The tracheal accordion and the position of the endotracheal tube.

The purpose of this review is to, first, determine the static factors that affect the length of the human trachea across different populations and, second, to investigate whether or not there are dynamic factors that cause the length of the human trachea to vary within the same individual. We also investigated whether these changes in tracheal length within the same individual are significant enough to increase the risk of endobronchial intubation or accidental extubation. A PubMed/MEDLINE and a Web of Science database English-language literature search was conducted in May 2016 with relevant keywords and MeSH terms when available. We found that gender, extremes of age, patient height, postsurgical changes and co-existing disease are static patient factors that affect the length of the human trachea. Dynamic clinical changes that occur under anaesthesia, including Trendelenburg position, head and neck flexion and extension, paralysis of the diaphragm and pneumoperitoneum, cause the trachea to act as an accordion, decreasing and increasing its length. The length of the human trachea in both awake and anaesthetised and paralysed patients is a critical consideration in preventing both endobronchial intubation and tracheal extubation. It is clear from the literature that tracheal length varies widely across populations and, additionally, with the dynamic clinical changes that occur under anaesthesia, the trachea acts as an accordion decreasing and increasing its length within the same individual. Knowledge of the magnitude of the change in tracheal dimensions in response to these factors is an important clinical consideration.

Subglottic tracheal stenosis in pregnancy: anaesthetic implications.

We present the first reported case of a pregnant patient with severe subglottic tracheal stenosis who required elective surgical tracheostomy prior to administration of labour analgesia.

Amphetamine abuse in pregnancy: anesthetic implications.

The prevalence of recreational substance abuse amongst young adults (including women in child-bearing age) has markedly increased over the past two decades and it remains one of the major problems facing our society today--worldwide. Amphetamine is one of the most common substances abused in pregnancy and one of the most potent sympathomimetic amines with respect to stimulatory effects on the central nervous system. The following case report illustrates the problems that may arise during anesthesia in the parturient with recent amphetamine intake.

Once a post-dural puncture headache patient always post-dural puncture headache patient?

It is well known that symptoms of post-dural puncture headache (PDPH) are more likely if there has been a preceding PDPH. We herein present a patient who developed a PDPH following each of two dural punctures separated by 9 years.

Complete recovery from prolonged cardio-pulmonary resuscitation following anaphylactic reaction to readministered intravenous cefazolin.

We describe a patient who developed a type I anaphylactic reaction to intravenous cefazolin. The patient had no known drug allergies and had previously received intraoperative intravenous cefazolin 2 months prior without any problems. Forty-fives after receiving cefazolin 1 g i.v. and while fully awake, the patient experienced shortness of breath, became unconscious, and then suffered a cardiac arrest. Resuscitation included endotracheal intubation, external cardiac compression, electrical defibrillation and multiple large doses of epinephrine, atropine, and sodium bicarbonate over the course of 2.5 h and three cardiac arrests. Nevertheless, the patient fully recovered. The intent of this case report is to address widely held concerns regarding cross-reactivity of cephalosporin, particularly cefazolin, to penicillin, the legitimacy of test dosing as a means to safely identify patients who will have an allergic reaction to cephalosporins and comment on patient-related predictors of survival following cardiopulmonary resuscitation and the good outcome in this case.

Decrease in the incidence of post-dural puncture headache: maintaining CSF volume.

The incidence of epidural needle-induced post-dural puncture headache (PDPH) in parturients following dural puncture with a large bore (18-gauge) needle has been reported to range 76-85%. We describe seven cases in which the performance of epidural anesthesia in parturients was complicated by an unintentional dural puncture with an 18-gauge epidural needle. In all seven cases, the unintentional dural puncture was followed by (i) injection of the CSF in the glass syringe back into the subarachnoid space through the epidural needle, (ii) insertion of a epidural catheter into the subarachnoid space (now referred to as an intrathecal catheter), (iii) injection of a small amount of preservative free saline (3-5 ml) into the subarachnoid space through the intrathecal catheter, (iv) administration of bolus and then continuous intrathecal labor analgesia through the intrathecal catheter and then (v) leaving the intrathecal catheter in-situ for a total of 12-20 h. PDPH occurred in only one of these cases (14%).

Post-dural puncture syndrome in an elderly patient with remote history of previous post-dural puncture syndrome.

History of previous post-dural puncture syndrome (PDPS) is a strong risk factor for another PDPS when spinal anesthesia is readministered to these patients. We herein report a case to show that this general rule may still apply even after the passage of 50 years.

Repeat cesarean section in a morbidly obese parturient: a new anesthetic option.

Combined spinal epidural anesthesia (CSEA) has become an increasingly popular anesthetic technique for repeat cesarean section. However, the advantages of this technique have not routinely been available to morbidly obese patients because of the lack of an appropriately long needle. We present a case of a morbidly obese parturient who underwent repeat cesarean section under CSEA conducted with the recently introduced (and commercially available) CSEA needle set, specifically designed for morbidly obese patients.

Anesthetic management of a parturient with congenital cavernous transformation of the portal vein and chronic thrombocytopenia.

Cavernous transformation of the portal vein is a rare disorder resulting from extrahepatic portal vein thrombosis and development of collateral venous circulation. We report a case of a pregnant patient with congenital cavernous transformation of the portal vein associated with persistent consumptive coagulopathy and chronic thrombocytopenia. Single dose spinal anesthesia was safely conducted for an uneventful cesarean delivery.

Cesarean section and Ehlers-Danlos syndrome: choice of anesthesia.

Ehlers-Danlos syndrome is a rare genetically transmitted connective tissue disorder, non-specific to pregnancy. Because of multi-organ involvement and varied presentations of this disease, no uniform anesthetic recommendations can be made. We report a case of a parturient with Ehlers-Danlos syndrome who presented in active labor with spontaneous rupture of membranes and footling breech presentation. She received single dose spinal anesthesia for an uneventful emergency cesarean section.

Cesarean section in a parturient with HIV and recent cocaine and alcohol intake: anesthetic implications.

We present a case of a human immunodeficiency virus (HIV) positive, poly-substance abusing parturient who presented for an emergency cesarean section following recent cocaine and alcohol intake. Spinal anesthesia was selected for the abdominal delivery. 4 min after delivery of the fetus, the patient developed hypotension, intermittent runs of ventricular tachycardia, premature ventricular complexes and ST-segment elevation. Induction of general anesthesia, endotracheal intubation, intravenous lidocaine and phenylephrine were required to restore stability. At the end of surgery the patient was stable and was extubated. The ST-segment elevation returned to normal 45 min postoperatively. Her postoperative course was uneventful.

The preoperative evaluation form: assessment of quality from one hundred thirty-eight institutions and recommendations for a high-quality form.

STUDY OBJECTIVE: To develop a rating system to evaluate the preoperative evaluation form in three categories: informational content, ease of use, and ease of reading; to analyze forms contributed by the Association of Anesthesia Clinical Directors; to offer an example of a more optimal form; and interest practitioners in evaluating the quality of their evaluation forms. SETTING: University medical center. DESIGN/MEASUREMENTS: The informational content of the forms was graded by a rating system developed to give a score based on the importance of the data to anesthesia management and legal documentation. Based on the amount of informational content, the forms were grouped into categories ranging from severely deficient to excellent. The ease of use and ease of reading were determined by specific criteria. MAIN RESULTS: 138 forms were analyzed. The mean +/- SD information score was 265 +/- 41, with a range of 140 to 333 (maximum score possible = 363). Fifteen percent of the forms were considered severely deficient to substandard whereas 52% were deemed very good to excellent. A large proportion of forms omitted at least one essential information item. Twelve percent and 6% were labeled poor with regard to ease of use and ease of reading, respectively. Academic centers performed significantly better in the content and ease of use of their forms compared to those from private centers. CONCLUSIONS: A good preoperative evaluation form is an important tool in the anesthetic management of a patient and plays a significant role in the medical legal arena. We found that a surprisingly high percentage of forms are missing important information. A form that contains all of the information and also meets our ease of use and reading standards was developed and offered as an example.