Learning from Experience – Intra Operative, Chapters 27 and 28

INTRA-OPERATIVE

Chapter 27

Nasal intubation Post Pharyngoplasty – Oral First for Nasal Intubation

Dr. Vasanthi Vidyasagaran*

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

A 4-year-old, female child weighing 12 kg was posted for correction of a congenital club foot. History of birth and early years were uneventful. Normal milestones achieved. Immunization was given up to date. On examination, the child was malnourished. She was pale, had angular stomatitis. She was mildly lethargic but otherwise her mentation was normal. There was no evidence of any other congenital anomalies. On auscultation of chest, no added sounds were present. Hb was 9 g. The surgery was planned under general anaesthesia with a caudal block.

She was premedicated with Inj. Atropine 0.2 mg and Inj. Fentanyl 25 mic g Induced with thiopentone 50 mg and intubated with atracurium 10 mg using a size 5 cuffed oral ETT. 5 ml 0.25 % bupivacaine was given into Caudal space under aseptic conditions.

Anaesthesia was maintained with Halothane, 50:50 Oxygen: nitrous oxide mixture. She was manually ventilated throughout surgery with a paediatric Jackson Rees circuit. After 45 minutes, the bag felt tight and there were secretions in the lung. The heart rate increased to 130/min and the saturation dropped to 94. 100% oxygen was given and another 25 micgm fentanyl to maintain the plane of anaesthesia. Auscultation revealed bilateral crepitations. There was no kink in the tube and the total fluid administered was 50 ml in the previous hour. 10 mg Lasix, followed by another 10 mgs, and positive pressure ventilation with 100 % oxygen. Fortunately, this improved the condition and the surgery was completed. She was reversed and extubated comfortably. The cause of this transient pulmonary oedema could not be deciphered.

Patient was referred to the Pediatrician. He suspected B1 deficiency.

Post operative echo study showed global hypokinesia and moderate LV dysfunction. Serum B1 assay confirmed the diagnosis of wet beri beri. Over the next week, a course of B1 thiamine injections improved her condition and the echo returned to normal. She was discharged without any further sequelae.

Discussion

This was an interesting case of intraoperative pulmonary oedema in a paediatric patient who was posted for an elective orthopaedic procedure. Routine preoperative examination and investigations do not always highlight specific pathology like malnutrition.

Malnutrition is a still common clinical presentation in paediatric population in Indian community, in lower socioeconomic groups although efforts have been taken to improve nutrition. Hence it is all the more important for us to clinically suspect and identify malnutrition with care and ask for specific investigations if necessary. Simple treatment will prevent future problems in these patients.

Beri beri is a deficiency disease caused by Thiamine deficiency, predominant in rice eating population. Thiamine plays an important role in glucose metabolism.

t risk patient groups: Dietary deficiency due to poor intake, (chronic alcoholism), malabsorption syndromes, post bowel surgery, post bariatric surgery.

Deficiency has variable impact:

(1). Dry Beriberi: N-Methyl D- aspartate receptor mediated Neurotoxicity is implicated. (Wernicke encephalopathy) Typically, these patients have polyneuritis, ascending paralysis, progressive weakness, and encephalopathy in severe cases. Korsakoff syndrome is triad of confusion, memory loss and confabulation.

(2). Dry Beriberi: N-Methyl D- aspartate receptor mediated Neurotoxicity is implicated. (Wernicke encephalopathy) Typically, these patients have polyneuritis, ascending paralysis, progressive weakness, and encephalopathy in severe cases. Korsakoff syndrome is triad of confusion, memory loss and confabulation.

Our patient was an undiagnosed case of Beriberi, who presented with cardiac failure under anaesthesia during surgery, which was quite rare and totally unexpected.

Malnutrition related diseases and their serious implications is something to bear in mind while anaesthetizing such patient groups.

In this patient, the pulmonary oedema was first managed clinically and the cause was established only in the post-operative period.

References

Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg. 2008 Nov. 248(5):714-20
Martin PR, Singleton CK, Hiller-Sturmhofel S. The role of thiamine deficiency in alcoholic brain disease.Alcohol Res Health. 2003. 27(2):134-42
World Health Organization. Thiamine Deficiency and its prevention and control in major emergencies. 1999. Available at http://whqlibdoc.who.int/hq/1999/WHO_NHD_99.13.pdf.

Chapter 28

Phenylephrine Eye Drops in a Child

Child for examination of eye under anaesthesia

A 3-year-old boy weighing 15 kilograms with visual problems was posted for examination of eye under anaesthesia. He was very violent and uncooperative. It was posted as an outpatient procedure.

10 mg of Ketamine, and 1mg midazolam were given IV slowly. He was oxygenated with nasal prongs and he was breathing spontaneously. Routine monitoring with sao2 ECG and NIBP were done.

The surgeon applied topical Phenylephrine eye drops into both the eyes. As the surgeon began to examine the eye, there was tachycardia, and ventricular arrhythmia on the monitor. They were brief and resolved very quickly. No other clinical changes were observed. He was not given any other medication. The procedure was over within five minutes, and patient made an uneventful recovery.

Fortunately, the arrhythmia reverted to sinus rhythm without having to intervene. This could have been due to drug interactions between ketamine and phenylephrine.

Discussion

It is not advisable to start even minor ophthalmic procedures under local anaesthesia without the presence of an anaesthesiologist, and a proper theatre setting with all necessary resuscitation equipment.

Ophthalmic general anaesthesia is often challenging, because patient groups involved are usually extremes of age with comorbidities, requiring particular attention to detail. Paediatric ophthalmic anaesthesia is a great challenge as these children invariably have co-existing congenital anomalies and are often syndromic children with difficult airway. They may also be brought for repeated procedures requiring multiple anaesthesia during a short span of time.

Anaesthesia for ophthalmic procedures is not given its due importance in the curriculum during training of a post-graduate in anaesthesia. They are not exposed to the problems and complications peculiar to the speciality, and have to depend solely on the theoretical knowledge to deal with problems during practice. Hopefully this situation will change in future.

References

Fraunfelder FW, Fraunfelder FT, Jensvold B. Adverse systemic effects from pledgets of topical ocular phenylephrine 10%. Am J Ophthalmol 2002; 134: 624-5?
Baldwin FJ, Morley AP. Intraoperative pulmonary oedema in a child following systemic absorption of phenylephrine eye drops. Br J Anaesth 2002; 88: 440- 2.
Barash PG, Cullen BF, Stoelting RK. Clinical Anaesthesia. 5th ed. Lippincott Williams & Wilkins, Philadelphia, 2006: 974-998

Learning from Experience – Intra Operative, Chapters 27 and 28

INTRA-OPERATIVE

Chapter 27

Nasal intubation Post Pharyngoplasty – Oral First for Nasal Intubation

Discussion

Deficiency has variable impact:

References

Chapter 28

Phenylephrine Eye Drops in a Child

Child for examination of eye under anaesthesia

Discussion

References

Journals