Difficult airway management of a patient with limited range of motion in the temporomandibular joint and cervical extension caused by psoriatic arthritis: a case report.

BACKGROUND: Psoriasis vulgaris, a chronic inflammatory skin disease, rarely causes temporomandibular arthritis. We report a case of difficult airway management of a patient with limited range of motion in the temporomandibular joint and cervical extension caused by psoriatic arthritis. CASE PRESENTATION: A 33-year-old man was scheduled to undergo laparoscopic colectomy. On admission, he was diagnosed with psoriatic arthritis. After induction of general anesthesia, we attempted intubation using Pentax Airway Scope® with a thin intlock blade and using a bronchoscope, but it was impossible because of the limited oral space and mandibular elevation. Because of concerns about cannot intubate, cannot ventilate, we antagonized the neuromuscular block and he emerged from general anesthesia. Finally, we succeeded in awake intubation via the nasal cavity using a bronchoscope under spontaneous respiration. CONCLUSIONS: Although psoriasis vulgaris is very rarely associated with temporomandibular arthritis, anesthesiologists should consider that it can cause perioperative difficult airways.

Superior sealing effect of a three-dimensional printed modified supraglottic airway compared with the i-gel in a three-dimensional printed airway model.

PURPOSE: The aim of this study was to compare the force exerted by a three-dimensional (3D) printed modified supraglottic airway (mSGA) vs. that exerted by the i-gel on a 3D printed airway model. METHODS: After a preliminary experiment in Thiel embalmed cadavers, we created a 3D printed mSGA and five 3D printed airway models based on computed tomography data from five female Japanese patients. We compared the force exerted by the i-gel and mSGA on the larynx of the 3D printed airway models. In addition, tidal volumes with insertion of the airway devices into the 3D printed airway model and administration of different levels of pressure-controlled ventilation (PCV) were compared. RESULTS: The values below indicate mean values ± SD (p value, 95% confidence interval) for the mSGA and i-gel, respectively. The forces exerted by the cuff parts were as follows: ventral: 12.5 ± 5.4 vs. 20.7 ± 3.7 N (p = 0.0001, - 10.0 to - 6.5), proximal: 1.9 ± 1.4 vs. 1.7 ± 1.3 N (p = 0.322, - 0.26 to 0.74), and dorsal parts: 6.9 ± 2.2 vs. 12.5 ± 4.8 N (p = 0.0001, - 7.9 to - 3.4), respectively. We also found significantly higher tidal volumes with the mSGA under PCV of 10, 15, and 20 cmH2O. CONCLUSIONS: The method of creating the mSGA that we proposed in this study can be applied to development of novel SGAs that is anatomically more suitable for pharyngolaryngeal structure.

Comparison of fluid leakage across endotracheal tube cuffs using a three-dimensional printed model of the human trachea.

The objective of this study was to compare fluid leakage across endotracheal tube cuffs using a three-dimensional (3D)-printed human tracheal model that anatomically simulates the human trachea. We made two models based on computed tomography data of the neck and chest. Using a Mallinckrodt Hi-Lo™ (HL), ThinCuff(®) (TC), and Mallinckrodt TaperGuard™ (TG), we sequentially measured the amount of fluid leakage across each endotracheal tube cuff after applying saline or viscous liquid above the cuff. The TG allowed significantly less leakage than the HL and TC with both saline and the viscous liquid. Our study, using a 3D-printed tracheal model, indicated that a conical-shaped endotracheal tube cuff significantly reduces fluid leakage across the cuff compared with conventional cylindrical-shaped cuffs made of polyurethane or polyvinylchloride, contrary to the results of a previous study using a solid cylindrical structure.

Treatment of life-threatening hypercapnia with isoflurane in an infant with status asthmaticus.

We encountered a 2-year-old child with life-threatening hypercapnia, with a PaCO(2) of 238 mm Hg and severe respiratory and metabolic acidosis, due to status asthmaticus that was refractory to steroid and bronchodilator therapy. Suspecting ventilatory failure and excessive ventilation-induced obstructive shock, we started respiratory physiotherapy in synchrony with her respiration, to facilitate exhalation from her over-inflated lungs. Isoflurane inhalation was commenced in preparation for extracorporeal circulation, to reduce the hypercapnia. The combination of respiratory physiotherapy and isoflurane inhalation resulted in a rapid decrease in ventilatory resistance and PaCO(2) levels within a few minutes, with recovery of consciousness within 60 min. Isoflurane inhalation was gradually discontinued and steroid and aminophylline therapy were commenced. The patient recovered completely without any recurrence of her bronchospasm and without any residual neurological deficits. In our patient with a severe asthmatic attack, decreased exhalation secondary to asthma and overventilation during artificial ventilation resulted in overinflation of the lungs, which in turn led to cerebral edema and obstructive cardiac failure. The favorable outcome in this case was due to the short duration of hypercapnia. Hence, we conclude that the duration of hypercapnia is an important determinant of the morbidity and mortality of status asthmaticus-induced severe hypercapnia.

[Excision of a superior vena cava aneurysm with venous malformations in the face, neck and mouth].

Aneurysm of the superior vena cava is a very rare disease, and there have been few reports of such cases. We report a case of superior vena cava aneurysm excision with venous malformations in the face, neck and mouth. The aneurysm was excised after performing sclerosing therapy for multiple hemangiomas over a period of about one year.

[Anesthetic management of organ donation after brain death using continuous total hemoglobin measurement].

A 60-year-old woman declared brain dead was scheduled for organ donation. We continuously measured total hemoglobin values (SpHb) using a Radical-7 monitor (Masimo Co, Irvine, CA, USA) to maintain the functions of organs and oxygen delivery. At the start of surgery, the SpHb value was 9.3 g x dl(-1). Packed red blood cells were transfused immediately No anesthetics or opioids were used during the operation. Blood pressure suddenly decreased to below 80 mmHg because of bleeding, manipulation of organs, and/or compression of the vena cava. Six units of red blood cells and 900 ml of colloids were rapidly transfused with real-time monitoring of SpHb values. On cross-clamping of the aorta, the SpHb value increased up to 10.2 g x dl(-1). The heart, lungs, liver, pancreas, and kidneys were donated from the patient without organ dysfunction. The highlight of this case report is that anesthesiologists could use SpHb monitoring for management of hemodynamics in a brain-dead organ donor.