Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report.

PURPOSE: To report a case where failure to provide adequate one-lung ventilation during transbronchial intubation resulted in a potentially fatal mishap. CLINICAL FEATURES: A 61-yr-old male was scheduled for right lung lobectomy. Induction of general anesthesia was smooth, and subsequent resection of the right middle lobe was uneventful. Difficult ventilation with high airway pressure and poor right lung re-expansion prompted repositioning of the double-lumen tube after the resection. The removal of the right middle bronchial clamp and associated right mainstem manipulation caused flooding of blood into the double-lumen tube. Mindful of the risk of fatal desaturation, the surgeon immediately opened the right mainstem bronchus and cleared the airway. Confirmation of a displaced double-lumen tube prompted the surgeon to insert an endotracheal tube (internal diameter 5.5 mm) from the opened right mainstem bronchus to the left main bronchus to maintain oxygenation. Although bronchoscopic examination confirmed proper location of the reinserted tube, oxygen saturation was not sufficiently (60%) improved. Another 5.5-mm endotracheal tube was inserted, with its tip inside the right upper bronchiole, for further ventilatory support. Finally, a rise in SpO2 to around 95% allowed completion of surgery. CONCLUSIONS: Displacement of the double-lumen endobronchial tube and flooding with clotted blood will result in potentially fatal ventilation difficulties. Repositioning and cleaning of the tube must be prompt to reduce the risk of hypoxemia. Where emergency single-lung ventilation is required, we suggest the utilization of a modified single-lumen endotracheal tube with a shortened cuff-tip length to ensure an adequate margin of safety for mainstem bronchus intubation.

Vascular injury during a lumbar laminectomy.

A lumbar laminectomy is a common and routine operation. Damage to abdominal vascular structures during surgery is a relatively infrequent complication; however, when it does occur, it is sudden and life-threatening. We herein report on 2 cases of abdominal vascular injury which occurred during lumbar microdiscectomies. The first case was a 34-year-old man. A bloody surgical field was noted 45 min into the operation along with an increase in heart rate and a decrease in blood pressure. After fluid resuscitation and an ephedrine injection, his vital signs stabilized. The patient was then sent to the surgical intensive care unit for observation. An emergent abdominal computer tomography scan revealed right retroperitoneal hematoma, and an urgent exploratory laparotomy was performed to check for bleeding and to remove the hematoma. The second case was a 61-year-old woman with recurrent disc herniation. The operation was proceeding smoothly for 90 min, when a large amount of fresh blood suddenly gushed out. Her blood pressure immediately dropped to that of a state of shock. The patient was turned back to a supine position, and an emergent laparotomy was done to repair the injured vessels. Both patients had uneventful recoveries.

Anesthetic management of a parturient undergoing cesarean section with a tracheal tumor and hemoptysis.

Anesthetic management of a parturient with respiratory failure associated with hemoptysis, dyspnea, and orthopnea is difficult. An anesthesiologist should realize that the patient's major problem is not solved during the surgery. This circumstance is similar to a patient with associated cardiac disease scheduled for non-cardiac surgery. General anesthesia with endotracheal intubation can provide safe oxygenation for both the parturient and the fetus, but with possible unexpected massive hemoptysis and tumor seeding. Prolonged intubation may delay the patient's pulmonary treatment course. Laryngeal mask anesthesia can provide an airway, but must not be secured due to the risk of aspiration. The need of high doses of inhalation drugs may hinder uterine contractions. The addition of a muscle relaxant will change the patient's respiratory patterns and physiology. Regional anesthesia alone might not be tolerated. A decrease in cough strength, as well as dyspnea, orthopnea, and hyperventilation may be harmful to both the parturient and the fetus. However, we successfully managed this case using epidural anesthesia combined with assisted mask ventilation instead of spontaneous breathing usually provided by a simple mask in almost all American Society of Anesthesiology (ASA) class I-II parturients during cesarean section. The anesthetic level was maintained at T8 with 18 ml of 2% Xylocaine mixed with 2 ml of 7% sodium bicarbonate with 1:200,000 epinephrine epidurally and with the patient in a supine position with the head up at 30 degrees to prevent cephalic spreading and to ensure better pulmonary ventilation.

Red Man's syndrome following administration of vancomycin in a patient under spinal anesthesia--a case report.

Prophylactic antibiotics are frequently administered during anesthesia to reduce the incidence of infection. The most common organisms revealed in wound infections are staphylococci. Vancomycin is the antibiotic of choice for resistant staphylococcal infections and bacterial endocarditis in patient allergic to penicillin. We had a case of tibial osteomyelitis, while undergoing removal of implants under spinal anesthesia developed hypotensions, bradycardia, consciousness change and skin erythematous macular rash after 0.1% vancomycin slow infusion for 10 min. After appropriate management, the patient recovered well and was discharged on the following day. Our report is intended to alert our colleagues that vancomycin can cause hypotension secondary to histamine release, direct myocardial depression and direct peripheral vasodilation. Even cardiac arrest had been reported in the literatures.