Perioperative visual loss after nonocular surgery.

Although rare, a change in visual acuity after surgery for nonocular procedures has devastating consequences. Increased recognition and discussion of this complication is reported in recent literature, most notably following spinal and cardiac surgery. Various pathologies may be responsible for perioperative visual loss (POVL), including ischemic optic neuropathy, retinal vascular occlusion, and cortical blindness. Here we review the incidence of the problem, the anatomy and physiology of the ocular circulation, variants of POVL, and proposed predisposing factors. Potential perioperative methods to prevent this complication are discussed, and suggested treatment modalities are presented.

Combination of oral ketamine and midazolam as a premedication for a severely autistic and combative patient.

Patients with impaired ability to understand and communicate can be difficult to manage perioperatively. They frequently require lateral thinking on the part of the anesthesiologists to make the induction process as smooth as possible. We present a case of a severely autistic and violent patient scheduled for dental rehabilitation under general anesthesia. A combination of oral ketamine and midazolam was mixed in the beverage Dr Pepper to mask the taste and the appearance of the drugs. The unique flavor of Dr Pepper is well suited to increase the palatibility and the acceptability of medications in children and patients with developmental delay.

Use of Intralipid in an infant with impending cardiovascular collapse due to local anesthetic toxicity.

Local anesthetic-associated cardiac toxicity following caudal epidural blockade is, fortunately, a rare event. Prompt recognition and early treatment is the key to successful resuscitation. Early use of the lipid emulsion Intralipid in bupivacaine-induced cardiac toxicity may lead to a good outcome.

Carbamazepine-induced angioedema.

Angioedema is a rare adverse reaction of carbamazepine, which causes localized tissue edema in submucosal and subcutaneous tissue mediated by histamine, serotonin, and kinins (bradykinin). We report a case of 34-year-old female who developed angioedema, 24 h after administration of carbamazepine for treating bipolar disorder. Patient's symptoms responded rapidly with antihistamine therapy and with the withdrawal of carbamazepine, the offending drug. Carbamazepine-induced angioedema is a life-threatening reaction which requires immediate treatment and monitoring in order to avoid morbidity and mortality.

Caring for the patients with cervical spine injuries: what have we learned?

PURPOSE: Anesthesiologists are often involved in the early management and resuscitation of patients who have sustained cervical spine injuries (CSIs). The most crucial step in managing a patient with suspected CSI is the prevention of further insult to the cervical spine (C-spine). In this review, important factors related to initial management, diagnosis, airway and anesthetic management of patients with CSI are presented. SOURCE: Medline search was performed to seek out the English-language literature using the following phrases and keywords: spine trauma; cervical spine; airway management after CSI. PRINCIPAL FINDINGS: Cervical spine injury occurs in up to 3% to 6% of all patients with trauma. The initial management of a patient with potential spine injury requires a high degree of suspicion for CSI so that early stabilization of the spine can be used to prevent further neurological damage. Diagnostic radiology has a critical role to play; however, clinical evaluation is equally important in excluding CSI in a conscious and cooperative patient. Although in-line stabilization reduces the movement at C-spine, traction causes clinically significant distraction and should be avoided. CONCLUSION: A high level of suspicion and anticipation are the major components of decision making and management in a patient with CSI. Endotracheal intubation using the Bullard laryngoscope may have some advantages over other techniques as it causes less head and C-spine extension than the conventional laryngoscope, and this results in a better view. However, the current opinion is that oral intubation using a Macintosh blade after intravenous induction of anesthesia and muscle relaxation along with inline stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI. In summation caution, close care and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique.

Cuffed endotracheal tubes in infants and children: a technique to continuously measure the intracuff pressure.

OBJECTIVES: Various devices have been used to measure the intracuff pressure (CP) of an endotracheal tube at the time of inflation; however, no device has found widespread acceptance for the continuous monitoring of CP. We devised a simple method to continuously measure the CP using an invasive pressure monitoring setup (IPMS), which is used routinely in the operating room to monitor arterial or central venous pressures. The accuracy of the device was compared to those obtained from a commercially available and clinically used manometer (MM). METHODS: Size 4.0, 5.0 and 6.0 mm ID cETTs were placed into one of 3 sizes of polyvinylchloride (PVC) tubes. The cuff of the cETT was inflated after inserting the cETT into the PVC pipes. After inflation, the CP was simultaneously checked using the MM and the IPMS. A total of 100 simultaneous (IPMS and MM) readings were obtained from each of the 3 sizes of cETT with the intracuff pressure randomly varying between 10 and 40 cmH2O. Statistical analysis included a Bland-Altman comparison to determine the bias, mean, and 95% levels of agreement (LOA), and a linear regression analysis. RESULTS: Linear regression analysis demonstrated an R(2) value of 0.988, 0.9899, and 0.9879 when comparing the pressure from the IPMS and MM from the 4.0, 5.0 and 6.0 mm cETT, respectively. CONCLUSIONS: A standard IPMS can be used to continuously monitor intracuff pressure with the use of a cETT. Although various techniques can be used safely to avoid hyperinflation of the cuff, they provide only an instantaneous measure of the CP. The current technique allows for continuous monitoring of CP during prolonged cases or in other clinical scenarios when such monitoring is required.