoked even during predilatation phase of trigeminal ablative procedures with catastrophic consequences and vigilant monitoring is warranted throughout the procedure in such cases. Tumul Chowdhury, MD, DM* Ronald B. Cappellani, MD, FRCPC* Bernhard Schaller, MD, PhD, DSCw for Trigeminocardiac Reflex Examination Group (TCREG) *Department of Neuroanesthesiology Health Sciences Center, University of Manitoba, Winnipeg, MB, Canada wDepartment of Research University of Southampton Southampton, UK r
2013 Lippincott Williams & Wilkins
![[Anesthetic management of a patient with multiple sclerosis - case report].](/assets/img/hold.png)
