Difficult airway in advanced Bechterew's disease: case report.

Advanced Bechterew's disease presents with increasing ossification of spinal column, from lower lumbar segments upwards, first causing impossibility to place spinal block in lumbar region, and later, due to stiffness of cervical spine, difficult intubation because of inability to extend and/or flex the neck during direct laryngoscopy and intubation. Mask ventilation, on the other hand, usually is possible. We report a case of a 77-year-old man scheduled for elective hernioplasty, with recently advanced Bechterew's disease. According to the recently accepted Mainz algorithm, we first intended to perform awake intubation through the nose by fiber bronchoscope. The bronchoscope passed easily down to tracheal bifurcation, but placing the endotracheal tube was unexpectedly impossible due to the consequences of broken nose the patient had suffered at the age of 8. Fiber bronchoscope was therefore retracted, and we used the Bonfils rigid fiberscope after induction of general anesthesia, achieving intubation in first attempt.

Difficult airway management in a polytraumatized patient with osteogenesis imperfecta and multiple congenital spinal and thoracic deformities and severe kyphoscoliosis: case report.

Airway management in a polytraumatized patient with severe spinal and thoracic deformities demands detailed investigation of anatomical characteristics of the head, neck and airways, as well as thoracic configuration, before attempting endotracheal intubation. This enables the physician to predict a difficult airway and prepare for difficult airway management. We present a case of a 50-year-old polytraumatized patient with multiple congenital bone deformities associated with the syndrome of osteogenesis imperfecta and severe kyphoscoliosis, unable of lying on his back due to gibbus, who was successfully intubated in first attempt using video laryngoscope and only mild sedation. In patients with such severe multiple deformities, the use of video laryngoscope or Bonfils rigid endoscope should be mandatory in order to ensure success of intubation in first attempt and to avoid the possible aspiration of gastric contents.

Subclinical neurocognitive dysfunction after carotid endarterectomy-the impact of shunting.

BACKGROUND: Subclinical neurocognitive deficit after carotid endarterectomy (CEA) has been reported in 25% of patients. The influence of the type of anesthesia and shunting on early postoperative neurocognitive function remains unclear. Therefore, we analyzed the cognitive function after CEA using a battery of psychometric tests before surgery and on the first postoperative day. METHODS: Twenty nine patients under regional and 28 under general anesthesia were included in the study. Regional anesthesia was administered inducing a superficial cervical block, and the general anesthesia was induced using a standardized manner. Then cognitive function was tested using a battery of psychometric tests before and 24 hours after surgery. S 100 beta was determined at the same time points. RESULTS: A statistical difference was found between the results of the testing before and after CEA: decline in digit symbol test (9%), perceptual speed (6%), and spatial working memory (44%) and improvement in verbal fluency (6%) and attention (5%). The only intraoperative factor that correlated with the cognitive dysfunction was shunt insertion; patients with a shunt had a lower perceptual speed (P=0.005) and worse spatial working memory (P=0.004). No correlation was found between the type of anesthesia or S 100 beta level and any psychometric test, but these results might be influenced by the small sample size in our study. CONCLUSIONS: Shunt insertion was the only parameter correlated with cognitive decline on the first day after CEA. Regional anesthesia might offer indirect benefit because of a reduced need of shunting in wakeful patients. Larger studies are required to clarify the role of shunting and type of anesthesia in early neurocognitive deficit after CEA and its impact on the quality of life.

Superficial versus combined (deep and superficial) cervical plexus block for carotid endarterectomy.

It is not clear if any technique of regional anesthesia for carotid endarterectomy has an advantage over another. Therefore, we analyzed analgesic efficacy side effects and complication rate in patients undergoing carotid surgery either under combined (deep and superficial) or superficial cervical block alone. Data on 324 patients that received either combined (n = 107) or superficial (n = 216) cervical block were prospectively analyzed. Data were collected on the intraoperative Verbal Analog Score (VAS), arterial pressure and heart rate. Analgesic efficacy was additionally assessed by the dose of supplemental 1% lidocaine and fentanyl and time before the first analgesic was administered at Intensive Care Unit. During surgery, VAS was slightly higher in the superficial group (median 0.6, range 0-3.9) than in the combined group (median 0.4, range 0-2.4; p < 0.001). The median supplemental lidocaine dose during the operation was higher in the superficial block group (2.4 mg/kg, range 1.1-3.5) than in the combined group (2.1, range 0.5-3.4 mg/kg; p < 0.001). Supplemental fentanyl was also higher in the superficial block group. There were no between-group differences in the time before the first postoperative analgesic, postoperative VAS and block-related complication rate. Accordingly combined block provided a slightly better analgesia during the surgery which was probably clinically irrelevant. There was no difference in postoperative analgesia and hemodynamic stability. So far, this is the largest prospective study in which superficial cervical block was found to be as efficacious as combined block which is associated with a considerably higher risk of complications.