[Difficult airway management in a patient with history of tracheotomy].

A 12-year-old girl was scheduled to undergo tympanoplasty. She had received tracheotomy at the age of 10 months. As preoperative bronchofiberscope could reach the glottis with no difficulty, we chose rapid induction. Suddenly after the administration of thiopental, fentanyl and vecuronium bromide, we could not keep mask ventilation. As sniffing position and insertion of airway could not improve difficult ventilation, we intubated quickly. The intubation was easy. We consider that difficult ventilation was not due to upper airway trouble but due to tracheotomy. Muscles around the granuloma were relaxed, and the trachea was closed, just at the height of tracheotomy. We conclude that it may sometimes be difficult in a child with history of tracheotomy to keep mask ventilation.

[Marked reduction of life-threatening ventricular tachyarrhythmias in a critically ill patient by intravenous administration of magnesium sulfate].

A 90-year-old man with ischemic heart disease underwent an emergent operation for a ruptured abdominal aortic aneurysm. The patient was brought to the operating room in a state of hypovolemic shock, and developed myocardial ischemia and intractable ventricular arrhythmias during the operation. Intensive cardiopulmonary resuscitation including rapid transfusion, external cardiac massage, electrical defibrillation, and extensive use of cardiovascular drugs restored hemodynamic stability temporarily. However, ventricular tachyarrhythmias readily recurred and caused cardiovascular collapse. Despite a normal value of blood ionized magnesium, we administered two grams of magnesium sulfate intravenously, which drastically reduced ventricular arrhythmias. Although a number of reports have shown the effectiveness of magnesium in correcting lethal ventricular arrhythmias, the rank of magnesium administration has not been well established in standard algorithms for arrhythmia therapy. Now that the concentration of ionized magnesium in the blood can be easily measured in clinical settings, its role as an antiarrhythmic agent should be extensively reevaluated.