Anesthetic challenges in a patient with Hirayama disease with quadriparesis and autonomic dysfunction undergoing cervical spine surgery

Hirayama disease is a rare neurological disorder, characterized by muscular atrophy of the distal upper extremities. The occurrence of spastic quadriparesis and autonomic dysfunction is rarely reported and has important perioperative considerations during cervical spine surgery for the treatment of this disorder. The role of the anesthesiologist is vital in the thorough assessment of the patient for the involvement of the pyramidal tract, autonomic dysfunction, gastroparesis, hyperreactive airway disease, and documentation of neurological deficits. Intraoperative concerns include safe manipulation of the airway during mask ventilation and the use of a flexible fibreoptic bronchoscope during endotracheal intubation to prevent neck flexion. It is also essential to avoid drugs, leading to histamine release. The use of multimodal monitoring including bispectral index and neuromuscular monitoring is crucial to prevent delayed recovery. Anticipation and management of exaggerated hypotension in response to anesthetic induction agents and prone position is the key to a successful outcome in patients with autonomic dysfunction.

Overcoming anaesthetic challenges in a pregnant woman with pituitary apoplexy undergoing endoscopic trans-sphenoidal resection of the pituitary tumour

Pituitary apoplexy is a rare condition that occurs due to acute haemorrhage in the pituitary gland and usually presents with features of acute hypopituitarism, visual defects and ophthalmoplegia. Pregnancy is one of the risk factors for pituitary apoplexy. Medical management is the first line of management in pregnancy irrespective of the gestational age. However, acute neuro-ophthalmological deterioration might warrant an urgent surgical decompression. Preoperative corticosteroids have dual benefits of providing hormonal replacement in the mother and also promoting fetal lung maturity in the offspring. Uterine contractions should be monitored and tocolysis provided as per requirements in a post-viable fetus.

Anaesthetic management of a toddler with uncorrected tetralogy of Fallot undergoing surgery for epidural haematoma

The literature on the anaesthetic management of a toddler presenting to the emergency department with an acute epidural haematoma with an uncorrected tetralogy of Fallot is sparse and management can be challenging. The main anaesthetic goals are to increase or maintain systemic vascular resistance and decrease pulmonary vascular resistance for cardiovascular stability, while maintaining cerebral perfusion pressure and decreasing intracranial pressure for cerebral protection. Thus, a balanced approach is desirable while managing such cases from emergency to the intensive care unit.

Challenging airway in a postmandibulectomy patient for carcinoma of the buccal mucosa undergoing laparoscopic cholecystectomy

Failure to secure the airway after administration of induction agent in a postmandibulectomy patient can lead to life-threatening complications; hence, recognising a difficult airway is of immense importance. Preoperative airway evaluation includes, but is not limited to, inter-incisor gap, modified Mallampati grading, neck movement, neck circumference, thyromental distance, sterno-mental distance, upper lip bite test and dental status. This case signifies the challenge encountered in securing the airway and the importance of thorough preoperative airway evaluation and preparedness before induction of anaesthesia in a postmandibulectomy patient for carcinoma of the buccal mucosa.

Intubating conditions and hemodynamic changes during awake fiberoptic intubation using fentanyl with ketamine versus dexmedetomidine for anticipated difficult airway: a randomized clinical trial

Background and objectives

Awake fiberoptic intubation (AFOI) is usually performed in patients with an anticipated difficult airway. Various sedation regimens are used during AFOI, however, most of them cause respiratory depression. The present study aims to compare the effectiveness of fentanyl with ketamine versus dexmedetomidine in search of a better sedation regimen which would achieve desirable intubating conditions and hemodynamic stability without causing respiratory depression.

Methods

This is a single centered randomized, double-blind clinical trial. Patients of both sexes between age 18–55 years and ASA (American Society of Anesthesiologists) physical status I–II with an anticipated difficult airway were randomly divided into two groups of thirty each. Group FK patients received intravenous fentanyl and ketamine, and group DX patients received dexmedetomidine, until Ramsay sedation scale ≥ 2. Heart rate (HR), mean blood pressure (MBP), oxygen saturation (SpO₂), respiratory rate (RR), endoscopy time, intubation time, first end-tidal carbon dioxide (ETCO₂) after intubation, endoscopist satisfaction score, and patient discomfort score were recorded during the study period. The level of recall was assessed on the next postoperative day.

Results

Endoscopist satisfaction score was better in group DX patients (p < 0.05). There was a smaller variation in HR and MBP from baseline with dexmedetomidine compared to fentanyl with ketamine. First ETCO₂ after intubation was higher in group FK patients (p <  0.05). No significant difference was found in patient discomfort score, intubation time, RR, SpO₂ and level of recall of the event.

Conclusions

The use of dexmedetomidine in AFOI provides better intubating conditions and hemodynamic stability compared to fentanyl with ketamine.

Airway challenges in bilateral temporomandibular joint ankylosis with adenoid hypertrophy: a case report

Temporomandibular joint ankylosis is one of the most challenging airway disorders associated with varying anatomical abnormalities like adenotonsillar hypertrophy, craniofacial malformations, macroglossia, etc. This case highlights the intubation difficulties confronted during the airway management of a 10-year-old girl presenting lately with bilateral temporomandibular joint ankylosis, hypoplastic mandible, and adenoid hypertrophy. This patient was intubated successfully by using a suction catheter assembly to negotiate the endotracheal tube across the adenoid, and an unmatched-size flexible intubation fiberscope through a "separate insertion" technique and external laryngeal manipulation. This case emphasises the significance of a comprehensive preoperative evaluation in preparing the anaesthetic plan of an anticipated difficult airway in a paediatric population, having diverse anatomical hurdles presenting concurrently.

Attachment of spermatozoa to in vitro matured bovine oocytes in TCM-199 and MEM media

Investigation was undertaken to study the efficacy of TCM 199 and MEM media in the process of oocyte maturation and fertilization after harvesting the oocytes from slaughtered cow and heifer ovaries by aspiration and mincing techniques. Out of 354 number of ovaries, mincing method could yield 1.35 (50.98%) of good quality oocytes per ovary as comparison to 0.61 (55.45%) by aspiration method. The TCM 199 and MEM could record the maturation of 85.71% and 60.26% of oocytes and the rate of sperm penetration was higher in TCM 199 matured oocytes (97.21%) as compared to MEM matured ones (74.46%). The staining of oocytes by aceto-orcein stain was also employed.