Download Anesthetic Management of clival chordoma

LETTERS TO EDITOR
Anesthetic Management of clival chordoma with
retropharyngeal extension: Importance of imaging
Neha Singh, MD*, Parnandi Bhaskar Rao, MD, PDCC**, Devendra Gupta, MD,
PDCC***, Sushil Prakash Ambesh, MD****
*Assistant Professor, Department of Anaesthesiology & Critical Care, P.I.M.S, Pondicherry-605014, India
**Assistant Professor, Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, Bhibaneshwar, Odisha, India
***Associate Professor, ****Professor
Department of Anaesthesiology,Intensive Care and Pain Medicine,SGPGIMS, Lucknow- 226014, (U.P), India
Correspondence: Dr. Neha Singh,MD; Assistant Professor, Department of Anaesthesiology & Critical Care, P.I.M.S,
Pondicherry-605014, (India); Phone: +91-04132656271; Mobile: 91-8056625735; Fax: 91-0413-2656272;
E-mail: [email protected]
Dear Editor,
Chordomas are rare but usually aggressive tumors
originating from embryonic remnants of the primitive
notochord which are usually extradural and induce bone
destruction.1 Although 35% occur in the skull base, they
represent only 0.1% of all skull base tumors.2
infusion 2 mcg/kg/hr. Surgery was performed in prone
position followed by supine position and rest of the
intraoperative period was uneventful. The duration of
surgery was 11 hrs. Patient was shifted to neurosurgical
ICU for elective ventilation and decannulated on fourth
postoperative day.
We emphasize on the importance of as specialized imaging
techniques for planning definitive airway management
which will lead to better perioperative outcome.
A 45 year old,148-cm,52 kg, ASA II lady was presented
with history of progressively increasing neck pain for 1
year, which aggravates on neck flexion and bilateral hard of
hearing. Preoperative evaluation was satisfactory except for
the involvement of XI and XII cranial nerves. As trans-oral
approach was planned, we opted for an awake fiberoptic
nasal intubation with tracheostomy backup in case of failed
intubation. Patient was explained about the procedure
and consent obtained. Pre-induction monitoring included
electrocardiogram (ECG) lead II and V, noninvasive blood
pressure (NIBP), heart rate (HR) and peripheral oxygen
saturation (SpO2). Venous access was established by using
two 16G cannula. She received intravenous midazolam
(1.5 mg), fentanyl (100 µg) and propofol infusion @ 100150 mcg/kg/min. During fibreoptic intubation it was
impossible to pass the scope beyond the nasopharynx
due to an obstruction, so procedure was abandoned and
surgical tracheostomy was performed under monitored
anesthesia care. Radiographic review showed that the
lesion has filled the nasopharyngeal space, obstructing the
passage of a flexible fibreoptic scope (Fig.1). Following
tracheostomy, anesthesia was induced with propofol (2.5
mg/kg), vecuronium bromide (0.1 mg/kg) and the circuit
was connected to the tracheostomy tube. Anesthesia
was maintained with Air:O2 :: 50:50, isoflurane 1-2%,
vecuronium infusion 1 mcg/kg/min infusion and fentanyl
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(2) MAY-AUG 2013
Figure 1 Ch0rd0na
Chordomas account for 1% of intracranial tumors and
4% of all primary bone tumors.2 Although survival from
chordomas is generally considered to be poor,2 there has
been improvement with modern treatments.3 Barrenechea
IJ et al. mentioned the use of fibreoptic technique for
intubation in cases of chordoma with cervical instability.4
As our plan of fibreoptic naso-tracheal intubation failed,
tracheotomy was performed. In cases of expected
difficult airway, it is suggested to consider fibreoptic
intubation approach as the initial method of choice as it
helps in detailed viewing of the anatomy, making it easy
to decide the further plan to secure airway in anticipated
difficult airway. Preoperative review of the imaging
211
letters to editor
also add to the predicting ability in such cases. Flexible
fibreoptic laryngoscopy has been a major advance in the
management of difficult intubation.5 Although elective
fibreoptic intubation is mostly successful, there are few
reports where this technique may fail or not be possible
REFERENCES
1. Sundaresan N, Rosen G, Boriani S. Primary
malignant tumors of the spine. Orthop Clin
North Am. Jan 2009;40:21-36. [PubMed]
2. Dahlin DC, Maccarty CS: Chordoma. Cancer
5 1952;28:1170–78.
3. Crockard HA, Steel T, Plowman N, Sıngh A,
Crossman J, Revesz T et al. A multidisciplinary
team approach to skull base chordomas. J
because of laryngeal pathologies or abnormalities.6
With this experience of failed flexible fibreoptic intubation
later managed by doing tracheostomy, we propose
assistance of specialized imaging techniques before taking
a decision regarding definitive airway management.
Neurosurg 2001;95:175-83. [PubMed]
Barrenechea IJ, Perin NI, Triana A, Lesser J,
Costantino P, Sen C. Surgical management of
chordomas of the cervical spine. J Neurosurg
Spine. 2007 ; 6:398-406. [PubMed]
5. Ovassapian A, Dykes MHN. The role of the
fibre-optic endoscopy in airway management.
Seminars in Anaesthesia. 1987;7:93–104.
4. [Online Access]
6. Takenaka I, Aoyama K, Nakamura M,
Fukuyama H, Urakami Y, Takenaka Y et
al. Oral styletted intubation under video
control in a patient with a large mobile glottic
tumour and a difficult airway. Can J Anaesth
2002;49:203–6. [PubMed]
 
Takayasu’s arteritis: An anesthetic challenge
Nidhi Bhatia, MD, DNB*, Kiran Jangra, MD**
*Assistant Professor, **Senior Resident
Dept. of Anesthesiology & Intensive Care, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh PIN-160 012, (India).
Correspondence: Nidhi Bhatia, Assistant Professor, Dept. of Anesthesiology & Intensive Care, Postgraduate Institute of
Medical Education & Research Sector-12, Chandigarh PIN-160 012, (India); Ph: +919914207483;
Email: [email protected]
Dear Editor,
Takayasu’s arteritis (TA) is a chronic progressive panendarteritis involving the aorta and its main branches,
associated with stenosis of major blood vessels, severe
uncontrolled hypertension and end-organ dysfunction,
making its perioperative management very challenging
for the anesthesiologist.
A 28 years old severely preeclamptic, full term
parturient with HELLP syndrome and an intrauterine
growth retarded (IUGR) baby, was scheduled for
elective cesarean section. Twelve years back, she was
diagnosed with TA, when she presented with dyspnea
on exertion and a history of repeated blackouts.
Since then she was regularly taking Tab prednisolone
(Wysolone™, Wyeth Ltd.) aspirin and prazocin.
On examination, pulsations were found to be absent in her
both carotids and left upper limb. She had a feeble pulse
in right upper limb but peripheral pulses in both lower
limbs were normal. Patient’s baseline blood pressure was
90/60 mmHg in right upper limb and 190/110 mmHg in
right lower limb. The patient’s respiratory and neurological
examination showed normal results. Preoperative
212
investigations showed three fold elevated liver enzymes and
low platelet count of 65,000, which increased to 1,50,000
after transfusion of single donor aphaeretic platelets.
Rest of the investigations and fundus examination were
within normal limits. Doppler examination confirmed the
presence of bilateral carotid and right subclavian artery
stenosis with normal renal arteries. Echocardiography
showed the presence of normal left ventricular function
with an ejection fraction of 50-55%, trivial mitral
regurgitation and no regional wall motion abnormality.
In the operating room, baseline monitoring and invasive
BP through the right dorsalis pedis artery was done. 20G
epidural catheter was placed in L3-L4 interspace, followed
by subarachnoid block with 6.5 mg hyperbaric bupivacaine
(0.5%) and 25 µg fentanyl in the same interspace. There
after the patient was placed in supine position, with a left
lateral tilt, and oxygen was administered via a face mask.
Ephedrine boluses were used for hypotensive episodes.
She remained hemodynamically stable in the intraoperative
period and had an uneventful postoperative course.
Four types of TA have been described in the literature1,
with Type I involving the aortic arch and its main branches,
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(2) MAY-AUG 2013
letters to editor
Type II being restricted to the descending thoracic and
abdominal aorta, Type III combining both Types I and II
and patients with Type IV showing involvement of even
the pulmonary artery. Our patient was categorized as Type
I, with involvement of the carotids and the brachiocephalic
trunk. Ishikawa2 graded TA based on the presence of
four major complications i.e., hypertension, retinopathy,
aneurysm formation and aortic regurgitation.
Pregnancy does not change the evolution of TA but
increases risk of decompensation of hypertension.3
Peripheral vascular resistance normally decreases
during pregnancy. As patients with TA have stenotic
vessels and a decrease in afterload, blood pressure
increases secondary to the increase in the blood
volume that accompanies pregnancy4. These patients
are known to have end-organ dysfunction as a result
of severe uncontrolled hypertension and major arterial
stenosis. They may also be receiving chronic steroid
treatment and may present with Cushingoid features
preoperatively. In such cases, perioperative steroid
supplementation is needed to prevent the occurrence
of Addisonian hypotensive crises.3,5,6 Invasive pressure
monitoring is required in these patients to avoid
hypoperfusion of brain and compromised fetus
In the past, both regional and general anesthesia has
been used successfully in these patients5,6 The choice
of anesthetic technique should take into consideration
maintenance of blood pressure in the intraoperative
and postoperative periods. Regional anesthesia is
preferred as level of consciousness and adequacy of
cerebral perfusion can be better assessed in an awake
patient. Moreover, according to previous reports,
patients with preeclampsia are also benefited with
regional anesthesia7 However, use of regional
anesthesia in patients with TA might cause a
precipitous fall in blood pressure due to sympathetic
blockade, that may be hazardous in patient with
compromised regional circulation because of
stenosed arteries.3 So, in our patient, we decided to
use low dose spinal anesthesia and supplement it with
epidural block. A decrease in blood pressure was
prevented with adequate preloading, Tredelenburg
position and vasopressors. However, one needs to
be very cautious while using vasopressors in patients
with preexisting compromised organ perfusion.
General anesthesia, on the other hand, is associated
with major hemodyanamic fluctuations during
induction, intubation and extubation which can
increase blood pressure to dangerous levels in patients
with severe preeclampsia. Drastic hypotension
may be precipitated with drugs such as propofol,
thiopentone, and inhalational anesthetic agents.
To conclude, in patients with TA complicated by
severe preeclampsia and compromised fetus, goal is
to maintain or improve intrauterine perfusion while
keeping patient’s vital signs stable. We conclude that
combined spinal-epidural anesthesia is safer in these
patients as no additional neurological monitoring is
required and hemodynamics are better controlled.
REFERENCES
1. Lupi-Herrera
E,
Sanchez-Torres
G,
Marcushamer J, Mispireta J, Horwitz S, Vela
JE.et al. Takayasu’s arteritis: clinical study
of 107 cases. Am Heart J 1977;93:94–102.
[PubMed]
2. Ishikawa K. Natural history and classification
of occlusive thromboaortopathy (Takayasu’s
disease). Circulation 1978;57:27–35. [PubMed]
[Free Full Text]
3. Ishikawa K, Matsuura S. Occlusive
thromboaortopathy (Takayasu’s disease) and
pregnancy. Clinical course and management of
33 pregnancies and deliveries. Am J Cardiol
1982;50:1293–300. [PubMed]
4. Check TG, Gutsche BB. Maternal physiologic
changes during pregnancy. In: Anesthesia
for obstetrics. Shnider SM, Levinson G, eds.
Baltimore: Williams & Wilkins, 1987:3–13.
5. Kathirvel S, Chavan S, Arya VK, Rehman
I, Babu V, Malhotra N, et al. Anesthetic
management of patients with Takayasu’s
arteritis: a case series and review. Anesth
Analg 2001;93:605. [PubMed] [Free Full Text]
6. Sharma BK, Jain S, Vasishta K. Outcome of
pregnancy in Takayasu arteritis. Int J Cardiol
2000;75:159-62. [PubMed]
7. Van Bogaert LJ. Spinal block for caesarean
section in parturient with PIH. East Afr Med J
1998;75:227–31. [PubMed]
 
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(2) MAY-AUG 2013
213
letters to editor
Endotracheal intubation with angiographic
catheter after esophageal intubation in emergency
department
Sukhen Samanta, MD, PDCC*, Sujay Samanta, MD**
*Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow-226014 (India)
**Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Channdigarh-160012 (India)
Correspondence: Dr. Sukhen Samanta, MD, PDCC(CCM), New PG Hostel, Room No. 218, SGPGI, Lucknow-226014
(India); E-mail: [email protected]; Mobile: 08004967745
Dear Editor,
Airway management must ensure uninterrupted
oxygenation and ventilation. It is a basic skill learnt
during all emergency and critical care training sessions.
Endotracheal intubation is a definitive way of securing
airway. Unanticipated difficulty in endotracheal intubation
can lead to increased morbidity, e.g. brain hypoxia, cardiac
arrest and risk of aspiration. We faced an unanticipated
difficult airway but successfully intubated the patient with
a simple technique with the help of angiographic catheter
(AC) in a limited resource situation. We have not found any
mention in the literature of such an easy technique with
minimum airway gadgets in difficult airway management.
A 22 years old male, suffering from hepatic encephalopathy
without coagulopathy, presented in our emergency
department (ED) with Glasgow Coma Scale (GCS)
7/15 at midnight. Lung auscultation revealed right sided
crepitations with SpO2 of 82% (probably due to aspiration).
He required intubation for airway protection to prevent
further aspiration and maintenance of oxygenation. His
airway examination was apparently normal with unknown
fasting status. After pre-oxygenation for 3 minutes he was
induced with fentanyl and midazolam and preservative free
lignocaine. On laryngoscopy, just tip of the epiglottis was
barely visible (CL grade 3 b), even after optimum external
laryngeal manipulation. An 8 mm endotracheal tube (ETT)
with stylet was tried and the cuff inflated with air, but five
point auscultation confirmed it to be inside the esophagus.
We passed a 14 F nasogastric tube through the esophageal
ETT in situ and suctioned his stomach contents. Then
shifting the first ETT to left corner of the patient’s mouth,
a second laryngoscopy was done. A sterile 9 F AC
(Medtronic, Minnesota, USA) with guide wire, lubricated
with lignocaine jelly, was passed just below the tip of
epiglottis and through the glottis; a tactile sensation was
felt by keeping the palm on trachea. A second ETT was
now railroaded over the AC (Figure 1). In this way, the
first ETT in the esophagus helped in preventing aspiration
and guiding AC into trachea. Whole of the procedure
was completed within 4 minutes without desaturating the
patient (Figure 2).
214
Figure 1: Angiographic catheter with guide wire as airway exchange
through ETT
Figure 2: Patient with both ETT (esophageal & tracheal) in situ.
Incidence of difficult laryngoscopy (defined as tracheal
intubation requiring >2 attempts at direct laryngoscopy)
is 1.5-8.5% in general anesthesia with failed intubation
0.3%.1 Alternative airway devices like the rigid or flexible
fibreoptic bronchoscope, intubating laryngeal mask airway
(ILMA), videolaryngoscope, C-Trach, and light wand etc.
are very effective in this situation. Airway management in
ED is often more challenging than in the operating rooms
due to lack of difficult airway gadgets and expert help. In
unanticipated difficult airway in pre-hospital emergency
setting, people have used gum elastic bougies, ILMA
and cricothyroidotomy.2] In the absence of such airway
instruments in ED, an our simple technique may be tried.
We suggest that if an esophageal intubation has inadvertently
been done in a difficult intubation situation, don’t remove
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(2) MAY-AUG 2013
letters to editor
it, rather keep it inflated to prevent aspiration. Even mask
ventilation can be successfully done with the help of a small
gauge piece sealing on left angle of the mouth. We used a
sterilised AC with atraumatic guide wire with minimum cost.
REFERENCES
1. 2. Crosby
ET, Cooper
RM, Douglas
MJ, Doyle DJ, Hung OR, Labrecque P, et
al. The unanticipated difficult airway with
recommendations for management. Can J
Anaesth. 1998;45:757-76. [PubMed]
Combes X, Jabre P, Margenet A, Merle
JC, Leroux B, Dru M, et al. Unanticipated
Difficult Airway Management in the Prehospital
AC has been used for nasogastric tube insertion but never
used in airway management.3,4 AC can also be resterilised
and can be kept inside the resuscitation kit from cardiac
catheterization laboratories.
Emergency Setting: Prospective Validation of
an Algorithm. Anesthesiology. 2011;114:10510. [PubMed] [Free Full Text]
3. Rutala WA, Weber DJ. Healthcare infection
control practices advisory committee
(HICPAC). Guideline for disinfection and
sterilization in healthcare facilities, 2008.
Available from: http://www.cdc.gov/hipac/pdf/
guidelines/Disinfection_Nov_2008.pdf. [Online
Access].
4. Ghatak T, Samanta S, Baronia AK . A new
technique to insert nasogastric tube in an
unconscious intubated patient. North Am J
Med Sci. 2013;5:68-70. [PubMed] [Free Full
Text]
 
Inadvertent hydrothorax after multi-lumen
central venous catheter placement
*Sujit Vasudevan Nair, MD*, Khalifa Abdullah Mohammed Al-Ghafri, MRCS**, Aziz
Haris, MD, STARCSI*, Rashid Manzoor Khan, MD* and Naresh Kaul, MD*
*Department of Anesthesia & ICU
** Department of Orthopedic
National Trauma Center, Khoula Hospital, Muscat (Sultanate of Oman)
Correspondence: Dr. Naresh Kaul, Sr. Consultant, Department of Anesthesia & ICU, Muscat (Sultanate of Oman); GSM: 00 968
99366241; E-mail: [email protected],
A quadric-lumen central venous catheter was placed via
the right subclavian route in a 15 year old healthy girl
undergoing corrective surgery for scoliosis (D4 – L1) in
the prone position under general anaesthesia. The distal
most catheter port was kept closed as free flow of blood
was absent in this channel. All other ports were working
well. As the surgery progressed over next 45 min, central
venous pressure and peak airway pressure gradually
increased with a concurrent fall in blood pressure. All
this was initially attributed to pressure being exerted over
the back of the chest by the operating surgeon and a
misplaced chest bolster. Also added to the confusion was
observation of blood tinged watery fluid in the operative
field which was erroneously attributed to be CSF leak from
a dural rent. Fluids and other medications continued to be
administered via the central line ports. It was only when
hypotension was noted to be unresponsive to ephedrine
injection via the central line that attention was directed
to the possibility of accidental hydrothorax secondary to
migration of the distal end of the central line. Immediate
postoperative AP view of the chest X-ray confirmed this
(Fig 1). Appropriate corrective measures were instituted
and patient made an uneventful recovery.
Clinical Pearls: 1. Aspirate free flow of relatively dark
colored blood via the needle prior to introduction of the
J-tip guide wire. 2. Ascertain free flow of blood via all
lumens of the catheter prior to its fixation. 3. Re-aspirate
blood after administration of 50-100 ml fluid,change of
patient position, and whenever in doubt.
Fig 1: Immediate postoperative chest x-ray (anteroposterior view) showing malpositioned subclavian central
venous catheter.
 
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(2) MAY-AUG 2013
215