Vocal cord dysfunction causing hypoxaemia in the postanaesthesia care unit

Hypoxaemia in the postanaesthesia care unit is common and the majority is caused by hypoventilation or upper airway obstruction due to the (residual) effects of anaesthetic and analgesic agents. We present a case of upper airway obstruction caused by vocal cord dysfunction, a less frequently occurring aetiology. The patient's case suggests a notable relationship between procedural laryngeal stimulus and the onset of symptoms. Approach to the diagnosis and flexible laryngoscopy to either rule-in or rule-out several relevant differentials are discussed.

Prehospital coagulation measurement by a portable blood analyzer in a helicopter emergency medical service (HEMS)

In helicopter emergency medical services, HEMS, coagulopathy presents both in trauma (e.g. consumption of coagulation factors) and non-trauma cases (e.g. anticoagulant use). Therefore, in HEMS coagulation measurements appear promising and Prothrombin Time (PT) and derived INR are attractive variables herein. We tested the feasibility of prehospital PT/INR coagulation measurements in HEMS. This study was performed at the Dutch HEMS, using a portable blood analyzer (i-Stat®1, Abbott). PT/INR measurements were performed on (hemodiluted) author's blood, and both trauma- and non-trauma HEMS patients. Device-related benefits of the i-Stat PT/INR system were portability, speed and ease of handling. Limitations included a rather narrow operational temperature range (16-30 °C). PT/INR measurements (n = 15) were performed on hemodiluted blood, and both trauma and non-trauma patients. The PT/INR results confirmed effects of hemodilution and anticoagulation, however, most measurement results were in the normal INR-range (0.9-1.2). We conclude that prehospital PT/INR measurements, although with limitations, are feasible in HEMS operations.

Airway management concerns in patient with gastric banding procedures

Laparoscopic adjustable gastric band (LAGB) is considered a relatively safe and effective treatment for obesity. Even after weight loss patients with LAGB are at increased risk of pulmonary aspiration during induction of general anaesthesia, possibly due to LAGB-induced anatomical and functional changes. We present a case of aspiration in a patient with LAGB following significant weight loss and 14 h of preoperative fasting and review the literature. In the presence of LAGB we propose specific anaesthesia management at least consisting of anti-Trendelenburg positioning; avoidance of mask-ventilation; use of the local rapid sequence induction strategy with endotracheal intubation and fully awake extubation.