Journal of clinical anesthesia
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Pulmonary edema developing after the relief of upper airway obstruction has been reported in association with a diversity of etiologic factors, including hanging, strangulation, tumors, foreign bodies, goiter, and laryngospasm. Since 1977, 18 cases of adults with postobstructive pulmonary edema associated with anesthesia have been reported. ⋯ Risk factors for the development of upper airway obstruction have been identified in the majority of these cases. A heightened awareness among anesthesiologists of this poorly recognized and hence often perplexing syndrome may help reduce the occurrence and facilitate the treatment of this potential complication of perioperative airway management.
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An 86-year-old man receiving antiarrhythmic treatment with an intravenous (IV) lidocaine infusion experienced a prolonged emergence from general anesthesia. A venous blood sample was sent for determination of the lidocaine concentration, the infusion was stopped, and the patient awakened 15 minutes later. ⋯ The overdose was the result of a miscalculated infusion rate, plus an underestimation of effects of age, cardiac disease, and general anesthesia on the rate of lidocaine biotransformation. Infusion of any drug during and after general anesthesia requires scrupulous attention to dosage determination and to the clinical condition of the patient receiving the infusion.
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Carboxyhemoglobin and methemoglobin levels in 312 units of banked blood and their relationship to the duration of storage were determined. The carboxyhemoglobin level decreased as the storage time increased, and its mean was 1.4% +/- 2.0% (SD) with a range from 0% to 9.6%. Methemoglobin increased during storage, showing a mean level of 1.6% +/- 0.4% and a range from 0.5% to 4.2%. ⋯ The mean initial level of carboxyhemoglobin was 4.4% +/- 1.6%, and the mean half-life of carboxyhemoglobin was approximately 47 days. Methemoglobin increased from an initial 1.3% +/- 0.2% to 2.4% +/- 0.6% at the end of storage. The use of banked blood containing high levels of these abnormal hemoglobins could be a potential risk in critically ill patients.
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Case Reports
Management of the difficult pediatric airway in an austere environment using the lightwand.
Increasingly, medical teams are providing sophisticated surgical treatment to pediatric patients in developing nations. Such care is often administered under relatively austere conditions using easily transported equipment. Because some of these patients may present with congenital or acquired airway abnormalities that make direct laryngoscopy difficult or impossible, alternative methods of endotracheal intubation should be available. ⋯ Use of the lightwand has a proven record of success and obviates the need for the heavier, more delicate, and more expensive flexible fiber-optic laryngoscope or pediatric bronchoscope. Two cases are reported in which pediatric patients with difficult airway anatomy due to severe burn scar contractures were successfully and easily intubated using the lightwand. This technique is useful for management of the difficult pediatric airway in the austere environment of the typical medical relief mission.
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Surgical removal of a cerebral hemisphere may be undertaken in patients with intractable seizure disorders. Anesthetic management of such patients has not been reviewed in detail before. This study retrospectively analyzed hospital records of ten patients undergoing cerebral hemispherectomy at the Johns Hopkins Hospital between July 1983 and February 1988. ⋯ Monitoring of intra-arterial pressure and central venous pressure (CVP) is necessary for patient management during the intraoperative and postoperative periods. Intravenous (IV) access should allow rapid intravascular volume administration as it becomes necessary. Patients should remain intubated and observed closely during the immediate postoperative period due to difficulties with hemodynamic stability, seizures, and hemorrhage.