Anesthetic considerations for the patient with Huntington's disease.

Huntington's disease (HD) is an autosomal, dominantly inherited disease with symptoms manifesting late in life. Patients suffer from motor dysfunction and progressive mental deterioration. HD patients present a number of anesthetic challenges as they are usually elderly, malnourished, and at risk for aspiration. Previous reports on anesthesia for patients with HD have warned that sodium pentothal and succinylcholine cause prolonged apnea in this patient population. In this article, a 78-year-old female presented for cataract extraction. Although her movement disorder was under good control with haloperidol, a general anesthetic was chosen for the procedure in order to ensure a tranquil surgical field. This article presents the successful management of a patient with HD using a balanced anesthetic technique combining judicious amounts of narcotics and barbiturates with isoflurane.

Evaluation of esmolol and fentanyl in controlling increases in heart rate and blood pressure during endotracheal intubation.

Laryngoscopy and intubation cause an adrenergic response manifested by tachycardia and hypertension. Various pharmacological agents, including fentanyl, have been administered prior to induction in an attempt to attenuate the adrenergic response but they all have limitations. Esmolol, an ultrashort-acting cardioselective beta blocker, has been administered by infusion to successfully protect surgical patients from the stresses of intubation. The objective of our study was to determine if esmolol would be equally effective when administered in a bolus with and without fentanyl. Forty-four ASA I and II females undergoing elective surgery were randomly divided into four groups and received the following agents prior to intubation: Group 1-esmolol 1 mg/kg and fentanyl 2 micrograms/kg, Group 2-placebo (normal saline), Group 3-esmolol 1 mg/kg and Group 4-fentanyl 3.5 micrograms/kg. Groups 1 and 4, which received fentanyl, demonstrated significantly less elevation in blood pressure. Esmolol appeared to attenuate increases in heart rate. Esmolol has a tissue distribution time of 2 minutes and an elimination half-life of 9 minutes. The window of its availability to the tissues is narrow, and timing of bolus administration is more critical than in administration by infusion. Doses in excess of 1 mg/kg appear to be necessary for effective control of heart rate. However, when used with fentanyl, esmolol provides effective protection against the adrenergic response to laryngoscopy and intubation.

Life threatening ventricular dysrhythmias: intervention with bretylium tosylate.

The impact of psychogenic and physical stressors has been shown to have a negative effect on cardiovascular homeostasis (Figure 2). As CRNAs, we have a responsibility to maintain the patient's equilibrium under the stress-provoking conditions of surgery. Experience in coronary care units over the last 16 years has shown that the majority of patients who develop primary ventricular fibrillation during AMI can be rapidly resuscitated by prompt defibrillation. Only in a small number of patients does ventricular tachycardia or ventricular fibrillation become recurrent or resistant to treatment. It is in this small number that bretylium has proven itself to be a life-saving treatment.