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B i s and hypothermic circulatory arrest



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  • 1. British Journal of Anaesthesia 85 (5): 788±90 (2000) CASE REPORTS Non-invasive positive pressure ventilation for severe thoracic trauma M. J. Gar®eld1* and R. M. Howard-Grif®n Intensive Care Unit, Ipswich Hospital NHS Trust, Heath Road, Ipswich IP4 5PD, UK 1 Present address: Anaesthetic Department, Norfolk and Norwich Hospital, Brunswick Road, Norwich NR1 3SR, UK *Corresponding author A 35-year-old man was admitted to the intensive care unit (ICU) following a road traf®c accident. He had sustained severe trauma to the left side of his chest, as well as other musculo- skeletal injuries. After a short initial period of ventilation of the lungs via a tracheal tube, he was managed using a combination of continuous positive airway pressure and non-invasive positive pressure ventilation. He avoided ventilator-associated pneumonia, and spent a large part of his time on the ICU without any invasive monitoring lines, another potential focus of infection. He was discharged from the ICU after 25 days without having suffered any septic complications. The role of non-invasive positive pressure ventilation in severe thoracic trauma is discussed. Br J Anaesth 2000; 85: 788±90 Keywords: ventilation, non-invasive; complications, trauma; complications, nosocomial pneumonia Accepted for publication: May 27, 2000Victims of thoracic trauma are often referred to critical care left ¯ail chest. His oxygen saturation by pulse oximeter wasservices for assistance with analgesia and ventilation. Some 85% on a fractional inspired oxygen concentration (FIO2) ofof these patients have historically required long periods of 0.6. This was thought to be accurate as the probe was on anventilatory support, and have therefore been at high risk of uninjured limb, there was a good trace on the monitor, andacquiring nosocomial pneumonia. We report a case in which the patient was centrally cyanosed. He was tachycardic,a patient with severe thoracic trauma (Abbreviated Injury with a heart rate of 140 beats min±1, and hypotensive, withScale score 5/6 for thoracic injury (where 0 represents no an initial systolic blood pressure of 55 mm Hg. He wasinjury, and 6 represents an unsurvivable injury1)) was resuscitated initially with crystalloid solution, followed bymanaged mainly using non-invasive positive pressure blood when it was available. He received a total of 5.5 litresventilation (NIPPV), an approach which, we postulated, of crystalloid, followed by 9 units of packed red blood cells.would be as effective as conventional ventilation, but His blood pressure responded well, if transiently, toexpose him to a lower risk of nosocomial pneumonia. intravascular ®lling. A chest x-ray (Fig. 1) showed fractures of the second± ninth ribs on the left, with disruption of the costovertebralCase report joints, resulting in a large ¯ail segment. There was severeA 35-year-old pedal cyclist was hit by, and trapped under, a contusion of most of the left lung and contusion of the rightheavy goods vehicle. He was extricated by the emergency lower lobe. He had a disruption of his left shoulder joint, aservices, and brought to the accident and emergency large laceration over his left iliac crest, and a fractured leftdepartment on a spinal board. His Glasgow coma score ankle. His Revised Trauma Score was 6.0, which representswas 15 throughout. He was complaining of severe left-sided an expected mortality of approximately 10%, and hischest pain and marked shortness of breath. He had a Trauma Score ± Injury Severity Score (TRISS) expectedrespiratory rate of 40 b.p.m., and the clinical features of a mortality was 18%.1 Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2000
  • 2. NIPPV for severe thoracic trauma On day 5, increasing oxygen requirement was treated with periods of intermittent positive pressure breathing (IPPB) via a Bird ventilator and continuous positive airway pressure (CPAP) by facemask. IPPB is a form of treatment, usually administered by the physiotherapists, which is designed to rein¯ate collapsed pulmonary segments and so reduce shunting of deoxygenated blood. The patient uses a mouthpiece; the lungs are ventilated with a constant pressure. Despite this, by day 7 his FIO2 had risen to 0.6, giving a PaO2 of only 9 kPa. Facial CPAP at a level of 7.5 cm H2O was continued and negative ¯uid balances were obtained by ¯uid restriction and forced diuresis by loop diuretics. Fluid balance was monitored in the usual way by detailed input/output charts and urethral catheterization. These treatments resulted in reduction of his FIO2 to 0.45.Fig 1 Admission chest x-ray, showing multiple left-sided rib fractures, On day 9, after internal ®xation of his ankle, the patientsmassive left, and right lower lobe pulmonary contusion. A left intercostal lungs were ventilated overnight. Following tracheal extub-drain is in situ. ation the next morning, he was given CPAP at a level of 7.5 cm H2O by facemask. At this stage he still had a large In view of his injuries and cardiorespiratory instability, ¯ail segment, and radiological and clinical evidence ofhis trachea was intubated and his lungs ventilated. A left continuing contusion in his left lung. The right basalchest drain drained initially 500 ml of blood, but the loss contusion had now resolved.quickly decreased. A right chest drain was inserted Over the next 72 h, the patient developed increasingprophylactically, in accordance with current Advanced respiratory distress, with an increasing respiratory rate (upTrauma Life Support (ATLS) teaching for a patient with to 50 b.p.m.), shallow breathing and an uneven respiratorysevere thoracic injury requiring positive pressure ventil- pattern, and the FIO2 had increased to 0.6, in order toation.2 This approach has arisen in view of the high risk of maintain a PaO2 of 10 kPa. On day 12, NIPPV wasan occult pneumothorax in such patients.3 4 commenced via a nasal mask (NIPPY2 ventilator, Aeromed, Computed tomography (CT) of the chest, cervical and UK), with an immediate reduction in his oxygen require-thoracic spine, performed after stabilization con®rmed the ments. He remained on continuous nasal NIPPV for ainitial chest x-ray ®ndings, as well as revealing bilateral further 9 days, with a reducing level of pressure support andsmall pneumothoraces and fractures of many of the spinous CPAP; the NIPPV was tolerated extremely well throughout.processes of the thoracic vertebrae. The neural arches were, His invasive lines were all removed on day 18.however, intact and there was no evidence of spinal cord By day 20, he was receiving only intermittent NIPPV, andinjury. The cervical spine appeared normal. otherwise had an oxygen saturation (SaO2) of 98% on 3 litres The patients lungs were ventilated using volume min±1 of oxygen via nasal cannulae. On day 22, he wascontrolled ventilation, with a positive end-expiratory pres- given NIPPV overnight only, and the NIPPV was discon-sure (PEEP) of 6 cm H2O, and an FIO2 of 0.35 (Servo 900C tinued on day 24. Nocturnal CPAP by facemask continuedventilator, Siemens-Elema, Sweden). This resulted in an for a further night, and he was discharged to the ward on dayarterial oxygen partial pressure (PaO2) of 13.7 kPa. He was 26.thought not to require an open lung strategy as his peak Apart from a 5-day course of ¯ucloxacillin to treat aairway pressure was acceptable (<25 cm H2O), and Staphylococcus aureus infection in a laceration, the patientoxygenation was not problematic. His initial cardiovascular required no antibiotics during his stay on the intensive careinstability was such that high levels of PEEP were thought unit (ICU). At no stage was there any evidence of systemicinadvisable. or pulmonary infection. After a 48-h period of stabilization, and once hiscoagulopathy (a result of the massive transfusion) hadbeen treated by infusion of fresh frozen plasma and Discussioncryoprecipitate, a thoracic epidural was inserted at the T7/ Ventilator-associated pneumonia represents a major sub-8 level, and infusion of bupivacaine commenced. The group of nosocomial pneumonia, a condition that isepidural provided good analgesia for the thoracic injuries, associated with a mortality of 30%.5 In those patients whobut the shoulder fracture continued to produce a lot of pain. survive, ventilator-associated pneumonia is associated withA patient-controlled analgesia infusion of morphine was increased morbidity, longer ICU stays, and hence increasedtherefore also commenced. These infusions resulted in good costs.6 The pathogenesis of this condition involves bacterialanalgesia, ventilatory support was weaned off, and his colonization of the upper aerodigestive tract, and hencetrachea was extubated on the fourth day after admission. oropharyngeal secretions. These contaminated secretions 789
  • 3. Gar®eld and Howard-Grif®npool above the cuff of the tracheal tube, and are aspirated to its use. We have since used NIPPV in a further twointo the trachea during patient movement, coughing, patients with bilateral ¯ail chest and lesser degrees oftracheal suctioning and many other manoeuvres.7±9 pulmonary contusion, and had very similar results withTracheal intubation has indeed been shown to be an regard to effectiveness of the ventilatory support, andimportant risk factor for the development of ventilator- avoidance of ventilator-associated pneumonia.associated pneumonia,10 and so it would seem sensible toavoid this if at all possible.11 NIPPV has been shown to be as effective as conventional Referencesventilation in a variety of settings, including exacerbations 1 Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: theof chronic obstructive pulmonary disease12 and acute TRISS method. J Trauma 1987; 27: 370±8respiratory failure.13 The causes of the acute respiratory 2 American College of Surgeons Committee on Trauma. Advancedfailure in the latter paper ranged from infection and Trauma Life Support for Doctors, 6th edition. Chicago, Illinois:pulmonary oedema to acute respiratory distress syndrome. American College of Surgeons, 1997; 127±41 3 Hill SL, Edmisten T, Holtzman G, Wright A. The occultTo date, there have been no reports of the use of NIPPV in pneumothorax: an increasing diagnostic entity in trauma. Amsevere chest trauma.14 Surg 1999; 65: 254±8 Nava et al.12 allocated random patients with exacerb- 4 Collins JA, Samra GS. Failure of chest X-rays to diagnoseations of chronic obstructive pulmonary disease to either pneumothoraces after blunt trauma. Anaesthesia 1998; 53: 74±8NIPPV or conventional ventilation, after an initial period of 5 Crabtree TD, Gleason TG, Pruett TL, Sawyer RG. Trends in48 h conventional ventilation. Seven out of 25 patients in the nosocomial pneumonia in surgical patients as we approach theconventionally ventilated group developed ventilator- 21st century: a prospective analysis. Am Surg 1999; 65: 706±9associated pneumonia, compared to none of the NIPPV 6 Kelleghan SI, Salemi C, Padilla S, et al. An effective continuous quality improvement approach to the prevention of ventilator-group (P=0.009). Antonelli et al.13 allocated random associated pneumonia. Am J Infect Control 1993; 13: 322±330patients to either NIPPV or conventional ventilation from 7 Bonten MJ, Gaillard CA, de Leeuw PW, Stobberingh EE. Role ofthe outset. Again, the patients ventilated non-invasively had colonisation of the upper intestinal tract in the pathogenesis ofa signi®cantly lower incidence of ventilator-associated ventilator-associated pneumonia. Clin Infect Dis 1997; 24: 309±19pneumonia and sinusitis. While this study had some minor 8 Greene R, Thompson S, Jantsch HS, et al. Detection of pooledmethodological ¯aws, it demonstrates a clear difference in secretions above endotracheal-tube cuffs: value of plaininfective complications between the two groups, and adds radiographs in sheep cadavers and patients. Am J Roentgenol 1994; 163: 1333±7further evidence to the hypothesis discussed above, that 9 Kingston DW, Phang PT, Leathley MJ. Increased incidence ofavoidance of tracheal intubation reduces the incidence of nosocomial pneumonia in mechanically ventilated patients withventilator-associated pneumonia, and thus decreases length subclinical aspiration. Am J Surg 1991; 161: 589±92of ICU stay and other variables.6 10 Craven DE, Steger KA. Epidemiology of nosocomial pneumonia. Thoracic injury consists of a spectrum of disease, ranging New perspectives on an old disease. Chest 1995; 108: 1S±16Sfrom rib fractures with mild pulmonary contusion to 11 Kollef MH. Avoidance of tracheal intubation as a strategy todisruption of the thoracic cage and acute respiratory distress prevent ventilator-associated pneumonia. Intensive Care Medsyndrome. Although many of the less severely injured 1999; 25: 553±5 12 Nava S, Ambrosino N, Clini E, et al. Non-invasive mechanicalpatients are now managed without ventilatory support, with ventilation in the weaning of patients with respiratory failure duea thoracic epidural and aggressive chest physiotherapy,14 to chronic obstructive pulmonary disease. Ann Intern Med 1998;there will always be a number for whom this is not 128: 721±8suf®cient. These patients, usually with signi®cant 13 Antonelli M, Conti G, Rocco M, et al. A comparison of non-hypoxaemia, often require an extended period of invasive invasive positive pressure ventilation and conventionalventilation,15 and the risk of ventilator-associated pneumo- mechanical ventilation in patients with acute respiratory failure.nia is thus high. We believe that in this group, avoidance of New Eng J Med 1998; 339: 429±35 14 Mazuski JE, Durham RM. Management of the chest injury. In:tracheal intubation and hence avoidance of ventilator- Webb AR, Shapiro MJ, Singer M, Suter PM, eds. Oxford Textbookassociated pneumonia may be a major step in reducing of Critical Care. Oxford: Oxford University Press, 1999; 715±8ICU stay, morbidity and mortality. NIPPV is safe, effective, 15 Jackson J. Management of thoracoabdominal injuries. In: Capanand, we believe, may be the mode of choice for managing LM, Miller SM, Turndorf H, eds. Trauma Anesthesia and Intensivepatients with thoracic trauma who have no contraindications Care. Philadelphia: Lipincott, 1991; 481±3 790
  • 4. British Journal of Anaesthesia 85 (5): 791±4 (2000)Lobectomy for cavitating lung abscess with haemoptysis: strategy for protecting the contralateral lung and also the non-involved lobe of the ipsilateral lung J. P®tzner1*, M. J. Peacock2, E. Tsirgiotis3 and I. H. Walkley1 1 Department of Anaesthesia, 2Thoracic Surgical Unit and 3Respiratory Medicine Unit, North Western Adelaide Health Service, 28 Woodville Road, Woodville, South Australia 5011, Australia *Corresponding author We describe the anaesthetic management of a patient undergoing lobectomy for cavitating lung abscess complicated by haemoptysis. Surgery for lung abscess is one of the absolute indications for the use of a double-lumen tube (DLT). Because pus or blood could impede ®breoptic- assisted DLT placement, a traditional, blind placement of the DLT was performed. To protect the uninvolved parts of the operated lung, ventilation of the lung with the abscess was not per- formed until the resection of the involved lobe had been completed. Br J Anaesth 2000; 85: 791±4 Keywords: anaesthesia, one lung anaesthesia; surgery, thoracic; lung, abscess; complications, haemoptysis Accepted for publication: May 27, 2000Current management of lung abscess1±3 in the main involves effort be made to minimize the dissemination of infectiveappropriate antibiotics, physiotherapy and, where indicated, material throughout the operated lung as well as the goodchest tube drainage: thoracotomy tends to be restricted to lung?those cases not responding to intensive and prolongedmedical management or those complicated by haemo-ptysis,4 empyema, malignancy or suspected malignancy. Case reportThus, unlike the era before antibiotics, today the thoracic Pneumonia that had failed to resolve over a 12-monthanaesthetist has limited experience in anaesthetizing period, in a 32-yr-old previously well woman, led to apatients with cavitating lung abscesses. One of the main consolidated left lower lobe with a large cavitating lungaims of anaesthesia is to protect the so-called good lung abscess. Early in this disease, she had developed haemop-from contamination, and the introduction of the endo- tysis and on many occasions had coughed varying amountsbronchial tube and the double-lumen tube (DLT) in the of frank blood, sometimes in excess of an estimated half-1950s overcame the need to employ awkward and incon- teacup. Later, she was coughing purulent sputum streakedvenient patient positioning, such as the Parry Brown or the with blood. She said that the episodes of haemoptysis wereOverholt positions. The former relied upon intra-operative caused by her lying ¯at, and as a consequence she slept in adrainage by gravity of infective material via the trachea, sitting position and would not allow herself to be placedwhile the latter relied upon retention by gravity within the otherwise. Such was her fear of further haemoptysis that sheabscess cavity. Now, the use of a DLT or a tube-and-blocker refused physiotherapy and totally rejected any suggestion ofis mandatory during thoracotomy for lung abscess or for postural drainage. Her weight decreased from 75 to 46 kg,frank haemoptysis.5 and she developed marked clubbing of the ®ngers and toes. Even so, when planning anaesthesia for a patient with a The preoperative chest x-ray and CT scan are shown inhigh risk of purulent material and/or blood draining by Figures 1 and 2 respectively.gravity into the major airways, the anaesthetist and surgeon Extensive investigation failed to identify any underlyingstill face several dilemmas. First, should the patient stay in pathology. There was no evidence of immunosuppression orthe sitting or semi-sitting position until lung separation is aspiration. Bronchoscopy revealed no endobronchial lesionachieved? Secondly, what is the operative teams preferred and washings were positive for Pseudomonas aeruginosa.DLT placement plan for such a case? Thirdly, should an She was admitted on several occasions with fever, increas- Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2000
  • 5. P®tzner et al. Fig 2 CT chest scan at the level of the apical segment of the left lower lobe, revealing consolidation and cavity formation. a single catheter-mount connected to the DLT bronchial lumen was observed to produce left chest movement. Transfer of ventilation to the tracheal lumen produced rightFig 1 Posteroanterior chest x-ray revealing a left lower lobe opacity andan abscess with ¯uid level. chest movement, and the tracheal cuff was in¯ated to produce a seal. Next, the single catheter mount was transferred back to the bronchial lumen and auscultationing dyspnoea and/or haemoptysis, and although on each over the anterior apical region of the left chest during gentleoccasion there was a response to broad-spectrum intra- hand ventilation con®rmed the presence of vesicular breathvenous antibiotics, lobectomy was advised when the sounds. From that point onward, single-lung intermittenthaemoptysis became more voluminous and she became positive pressure ventilation was restricted to the right lungsigni®cantly anaemic. The favoured preoperative diagnosis until the left lower lobe resection had been completed.was either localized bronchiectasis or pulmonary seques- During the period when it was not ventilated, the left lungtration. Histopathology of the resected lobe revealed was connected to a 3-litre oxygen reservoir at ambientan actinomycosis abscess but no other underlying abnor- pressure.6 For reasons that will be discussed, the ®breopticmality. bronchoscope was not used either before or after positioning The patient was anaesthetized in a semi-sitting (50° head- the patient for surgery.up) position, with meticulous preoxygenation, midazolam During the chest incision and until the thoracic cavity was1 mg, fentanyl 200 mg in divided doses, an initial dose of opened, the reservoir bag was seen to distend and collapsepropofol 80 mg and rocuronium 40 mg. While the patient as expected with each cycle of single-lung ventilation to thewas maintained in the 50° head-up position, gentle hand dependent lung.6 This tidal movement of the reservoir bagventilation with oxygen was performed for 3 min. The was in this case less pronounced than usual and, althoughpatient was then placed horizontally and, without further this was most likely a consequence of the left lower lobeventilation, elective rigid bronchoscopy was performed by pathology, the possibility of distal migration of the DLT tothe surgeon to assess bronchial anatomy/pathology and to occlude or partially occlude the left upper lobe bronchialperform tracheobronchial suction. An estimated 3 ml of ori®ce was also considered. However, because the peak andpurulent material was removed by direct suction from the plateau in¯ation pressures in the ventilated dependent righttrachea and airways, and the surgeon advised that the major lung were as expected and because there was no reduction inairways were small. pulse oximetry while performing single-lung ventilation In the light of this comment, and with ®breoptic with a fresh gas ¯ow of 50% N2O/O2, no intervention wasbronchoscope and left and right Robertshaw DLTs imme- thought necessary or justi®able. This decision was vindic-diately at hand, a 35 FG Left Sheridan DLT was inserted ated by prompt left upper lobe collapse when the chest wasblind, to the perceived desired depth. In¯ation of the opened and easy re-expansion when the surgery wasbronchial cuff to a tension greater than usual in the 5 ml¯ating syringe and the pilot cuff was achieved with a Once the chest was opened and the operated lung wasrelatively small volume of air. Cautious hand ventilation via able to collapse down, the oxygen reservoir was temporarily 792
  • 6. Anaesthesia for lung abscessdetached from the bronchial lumen of the DLT while further well have resulted in spillage of infective material into thepurulent material was removed by suction. Only then was lower lobe bronchus of the `good lung.some air cautiously removed from the DLT bronchial cuff to Alternatively, performing or attempting to performreturn it to a more usual tension. This was performed whilst ®breoptic assessment and ®breoptic-assisted intubationlistening with an ear pressed to the reservoir bag in order to with a patient maintained in the sitting position can beimmediately identify possible gas leakage past the cuff dif®cult or prolonged if secretions obscure vision.during the inspiratory phase of ventilation.6 Should suxamethonium have been used? Probably not in At surgery, the left lower lobe was distended and also this patient, but it would certainly be advisable in anypatchily consolidated. It was densely adherent over a large patient in whom dif®culties might be expected with gentlepart of its diaphragmatic surface, but, apart from the need to face-mask hand-ventilation.divide these adhesions, the lobectomy was uneventful and Should anaesthesia have been induced with the patientthe chest was closed with an apical and a basal drain. Before sitting on the horizontal lower half of an operating table thatthe re-expansion of the left upper lobe, the bronchial tree on is broken at the mid-point, with the patients thoraxthat side was again cleared by suction via the DLT bronchial reclining, abscess-side dependent, against the steeplylumen. At this time it was noticed that a considerable angulated upper half? Probably, yes! Once asleep andvolume of purulent material had drained from the operated paralysed, the patient could easily have been maintainedlung, ®lling the DLT bronchial lumen and extending into the abscess-side dependent, and the head-up tilt could havetubing leading to the reservoir bag. been reduced if necessary to facilitate bronchoscopy and Throughout the period of single-lung ventilation and an intubation.FIO2 reading of approximately 0.4, the SpO2 remained The next dilemma relates to the choice of DLT and thebetween 98 and 100%. plan for its placement. The necessary decisions will depend Postoperative recovery was uneventful, and the patient on previous experience and preferences. In this case, a rangewas able to lie happily in whatever position she liked. of DLTs and a ®breoptic bronchoscope were immediately at hand. The ®rst management option was the blind placement of a 35 FG Left Sheridan DLT, because it was felt that pus orDiscussion blood might obscure the view at ®breoptic bronchoscopy. AWith a cavitating lower lobe abscess, the ®rst dilemma plastic tube was chosen in preference to a Robertshaw DLTfacing the anaesthetist and surgeon is whether or not to aim because the external diameter of a medium Robertshawto achieve DLT lung separation while the patient is could have been too tight for the reputedly smallmaintained in a steep sitting or semi-sitting position. With airways. Otherwise, the more ®rmly anatomically shapedthe case described, this decision was in¯uenced by the fact Robertshaw tube would have been chosen. This DLTthat a preoperative rigid bronchoscopy was planned in order frequently appears to drop into place and, in the authorsto make a surgical assessment of the pathology, to clear view, is less likely to become dislodged by surgical tractionsecretions and to identify any atypical bronchial anatomy. in the course of the operation.Conacher has said for the same reasons, with regard to the If the left-sided Sheridan DLT had entered the right ratherneed for rigid bronchoscopy in the assessment or therapy of than the left main bronchus, the plan was to replace itbronchopleural ®stula, that `most experienced personnel immediately with a medium or small left Robertshaw. If theprefer to base the anaesthetic technique around this left Robertshaw had also entered the right main bronchus, itrequirement.7 was to have been replaced immediately with a right For the rigid bronchoscopy, the patient was anaesthetized Robertshaw. Use of the ®breoptic bronchoscope to guidein the semi-sitting position (about 50° from horizontal) but one of the left-sided clear plastic tubes down the left mainwas put in the horizontal position with the onset of good bronchus was considered as a last resort in our teams ordermuscle relaxation. The bronchoscopy and bronchial suction of priorities for this particular patient. However, since aunder direct vision were performed without delay, and no plastic and not a Robertshaw DLT was being used, a goodfurther ventilation was performed until after the DLT was case could have been made for positioning a ®breopticpositioned and the bronchial cuff in¯ated. Even so, some bronchoscope down the tracheal lumen and observing, ifmanagement teams might strive to retain the patient in the secretions had permitted, the passage of the bronchialsemi-sitting position for the bronchoscopy and until such component into the left main bronchus.8 9time as lung separation is secured. A conscious decision was made not to check DLT The course of action chosen depends on the preferred placement with the ®breoptic bronchoscope that waspractice of the individual surgical/anaesthesia team and by immediately at hand. The small volume of air injectedthe clinical circumstances of the individual patient. Rigid into the bronchial cuff of the left-sided DLT to produce anbronchoscopy with the patient 50° head-up used to be the airtight seal, the free gas movement in and out of the rightaccepted management for sputum retention after pulmonary lung and the con®rmation of vesicular breath sounds in theresection, but today it is a disappearing skill. Any partial left upper lobe by the anaesthetist who was also performingreduction of the degree of head-up tilt of our patient might the gentle hand ventilation were considered assurance 793
  • 7. P®tzner et al.enough. With these ®ndings and in this particular case, the In conclusion, anaesthesia for thoracotomy for cavitatinganaesthetist would not have de¯ated the cuffs and pulled lung abscess, with or without a history and hence risk ofback the tube, even if bronchoscopy via the DLT tracheal haemoptysis, should involve preoperative physiotherapy tolumen had failed to reveal any sign of the bronchial cuff. reduce secretions, appropriate patient positioning with the The third dilemma relates to the protection of the healthy lobe containing the abscess dependent relative to the rest ofparts of the lung that contains the abscess. The frequent the bronchial tree, careful preoxygenation, and an anaes-removal of secretions during surgery by suction via the DLT thesia plan that achieves prompt lung separation. Electivelumen on the diseased side is the standard recommend- rigid bronchoscopy before DLT placement allows bothation.5 A further and not previously reported measure is to surgical assessment of bronchial pathology and anatomy,refrain from ventilating the lung with the abscess until the and the ef®cient removal of secretions or pus. Once lungrisk of contamination is removed. If adopted, this will separation is achieved, not ventilating the lung with theinvolve a period of single-lung ventilation while the chest is abscess may reduce the risk of contamination of healthybeing opened and hence before the non-ventilated lung is parts of this lung. While the lung containing the abscess isable to collapse away from the chest wall. We recommend not being ventilated, there are both theoretical and practicalthat the airway of the non-ventilated lung is connected to an bene®ts in connecting this lung to an oxygen reservoir atambient-pressure oxygen reservoir to prevent ambient air ambient pressure. After the diseased lobe has been excised,and therefore nitrogen from entering the non-ventilated suction via the DLT lumen on that side before re-expansionlung.10 This practice has several bene®ts, both theoretical of the residual lobe will remove any purulent material thatand practical.6 has drained from the abscess in the course of surgery. One of the possible theoretical bene®ts while the patientis being positioned ready for surgery and while the chest isbeing opened is the oxygenation of the blood that continues Referencesto ¯ow through the non-ventilated but not yet collapsed 1 Bartlett JG. Lung abscess. In: Baum GL, Wolinsky E, eds. Textbooklung. This results in an atypical ventilation/perfusion of Pulmonary Diseases, 5th edn. Boston: Little, Brown, 1994; 607± 20mismatch, with good oxygenation of the shunted pulmonary 2 Davis B, Systrom DM. Lung abscess: pathogenesis, diagnosis andblood ¯ow but with no elimination of carbon dioxide once treatment. Curr Clin Topics Infect Dis 1998; 18: 252±73the PCO2 of gas in the reservoir bag has equilibrated with 3 Hirshberg B, Sklair-Levi M, Nir-Paz R, Ben-Sira L, Krivoruk V,that of the mixed venous blood. This atypical mismatch will Kramer MR. Factors predicting mortality of patients with lungin theory be expected to result in a small further increase in abscess. Chest 1999; 115: 746±50the relatively large arterial to end-tidal carbon dioxide 4 Philpott NJ, Woodhead MA, Wilson AG, Millard FJC. Lunggradient seen during thoracic anaesthesia.11 Thus, if there is abscess: a neglected cause of life threatening haemoptysis. Thorax 1993; 48: 674±5a delay in opening the chest and hence a delay in lung 5 Benumof JL, Alfery DD. Anesthesia for thoracic surgery. In:collapse, arterial blood gases may be required to guide the Miller RD, ed. Anesthesia, 5th edn. Philadelphia: Churchilllevel of minute volume ventilation. Livingstone, 2000; 1665±752 In the case presented, an additional practical bene®t of the 6 P®tzner J, Peacock MJ, Daniels BW. Ambient pressure oxygenambient-pressure oxygen reservoir was demonstrated. Once reservoir apparatus for use during one-lung anaesthesia.the chest was opened and surgery was progressing, the Anaesthesia 1999; 54: 454±8anaesthetist was able, by listening with the ear pressed 7 Conacher ID. Anaesthesia for thoracic and pulmonary surgery. In: Prys-Roberts C, Brown Jr BR, eds. International Practice ofagainst the reservoir bag,6 to de¯ate the bronchial cuff Anaesthesia. Oxford: Butterworth-Heinemann, 1996; 1/66/1±17carefully to a more usual tension without risk of creating an 8 Cheong KF, Koh KF. Placement of left-sided double-lumenunidenti®ed loss of the airtight seal. endobronchial tubes: comparison of clinical and ®breoptic- The small tidal movement in the reservoir bag before the guided placement. Br J Anaesth 1999; 82: 920±1chest was opened was probably caused by the pathological 9 P®tzner J. Double-lumen tube placement: protecting the goodprocess in the left lower lobe, and by infective material lung. Br J Anaesth 2000; 83: 291±2draining by gravity and obstructing or partially obstructing 10 P®tzner J, Peacock MJ, McAleer PT. Gas movement in the non- ventilated lung at the onset of single-lung ventilation for video-major airways on that side. It may also have been partly a assisted thoracoscopy. Anaesthesia 1999; 54: 437±43consequence of dependent lung ventilation causing mainly 11 IpYam PC, Innes PA, Jackson M, Snowdon SL, Russell GN.diaphragmatic rather than mediastinal displacement in this Variation in the arterial to end-tidal PCO2 difference during one-very thin patient.10 lung anaesthesia. Br J Anaesth 1994; 72: 21±4 794
  • 8. British Journal of Anaesthesia 85 (5): 795±7 (2000) Adult epiglottitis: an under-recognized, life-threatening condition W. A. Ames1*, V. M. M. Ward2, R. M. D. Tranter2 and M. Street2 1 Department of Anaesthesia, 1G323 University Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0048, USA. 2Royal Sussex County Hospital, Eastern Road, Brighton, UK *Corresponding author Epiglottitis in the adult can be fatal and should be treated with the same degree of concern and suspicion in respect of airway patency as in children. We present three cases of adult epiglot- titis in which the airway was lost prior to or during the intervention of an anaesthetist. We suggest that an emphasis on conservative management is distracting and belies the serious nature of this disease. Br J Anaesth 2000; 85: 795±7 Keywords: complications, epiglottitis Accepted for publication: May 27, 2000Epiglottitis is an in¯ammation of the supraglottic structures Case 2that can occur at any age. There is a reported increase in the A 73-yr-old male was admitted with less than a 24-h historyincidence of epiglottitis in the adult population.1 In contrast of sore throat, dysphagia and dyspnoea associated with mildto the aggressive management of epiglottitis in children, a inspiratory stridor. Fibreoptic nasendoscopy in the accidentmore conservative approach has been advocated in adults.2 and emergency department revealed a swollen, hyperaemicWe present three cases of adult epiglottitis where the airway epiglottis. Blood cultures were taken and he was com-was lost either before or during intervention of an menced on i.v. cefotaxime and dexamethasone 4 mg. Fouranaesthetist. hours later, on the otolaryngology ward, his respiratory status deteriorated rapidly. A surgical tracheostomy wasCase reports attempted under local anaesthesia but the procedure aban- doned when the patient became hypoxic and beganCase 1 convulsing. The anaesthetist was able to intubate the trachea orally in the unconscious patient, prior to transferA 41-yr-old male presented with a sudden onset of sore to the operating room for conventional tracheostomy. Thethroat, stridor and dyspnoea. He was previously ®t but patient was admitted to the intensive care unit and made anregularly smoked heroin. On arrival to the accident and uneventful recovery. The trachea was decannulated 4 daysemergency department, he rapidly developed complete later. Two blood cultures taken on the day of admission bothairway obstruction resulting in a respiratory arrest. grew Neisseria meningitis, later typed as Group Y. ThereManual ventilation by facemask proved ineffective and no was no other positive microbiology and virology screen wasi.v. access could be secured. Laryngoscopy was impossible normal.because of trismus. Intralingual succinylcholine 100 mg wasinjected and permitted laryngoscopy. A large mass arisingfrom the epiglottis was observed, completely obscuring thelarynx. Following oxygenation via an emergency cricothyr- Case 3oidotomy, the trachea was intubated nasally using a A 56-yr-old man was admitted to the accident and®breoptic bronchoscope. Intravenous cefotaxime was com- emergency department with acute onset of a sore throatmenced. A surgical tracheostomy was performed under and dysphagia. He was sitting up, dyspnoeic, and droolinggeneral anaesthesia and the patient admitted to a high saliva. A ¯exible nasendoscopy showed an oedematous,dependency area on the otolaryngology ward. A lateral soft enlarged epiglottis. An i.v. line was inserted, blood culturestissue neck radiograph (Fig. 1), MRI scan (Figs 2 and 3) and taken and Augmentin 1.2 g and hydrocortisone 200 mg were®breoptic nasendoscopy (Fig. 4) were performed once the given intravenously. The patient was transferred to theairway had been secured. The patient made a full recovery. operating theatre. During an inhalational induction ofCandida albicans was eventually cultured from the mass. anaesthesia with sevo¯urane, he developed complete airway Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2000
  • 9. Ames et al. Fig 3 Coronal MRI of case 1. Again the enlarged epiglottis (E) can beFig 1 Lateral soft tissue radiograph demonstrating the `thumb print sign seen above the laryngeal inlet (L).(E). The `vallecula sign (V) can be determined by identifying the baseof tongue (B) and tracing it inferiorly to the hyoid bone (B). If there isno pocket of air extending almost to the hyoid bone and roughly parallelto the pharyngotracheal air column, then the diagnosis of epiglottitis iscon®rmed. Laryngeal inlet is noted (L). Fig 4 Fibreoptic nasendoscopy view in case 1. Unlike the classic cherry red epiglottis in children, adult epiglottitis is characterized by diffuse in¯ammation of aryepiglottic structures. Both the epiglottis (E) and the arytenoids (A) are clearly in¯ammed. The laryngeal inlet (L) is noted.Fig 2 Sagittal MRI of case 1. The prominent swollen epiglottis (E) isclearly visible above the laryngeal inlet (L). The tracheostomy (T) is also Discussionnoted. Adult epiglottitis has an incidence of between 1±4 per 100 000 per annum3 4 and is described as having a lowobstruction. Intravenous succinylcholine 100 mg was morbidity and mortality.5 Nonetheless, mortality in adults isadministered and orotracheal intubation was attempted but around 7%, and some reports suggest it is as high as 20%.3failed. An emergency cricothyroidotomy was then per- Hingorani and colleagues6 observed that a similarly highformed using a 13-gauge transtracheal catheter. Jet venti- mortality in children prompted a change to an interventionallation was commenced and continued whilst a surgical practice. Even though adult epiglottitis is unpredictable andtracheostomy was performed. The trachea was decannulated occasionally catastrophic in outcome, conservative man-3 days later. Blood cultures were negative. agement is still preferred by many authors.2 5 796
  • 10. Adult epiglottitis Haemophilus in¯uenzae type B is found in as few as 17% in case 3). Friedman therefore recommended a rapidof adult patients with suspected epiglottitis.7 There is also a sequence induction with the facility to perform a cricothyr-high rate of negative blood cultures possibly suggestive of a oid puncture if intubation proves dif®cult.13 Bag and maskviral cause (although only herpes simplex has been ventilation can simply worsen or complete the airwayreported).5 Meningococcal epiglottitis is extremely rare obstruction and should be avoided.and we present only the seventh reported case; the ®rst was Neuromuscular blocking drugs are traditionally avoidedreported in 1995.8 Alternatively, epiglottitis may occur in epiglottitis (although succinylcholine was listed on afollowing mechanical injury such as the ingestion of caustic recent protocol for the management of paediatric epiglotti-material or the inhalation of hot objects, smoke or vapours. tis14). We used succinylcholine in two of the above caseEpiglottitis following illicit drug use has been described as a reports, including one intralingual injection. Although thisresult of the accidental inhalation of a heated objects.9 route is described in children, we could ®nd no reference toAlthough there has been an association with cigarette its use in adults.smoking,10 there are no reports linking epiglottitis and the In summary, a belief that epiglottitis is rare in adults hassmoking of heroin. The causal organism or factor is, contributed to misdiagnosis and high mortality rates. Wetherefore, often less identi®able in adults than in children. present three cases that are typical of adult epiglottitis, in An adult with epiglottitis usually presents with symptoms that there is no one identi®able causal agent or factor thatof sore throat and painful dysphagia.3 Drooling and stridor would allow rationalisation of a particular therapy. Toare infrequent presenting signs. In fact the presence of advocate conservative management belies the aggressivestridor, dyspnoea and a short duration of symptoms prior to nature of this disease. We believe there should be a greaterpresentation, are all described as predictors of airway loss in emphasis on early interventional support of the airway.the adult with epiglottitis.4 10 This is, however, controver-sial. For example, Wolf2 presented 30 patients in whomstridor was present and who were subsequently successfully Referencestreated conservatively. On the other hand, Mayo-Smith 1 Ryan M, Hunt M, Snowberger T. A changing pattern ofdescribed a patient who had no history of stridor, yet epiglottitis. Clin Pediatr 1992; 9: 532±5 2 Wolf M, Strauss B, Kronenberg J, Leventon G. Conservativesuddenly developed airway obstruction and died.11 Indeed management of adult epiglottitis. Laryngoscope 1990; 110: 183±5the three cases we present support the fact that the disease 3 Carey MJ. Epiglottitis in adults. Am J Emerg Med 1996; 14: 421±4presentation and progression is variable and that there are no 4 Solomon P, Weisbrod M, Irish JC, Gullane PJ. Adult epiglottitis:reliable markers that predict the need for invasive airway the Toronto Hospital experience. J Otolaryngol 1998; 27: 332±6support. 5 Frantz TD, Rasgon BM, Quesenberry CP Jr. Acute epiglottitis in The diagnosis of epiglottitis is essentially clinical but can adults. Analysis of 129 cases. JAMA 1994; 272: 1358±60be supported by indirect laryngoscopy. Typically, there is 6 Hingorani AD, Dziersk J, Jones AT, Golding-Wood D, Leigh JM. Adult epiglottitis: establish an early airway. BMJ 1994; 308: 719diffuse swelling of the aryepiglottic structures unlike the 7 Trollfors B, Nylen O, Carenfelt C, Fogle-Hansson M, Freijd A,classic cherry red epiglottis in children. Otherwise, once the Geterud A, Hugosson S, Prellner K, Neovius E, Nordell H,airway is deemed safe, a lateral, soft tissue radiograph may Backman A, Kaijser B, Lagergard T, Leinonen M, Olcen P,show a thickening of the epiglottis (`thumb print sign; see Pilichowska-Paszkiet J. Aetiology of acute epiglottitis in adults.Fig. 1). Ducic and colleagues have proposed the `vallecula Scand J Infect Dis 1998; 30: 49±1sign to improve the diagnostic accuracy of soft tissue 8 Schwam E, Cox J. Fulminant meningococcal supraglottitis: anradiographs.12 This stepwise approach attempts to identify emerging infectious syndrome. Emerg Infect Dis 1999; 5: 464±7 9 Mayo-Smith MF, Spinale J. Thermal epiglottitis in adults: a newthe vallecula as it nears the level of the hyoid bone. In the complication of illicit drug use. J Emerg Med 1997; 15: 483±5absence of a `deep and well-de®ned vallecula, the 10 Hebert PC, Ducic Y, Boisvert D, Lamothe A. Adult epiglottitis inradiological ®ndings support the diagnosis of epiglottitis. a Canadian setting. Laryngoscope 1998; 108: 64±9 If the clinical diagnosis of epiglottitis is made and the 11 Mayo-Smith M. Fatal respiratory arrest in adult epiglottits in theairway judged to be at risk, intervention should not be intensive care unit. Implications for airway management. Chestdelayed by attempts to obtain cultures or radiographs. 1993; 104: 964±5Treatment should begin promptly with intravenous antibi- 12 Ducic Y, Hebert PC, MacLachlan L, Neufeld K, Lamothe A. Description and evaluation of the vallecula sign: a newotics. Steroids have no accepted place and the bene®t of radiological sign in the diagnosis of adult epiglottitis. Ann Emergepinephrine, either nebulized or intramuscular, has yet to be Med 1997; 30: 1±6con®rmed. 13 Friedman M, Toriumi DM, Gyrbauskas V, Applebaum EL. A plea Either orotracheal intubation or tracheostomy may be for uniformity in the staging and management of adult epiglottitis.performed under local anaesthesia but both are potentially Ear Nose Throat J 1988; 67: 873±80stimulating procedures which may precipitate sudden loss 14 Parsons DS, Smith RB, Mair EA, Dlabal LJ. Unique caseof the airway. General anaesthesia may be performed with presentations of acute epiglottic swelling and a protocol for acute airway compromise. Laryngoscope 1996; 106: 1287±91an inhalational induction but can be complicated by arelatively prolonged excitation phase in adults (as occurred 797
  • 11. British Journal of Anaesthesia 85 (5): 798±800 (2000) Falsely elevated bispectral index during deep hypothermic circulatory arrest G. Mychaskiw*, B. J. Heath and J. H. Eichhorn University of Mississippi School of Medicine, Cardiac Anesthesiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MI 39216-4505, USA *Corresponding author A 2-month-old infant underwent repair of a ventricular septal defect under deep hypothermic circulatory arrest. Bispectral index and EEG suppression ratio were evaluated using an Aspect BIS monitor. Erroneous readings from the monitor could have led to a potentially dangerous alteration in surgical and anaesthetic management. Br J Anaesth 2000; 85: 798±800 Keywords: monitoring, electroencephalography Accepted for publication: May 27, 2000The bispectral index (BIS) is rapidly gaining acceptance oximeter (Somanetics Corporation, Troy, MI, USA). Inas a measure of hypnosis under anaesthesia. preparation for deep hypothermic circulatory arrest,Additionally, the BIS monitor unit can be used as a methylprednisolone, 10 mg kg±1 was administered and thereadily available and easily interpreted tool to ensure head was packed in ice. Following anticoagulation withEEG burst suppression during deep hypothermic circu- heparin, aortic and right atrial cannulae were placed andlatory arrest. This is displayed as a suppression ratio, cardiopulmonary bypass (CPB) was started. At the start ofwhich is the percentage of time during the preceding CPB the BIS was in the 40s. The patient was cooled to a core60 s in which EEG burst suppression occurred. We temperature of 18°C and deep hypothermic circulatoryreport a case where a BIS monitor (Aspect Medical arrest was instituted after 15 min of cooling time on CPB. AtSystems, Spotsylvania, VA, USA) demonstrated errone- the time of deep hypothermic circulatory arrest the BIS wasous readings during deep hypothermic circulatory arrest zero with a suppression ratio of 100. The cerebral mixedthat could have altered the anaesthetic and surgical venous oxygen saturation (SrO2) had increased from baselinemanagement of the patient. by more than 100% during cooling. Within the ®rst 5 min of deep hypothermic circulatory arrest, the SrO2 decreased to baseline. By 15 min of deepCase report hypothermic circulatory arrest the SrO2 had decreased overA 2-month-old, 3 kg male patient presented to the cardiac 50% from baseline and was below the limits of measure-surgery service for repair of a ventricular septal defect ment. The patients core temperature had started to slowly(VSD). Cardiac catheterization revealed a large muscular drift upward and by this time had reached 22°C. At 16 minVSD with a pulmonary to systemic blood ¯ow ratio of of deep hypothermic circulatory arrest the BIS abruptlygreater than 4 to 1. The patient was medically managed with increased to 98±100, with a suppression ratio of 0±10digoxin and furosemide and had no clinical evidence of (Fig. 1). The raw EEG tracing on the BIS monitor appearedcongestive heart failure at the time of surgery. ¯at and unchanged. The EMG readout on the monitor After placement of standard, non-invasive monitors, the throughout CPB was negligible. The surgeon was advised ofpatient was anaesthetized with fentanyl, 10 mg kg±1, the monitor readings and was asked to resume CPB as soonvecuronium, 0.1 mg kg±1, 30% oxygen in nitrous oxide, as possible. The repair was expedited and the patientand iso¯urane, 0.5±2.0 vol%. Anaesthesia was maintained returned to CPB within 5 min. Immediately on return towith the volatile agent and occasionally supplemented with CPB, the SrO2 again increased to over 100% offentanyl and vecuronium. Additional monitors placed after baseline. After approximately 10 min of rewarming theinduction included a femoral arterial catheter, internal BIS returned to its pre-deep hypothermic circulatory arrestjugular triple lumen catheter, Aspect model A-2000 BIS level in the 40s. The patient was weaned from CPB andmonitor (system revision 0.41) and cerebral venous the procedure concluded without further incident. He was Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2000
  • 12. Falsely elevated bispectral indexFig 1 Printout of BIS values during case. Note BIS in 40s at start of CPB, 09.35 h. BIS decreased to 00 by start of deep hypothermic circulatoryarrest, 09.50 h. BIS abruptly increased to 98±100 at 10.06 h, with return to baseline starting at 10.16 h as rewarming continued.extubated the next morning having suffered no apparent value in helping to assess optimal brain protection prior toneurological sequelae. deep hypothermic circulatory arrest. In this case the brain was cooled for 15 min prior to deep hypothermic circulatory arrest. The period of cooling wasDiscussion somewhat shorter than the usual practice at this institution,The bispectral index is an arti®cial variable arrived at by and was dictated by the surgeon as he felt the arrest timecomputer processing of, most commonly, a one-channel would be very brief for anatomic reasons. This appeared toEEG pattern via a proprietary algorithm of the Aspect have the desired result of metabolic suppression, asCorporation. This value, scaled from 0 to 100 re¯ects a evidenced by the signi®cant increase in SrO2. Appropri-patients level of hypnosis, and potentially, probability of ately, the BIS decreased while the suppression ratiorecall.1 This has become an important, if somewhat increased, correlating with EEG suppression induced byemotionally charged, anaesthetic safety issue in the last cooling. The rapid decrease in SrO2 following deepfew years. Some have even speculated that BIS monitoring hypothermic circulatory arrest, however, was disturbingwill become the next `standard of care.2 This has led to a and suggested a possible depletion of oxygen stores in therapid proliferation in the number of BIS monitors available brain, which may be seen following heterogeneous cooling,in operating rooms across the USA. The Aspect monitors, especially following an abbreviated cooling time. As thethe only presently available, are easy to use and interpret, temperature drifted upward, the BIS increased abruptly torequiring very little time to fully orient and train most high levels at 23°C after 16 min of deep hypothermicanaesthesia practitioners. An added advantage of the Aspect circulatory arrest. The most worrisome thought was that thismonitors is their ability to display real-time EEG tracings, could possibly represent the monitors interpretation ofaccompanied by the suppression ratio. With the caveat that seizure EEG secondary to anoxic insult. The surgeon wasthis offers a very limited picture of the total brain EEG advised of these concerns, but this was tempered by theactivity, the BIS monitors are thus a readily available and real-time EEG waveform, which appeared to be highlyeasily used EEG processing system for the detection of suppressed. It was our impression that this was most likelygross global changes. an artefactual product of the algorithms misinterpretation EEG monitoring during deep hypothermic circulatory of EMG activity or other radiofrequency interference. Thearrest is of controversial bene®t. It has been suggested that ice surrounding the patients head was wrapped in plasticoutcome is improved when EEG burst suppression is and towelling, thus increased electrode impedance was notachieved by cooling.3 Burst suppression has been used as thought to be a factor. The surgeon quickly completed thean indicator of adequate brain protection during deep repair and the patient was returned to CPB. When the brainhypothermic circulatory arrest.4 There are other studies, had been rewarmed, the BIS returned to pre-cooling levels,however, which do not demonstrate improved outcome further reinforcing our belief that this was an artefact,from use of EEG monitoring.5 As a result of these issues, although amelioration of seizure activity by improvedcoupled with the logistical and economic pressures of perfusion remained a possibility. In approximately 30equipment and personnel availability, EEG monitoring deep hypothermic circulatory arrest cases prior to the oneduring deep hypothermic circulatory arrest is not applied reported, the BIS had not displayed this activity, but ratheruniversally and varies greatly among institutions. The wide remained highly suppressed until the brain had beenavailability and ease of use of the Aspect BIS monitors rewarmed. It has also not appeared in the 10 casesobviates some of these concerns. Although its bene®t has subsequent to the case reported. In the postoperative periodnot been demonstrated in peer-reviewed studies, the the patient demonstrated no evidence of neurologic insultsuppression ratio detected by BIS monitors may be of and was discharged home after an uneventful recovery. 799
  • 13. Kitagawa et al. Both EMG activity and radiofrequency interference from lead to unnecessary therapeutic interventions. Observationelectrical equipment in the operating theatre in¯uence the of the real-time EEG waveform may aid in the diagnosis ofBIS algorithm. Under normal conditions, the EEG is of this artefact, which, in our experience, occurs infrequently.suf®cient power to override these other electrical sources Further studies are necessary to determine if monitoringand is thus weighted appropriately by the algorithm. In suppression ratio and BIS during deep hypothermic circu-circumstances of extreme EEG suppression, as during deep latory arrest is bene®cial and cost effective.hypothermic circulatory arrest, it is possible that electricalinterference from either EMG or radiofrequency noise maybe interpreted by the algorithm as EEG activity and assigned Acknowledgementa high BIS value. When EEG activity resumes, as during All work funded through the Department of Anesthesiology, University of Mississippi School of Medicine.rewarming, the monitor then re-interprets it appropriately,discounting the EMG and radiofrequency activity in thealgorithm (personal communication, David Zaraket, Aspect ReferencesCorporation). This appears to have happened in our case, as 1 Sigl JC, Chamoun NC. An introduction to bispectral indexthere was no demonstrable evidence of neurologic insult, analysis for the EEG. J Clin Mon 1994; 10: 392±404such as seizure activity or choreoathetosis, seen post- 2 Mychaskiw G, Eichhorn JH. Patient safety and cost bene®ts ofoperatively. monitoring. In: Lake C, Hines RL, Blitt C, eds. Clinical Monitoring: In conclusion, we present a case where electrical Practical Applications. New York, NY: W.B. Saunders (in press). 3 Nakashima K, Todd MM, Warner DS. The relation betweeninterference was misinterpreted as EEG activity by an cerebral metabolic rate and ischemic depolarization. AAspect A-2000 BIS monitor during a period of intense EEG comparison of the effects of hypothermia, pentobarbital andsuppression. This misinterpretation was displayed as a high iso¯urane. Anesthesiology 1995; 82: 1199±1208BIS value with a low suppression ratio. Observation of the 4 Sebel PS. Central nervous system monitoring during open heartreal-time EEG waveform suggested that this was an artefact, surgery: an update. J Cardiothorac Vasc Anesth 1998; 12: 3±8but was not absolutely conclusive. During periods of 5 Roach GW, Newman MF, Murkin JM, et al. Ineffectiveness ofsigni®cant EEG suppression, BIS monitors may mis- burst suppression therapy in mitigating perioperative cerebro- vascular dysfunction. Anesthesiology 1999; 90: 1255±64interpret electrical interference as EEG and could possibly British Journal of Anaesthesia 85 (5): 800±2 (2000) Perioperative management of a patient requiring surgery for pituitary apoplexy and severe angina pectoris H. Kitagawa*, K. Takahashi, Y. Hirasaki and T. Ishii Department of Anesthesia, Nagahama City Hospital, 313 Ohinui-cho, Nagahama, Shiga, 526-8580, Japan *Corresponding author We describe the management of a 71-yr-old man with pituitary apoplexy and severe angina pectoris who underwent treatment of an intra-cranial haemorrhage and open-heart surgery requiring anticoagulant therapy within a very short period. Subtotal removal of the pituitary tumour was undertaken under stable cardiovascular conditions. But ventricular ®brillation occurred after the neurosurgery in the intensive care unit. After the patient was de®brillated, intra-aortic balloon pumping was necessary to assist coronary artery blood ¯ow. Twenty hours after neurosurgery, oozing from the surgical wound stopped and coronary artery bypass graft- ing with full heparinization was performed uneventfully. Br J Anaesth 2000; 85: 800±2 Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2000
  • 14. Pituitary apoplexy and severe angina Keywords: complications, intracranial haemorrhage; surgery, cardiovascular, brain tumour; heart, ischaemia Accepted for publication: May 27, 2000Pituitary apoplexy is a clinical syndrome of sudden haemor- ventilation with a tidal volume of 10 ml kg±1 andrhagic necrosis of the pituitary gland.1 2 Subsequently, respiratory rate of 12 min±1 was adjusted to maintaintumour expansion causes headache, visual ®eld de®cit and normocapnia. Dopamine 3±7 mg kg±1 min±1, nitro-ophthalmoplegia. Recovery of the patient depends on the glycerine 0.15±0.7 mg kg±1 min±1, diltiazem 0.06±0.1duration and severity of symptoms. Surgical treatment of mg kg±1 h±1 and lidocaine 1 mg kg±1 h±1 wereintracranial haemorrhage is recommended immediately administered continuously throughout surgery. Afterafter appearance of the neurological symptoms. bifrontal craniotomy, the neurosurgeon approached the We experienced a rare case of a patient with pituitary tumour inter-hemispherically and performed subtotalapoplexy coexisting with severe angina pectoris, which tumour resection. The 10-h surgery was completedrequired urgent coronary artery revascularization. However, without complication and with a blood loss of onlyanticoagulant therapy for cardiopulmonary bypass (CPB) 300 ml. Examination of the surgical specimens revealedmight have induced intra-cranial haemorrhage. Pituitary haemorrhagic and necrotic pituitary tissue. After surgery,apoplexy has been reported to occur following coronary the patient was haemodynamically stable and wasartery bypass grafting.3±7 Sequential management of the transferred to an intensive care unit, where he wasintracranial haemorrhage and open-heart surgery requiring ventilated mechanically and sedated with midazolam.anticoagulation present a challenge to the anaesthetist. When suctioning was performed through the tracheal tube, ventricular ®brillation suddenly occurred. The patient was cardioverted, additional lidocaine (1 mg kg±1)Case report was administered and sinus rhythm returned. However,A 71-yr-old man (weight 54 kg) was referred to our premature ventricle complexes occurred frequently andhospital for surgical treatment of severe triple-vessel systolic blood pressure was below 90 mm Hg. An intra-coronary artery disease. On admission, he was suffering aortic balloon pump was placed through the left femoralfrequent episodes of angina pectoris at rest requiring artery to assist coronary artery blood ¯ow. We did nottreatment with nitroglycerine (0.3 mg kg±1 min±1), use any anticoagulant to prevent bleeding from thediltiazem (0.06 mg kg±1 h±1) and lidocaine (1 mg kg±1 surgical site. We delayed cardiac surgery for about 20 hh±1) i.v. He had a past medical history of hypertension after neurosurgery until oozing from the subcutaneousand a myocardial infarction. drainage site stopped. The CABG procedure was then A pituitary tumour had been diagnosed by cranial undertaken. Upon arrival in the operating room, acomputed tomography (CT) 2 days before admission. He pulmonary artery catheter was placed via the internalhad had a slight headache but no other neurological de®cits. jugular vein. Anaesthesia was induced with midazolam 2In hospital awaiting cardiac surgery, he became comatose mg and fentanyl 100 mg, then maintained with propofoland was found to have a Glasgow Coma Score (GCS) of 6. 2 mg kg±1 h±1 and fentanyl 2 mg kg±1 h±1 intravenously.Neurological examination revealed dilated bilateral pupils, Muscle relaxation was obtained with pancuronium 6 mga visual ®eld de®cit, ophthalmoplegia and proptosis. and maintained with intermittent boluses. The patientReview of the CT showed a fairly large, iso-dense and continued to receive dopamine, nitroglycerine, diltiazemhigh-density sellar mass with haemorrhage. The tumour and lidocaine at the same doses until starting CPB. Theextended into the suprasellar cistern with compression of the duration of aortic clamping was 60 min and that of CPBoptic nerves and cavernous sinus on both sides. There was was 100 min. The patient was weaned from CPBhaemorrhage into the ventricle and brain tissue. uneventfully, but balloon pump was continued. He underwent emergency neurosurgery before cardiac Mechanical ventilatory support was continued in thesurgery. In the operating room, invasive blood pressure, intensive care unit. On the second day postoperatively,central venous pressure, pulse oximetry, end-tidal carbon CT brain revealed no haemorrhage. The patient regaineddioxide and the electrocardiogram were monitored. airway re¯exes and spontaneous ventilation. The tracheaAnaesthesia was induced with midazolam 2 mg and was extubated. A week after neurosurgery, diabetesfentanyl 200 mg. Pancuronium 8 mg was administered to insipidus developed and was treated with vasopressin 10facilitate tracheal intubation. Anaesthesia was maintained u. day±1 intravenously. For about a month after thewith 0.5±2% sevo¯urane and an i.v. fentanyl (2 mg kg±1 CABG procedure, his conscious state ¯uctuated betweenh±1) infusion, and muscle relaxation was maintained somnolence and delirium. When delirious, the patientwith intermittent boluses of pancuronium. Mechanical was sedated by a midazolam 1±2 mg h±1 infusion. 801
  • 15. Kitagawa et al.Within a month, he recovered and had a GCS of 14. surgery, it might worsen the angina pectoris.1 2 For example,Visual ®eld de®cit and ophthalmoplegia gradually administration of vasopressin induces coronary vasocon-improved. striction. It is, therefore, important to perform cardiac surgery before any uncontrollable endocrine failure occurs. This is one of the reasons why we performed theDiscussion neurosurgery before the cardiac surgery.Pituitary apoplexy is due to an intra-cranial tumour, into In conclusion, we managed a patient with severe anginawhich haemorrhage produces an expanding mass, causing pectoris and pituitary apoplexy. We have described a twovisual and neurological impairment. The patient requires staged operation with sequential management of intra-neurosurgical treatment immediately. Severe unstable cranial haemorrhage and open-heart surgery requiringangina with the necessity for an urgent CABG procedure anticoagulant therapy. Our case illustrates the importancecoexisted with the pituitary expansion in this patient. It is of coronary care during the time between the twooften suggested that non-cardiac surgery and CABG should performed simultaneously.8 9 In this case, however,anticoagulant therapy with CPB would have induced intra-cranial haemorrhage and the neurological prognosis could Referenceshave been worse. Confronted with such con¯icting situ- 1 Rolih CA, Ober KP. Pituitary apoplexy. Endocrinol Metab Clinations, we had a dilemma regarding the best surgical North Am 1993; 22: 291±302management. 2 Gaillard RC. Pituitary gland emergencies. Ballieres Clin Endocrinol Metab 1992; 6: 57±75 In patients with severe angina pectoris and a history of 3 Wiesmann M, Gliemroth J, Kehler U, Missler U. Pituitarymyocardial infarction, the risk of perioperative cardiac apoplexy after cardiac surgery presenting as deep coma withcomplications including death is increased. The American dilated pupils. Acta Anaesthesiol Scand 1999; 43: 236±38Heart Association reported that the frequency of myocardial 4 Shapiro LM. Pituitary apoplexy following coronary artery bypassinfarction and death during simultaneous carotid endarter- surgery. J Surg Oncol 1990; 44: 66±8ectomy and a CABG procedure is lower than in a staged 5 Pliam MB, Cohen M, Cheng L, Spaenle M, Bronstein MH,operation.10 Allie and colleagues recommended that a rapid Atkin TW. Pituitary adenomas complicating cardiac surgery: summary and review of 11 cases. J Cardiovasc Surg 1995; 10:staged procedure (an interval between endarterectomy and 125±32CABG procedure of less than 24 h) with intra-aortic balloon 6 Slavin M, Budabin M. Pituitary apoplexy associated with cardiacpumping was safe and effective in the very high risk patient surgery. Am J Ophthalmol 1984; 98: 291±6population with coronary artery disease.11 But the optimal 7 Cooper DM, Bazaral MG, Furlan AJ, Sevilla E, Ghattas MA,strategies for the management of patients with carotid and Sheeler LR, Little JR, Hahn JF, Sheldon WC, Loop FD. Pituitarycoronary artery disease have not been established. In this apoplexy: a complication of cardiac surgery. Ann Thorac Surgpatient, the neurological prognosis depended on immediate 1986; 41: 547±50 8 Davidkov L, Ninkov P, Aleksandrov G, Nachev G, Chirkov A.neurosurgical decompression. We, therefore, performed One-stage operations in pathology of the heart valves andneurosurgery before the CABG procedure as a staged coronary vessels and other general surgical diseases in 124operation. patients. Khirurgiia (So®ia) 1995; 48: 43±7 The point at which intra-cranial haemostasis is achieved 9 Kamiike W, Miyata M, Izukura M, et al. Simultaneous surgery forafter neurosurgery remains uncertain. Wijdicks reported coronary artery disease and gastric cancer. World J Surg 1994;that restarting anticoagulation therapy in a patient with 18: 879±82mechanical heart valves is safe 1±2 weeks after intracranial 10 Moore WS, Barnett HJM, Beebe HG, et al. Guidelines for carotid endarterectomy, A multidisciplinary consensus statement fromhaemorrhage.12 However, in this patient, we could not delay the ad hoc committee. American Heart Association. Stroke 1995;the CABG procedure because the patient had ventricular 26: 188±201®brillation and required mechanical support using intra- 11 Allie DE, Lirtzman M, Malik AP, Kowalski JM, Barker EA, Walkeraortic balloon pumping. When the oozing from the CM. Rapid-staged strategy for concomitant critical carotid andneurosurgical wound stopped, we immediately performed left main coronary disease with left ventricular dysfunction: IABPthe cardiac surgery using anticoagulant therapy 20 h after use. Ann Thorac Surg 1998; 66: 1230±5neurosurgery. 12 Wijdicks EFM, Schievink WI, Brown RD, Mullany CJ. The dilemma of discontinuation of anticoagulation therapy for Endocrine failure is a problem in a staged operation. If patients with intracranial haemorrhage and mechanical heartacute adrenal insuf®ciency, hypothyroidism and diabetes valves. Neurosurgery 1998; 42: 769±73insipidus occur during the perioperative period of cardiac 802