Preoperative Amlodipine Is Efficacious in Preventing Intraoperative HDI in Pheochromocytoma: Pilot RCT.

CONTEXT: Preoperative blockade with α-blockers is recommended in patients with pheochromocytoma/paraganglioma (PPGL). The data on calcium channel blockade (CCB) in PPGL are scarce. OBJECTIVE: We aimed to compare the efficacy of CCB and α-blockers on intraoperative hemodynamic instability (HDI) in PPGL. METHODS: In the interim analysis of this monocentric, pilot, open-label, randomized controlled trial, patients with solitary, secretory, and nonmetastatic PPGL were randomized to oral prazosin gastrointestinal therapeutic system (GITS) (maximum 30 mg, n = 9) or amlodipine (maximum 20 mg, n = 11). The primary outcomes were the episodes and duration of hypertension (systolic blood pressure ≥ 160 mmHg) and hypotension (mean arterial pressure < 60 mmHg) and duration of HDI (hypertension and/or hypotension) as a percentage of total surgical time (from induction of anesthesia to skin closure). RESULTS: The median (IQR) episodes (2 [1-3] vs 0 [0-1]; P = 0.002) and duration of hypertension (19 [14-42] vs 0 [0-3] minutes; P = 0.001) and intraoperative HDI duration (22.85 ±â€…18.4% vs 2.44 ±â€…2.4%; CI, 8.68-32.14%; P 0.002) were significantly higher in the prazosin GITS arm than the amlodipine arm, whereas episodes and duration of hypotension did not differ between the 2 groups. There was no perioperative mortality. One patient had intraoperative ST depression on the electrocardiogram. The drug-related adverse effects were pedal edema (1 in amlodipine), dizziness (1 in prazosin GITS), and tachycardia (6 in prazosin GITS and 3 in amlodipine). CONCLUSION: Preoperative blockade with amlodipine is an efficacious alternative to prazosin GITS in preventing intraoperative HDI in PPGL. Larger studies that compare preoperative blockade by amlodipine with other α-blockers like phenoxybenzamine and/or doxazosin in PPGL patients are warranted.

A prospective observational study of predictors of difficult intubation in Indian patients.

BACKGROUND AND AIMS: During routine preoperative assessment of patients one of the commonest practices is predicting difficulty of intubation. The present study was undertaken to evaluate parameters associated with difficult intubation and to test on new set of patients. At the end, to form simple predictive rule to decreased the number of false alarms. MATERIAL AND METHODS: In initial series of 483 Indian population patients we measured age, sex, weight, height, interincisor gap, mandibular length, neck movement, neck circumference, subluxation of mandible, sternocricoid distance, and identified factors associated with difficult intubation. These were applied on next 480 patients of prospective series and simple predictive rule in form of risk sum score was developed. RESULTS: After analyzing initial series data we found that weight (P = 0.033), height (P = 0.034), interincisor gap (P = 0.005), subluxation (P < 0.001), neck movement (P < 0.001), and sternocricoid distance (P = 0.020) were significantly associated with difficult intubation. These six factors were applied on next set of 480 patients to found accuracy of predicting difficult intubation of weight (51.7%), height (83.8%), interincisor gap (80.2%), subluxation (77.7%), neck movement (82.7%), and sternocricoid distance (79.2). Total score greater than 2 predicted 92.8% of difficult laryngoscopies correctly as against 33.9% would be falsely labeled as difficult. CONCLUSION: Interincisor gap and sternocricoid distance are the two most sensitive factors predicting difficult intubation in Indian patients. However, risk sum score of more than 6 may lead to better anticipation of truly difficult intubations.

Anaesthetic Management in Transoral Endoscopic Thyroidectomy.

Young females undergoing thyroid surgery are apprehensive about the surgical scar. This leads to the introduction of Transoral Endoscopic Thyroidectomy (TOET). TOET is gaining popularity for its minimally invasive and cosmetically sound approach to perform thyroidectomies in young patients. The surgical site being the mouth orifice poses a challenge to the anaesthesiologist to secure a definitive airway. The case report is that of a young female undergoing TOET for whom we have successfully performed nasal intubation with a North Pole ivory endotracheal tube (ET).

Use of a Macintosh blade in extrahepatic portal vein obstruction with difficult intubation: two case reports.

BACKGROUND: We report the management of two patents from the Indian subcontinent with extrahepatic portal vein obstruction presenting with anticipated difficult airway. A Macintosh blade was used to secure the airway after using various instruments designed for difficult airway. To the best of our knowledge, no case has previously been reported in which a Macintosh blade was used successfully in patients with extrahepatic portal vein obstruction with a difficult airway. CASE PRESENTATION: Two women (case 1 and case 2) of South Asian ethnicity with extrahepatic portal vein obstruction presented for an elective splenorenal shunt. They both had micrognathia and restricted mouth openings. They had similar airway profiles with mouth openings of just 2 cm, Mallampati class IV, a thyromental distance <4 cm, a hyomental distance <2.5 cm, and a sternomental distance of 10 cm. Awake intubation was attempted in both patients after standard airway preparation in the form of preoperative 4 % lignocaine nebulization and 2 % viscous lignocaine gargle along with an on-table supralaryngeal nerve block using 2 % lignocaine and transtracheal infiltration with 4 % lignocaine. The patient in case 1 tolerated the procedure well whereas the patient in case 2 had to be given propofol 60 mg. Endotracheal intubation with a 6.5 mm polyvinyl chloride endotracheal tube was attempted using a Truview EVO2, an Airtraq, and a Miller blade no. 3 but was unsuccessful. Finally, a trial intubation was performed successfully with a Macintosh blade with a stubby handle assisted by a Frova Intubating Introducer in case 1 and a gum elastic bougie in case 2. CONCLUSIONS: Although many instruments have been introduced to manage difficult airways, our experience in these cases suggests that the Macintosh blade can be used first when attempting endotracheal intubation before using other instruments. Patients from the Indian subcontinent with extrahepatic portal vein obstruction are often found to have associated temporomandibular joint ankyloses (hence difficult airways). We hypothesize that a difficult intubation should be anticipated in these patients. Such an association has not been made before.