A survey of operative airway management practices for midface fractures.

We surveyed 218 Level I trauma centers to determine operative airway management preferences for patients with midface fractures requiring maxillomandibular fixation. A two-page survey was distributed to anesthesiologists, plastic surgeons, otolaryngologists, and oral surgeons participating in the management of major craniofacial trauma at each center. Specific fracture patterns were described, and the preferences for endotracheal intubation for operative management were surveyed among the respondents. We analyzed 105 responses from surgeons and 51 responses from anesthesiologists. Although there were differences in the preferences expressed by surgeons compared with anesthesiologists, more than 50% of the respondents in each practice category chose some form of nasotracheal intubation for fracture patterns involving the midface. Tracheostomy was a first choice for patients with panfacial fractures or those with loss of consciousness and midface fractures. This report serves as a basis for surgeons and anesthesiologists to review their practices and discuss planning of operative airway management for the patients with these fracture patterns. On the basis of this survey, midface fractures need not prohibit any consideration of nasotracheal intubation.

Intraoperative hypothermia associated with lower extremity tourniquet deflation.

STUDY OBJECTIVE: To determine the rapidity and extent of core temperature decrease following release of a lower extremity pneumatic tourniquet. DESIGN: Prospective study. SETTING: Inpatient surgery in a university trauma center. PATIENTS: 11 ASA status I and II adults undergoing unilateral lower extremity fracture fixation in which a tourniquet was used, with general anesthesia. INTERVENTIONS: Temperature was measured in the esophagus before and after lower extremity tourniquet release. MEASUREMENTS AND MAIN RESULTS: Tourniquet times ranged from 41 to 129 minutes (mean 98.5 +/- 9.1 minutes). Following tourniquet deflation core temperature decreased in all patients, with a maximal decline at 10 minutes, the termination of measurements, although trending downward. Esophageal temperature decreased an average of 0.46 degree C +/- 0.2 degree C at 5 minutes, and 0.67 degree C +/- 0.2 degree C at 10 minutes following tourniquet release, respectively. Temperature changes were significant (p = 0.0001) at both time intervals. CONCLUSION: Core temperature drops significantly immediately following release of the tourniquet at the esophageal temperature monitoring site. This decrease is the result of cooling of systemic blood reperfusing the hypothermic limb, and mixing of cool, "washed out" blood with the systemic circulation. As the consequences of hypothermia are well-known, we recommend core temperature monitoring in all patients having lower extremity tourniquet placed during general anesthesia, as well as vigilant monitoring for prolonged effects of anesthetics in the postoperative period.

Clonazepam for the treatment of lancinating phantom limb pain.

OBJECTIVE: To propose clonazepam for use in the empiric treatment of shooting/shocking phantom limb pain. SETTING: Outpatient pain clinic associated with a university hospital. PATIENTS: Two patients with phantom limb pain after total hip disarticulation. INTERVENTIONS: Treatment with clonazepam. RESULTS AND CONCLUSIONS: Clonazepam provided effective relief for > 6 months in two patients with shooting/shocking phantom limb pain. Although clonazepam therapy is not new, it appears to have been omitted from current pain texts and journals as a treatment option for phantom limb pain.