Incidental finding of foreign bodies during nasal intubation in a mentally challenged patient.

Nasal foreign bodies are frequently encountered among children and mentally challenged patients. They are often asymptomatic and may remain undetected for years. We are presenting a case of an incidental finding of foreign bodies during nasal intubation in a mentally challenged patient.

Late onset congenital central hypoventilation syndrome after exposure to general anesthesia.

PURPOSE: Prolonged postoperative hypoventilation presents a challenge to anesthesiologists with regard to assessing etiology and related treatment. We present a case of recurrent episodes of postoperative hypoventilation in a previously asymptomatic child after uneventful general anesthesia. In this case, the child eventually required lifelong ventilatory support during sleep. CLINICAL FEATURES: A case of postoperative hypoventilation in a previously asymptomatic six-year-old child was investigated to determine the possible etiology. After uneventful general anesthesia for dental surgery, the child experienced recurrent episodes of hypoventilation associated with sleep. The child's lungs were mechanically ventilated due to failure of all trials of weaning. Clinical examination was unremarkable and laboratory investigations excluded the possibility of thyroid, hepatic, renal, and neuromuscular diseases. Computerized tomography, magnetic resonance imaging, and electroencephalogram studies were within normal limits. A negative pyridostigmine trial ruled out myasthenia. The child was finally diagnosed as having "late onset congenital central hypoventilation syndrome". Genetic testing revealed a PHOX2B mutation consistent with this diagnosis. The child was discharged home on mechanical ventilatory support during sleep. CONCLUSION: Congenital central hypoventilation syndrome is a rare lifelong multisystem disorder which may occur during the neonatal period as a result of severe genetic mutation in the PHOX2B gene. In mild mutations, a triggering factor, such as sedation or anesthesia, may be required for the syndrome to manifest itself. These patients often require lifelong mechanical ventilatory support, particularly during sleep.

Anesthesia for gingivectomy and dental extractions in a child with I-cell disease--a case report.

I-cell disease (mucolipidosis II) is a rare metabolic disorder resulting from the deficiency of a specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease. Developmental delay and growth failure are common presentations of I-cell disease. Psychomotor deterioration is rapid and progressive. Some physical signs, such as hip dislocations, inguinal hernia, hepatomegaly, joint limitation, and skin changes may be present at birth. Coarse facial features and skeletal abnormalities become more conspicuous with time. The life expectancy of children with this condition is poor, with death usually occurring around the fifth year. A case report of the anesthetic management of gingivectomy with multiple dental extractions in a 5 years old Omani female, with I-cell disease, is presented. The problems faced and their management during anesthesia are described.

Anaesthetic management of congenital laryngeal web presenting with acute upper airway obstruction.

This is a case of failed intubation in a child of 15 months due to presence of laryngeal web. The airway was maintained by Cole Neonatal tube size 2 mm held at the available orifice of the glottis with maintenance of spontaneous respiration under general anesthesia till emergency tracheostomy was performed.

Comparative study of 2 anesthesia techniques for pediatric refractive surgery.

PURPOSE: To compare the effectiveness of 2 anesthesia techniques for pediatric refractive surgery, propofol/fentanyl and ketamine/midazolam. SETTING: Department of Ophthalmology, Magraby Eye & Ear Center, Muscat, Oman. METHODS: This prospective clinical study was of children ranging in age range from 3 to 12 years who were followed for myopic anisometropia with amblyopia after failure of conventional correction or patients with superficial stromal corneal opacities. The children were scheduled to have refractive surgery under general anesthesia using propofol/fentanyl (P/F group) or ketamine/midazolam (K/M group). All drugs were administered intravenously. RESULTS: Thirty patients were included in the study and were divided randomly into 2 equal groups. Both groups were comparable in age, weight, sex, duration of anesthesia, and duration of surgery. Time to complete recovery was significantly shorter in the P/F group. The hemodynamic changes observed in this study were not of clinical significance. Three patients in the P/F group showed arterial oxygen (O2) saturation of less than 90% and supplemental O2 was given by nasal cannula. The incidence of postoperative agitation and vomiting was significantly higher in the K/M group, while the need for jaw thrust was significantly higher in the P/F group. The difference between both groups in the ophthalmologist satisfaction score was not significant. CONCLUSIONS: Propofol offered some advantages for brief procedures outside the traditional operating rooms. It is short acting, and has a rapid offset resulting in shorter postoperative monitoring and a smoother recovery profile. It has greater potential for respiratory depression than ketamine. Hence, greater vigilance and experience with the pediatric airway is recommended with its use.

Preanesthetic medication in children: A comparison of intranasal dexmedetomidine versus oral midazolam.

BACKGROUND: Relieving preoperative anxiety is an important concern for the pediatric anesthesiologist. Midazolam has become the most frequently used premedication in children. However, new drugs such as the α(2) -agonists have emerged as alternatives for premedication in pediatric anesthesia. METHODS: One hundred and twenty children scheduled for adenotonsillectomy were enrolled in this prospective, double-blind, randomized study. The children were divided into two equal groups to receive either intranasal dexmedetomidine 1 µg/kg (group D), or oral midazolam 0.5 mg/kg (group M) at approximately 60 and 30 mins, respectively, before induction of anesthesia. Preoperative sedative effects, anxiety level changes, and the ease of child-parent separation were assessed. Also, the recovery profile and postoperative analgesic properties were assessed. RESULTS: Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation levels (P=0.042), lower anxiety levels (P=0.036), and easier child-parent separation (P=0.029) than children who received oral midazolam at the time of transferring the patients to the operating room. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both the groups (P=0.067). Also, the number of children who required fentanyl as rescue analgesia medication was significantly less (P=0.027) in the dexmedetomidine group. CONCLUSION: Intranasal dexmedetomidine appears to be a better choice for preanesthetic medication than oral midazolam in our study. Dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child-parent separation at the time of transferring patients to the operating room than children who received oral midazolam. Moreover, intranasal dexmedetomidine has better analgesic property than oral midazolam with discharge time from postanesthetic care unit similar to oral midazolam.

Dexmedetomidine versus propofol for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia.

PURPOSE: The purpose of this study was to evaluate the hemodynamic, respiratory effects, the recovery profile, surgeons, and patients satisfaction with dexmedetomidine sedation compared with those of propofol sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia. METHODS: Sixty patients were enrolled in this prospective, single-blind, randomized study. The patients were divided into two groups to receive either dexmedetomidine (group D) or propofol (group P). Sedation level was titrated to a Ramsay sedation scale (RSS) of 3. Hemodynamic and respiratory effects, postoperative recovery time, analgesic effects, surgeons and patients satisfaction were assessed. RESULTS: Both groups provided a similar significant reduction in heart rate and mean arterial pressure compared with baseline values. The respiratory rate values of the dexmedetomidine group were significantly higher than those in the propofol group. The oxygen saturation values of the dexmedetomidine group were significantly higher than those of the propofol group. The expired CO(2) was similar in both groups. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both groups. Dexmedetomidine patients have significantly lower visual analog scale for pain than propofol patients. The surgeon satisfaction with patients' sedation was similar for both groups. The patients' satisfaction was higher in the dexmedetomidine group. CONCLUSION: Dexmedetomidine at similar sedation levels with propofol was associated with equivalent hemodynamic effects, maintaining an adequate respiratory function, similar time of discharge from PACU, better analgesic properties, similar surgeon's satisfaction, and higher patient's satisfaction. Thus, dexmedetomidine may prove to be a valuable adjuvant for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia.

Combined use of remifentanil and propofol to limit patient movement during retinal detachment surgery under local anesthesia.

BACKGROUND: One of the drawbacks of performing ophthalmic surgery under local anesthesia is patient movement, which might affect optimal surgical outcome. PURPOSE: The study aims to evaluate the efficacy of the combined use of propofol and remifentanil as a sedative technique in comparison with the use of propofol alone to limit patient discomfort and movement during local anesthesia for vitreo-retinal surgery lasting for more than two hours. MATERIALS AND METHODS: A total of 140 patients scheduled for vitreo-retinal surgery under local anesthesia, with an expected surgical time of more than two hours, were included in the study. Patients were divided randomly into two equal groups: group I where patients were given propofol and remifentanil by continuous infusion and group II where patients were given propofol alone by continuous infusion. RESULTS: The two groups were comparable with regard to age, weight, gender, ASA physical status and duration of surgery. There was a significant decrease in heart rate and mean arterial blood pressure (MABP) in each group 10 minutes after the start of sedation compared with pre-sedation data and continued all through the procedure. There was an insignificant difference between the two groups with regard to changes in heart rate and MABP all through surgical procedure. There was no significant difference between the two groups with regard to the incidence of complications except for an increased incidence of breakthrough pain and discomfort which necessitated the use of fentanyl as a rescue treatment in the propofol group P<0.001. There were no instances of movements with a major effect on the surgical field, which could have affected surgical outcome, in the two groups. The number of patients who did not move was significantly higher, 56 (80%), in group I compared with 38 (54.29%) in group II with P<0.001. The ophthalmologist satisfaction scale was significantly higher in group I (4.5±0.63) compared with group II (3.7±1.04) with P=0.0016. CONCLUSION: The combined use of propofol and remifentanil as a continuous infusion before performance of the block and during lengthy vitreo-retinal surgery was associated with a lower incidence of patient discomfort, breakthrough pain, and patient movement along with high degree of surgeons' satisfaction and hemodynamic stability.

Difficult intubation management in a child with I-cell disease.

I-cell disease (mucolipidosis II) is a rare metabolic disorder resulting from the deficiency of a specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease. Developmental delay and growth failure are common presentations of I-cell disease. Psychomotor deterioration is rapid and progressive. Some physical signs such as hip dislocations, inguinal hernia, hepatomegaly, joint limitation, and skin changes may be present at birth. Coarse facial features and skeletal abnormalities become more conspicuous with time. The life expectancy of children with this condition is poor, with death usually occurring around the fifth year. A case report of the anesthetic management of gingivectomy with multiple dental extractions in a 5-year-old Omani female with I-cell disease is presented. The problems faced and their management during anesthesia are described.

Randomized trial of superficial peribulbar compared with conventional peribulbar anesthesia for cataract extraction.

PURPOSE: Evaluate efficacy of superficial peribulbar anesthesia for cataract extraction compared with conventional peribulbar anesthesia. SETTING: Department of Ophthalmology, Al Nahdha Hospital (Tertiary Ophthalmic and ENT Hospital) and Magraby Eye & Ear Center, Muscat, Sultanate of Oman. METHODS: Patients scheduled for cataract extraction with intraocular lens implantation were randomly divided into two groups according to anesthetic technique used. The first group patients were anesthetized using superficial peribulbar anesthesia, while second group patients were anesthetized using conventional peribulbar block. The efficacy of the blockade was judged by onset and degree of akinesia and volume of local anesthetic needed to obtain acceptable akinesia, sensation of pain during surgery, effect on intraocular pressure, degree of patient satisfaction, and incidence of complications. RESULTS: Nine hundred patients scheduled for cataract extraction with intraocular lens implantation during the period of June 2003 and October 2006 were included in this study. Five hundred cases were anesthetized using superficial peribulbar anesthesia and four hundred cases were anesthetized using conventional peribulbar block. The two groups were comparable as regards age, weight, gender, duration of surgery, and degree of analgesia. Superficial peribulbar anesthesia provided faster onset, higher degree of akinesia with less volume of local anesthetics used, no need for supplementary reinjection, no effect on intraocular pressure, and better patient satisfaction score compared with conventional peribulbar anesthesia. There were no serious complications in both groups. The incidence of subconjunctival hemorrhage was significantly higher in superficial peribulbar group (18%) compared with conventional peribulbar block (0.5%). CONCLUSION: Superficial peribulbar anesthesia is a safe, simple, quick to perform, and effective method of anesthesia for cataract surgery with better patient satisfaction, better akinesia, and comparable analgesia compared with conventional peribulbar block. Subconjunctival hemorrhage is a self-limited complication associated with this technique.

Preemptive analgesia in rhegmatogenous retinal detachment surgery: is it effective?

PURPOSE: To evaluate the efficacy of preemptive analgesia in surgical repair of retinal detachment (RD) using scleral buckle and cryopexy under general anesthesia. METHODS: Thirty patients who were scheduled for rhegmatogenous RD surgical repair using scleral buckle and cryopexy and who were American Society of Anesthesiologists physical status I, II, or III were included in this study. The patients were randomly divided into two equal groups. The surgery was done under general anesthesia in both groups, but in Group 2, sub-Tenon anesthesia was given as preemptive analgesia after induction anesthesia and before start of surgery. Both groups were statistically comparable as regards patient age and weight and duration of anesthesia and surgery. RESULTS: The incidences of intraoperative oculocardiac reflex and postoperative vomiting were significantly lower in Group 2 compared with Group 1 (P < 0.001 and 0.0113, respectively). The time of first postoperative analgesic dose was significantly shorter in Group 1 (46.67 +/- 18.84 minutes) compared with Group 2 (162.67 +/- 29.391 minutes) (P < 0.001). The total analgesic consumption per 24 hours was significantly higher in Group 1 compared with Group 2 (P < 0.001). The time of discharge from the hospital was significantly shorter in Group 2 (8.8 +/- 2.704 hours) compared with Group 1 (12.4 +/- 3.481 hours) (P = 0.0018). CONCLUSION: The use of sub-Tenon block as preemptive analgesia after induction of general anesthesia and before the start of rhegmatogenous RD surgical repair was effective in reducing postoperative pain and analgesic requirements compared with an unblocked group. The use of sub-Tenon block was also effective in reducing intraoperative incidence of oculocardiac reflex and postoperative incidence of vomiting.