Intrathecal Baclofen Injection to Avoid Withdrawal in a Multiple Sclerosis Patient Undergoing Lumbar Spine Surgery: A Case Report.

Spasticity of spinal or cerebral origin is frequently treated with baclofen. Treatment interruption initially results in rebound spasticity; life-threatening withdrawal symptoms may follow. Severe rebound spasticity of leg muscles occurred in a multiple sclerosis patient after a 10-hour long perioperative pause of oral baclofen intake. In a subsequent spine surgery, recurrence was prevented by substituting a cumulative 12-hour oral baclofen dose with an intraoperative intrathecal injection. Administration of intrathecal baclofen during prolonged surgery in patients dependent on oral baclofen may improve patient comfort and prevent early withdrawal symptoms. The most optimal conversion ratio from oral to intrathecal baclofen is still undetermined.

Perioperative Factors Affecting Ambulatory Outcomes Following Laparoscopic-Adjustable Gastric Banding.

OBJECTIVE: Morbidly obese patients are traditionally hospitalised following bariatric surgery. However, laparoscopic-adjustable gastric banding (LAGB) is amenable for ambulatory care. We hypothesised that the majority of patients can receive an ambulatory LAGB and that both surgical and anaesthetic perioperative factors will significantly affect non-ambulatory LAGB outcomes. METHODS: Medical records of 201 consecutive LAGB patients performed at the University of Kansas Medical Centre during a 3-y period were reviewed. Demographic, medical, laboratory, anaesthetic, intraoperative and postoperative data were collected. Factors associated with non-ambulatory outcomes were identified and analysed using logistic regression, and a classification tree analysis was used to rank the descriptive model factor to the non-ambulatory outcome. RESULTS: Average patient age was 43.4±11.4 years, and average body mass index was 48.2±10.3 kg m2-1. A total of 155 patients (77.1%; 95% confidence interval, 71%-83%; p<0.0001) were discharged home within 2-3 hours of surgery, whereas 36 stayed for 23 hours and 10 required hospital admission for 1-2 days. Increased surgical port numbers (p=0.007), ≥50% of total intraoperative fentanyl administered in the recovery room (post-anaesthesia care unit) for the treatment of postoperative pain (p=0.007) and a lack of prophylactic beta-blockade (p=0.001) were three factors associated with non-ambulatory outcomes. Obstructive sleep apnoea was not associated with a non-ambulatory outcome (p=0.83). CONCLUSION: The majority of patients received an ambulatory LAGB. Meticulous laparoscopic surgical technique with the least feasible number of access ports and multimodal analgesic technique aimed at reduction of postoperative opioid consumption are the most important factors for a successful ambulatory LAGB outcome.

Utility of dexmedetomidine in sedation for radiofrequency ablation of atrial fibrillation.

The utility of dexmedetomidine (DEX) as an adjunct to conventional procedural sedation using midazolam and fentanyl was evaluated in 11 adult patients undergoing radiofrequency catheter ablation (RFCA) of atrial fibrillation. In a subsequent comparison to 11 demographically matched controls (n = 22) that previously received only midazolam- and fentanyl-based sedation, no significant differences in consumption of midazolam (median, 5 vs 10 mg; P = .3), fentanyl (median, 275 vs 400 mcg, P = .2), respiratory parameters, and procedural outcome were found. However, median reductions of arterial blood pressure were significant: systolic (-26.1 vs -16.7 mm Hg, P = .006), diastolic (-26.7 vs -2.9 mm Hg, P = .01), and mean (-25.8 vs -8.5 mm Hg, P = .006). Reductions of blood pressure limited utility of DEX as adjunct in sedation for RFCA of atrial fibrillation.

Clinical comparison of two stylet angles for orotracheal intubation with the GlideScope video laryngoscope.

STUDY OBJECTIVE: To compare the success of orotracheal intubation in 62 seconds or less using the GlideScope video laryngoscope (GVL) and a 60 degrees or 90 degrees angled stylet with reverse loading of the endotracheal tube (ETT). DESIGN: Prospective, randomized study. SETTING: Operating room of a university hospital. PATIENTS: 120 ASA physical status I, II, and III adult patients undergoing elective surgery requiring general anesthesia with orotracheal intubation. INTERVENTIONS: Patients were randomly allocated to two groups (n = 60 each); both groups received general anesthesia and neuromuscular relaxation. A conventional ETT was styleted and then bent from its straight configuration just above the cuff, either at 60 degrees or 90 degrees against its concave natural curve (reverse loading). Four attending anesthesiologists, who were blinded as to stylet assignment (the 60 degrees or 90 degrees group), intubated the tracheas of all patients with the GVL using either the primary or secondary stylet. MEASUREMENTS: The primary outcome was success of orotracheal intubation in 62 seconds or less. The secondary outcome was actual time to intubation (TTI). MAIN RESULTS: The odds ratio (OR) for intubation success was higher in the 90 degrees group than the 60 degrees group (OR = 10.41; P < 0.03), as evidenced by 59 of 60 patients whose tracheas were intubated successfully within 62 seconds, compared with 51 of 60 patients in the 60 degrees group. Seven of the 9 failures were due to inability of the 60 degrees stylet to reach the glottic opening. The three remaining failures were associated with TTI of more than 62 seconds. CONCLUSIONS: The 90 degrees angled malleable stylet with reverse loading of the ETT provided more reliable ETT delivery to the glottic opening and had a higher success rate than the 60 degrees stylet.

Management of the airway in multitrauma.

PURPOSE OF REVIEW: The primary purpose of this article is to highlight the latest airway research in multitrauma. RECENT FINDINGS: Management of the airway in multitrauma patients is a critical resuscitation task. Prehospital airway management is difficult with a high risk of failure, complications, or both. In-hospital performed conventional oral intubation with manual in-line stabilization, cricoid pressure, and a backup plan for a surgical airway is still the most efficient and effective approach for early airway control in multitrauma patients. Selective utilization of airway maintenance, instead of ultimate airway control in the field, has been suggested as a primary prehospital strategy. Properties of videolaryngoscopes complement standard laryngoscopes. When compared with a Macintosh laryngoscope, the Airtraq and Airwayscope diminish cervical spine motion during elective orotracheal intubation. Penetrating neck injuries are the most frequent indication for awake intubation, whereas patients with maxillofacial injuries have the highest rate of initial surgical airway. SUMMARY: Risks and benefits of ultimate prehospital airway control is a controversial topic. Utilization of videolaryngoscopes in multitrauma remains open for research. Standardization of training requirements, equipment, and development of prehospital and in-hospital airway algorithms are needed to improve outcomes. Rational utilization of available airway devices, development of new devices, or both may help to promote this goal.