Incidental thrombocytosis: Should it concern the anesthesiologist?

Preoperative thrombocytosis, often detected incidentally in surgical patients and inadvertently overlooked, has important implications for the anesthesiologists. The primary form is a chronic clonal myeloproliferative disorder usually affecting adults while the secondary type is a benign reactive disease commonly found in children. Serious perioperative hemostatic complications are reported in primary thrombocytosis and hence, a detailed preoperative evaluation and initiation of therapy to lower the platelet count (PC) is required before undertaking surgery. Patients with reactive thrombocytosis however, usually have complication-free surgeries, and if there is no prior evidence of hemostatic complications and the reactive cause can be identified, no specific perioperative intervention may be required. A thorough preanesthetic checkup and implementation of basic thrombo-prophylaxis measures in all patients with a raised PC is advocated. We present here our experience with three infants diagnosed with high preoperative PC, presumably due to reactive causes, who underwent uneventful neurosurgeries at our institution.

Laryngoscopic View after Application of Manual In-Line Stabilization - A Comparison with Early Morning Sniffing Position in the Same Patient.

Background: The application of manual in-line stabilization (MILS) for minimizing spinal cord injury is known to increase difficulty in airway management. Aim: The study aims to assess the change in Modified Cormack-Lehane (CL) laryngoscopic view with the application of MILS from the early morning sniffing position (EMSP) in adult patients. Setting and Design: This was a prospective, interventional, self-controlled study conducted on 220 patients aged 18-65 years, belonging to the American Society of Anesthesiologists Physical Status Class I or II, having a normal airway, and scheduled for elective surgery under general anesthesia. Materials and Methods: After inducing general anesthesia, MILS was applied to the patient's neck, and a Modified CL view of the vocal cords was recorded under direct laryngoscopy. The view was again noted after applying backward-upward-rightward pressure (BURP). MILS and BURP were released. The view was obtained again with and without BURP in EMSP. Statistical Analysis: Normality of data was tested by Kolmogorov-Smirnov test. Wilcoxon ranked-sum test for quantitative variables and Chi-square test for qualitative variables were used. Results: On application of MILS, the majority of patients had Modified CL Grade 3a (121 patients) and 3b (53 patients) views. The majority of patients had Modified CL Grade 1 (114 patients) and 2a (71 patients) views on placing in EMSP. These findings were statistically significant (P < 0.0001). Consequent to the placement of BURP upon MILS, patients with lower CL Grade views (2b: 101 patients) were significantly higher (P < 0.0001) in comparison with MILS alone. Conclusion: In patients with a normal airway, MILS leads to a significantly greater incidence of higher grades of laryngoscopic views in comparison to EMSP. Use of BURP after MILS causes significantly less incidence of higher grades of laryngoscopic view when compared with MILS alone. All patients requiring MILS should be considered to be a difficult airway, and hence, preparation should be done accordingly.

Comparison of Videolaryngoscope and Intubating Laryngeal Mask Airway for Tracheal Intubation with Manual-in-line Stabilization in Patients Undergoing Cervical Spine Surgery.

BACKGROUND: This prospective, randomized study compared CMAC® videolaryngoscope with intubating laryngeal mask airway (ILMA) for intubation under manual-in-line-stabilization (MILS) in patients undergoing cervical spine surgery. Settings and Design: Sixty-five ASA Physical Status Classes I and II patients aged 18-65 years undergoing elective cervical spine surgery were randomly allocated into two groups: group CM-intubation with CMAC® videolaryngoscope (n = 33) and Group IL-intubation using ILMA (n = 32). MATERIALS AND METHODS: Intubation was performed in all patients after the application of MILS. The primary outcomes included first attempt and overall intubation success rate, intubation time, and apnea time. The secondary objectives were degree of head movement, hemodynamic response, incidence of desaturation, sore throat, and tissue injury. STATISTICAL ANALYSIS: Normality of data was tested by the Kolmogorov-Smirnov test. Quantitative variables were compared using the unpaired t-test or Wilcoxon Mann-Whitney test and qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. RESULTS: CM group had a higher first attempt (96.97%, P = 0.054) and overall (100%, P = 0.053) intubation success rate than IL group (81.25% and 87.5%, respectively). Group CM had a significantly shorter (P < 0.0001) intubation time (33.13 ± 11.82 s) than IL group (55.71 ± 19.28 s), but group CM had significantly longer (P < 0.0001) apnea time (33.13 ± 11.82 s) than IL group (22.03 ± 7.14 s). The incidence of head movement was significantly lower in IL group (P = 0.011). Hypoxemia did not occur. Postintubation hemodynamic changes and tissue injury were significantly higher in ILMA group. CONCLUSION: CMAC group had higher intubation success rate and significantly shorter intubation time. However, ILMA group had a significantly shorter apnea time and significantly lower incidence of head movements.

Acute pulmonary edema and thrombocytopenia following venous air embolism during sitting position neurosurgery.

Venous air embolism (VAE) is a well-known complication of sitting position neurosurgery which most characteristically manifests as mild to severe hemodynamic alterations. Development of pulmonary edema is a known, though infrequent, manifestation of VAE. We report here the occurrence of acute pulmonary edema without accompanying hemodynamic changes in a patient undergoing retromastoid craniotomy and tumor decompression in the sitting position. The patient required supportive treatment and elective ventilation for 11 days before the edema resolved. He also developed significant postoperative thrombocytopenia which though, was self-limiting. Thus, VAE may manifest with atypical manifestations like pulmonary edema and thrombocytopenia that can significantly contribute to postoperative patient morbidity.

Managing tracheal extubation in infants with stridor and congenital neuraxial anomalies.

Stridor is a serious complication of congenital neuraxial anomalies, which though, can get completely resolved with early neurosurgical correction of the anomaly. However, stridor relief may or may not be achieved soon after surgery. Persistent postoperative stridor can potentially cause extubation failure that may be difficult to handle in small children. There are no extubation guidelines for difficult pediatric airways as yet, and fewer appropriate airway-assist devices for routine use. Management of an infant with occipital encephalocele, hydrocephalus and bilateral abductor vocal cord palsy, who developed post-extubation respiratory distress due to stridor is discussed, together with the relevant tracheal extubation issues in such cases.

Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal and epidural anaesthesia.

BACKGROUND: Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one. OBJECTIVES: WE PERFORMED A STUDY TO COMPARE TWO POPULAR CSE TECHNIQUES: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT). METHODS: After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared. RESULTS: SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups. CONCLUSION: SDT is an acceptable alternative to DST and SST.

Negative-pressure pulmonary oedema in a patient undergoing shoulder arthroscopy.

An 18-year-old ASA-I patient who underwent elective left shoulder arthroscopy developed severe airway obstruction post-extubation due to fluid extravasation from the shoulder joint into the neck and airway tissue. Re-intubation for relief of obstruction resulted in negative-pressure pulmonary oedema. The patient was electively ventilated in the intensive care unit and recovered uneventfully. A high index of suspicion along with monitoring of neck circumference can prevent this kind of complication.