ANESTHESIA & ANALGESIA - IARS

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ABSTRACTS ANESTH ANALG
2004; 98; S-1–S-282
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ANAESTHETIC MANAGEMENT OF CHILDREN WITH
TEMPOROMANDIBULAR JOINT ANKYLOSIS
AUTHORS: D. K. Sreevastava;
AFFILIATION: Armed Forces Medical college, Pune, India.
INTRODUCTION: Children with temporo- mandibular joint (TMJ)
ankylosis need careful airway assessment and specialized techniques
may be needed to gain safe control of the upper airway. The paper
would discuss the typical problems associated with TMJ ankylosis
against the backdrop of our set up, our institutional experience and the
changing practices in airway management.
METHODS: Anaesthesia records of 20 patients with severe degree of
TMJ ankylosis of bony variety only, over three year period were
reviewed. Special emphasis was laid upon preoperative airway
assessment, anaesthetic agents and technique used, choice of intubation
methods, complications during the airway management, intraoperative
events and postoperative sequel if any.
RESULTS: The youngest patient was 3 yrs old. There were 12 male
patients as against 8 females. All cases had fixed restriction to mouth
opening which was less than 2.5 cm. 9 patients had no or negligible
mouth opening. Facial asymmetry and mandibular deviation were the
commonest features amongst all the patients. Surgery resulted in mouth
opening of more than 2.5 cm in all the cases. Nasotracheal intubation
was done in all the cases. 2 patients were subjected to blind nasal
intubation without using any aid where as in the rest fibreoptic
bronchoscope (FOB) assisted nasal intubation was done. All cases were
done under anaesthesia which was maintained with the help of nasal
airway connected to a T-piece circuit till the time tube was placed.
There were three cases of trigeminovagal reflex. Extubation related
problems were uncommon in our study.
CONCLUSION: TMJ ankylosis is one of the most difficult types of
airways to secure. In these patients , various intubation techniques
include trans nasal Fibreoptic bronchoscope assisted intubation, blind
nasal intubation, nasal guided intubation, intubation with radiographic
C-arm assistance, retrograde intubation , use of special instruments and
lastly surgical airway. The role of blind nasal intubation or retrograde
intubation in management of an anticipated airway difficulty appears to
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NEUROBLASTOMA WITH EXCESSIVE CATECHOLAMINE
SECRETION: PERIOPERATIVE MANAGEMENT IN A
CHILD
AUTHORS: J. W. Sparks, C. Seefelder;
AFFILIATION: Department of Anesthesiology, Perioperative
Medicine and Pain Treatment; Harvard Medical School,
Children's Hospital Boston, Boston, MA.
INTRODUCTION: A 5 year old female with an abdominal mass
suspected to be neuroblastoma presented for biopsy and central line
placement. Intraoperatively, severe hypertension required nitroprusside
infusion, mechanical ventilation and unanticipated admission to the
ICU. Diagnostic work up revealed stage III neuroblastoma with
dramatically elevated catecholamine levels [norepinephrine (serum:
22,610pg/ml urine: 3280 mcg/g Cr.) and dopamine (serum: 3744pg/ml
urine: 3430 mcg/g Cr.)]. Treatment with phenoxybenzamine was
started. During her first two cycles of chemotherapy, severe
hypertension occurred with systolic blood pressures above 240 mm. Hg
and diastolic blood pressures above 110 mm. Hg. As a result, enalapril
was added for blood pressure stabilization. The following two cycles
were tolerated without hemodynamic perturbations and the patient was
scheduled for surgical resection.
METHODS: The patient was admitted 3 days preoperatively to
transition from phenoxybenzamine, enalapril and diamox to doxazosin
therapy. Doxazosin was initiated at 0.5 mg and titrated to 1.5 mg bid
prior to surgery. Preoperative echocardiogram revealed asymmetric
LVH with normal biventricular function and an EKG demonstrated a
prolonged QTc of 510 msec. without arrhythmia. Following premedication
with midazolam, an uneventful induction with propofol,
fentanyl and cisatracurim was performed and the patient was intubated.
Maintenance of anesthesia was achieved with isoflurane in an air/
oxygen mixture along with bupivicaine and hydromorphone continuous
epidural infusion. Fenoldopam, magnesium and nitroprusside infusions
were used to control intermittent catecholamine induced hypertension
during tumor manipulation. With removal of the tumor, all vasodilator
infusions, including the epidural infusion, were discontinued and
be diminishing now. Our experience underscores the importance of
FOB aided intubation which should be the first choice in these cases
and can eliminate the morbidity associated with surgical airway with
reasonable experience.
phenylephrine, along with dopamine, infusion was initiated to treat the
anticipated reduction in heart rate and blood pressure.
RESULTS: The patient transported to the ICU intubated and in stable
condition with dopamine @ 5 mcg/kg/min and phenylephrine @ 0.5
mcg/kg/min. Postoperative analgesia was provided via bupivicaine and
hydromorphone continuous epidural infusion. Extubation occurred the
following morning and vasoactive infusions were discontinued on the
second postoperative day. She was discharged home on postoperative
day seven without antihypertensives and urine catecholamine levels
returned to normal. Her prolonged QTc on EKG normalized prior to
discharge.
DISCUSSION: Neuroblastomas may be associated with elevated
catecholamine levels and increased blood pressure. Massively increased
catecholamine levels, as in this patient, are unusual and require
perioperative management according to guidelines for
pheochromocytomas to avoid perioperative morbidity and mortality.
Because its non-competitive nature allows direct alpha-agonist therapy
for management of hypotension, doxazosin has been recommended
over phenoxybenzamine for preoperative alpha adrenergic receptor
blocker in cases of pheochromocytoma resection 1 . Doxazosin’s
selective alpha-1 adrenoceptor antagonism reduces risk of arrhythmias,
and its shorter duration reduces risk of postoperative hypotension 1 .
Considering the longstanding catecholamine storm in our patient, her
rapid discontinuation from vasopressors and stable perioperative course
following preoperative management with doxazosin was remarkable.
REFERENCE: 1 BrJ.Anaesthesia 2000;85:44-57