A Full Meal At 5 am!

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: [email protected]

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Anaemia-or-Hydrocele

INTRA-OPERATIVE

The intra-operative period is most fascinating, as we could experience a wide variety of surprises in spite of thorough checklists. These surprises may arise from machines and equipment, patients’ reactions to drugs, or even decisions on the table to modify a surgical procedure or anaesthetic technique. With good pre-operative planning, preparation and intra-operative execution, complications in this stage can be minimized.

We work as a team in the operating theatre and the most important member of this team is the patient. That being said, compatibility between the surgeon and anesthetist is of absolute importance, and clear communication without a blame culture will set the scene for a smooth sail. Good interactions with other paramedical staff in the operating room is also of vital importance in running a theatre, especially when a problem arises.

All our senses must be alert at all times for a prompt response towards a potential adverse event. While the whole theatre will be a happy place when things go according to plan, the scene can change within seconds when an untoward event occurs. That’s when as the anesthetist in-charge, we should rise to the occasion – use our expertise, remain calm, react quickly and get the situation under control. This requires a lot of patience and thinking, and should be taught to anesthesiologists in training.

Our role is to try and maintain physiological processes like hemodynamics and ventilation in the presence of a pathology, and that makes our job particularly challenging in the intra- operative period as discussed in the following chapters.

Chapter 1

A six-year-old child was posted for multiple root canal fillings under general anesthesia as a day care procedure. He was seen by the anesthetist the previous day and all instructions including starvation were clearly given to the parents. On the day of the procedure, the child was screaming and jumping. He also had attention deficit disorder. So, the anesthetist quickly induced the child with a mask using high concentration of sevoflurane. Once the child was asleep she was about to start the intravenous line when the child started retching and vomiting solid food particles. Caught completely unaware, the anesthetist quickly applied suction and intubated the child without any delay. In the meantime, intravenous access was secured and a dose of steroid was given. Fortunately, the child made an uneventful recovery. The mother had given a full meal at 5 am! The procedure was postponed.

Discussion

Day care procedures need extra precaution as far as starvation is concerned since they are not under supervision. This is of concern especially in the pediatric population as parents are hesitant to starve the child. This is classic example and is not uncommon to encounter in practice It is mandatory to check about the last meal; however small the procedure may be. If this child had collapsed, the anesthetist would have been penalized, even when it is quite obvious that it’s not his/her fault.

It will make headlines in the news, for, the press needs just sensational negative news, and fail to enquire the actual details before reporting such incidents and somehow, anesthesia seems to be their favorite to implicate. It’s probably the ignorance of the reporters. Only an anesthetist will know the struggle and stress he/she undergoes to keep a patient safe and comfortable. This practice of implicating anesthesia, and the anesthetist without any basis must be avoided, as it also demoralizes the anesthetist who is honestly trying to help the patient.

Unless all protocols are adhered to strictly, Day Care Anesthesia can be quite tricky. There are some changes regarding preoperative starvation protocols in recent times, in accordance to ERAS. That does not apply to solids and it should be avoided at least six hours prior to surgery.

Check and re-check if pre-operative instructions have been followed before inducing the patient. Never forget the basic principles of having suction ready.

References

  1. Practice Guidelines for Preoperative Fasting – American Society of… www.asahq.org/…/standards-guidelines/practice-guidelines-for-preoperative- fasting.
  2. Preoperative fasting guidelines – UpToDate https://www.uptodate.com/contents /preoperative-fasting-guidelines Jan 13, 2017 – The rationale and recommendations for preoperative fasting are reviewed here.
  3. Practice guidelines for preoperative fasting NCBI https://www.ncbi.nlm.nih.gov/pubmed/213077702011

 

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Chapter 2

Air Embolism In Neurosurgery: Clinical Diagnosis

A 45-year-old man was posted for a tumour removal from the posterior cranial fossa. The surgery was to be performed in the sitting position. He was otherwise clinically fit and all his investigations were within normal limits. The procedure was started under general anaesthesia. Standard monitoring was applied. His HR was 78/min, and BP was 100/70. Central venous line was placed in the right internal jugular vein.

Two hours into surgery, ventilator showed high airway pressures despite adequate dose of muscle relaxant. So, ventilation was checked manually. There was tightness in the reservoir bag and it was becoming increasingly difficult to ventilate the patient. The HR increased to 120/min and the BP dropped to 80/50 mm Hg. There was bleeding in the site of surgery which the surgeon was trying to control.

Suspecting air embolism, 100% oxygen was immediately administered. The surgeon was asked to temporarily discontinue surgery in order to stabilize the patient. Steep head down position was given. Aspiration of air from the central line was attempted. There was a gush of air of about 35 ml into the syringe.

The haemodynamics reverted to HR = 95 beats/min, BP = 100/60 mm Hg, and the bag compliance improved. The surgical field was also flooded with saline. A small rent in the venous sinus was noticed and sutured. Patient made an uneventful recovery.

Discussion

Venous air embolism is a life-threatening condition observed most commonly in surgeries in sitting position. It may also be seen during central venous catheterisation or open chest trauma. It is a well- recognized complication during neurosurgery in the sitting position due to the proximity of venous sinuses.

Small quantities of air into the peripheral veins may not cause major haemodynamic disturbances. However, when this happens in the sitting position, the negative pressure in the cerebral venous sinus rapidly sucks in air from the atmosphere. There is a direct communication via the neck veins to the heart leading to a disastrous effect. When it is 50 ml or more large air bubbles obstruct pulmonary outflow tract. An air lock is produced in the right ventricular outflow tract. This leads to acute right ventricular failure and cardiac arrest.

The high suspicion and vigilant care provided by the anaesthetist allowed for immediate diagnosis and prompt treatment. The position recommended is called Durant’s position, which is a steep head down position with a left lateral tilt. This prevents air from entering the right ventricular outflow tract, thus maintaining right sided cardiac output.

If and when the condition is diagnosed early, timely aspiration of air prevents catastrophe. One must not hesitate to attempt this life saving procedure. Further supportive treatment in the form of intravenous fluids, vasopressors and positive pressure ventilation must be initiated. The site of venous injury should be identified and further air embolism must be prevented.

This was a case which was done even before end tidal CO2 was introduced in India. Vigilant clinical monitoring helped us save this patient. This situation is possible in our country even now, where we are expected to anaesthetize patients without even the mandatory minimal monitoring but major surgical procedures are done even in remote centres with the best of surgical equipment. It is high time that we resist this practice and insist on following standard safe protocol. However, we should also understand that monitors are there for us to detect complications early, but it is in our hands to react and treat appropriately. No device can replace a clinician.

References

  1. Zirky AA, DeSousa K, Alanezi KH. Carbon dioxide embolism during laparoscopic sleeve gastrectomy. J Anaesthesiol Clin Phamacol. 2011;27:262-5.
  2. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106(1):164-77.
  3. Sviri S, Woods WP, van Heerden PV. Air embolism – a case series and review. Crit Care Resusc. 2004;6(4):271-6.
  4. Wong AY, Irwin MG. Large venous air embolism in the sitting position despite monitoring with transoesophageal echocardiography. Anaesthesia. 2005;60(8):811-3.
  5. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140(12):1025-33.
  6. Oppenheimer MJ, Durant TM, and Lynch P: Body position related to venous air embolism and associated cardiovascular-respiratory changes. Am J Med Sci. 1953;225:362-73.

 

 

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