Probable case of vascular air embolism during endonasal CO2 laser surgery.

Laser surgery in narrow luminal cavities can lead to venous air embolism (VAE) due to high pressure or high flow clearing/cooling systems. We report the first case of initially misdiagnosed VAE during endonasal CO(2) laser surgery. A 56-year-old patient underwent uvulopalatopharyngoplasty and septoplasty with bilateral CO(2) laser turbinoplasty for turbinate hypertrophy and uvula deviation. At the end of the procedure (performed on the right nasal side), the patient presented with an abrupt decrease in end tidal carbon dioxide concentration (EtCO(2)), oxygen saturation (SpO(2)), and arterial pressure and experienced cardiac arrest. The patient was then successfully resuscitated and transferred to the ICU. After excluding pulmonary embolic disease with angio-CT scan, the event was interpreted as VAE due to the clearing/cooling gas flow of the CO(2) laser probe. Although capnometry cannot be considered specific to diagnose VAE, the occurrence of cardiac arrest preceded by an abrupt decrease in EtCO(2) and SpO(2) and the rapid resolution of symptoms after resuscitation led us to retrospectively suspect that VAE was the cause. The literature reports cases of VAE during laser surgery in narrow luminal cavities. When operating in narrow luminal cavities, using a liquid instead of a gas as a clearing/cooling system for the distal end of the probe in laser instruments and avoiding direct contact with tissues is advisable. Anesthesiologists, surgeons and the nursing staff practicing endoscopic laser surgery should have wide knowledge of the risks linked to this technique in order to minimize risk to the patient and to manage VAE should it eventually occur.

[Mathematical approach to the study of the capnographic curve]. / Approccio matematico allo studio della curva capnografica.

An application of Hill's formula in the interpretation of slope of second phase of capnographic curve is suggested. This method can be used to demonstrate an acute rising of airway resistances, but failed to discriminate between normal and chronically broncho-pulmonary obstructed subjects. We suggest that a study of modifications of second phase slope and Q angle can give more information about airway resistances.

[Continuous-infusion ketamine]. / Contributo clinico all'uso della ketamina per infusione continua.

An investigation was made of the employment of ketamin as the sole anaesthetic in general surgery, using continuous infusion of a 1% solution for both induction and maintenance in 118 cases. ECG was monitored and arterial pressure was measured invasively. Central venous pressure was also determined in 10 cases. Changes in serum enzyme values during and after surgery were examined in 35 patients. Blood samples were withdrawn before induction, after the return to consciousness, and 24 hr after the operation. Side-effects were common, but slight. Five patients suffered from nightmares, but these were persons with marked imaginative activity and a melancholic nature. Cardiocirculatory function was satisfactory. In particular, peripheral perfusion was excellent in all cases.

[Premedication with intranasal midazolam in children of various ages]. / Premedicazione con midazolam per via nasale nelle diverse età pediatriche.

BACKGROUND AND AIM: To evaluate the efficacy of premedication with midazolam (mdz) administered using a nasal route compared to diazepam (dz) administered by mouth in children of different ages. EXPERIMENTAL DESIGN: A comparative type study was performed in randomly selected pediatric patients undergoing surgery. The study lasted 3 months. SETTING: Recovery room and operating theatre for Pediatric Surgery and ENT. PATIENTS: A total of 248 patients were studied, divided into 3 age groups: group A were aged under 2 years; group B were pre-school age and group C were school-age. OPERATIONS: Two subgroups were formed based on the premedication used: group M = 0.2 mg/kg of mdz using a nasal route on arrival in the operating unit; group D = 0.2 mg/kg of dz per os 45' before induction. PARAMETERS STUDIED: In addition to acceptance of treatment, which was deemed to be good, poor or refused, the authors evaluated the level of sedation (score from 5 to 1: awake-asleep), anxiety on entering SO (score from 1 to 4: none-excessive) and the level of collaboration during the induction of general anesthesia (score 1-4: excellent-nil). RESULTS: The nasal route was well accepted by 59% of patients in group A, 62% of group B and 97% of group C. Statistical analysis using Kruskall Wallis test showed significant differences in groups A and B between the two subgroups M and D for all the parameters studied, whereas there were no significant differences in group C. CONCLUSIONS: Premedication with mdz using a nasal route was safe and efficacious, above all in early and later infancy.

Rhabdomyolysis and operating position.

Rhabdomyolysis during routine surgery was studied in three groups of patients who had surgery, with limited trauma to muscle, in the lateral and supine positions, and prone on the spinal frame. A range of blood tests was performed (before surgery, and on the first, third and seventh day after operation). These showed that a creatine kinase increase in the 24 hours and the early appearance of myoglobin in the serum were the best indicators. Rhabdomyolysis was associated with the lateral position and long lasting surgery. No blood test before surgery was of any predictive value.