Air leakage due to the cuff hanging on the vocal cords during nasotracheal intubation: a case report

Nasotracheal intubation is commonly performed under general anesthesia in oral and maxillofacial surgery. For the convenience of surgery, nasal Ring-Adair-Elwyn (RAE) tubes are mainly used. Because the nasal RAE tubes were bent in an “L” shape, the insertion depth was limited. Particularly, it is necessary to accurately determine the appropriate depth of the RAE tubes in children. Several types of nasal RAE tubes are used in the medical market, which vary in material and length. We performed endotracheal intubation using a nasal RAE tube for double-jaw surgery, but air leakage persisted even when the air pressure in the cuff was increased. When checked with a laryngoscope, it was confirmed that the tube was pushed out, and the cuff was caught on the vocal cords, causing air leakage. Since inserting the tube deeply did not solve the problem, replacing it with a nasal RAE tube (Polar TM , Preformed Tracheal Tube, Smith Medical, Inc., USA) did not cause air leakage; thus, we reported this case.

Sudden Bispectral Index Reduction and Suppression Ratio Increase Associated with Bradycardia in a Patient Undergoing Breast Conserving Surgery

BACKGROUND: The bispectral index (BIS) is a valuable indicator for measuring sedation levels and patient consciousness. Recent reports have highlighted its clinical value as an indicator for anesthesia-related cerebral hypoperfusion and ischemic brain damage. CASE REPORT: A 55-year-old female patient underwent right breast conservation surgery during general anesthesia. During surgery, the patient experienced abrupt bradycardia (heart rate of 36 bpm) without hypotension. During bradycardia, her BIS was severely reduced from 45 to 20 along with elvated suppression ratio (50). After injection of 0.5mg of atropine, her BIS level was recovered, her heart rate was increased, and her suppression ratio was decreased. CONCLUSION: The patient recovered from anesthesia without showing any signs of neurological sequelae based on BIS level monitoring.

Recurrent ST segment elevations in a patient with asymptomatic early repolarization during head and neck surgery: implications of vasospastic angina

A 57-year-old woman scheduled for cochlear implant removal exhibited preoperative electrocardiographic findings of early repolarization (ER). Four episodes of transient ST segment elevations during surgery raised suspicion for vasospastic angina (VA). In the post-anesthetic care unit, the patient complained of chest discomfort and received sublingual nitroglycerin with uncertain effect. The patient refused to proceed with postoperative invasive coronary angiography, resulting in inconclusive diagnosis. Intraoperative circumstances limit the diagnosis of VA, which emphasizes the need for further testing to confirm the diagnosis. When VA is suspected in patients with underlying ER, it is reasonable to consider invasive examination to establish the diagnosis and prevent recurrence of VA. If ST changes are observed during surgery in patients with preoperative ER, careful monitoring is recommended. Due to general anesthesia, the absence of patient symptoms limits the definitive diagnosis of those with suspected VA. Therefore, additional postoperative surveillance is recommended.

Pulmonary aspiration during intubation in a high-risk patient: A video clip and clinical implications

We report a case of pulmonary aspiration during induction of general anesthesia in a patient who was status post esophagectomy. Sudden, unexpected aspiration occurred even though the patient had fasted adequately (over 13 hours) and received rapid sequence anesthesia induction. Since during esophagectomy, the lower esophageal sphincter is excised, stomach vagal innervation is lost, and the stomach is flaccid, draining only by gravity, the patient becomes vulnerable to aspiration. As the incidence of perioperative pulmonary aspiration is relatively low, precautions to prevent aspiration tend to be overlooked. We present a video clip showing pulmonary aspiration and discuss the literature concerning the risk of aspiration and its preventive strategies.