Both non-surgical dental treatment and extractions increase the risk of medication-related osteonecrosis of the jaw: case-control study

Abstract

Objectives

Medication-related osteonecrosis of the jaws (MRONJ) is a serious condition whose risk factors remain unclear. The aim of this study is to investigate the role of oral health and of dental treatment in the development of MRONJ.

Materials and methods

A case-control study was conducted in Brisbane, Australia. Hospital records were used to identify incident cases of MRONJ between January 2010 and March 2017. Cases were individually matched to up to 3 controls according to age, sex, primary disease, and type of antiresorptive therapy. Demographic data, medical histories and public dental records were collected. Associations between oral health, dental treatment, and MRONJ were investigated using conditional logistic regression.

Results

Overall, 44 cases were identified and matched to 115 controls (total sample = 159). Only one-third of patients received a dental examination in the year prior to commencing antiresorptive therapy (27% of cases and 34% of controls). After adjusting for potentially confounding variables, non-surgical dental treatment (OR = 6.3; 95% CI = 2.1, 19.1; p < 0.001) and dental extractions (OR = 8.0; 95% CI = 3.0, 21.0, p < 0.001) were significantly associated with development of MRONJ.

Conclusions

Current levels of preventative dental care are insufficient to eliminate the need for dental treatment and extractions during antiresorptive therapy, and the consequent increase in risk of MRONJ.

Clinical relevance

Optimizing the health of the oral cavity and ongoing preventative dental care must be a priority for patients prior to the initiation of antiresorptive medications.

http://bit.ly/2SN74mY

UV radiation on scalp skin surface induces scalp hair follicle damage ex vivo and is alleviated by the topical treatment with caffeine

Abstract

Objectives

While the effect of ultraviolet radiation (UVR) on human skin has been extensively studied, very little is known on how UVR impacts on hair follicle (HF) homeostasis. Here, we investigated how solar spectrum UVR that hits the human skin surface impacts on HF biology, and whether any detrimental effects can be mitigated by a widely used cosmetic and nutraceutical ingredient, caffeine.

Methods

Human scalp skin with terminal HFs was irradiated transepidermally ex vivo using either 10 J/cm² UVA (340‐440 nm) + 20 mJ/cm² UVB (290–320 nm) (low dose) or 50 J/cm² UVA + 50 mJ/cm² UVB (high dose) and organ‐cultured under serum‐free conditions for 1 or 3 days. 0.1% caffeine (5.15 mM) was topically applied for 3 days prior to UV exposure with 40 J/cm² UVA + 40 mJ/cm² UVB and for 3 days after UVR. The effects on various toxicity and vitality read‐out parameters were measured in defined skin and HF compartments.

Results

Consistent with previous results, transepidermally UVR exerted skin cytotoxicity and epidermal damage. Treatment with high and/or low UVA+UVB doses also induced oxidative DNA damage and cytotoxicity in human HFs. In addition, it decreased proliferation and promoted apoptosis of HF outer root sheath (ORS) and hair matrix (HM) keratinocytes, stimulated catagen development, differentially regulated the expression of HF growth factors, and induced perifollicular mast cell degranulation. UVR‐mediated HF damage is more severe after irradiation with high UVR dose and reached also deeper HF compartments. The topical application of 0.1% caffeine did not induce skin or HF cytotoxicity and stimulated the expression of IGF‐1 in the proximal HF ORS. However, it promoted keratinocyte apoptosis in selected HF compartments. Moreover, caffeine provided protection towards UVR‐mediated HF cytotoxicity and dystrophy, keratinocyte apoptosis, and negative modulation of the catagen‐promoting growth factor.

Conclusion

Our study highlights the clinical relevance of our scalp UV irradiation ex vivo assay and provides the first evidence that transepidermal UV radiation negatively affects important human HF functions, suggesting that it is a sensible prophylactic strategy to integrate agents such as caffeine that can act as HF photoprotectants into sun‐protective cosmeceutical and nutraceutical formulations.

This article is protected by copyright. All rights reserved.

http://bit.ly/2MZUPOz

The microRNA-375 as a potentially promising biomarker to predict the prognosis of patients with head and neck or esophageal squamous cell carcinoma: a meta-analysis

Abstract

Background

The prognostic value of microRNA-375 (miR-375) expression in squamous cell carcinoma (SCC) had been reported in the previous studies; however, the results remain inconsistent. This study was performed to investigate the prognostic significance of miR-375 expression in SCC based on all eligible evidences.

Methods

Relevant studies were identified by searching PubMed, Embace, Medline, Cochrane Library, and China Biology Medicine disk. Survival outcome including overall survival (OS) and other survival outcomes were used as the primary endpoint to evaluate the prognostic outcome of patients with SCC. All statistical analyses were performed in RevMan software version 5.3 and STATA software version 14.1. Furthermore, the quality of included studies was assessed by The Newcastle–Ottawa Scale.

Results

In total, 13 studies, including 1340 patients, met the inclusion criteria for our meta-analysis. The pooled analysis results indicated that downregulation of miR-375 significantly predicted poor OS (HR 1.58, 95% CI 1.34–1.88, P < 0.001). Downregulated miR-375 was also correlated with the other survival outcomes. Subgroup analysis based on tumor type found that lower expression of miR-375 was significantly related with poor OS in patients with esophageal squamous cell carcinoma (ESCC) (HR 1.58, 95% CI 1.29–1.94, P < 0.001) and head and neck squamous cell carcinoma (HNSCC) (HR 1.59, 95% CI 1.16–2.18, P = 0.004).

Conclusions

This meta-analysis demonstrated that the downexpression of miR-375 was significantly correlated with poor OS in patients with SCCs and indicated the potential clinical use of miR-375 as a molecular biomarker, particularly in assessing prognosis for patients with ESCC and HNSCC.

http://bit.ly/2E58DVf

Propofol and isoflurane on intraoperative motor evoked potentials

The effects of propofol and isoflurane on intraoperative motor evoked potentials during spinal cord tumour removal surgery - A prospective randomised trial p. 92

Parthiban Velayutham, Verghese T Cherian, Vedantam Rajshekhar, Krothapalli S Babu

DOI:10.4103/ija.IJA_421_18  

Background and Aims: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. Methods: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. Results: Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = −0.71, −0.66 respectively, P < 0.01) as compared to propofol (r = −0.60, −0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. Conclusion: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours.

Analgesia nociception index and systemic haemodynamics during anaesthetic induction and tracheal intubation

: A secondary analysis of a randomised controlled trial p. 100

Kamath Sriganesh, Kaushic A Theerth, Madhusudan Reddy, Dhritiman Chakrabarti, Ganne Sesha Umamaheswara Rao

DOI:10.4103/ija.IJA_656_18  

Background and Aims: Direct laryngoscopy and tracheal intubation is a noxious stimulation that induces significant stress response. Currently, this nociceptive response is assessed mainly by haemodynamic changes. Recently, analgesia nociception index (ANI) is introduced into anaesthesia practice and provides objective information about parasympathetic (low nociceptive stress) and sympathetic (high nociceptive stress) balance, which reflects the degree of intraoperative nociception/analgesia. This study evaluated the changes in ANI and haemodynamics during anaesthetic induction and intubation, and their correlation during tracheal intubation. Methods: Sixty adult patients scheduled for elective brain tumour surgery under general anaesthesia were studied for changes in ANI, heart rate (HR) and mean blood pressure (MBP) during anaesthetic induction and intubation. This was a secondary analysis of a previously published trial. Linear mixed effects model was used to evaluate changes in ANI, HR and MBP and to test correlation between ANI and haemodynamics. Results: Anaesthetic induction reduced ANI (but not below the critical threshold of nociception of 50) and MBP, and increased the HR (P < 0.001). Direct laryngoscopy and tracheal intubation resulted in increase in HR and MBP with decrease in ANI below the threshold of 50 (P < 0.001). A linear negative correlation was observed between ANI and HR; r = −0.405, P < 0.001, and ANI and MBP; r = −0.415, P= 0.001. Conclusion: Significant changes are observed in ANI during anaesthetic induction and intubation. There is a negative linear correlation between ANI and systemic haemodynamics during intubation.

Postoperative analgesic efficacy : Low bolus dose of IP dexmedetomidine is as efficacious as IV dexmedetomidine (0.5 μg/kg) along with IP bupivacaine

Comparison of postoperative analgesic efficacy of low-dose bolus intravenous dexmedetomidine and intraperitoneal dexmedetomidine with bupivacaine in patients undergoing laparoscopic cholecystectomy: A randomised, controlled trial p. 106

Geetanjali Tolia Chilkoti, Manish Kumar, Medha Mohta, Ashok Kumar Saxena, Naveen Sharma, Jitender Singh

DOI:10.4103/ija.IJA_440_18  

Background and Aims: Recently, low-dose intravenous (IV) dexmedetomidine has been evaluated for obtunding the pneumoperitoneum-induced haemodynamic changes and its analgesic efficacy in laparoscopic cholecystectomy. The aim was to determine the postoperative analgesic efficacy of low-dose bolus of 0.5 μg/kg dexmedetomidine via IV and intraperitoneal (IP) route in laparoscopic cholecystectomy. Methods: Seventy-five patients, aged 18–60 years of ASA physical status I and II, undergoing laparoscopic cholecystectomy under general anaesthesia were included. Patients in Group C received IP bupivacaine. Patients in Group IV received 0.5 μg/kg dexmedetomidine infusion IV after removal of gall bladder along with IP bupivacaine and Group IP received 0.5 μg/kg dexmedetomidine in 40 mL of 0.25% bupivacaine IP. The primary outcome was 'time to first request of analgesia' and the secondary outcomes were 'total consumption of tramadol in 24 hours,' visual analogue scale (VAS) pain score. Results: In total, 75 patients with 25 in each group were included. Time to first request of analgesia was found to be significantly lower in IV (59.68 ± 71.05 min, P= 0.00) and IP group (90.80 ± 80.46 min, P = 0.001) compared tp Group C (59.68 ± 71.05 min). Mean tramadol consumption in 24 hours (152.40 ± 60.958 vs 137.64 ± 52.40 mg) and mean VAS pain score were comparable in both IV and IP groups in the initial 12 h. Conclusion: Low bolus dose of IP dexmedetomidine is as efficacious as IV dexmedetomidine (0.5 μg/kg) along with IP bupivacaine in laparoscopic cholecystectomy.

Altered anatomical relationship between internal jugular vein and common carotid artery with supraglottic airway in children

Ultrasonographic assessment of altered anatomical relationship between internal jugular vein and common carotid artery with supraglottic airway in children: LMA vs i-gel™ p. 114

Rakhi Khemka, Sonal Rastogi, Arunangshu Chakraborty, Subir Sinha

DOI:10.4103/ija.IJA_747_18  

Background and Aims: Use of ultrasound (US) during internal jugular vein (IJV) cannulation reduces the risk of associated complications in children under general anaesthesia. We studied the effect of two varieties of supraglottic airway device (SGAD), the Ambu AuraOnce™ LMA (Ambu LMA), and i-gel™ on the anatomical relationship between IJV and common carotid artery (CCA). Both these SGAD are known to have similar safety profile in paediatric age group. Methods: A total of 62 children were randomly allocated into 2 groups. In group L: Ambu AuraOnce™ LMA (Ambu LMA) and in group I: i-gel™ was inserted. After induction of GA, US images were taken with head in neutral and 30 degrees rotated to the opposite side both before and after insertion of SGAD. The relationship between IJV and CCA was noted as lateral, anterolateral, and anterior. Degree of overlap between the two vessels was also noted. Results: Lateral rotation of the head significantly alters the relationship between the IJV and CCA and also increases the degree of overlap between them. Though these changes were noted to be similar with both varieties of SGAD, but between the two varieties of SGAD, these changes were significantly higher in group I. Conclusion: Higher oesophageal sealing pressure exerted by i-gel™ as compared to other SGAD might cause increased distortion of the surrounding soft tissue leading to altered anatomical relationship between IJV and CCA, which makes the CCA vulnerable to puncture during IJV cannulation using landmark technique.

Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis

LETTER TO EDITOR

Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 148-150

Saurav, Shalendra Singh, S Kiran, Alok Jaiswal
Department of Anaesthesiologist and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication

11-Feb-2019

Correspondence Address:
Dr. Shalendra Singh
Department of Anaesthesiologist and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra 
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ija.IJA_573_18

 

How to cite this article: Saurav, Singh S, Kiran S, Jaiswal A. Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis. Indian J Anaesth 2019;63:148-50

How to cite this URL: Saurav, Singh S, Kiran S, Jaiswal A. Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:148-50. Available from: http://www.ijaweb.org/text.asp?2019/63/2/148/251972

Sir,

It is not very common to manage a patient with ankylosing spondylitis (AS) and bilateral 'temporomandibular joint' (TMJ) ankylosis with cervical spine fusion to undergo alloplastic joint replacement. However, anaesthetic management of such patients in the context of difficult airway has been described.^[1] AS presents challenges to the anaesthesiologist as a consequence of potential difficult airway, cardiovascular, respiratory complications and increased risk of neurological complications. Incidence of TMJ involvement is 4–24% in AS; however, a case where bilateral TMJ ankylosis associated with cervical spine fusion and AS having undergone total alloplastic joint replacement is rare.

A 39-year-old male patient with complaint of difficulty in mouth opening for the past 18 years presented for bilateral alloplastic TMJ replacement. Airway examination revealed 6 mm of interincisor distance, grade IV Mallampati score with no lateral movement of the mandible, along with rigidity of cervical spine. Computerised tomography scan of both TMJs confirmed severe ankylosis [Figure 1]. X-ray of the cervical spine revealed fusion of the cervical spine [Figure 2]. All routine investigations including haemogram, biochemistry, chest X-ray and ECG were within normal limits. No abnormality was detected in lung function tests and arterial blood gas analysis.

Figure 1: Three-dimensional CT scan of patient showing bilateral TMJ ankylosis Click here to view

Figure 2: Lateral view X-ray of neck showing cervical spine fusion Click here to view

He was planned for general anaesthesia with awake fibreoptic nasal intubation which is the gold standard^[2] in view of restricted mouth opening and potential loss of airway under muscle relaxant. In the operation theatre, trolley for emergency surgical tracheostomy was kept ready. All standard monitoring devices were attached and the patient was pre-medicated with inj. glycopyrrolate 0.2 mg intravenous (IV) and inj. midazolam 1 mg IV. For nasal decongestion and topical anaesthesia, xylometazoline 0.05% nasal drops (3–5 drops) were instilled and nasal packing by gauze soaked in 2% lignocaine was done. Recurrent laryngeal nerve block was performed by injecting 2 ml of 4% lignocaine after piercing the cricothyroid membrane. Mild sedation for the awake fibreoptic intubation was achieved with inj. dexmedetomidine 20 μg IV and inj. ketamine 20 mg IV. After pre-oxygenation, both nasal passages were lubricated with lubricant jelly and fibreoptic bronchoscope was passed through the left nasal passage. After manipulation, epiglottis was visualised, and with spray-as-you-go technique using 4% topical lignocaine glottis was visualised. The pre-loaded flexo-metallic cuffed endotracheal tube size 7.0 mm was gently advanced over the bronchoscope. The position of the tube was confirmed by ETCO₂ and the anaesthesia was induced with inj. propofol 120 mg IV and maintained on O₂, N₂O, isoflurane and vecuronium. Intraoperative period was uneventful. Operating on each side of his face posed a practical problem because of the rigidity of his cervical spine, which required a bodily tilt of the operating table by 15–25° on each side. Neck support was used during anaesthesia and movements of the neck in the presence of neuromuscular blockade were restricted to avoid neurological injury. Three litres of crystalloid were infused intraoperatively with a total blood loss of 350 ml. The patient was shifted to surgical intensive care unit (SICU) with endotracheal tube in situ and maintained on assisted ventilation support in view of difficult airway and risk of airway oedema. After 12 h, the trachea was extubated uneventfully in SICU over an airway exchange catheter in view of potential difficult extubation. The same precautions regarding patient positioning and neck movement were applied at emergence, as with intubation. The patient was discharged on the seventh postoperative day.

To conclude, we successfully managed a case of AS with bilateral TMJ ankylosis having cervical spine fusion undergoing alloplastic joint replacement. It is emphasised that the prime concerns of the anaesthesiologists are to maintain a patent airway and maintain immobility of cervical spine, apart from the other anaesthetic concerns during perioperative management of such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Dave N, Sharma RK. Temporomandibular joint ankylosis in a case of ankylosing spondylitis – Anaesthetic management. Indian J Anaesth 2004;48:54-6.     [Full text]
2.	Vas L, Sawant P. A review of anaesthetic technique in 15 paediatric patients with temporomandibular joint ankylosis. Paediatr Anaesth 2001;11:237-44.

Figures

  [Figure 1], [Figure 2]

During general anaesthesia an average adult produces 10–12 l of carbon dioxide per hour

LETTER TO EDITOR

Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 150-151

Unseen complication of the exhausted soda lime

Deepak Dwivedi, Saurabh Sud, Sadhan Sawhney, Shyam P Panjiyar
Department of Anesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India

Date of Web Publication

11-Feb-2019

Correspondence Address:
Dr. Saurabh Sud
Department of Anesthesia and Critical Care, Command Hospital (Southern Command) Armed Forces Medical College, Pune - 411 040, Maharashtra 
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ija.IJA_623_18

 

How to cite this article: Dwivedi D, Sud S, Sawhney S, Panjiyar SP. Unseen complication of the exhausted soda lime. Indian J Anaesth 2019;63:150-1

How to cite this URL: Dwivedi D, Sud S, Sawhney S, Panjiyar SP. Unseen complication of the exhausted soda lime. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:150-1. Available from: http://www.ijaweb.org/text.asp?2019/63/2/150/251974

Sir,

During general anaesthesia an average adult produces 10–12 l of carbon dioxide per hour. Ralph Waters in 1923 pioneered the use of soda lime for chemically absorbing carbon dioxide.^[1] Approximately 100 g of soda lime absorbs around 26 l of carbon dioxide.^[2] Soda lime by removing carbon dioxide from fresh gas flow helps in recirculating the unused gases back into the circle system. This helps in economically reducing the requirement of fresh gas flow (oxygen, nitrous, and inhalation agents), and thus decreases pollution in operation theatre. We present here reporting of an unusual incident of an excessive water collection in the soda lime canister assembly at the anaesthesia workstation.

A 56-year-old lady was administered general anaesthesia with continuous epidural analgesia for total abdominal hysterectomy. After 25 min into surgery, monitoring showed increased peak airway pressure from the baseline of 16 to 28 cm H₂O and increase in end-tidal carbon dioxide (ETCO₂) from the initial value of 35 to 46 mmHg with normal wave morphology of the capnogram not touching the baseline, indicating toward rebreathing. The heart rate (HR) and mean arterial pressure (MAP) showed more than 25% variation from the baseline.

At this juncture the probable causes of the increased airway pressure such as excessive tidal volume, high inspiratory flow rate, kinking of endotracheal tube, and endobronchial intubation were ruled out and patient factors such as obesity, head down position, pneumoperitoneum, tension pneumothorax, and bronchospasm were also excluded.^[3] On inspection, the faulty packing of soda lime canister was observed in both upper and lower canisters with 20% of space left empty. Moreover, there was a presence of totally exhausted soda lime in the upper canister, and the lower canister was warm to touch with water levels between the outer wall of the lower canister and the inner wall of the canister assembly [Figure 1]a and [Figure 1]b. Further to this, each time when the bellows moved, it resulted in water being sucked in and out of the canister with bubbling evident in the canister assembly [[Figure 1]a and [Video 1] (online)]. The soda lime was changed and when inspected revealed completely exhausted (white) dry soda lime granules of the upper canister in comparison to wet and less exhausted lower canister soda lime granules [Figure 1]b. Following the change of soda lime, patient's peak airway pressure, ETCO₂, HR, and MAP stabilised and the rest of the surgery proceeded uneventfully.

Figure 1: (a) Excessive water bubbling between the outer wall of lower soda lime canister and the inner wall of the canister assembly. (b) The exhausted dry soda lime in the upper canister and the wet soda lime in the lower canister Click here to view

Regeneration/peaking occurs because of surface regeneration of active hydroxides at the soda lime granules surface.^[4] The amount of regeneration depends on the duration of rest given to soda lime and this may be the explanation of the reappearance of the original pink color next morning in our case after its continuous use a day before the incident.

Explanation for both rebreathing leading to hypercapnia and collection of excessive water could be due to channeling, which led to nonhomogenous flow of gases that occurs due to incorrect packing of soda lime in the canister.^[1] The gas as well as the moisture collected from the exhaustion of the upper canister took the path of the least resistance forming channels and bypassing majority of the soda lime granules and hence moisture was collected in large quantity by gravity into the canister assembly. Presence of the excessive moist granules led to the phenomenon called "caking," which increased the peak airway pressure in our case.^[2],[5] Therefore, careful marking of the date of change on the canister alone cannot guarantee prevention of such phenomenon, but utmost vigilance, care during refilling of canister, and knowing the total duration of use of the soda lime the day before the surgery should help in preventing such incidents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Stolp BW, Moon RE. Sodasorb CO2 Absorbents Manual – Shearwater Research. [monograph on the internet]. Cambridge: W.R Grace and Co.- Conn; 1993. Available from: https://www.shearwater.com/wp-content/uploads/2012/08/Sodasorb_Manual.pdf. [Last cited on 2018 Aug 23].
2.	Yamakage M, Takahashi K, Takahashi M, Satoh JI, Namiki A. Performance of four carbon dioxide absorbents in experimental and clinical settings. Anaesthesia 2009;64:287-92.
3.	Looseley A. Management of bronchospasm during general anaesthesia. Anaesthesia 2011;27:17-21.
4.	Young TM. Performance of two carbon dioxide absorbers The MIE Jumbo and the BOC MKIII. Anaesthesia 1966;24:417-27.
5.	Elam JO. Channeling and overpacking in carbon dioxide elimination in semiclosed systems. Anesthesiology 1958;19:403-4.

Figures

  [Figure 1]

Anaesthesia for tracheal reconstruction

LETTER TO EDITOR

Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 152-153

Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe

Vaijayanti Nitin Gadre, Deoshree Bal Ramteke, Sushila Ramkishan Yadav, Esmat Gulamraza Mundrawala
Department of Anesthesiology, Grant Government Medical College, Mumbai, Maharashtra, India

Date of Web Publication

11-Feb-2019

Correspondence Address:
Dr. Vaijayanti Nitin Gadre
'Sniti-11', General Jagannath Bhosale Marg, Oppo. Mantralaya, Near Sachivalaya Gymkhana, Mumbai - 400 021, Maharashtra 
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ija.IJA_629_18

 

How to cite this article: Gadre VN, Ramteke DB, Yadav SR, Mundrawala EG. Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe. Indian J Anaesth 2019;63:152-3

How to cite this URL: Gadre VN, Ramteke DB, Yadav SR, Mundrawala EG. Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:152-3. Available from: http://www.ijaweb.org/text.asp?2019/63/2/152/251975

Sir,

Narrowing of trachea due to prolonged intubation, thyroid mass or cervical malignancies is known. We report a case of tracheal stenosis for proposed tracheal reconstruction.

A 21-year-old 70-kg tracheostomised male had difficulty in breathing through his 4.5-mm tracheostomy tube. He had undergone craniotomy 4 years back, had received mechanical ventilation for 15 days and was discharged after a month with a 7.5 mm tracheostomy tube. Over a period of 4 years, the trachea could not be decannulated even after repeated laser dilatation. Computerised tomography of neck showed 1.4-cm long near-complete (7 mm diameter) obliteration of trachea at C7 to T1 level. The patient was posted for anterior tracheoplasty with tibial periosteal grafting. In the operating room, difficult airway cart including additional small-sized endotracheal tubes was kept ready. The patient was positioned supine, monitors were attached and intravenous access was secured. Nebulisation was done with 2% lignocaine 1 ml for 15 min and for premedication, intravenous ondansetron 4 mg, glycopyrrolate 0.2 mg, midazolam 1 mg, hydrocortisone 100 mg and fentanyl 60 μg were given slowly. Pre-oxygenation was done with closed circuit attached to the tracheostomy tube; anaesthesia was induced with propofol 2 mg/kg and a ratio of O₂:N₂O was maintained at 50:50 and 2% sevoflurane was given on spontaneous-assisted ventilation. Flexible fibre-optic nasopharyngolaryngoscope was introduced through left nostril by the surgeon to study the vocal cord dynamics and rule out inter-arytenoid and subglottic fibrosis. Overhanging epiglottis was also ruled out before deciding definitive tracheal correction. For examining the sub-glottis up to carina, vecuronium 3 mg IV was given. This step helped surgeons to count total intact tracheal rings above the stoma to plan the extent of tracheal resection or trachaeoplasty with stenting. Only 10 rings were present (normal 16–18); hence, 6-cm long and 1.8-mm internal diameter stent (Montgomery T tube) was inserted to ensure optimal tracheal length. To allow surgery as well as uninterrupted ventilation at this step, laryngeal mask airway (LMA classic size 4) was inserted, cuff was inflated, ventilation was confirmed and continued via the first anaesthesia workstation. The tracheostomy tube was removed [Figure 1] and the open stoma was secured with a sterile cuffed flexo-metallic endotracheal tube (size 5). The machine end of this tube was blocked by anaesthesiologist's gloved finger to prevent leakage of ventilated gases. As and when required, this endotracheal tube was connected to a second anaesthesia workstation. Ventilation continued alternatively through distal endotracheal tube or LMA, in coordination with proximal and distal end suturing, respectively, of the stent inside the trachea.

Figure 1: Figure showing open stoma and LMA inserted Click here to view

A horizontal incision was taken below the level of stoma, a subplatysmal flap was elevated, the strap muscles were separated and the trachea with stoma was exposed. The perpendicular end of the T-tube was cut and the longitudinal portion inserted from the lower end of the cricoid cartilage superiorly up to the first tracheal ring inferiorly. The anterior wall of the resected trachea was reconstructed with a 5-cm × 2-cm tibial periosteum graft, haemostasis was achieved and wound was closed in layers after confirming no air leak. Ventilation was controlled through the LMA throughout until closure. After return of spontaneous ventilation, reversal was done with neostigmine 0.05 mg/kg and glycopyrrolate 0.008 mg/kg. Patient was extubated and shifted to critical care for monitoring.

Anaesthesia for surgical procedures on the trachea and major airways is essentially perilous because an already compromised airway needs to be shared with the surgeon. The unique challenge is the ability to maintain adequate oxygenation and uninterrupted ventilation. A discrete plan for ventilation at each surgical step is needed. Considering the extent of tracheal pathology, preparations for alternative modes of ventilation are employed in coordination with the surgeon. In the face of an open airway, ventilation can be managed by manual oxygen through a small bore anode tube placed through the upper tracheal lesion combined with a distal endotracheal or bronchial tube inserted distal to the stenosis.^[1] Earlier belief was that maximum length of the trachea that can be resected is 2 cm.^[2] Lesions requiring resection of more than 6 cm or more than 50% of total length of trachea in adults or more than 30% trachea in children are considered inoperable. Longer segment involvement after previous surgery needs patch augmentation or slide trachaeoplasty.^[3] Tissue engineering advances have successfully used cadaveric allografts and autologous tissue.^[4]

In the present case, T-tube was appropriate to palliate the obstruction. It allowed respiration through nasopharynx, preserved humidification and speech. It has no tissue irritation and hence proved useful.

Patient was advised postoperatively to retain follow-up until complete reepithelialisation and undergo stent removal.

Meticulous preoperative planning, precise airway control and perfect coordination to oxygenate the patient with each distinct surgical step were the essence of our successful management of anaesthesia during transected airway surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Barash PG, Cullen BF, Stoelting RK. Anaesthesia for thoracic surgery. In: Clinical Anaesthesia 5th ed, ch. 29. Philadelphia: Lippincott Williams and Wilkins. A Walter Kluwer company; 2006. p. 813-55.
2.	Heitmiller RF. Tracheal release maneuvers. Chest Surg Clin N Am 1996;6:675-83.
3.	Grillo HC. Primary tracheal tumours. In: HC Grillo, editor. Surgery of Trachea and Bronchi. Hamilton: BC Decker; 2004, p. 791-802.
4.	Jungebluth P, Moll G, Baiguera S, Macchiarini P. Tissue engineered airway: A regenerative solution. Clinical Pharmacol Therap 2012;91:81-93.

Figures

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