[Small-volume resuscitation in hypovolemic shock. Remarks on the work of U. Kreimeier et al. Anaesthesist (1997) 46:309-328].
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Cardiopulmonary Resuscitation↗
Biomedical subjects
T Standl
Publications and source records attributed to T Standl.
Safety and efficacy of spinal vs general anaesthesia in bone marrow harvesting.
Bone marrow harvesting (BMH) can be performed with either general (GA) or spinal anaesthesia (SPA). Whether SPA is advantageous in BMH and if this technique is safe for procedures performed in the prone position is still controversial. To evaluate the safety and efficacy of both anaesthetic techniques in BMH, 37 allogeneic donors (nine female, 28 male; 34.3 +/- 9 years; ASA class 1-2) received either spinal (group 1, n =20) or general anaesthesia (group 2, n = 17) according to their personal wishes. Under standardised harvesting conditions, haematology parameters, cell counts (MNC, CD34+), haemodynamic parameters, adverse reactions and patient satisfaction were registered. No differences were seen between groups with respect to demographic data, harvesting time (55 +/- 17 vs 60 +/- 16 min) and bone marrow cell counts (MNC: 6.68 +/- 2.1 vs 5.7 +/- 1.7 ml/10(6)). The incidence of hypotension was higher in group 1 (45 vs 10.8%; P =0.042). Postoperative analgesic requirement and emesis were increased in group 2 (P < 0.04) in comparison to group 1. In conclusion, the present study failed to show superiority of spinal over general anaesthesia with regard to the quality of the harvested bone marrow. However, the lower incidence of complaints after spinal anaesthesia appears to offer an advantage over GA in healthy allogeneic bone marrow donors.
Adult↗
[Successful resuscitation after bolus injection of tissue-type plasminogen activator in emergency admission].
UNLABELLED: We report on a 30-year old female patient with suspected fulminant pulmonary embolism and cardiac arrest following ambulatory arthroscopy nine days before the event. After 15 minutes of unsuccessful cardiopulmonary resuscitation (CPR) on the ambulance the patient was transferred to the emergency unit of a hospital and was treated with bolus injection of 50 mg t-PA initially and 50 mg over the next two hours. Five minutes after the initial bolus the circulation could be stabilised and the patient could be extubated the next morning. The patient did not present any neurological deficit on the day of discharge nor did she show any bleeding complications. The time elapsing from notice to emergency service to arrival at hospital was about 35 minutes. DISCUSSION: In patients with massive and life-threatening pulmonary embolism thrombolysis offers an opportunity to manage this critical situation. Due to the serious prognosis of these patients the potential benefit of thrombolysis outweighs the lack of preceding diagnostic procedures and the risk of potential side-effects. CONCLUSION: In the light of an excellent outcome of this patient thrombolytic therapy with t-PA appears to be justified under continued CPR if fulminant pulmonary embolism is suspected.
Adult↗
[Hemoglobin solutions: volume replacement or oxygen therapy?].
The development of haemoglobin solutions has progressed significantly in the last 15 years because of a perceived short fall in allogeneic blood within the next decades and increased concern about transmitted infectious diseases. Animal studies have shown that modern highly purified and chemically modified haemoglobin preparations are free of toxic side effects, provide adequate volume replacement and have vasoconstrictive effects that enhance systemic vascular resistance and mean arterial pressures after haemorrhage and in models of nearly complete blood replacement. Microcirculatory effects of haemoglobin-based oxygen carriers are dependent on the respective organ and species in which they are applied and on their degree of purification and chemical modification. Because of different physico-chemical properties in comparison with red cells, haemoglobin solutions provide sufficient tissue oxygenation in areas with critically restricted perfusion even when applied in small doses. First studies in volunteers and patients showed efficacy and tolerability of different newly developed haemoglobin solutions during acute normovolaemic haemodilution and in perioperative blood replacement. However, only little information exists to date in terms of metabolism of haemoglobin preparations and their potential immunogenicity and immunosuppressive side effects. Technical problems with the clinical use of haemoglobin solutions arise because of interference of plasma haemoglobin with routine laboratory tests and oximetry. Future indications for haemoglobin solutions as an oxygen therapeutic allow for application of small doses of such preparations and may help to avoid major technical problems. More clinical studies have to be undertaken to confirm the effectivity and safety of the different haemoglobin solutions and to find out the optimal indications beyond acute preclinical and perioperative blood replacement.
Animals↗
Bovine haemoglobin-based oxygen carrier for patients undergoing haemodilution before liver resection.
We have studied the use of ultrapurified polymerized bovine haemoglobin (HBOC-201) in patients undergoing preoperative haemodilution before liver resection. After autologous blood donation of 1 litre, 12 patients (six males, six females, mean age 59 (35-69) yr) received Ringer's lactate solution 2 litre and, in a random design, 6% hydroxyethyl starch 70,000/0.5 (HES) 3 ml kg-1 or HBOC-201 0.4 g kg-1 within 30 min. Blood samples were obtained for blood chemistry, co-oximetry, haematology, coagulation profiles and immunology examinations before operation, on the day of surgery, on days 2-4 and 7 after operation, on the discharge day and 3 months after operation. There were no differences in patient characteristics, blood loss, amount of solutions infused, transfused allogeneic blood or duration of hospital stay. There were no local or systemic allergic reactions with infusion of HES or HBOC-201. Patients receiving HBOC-201 developed more pronounced leucocytosis and reticulocytosis during the early postoperative days compared with HES-treated patients. The mean maximum plasma haemoglobin concentration was 1.0 (SD 0.2) g dl-1 at the end of infusion of HBOC-201 was 8.5 h. Patients in both groups experienced temporary changes in liver enzymes and coagulation variables which returned to normal before discharge. Urinalysis revealed no difference between groups and no free haemoglobin was detected in urine. Patients receiving HBOC-201 showed no IgE and only a slight increase in IgG titres to HBOC-201 on the day of discharge; these were not detectable at 3 months. Single-dose administration of HBOC-201 was well tolerated by patients undergoing elective liver resection surgery and appears to be safe as a substitute during preoperative haemodilution.
Adult↗
The safety of continuous spinal anesthesia.
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Anesthesia, Spinal↗
Physostigmine prevents postanesthetic shivering as does meperidine or clonidine.
BACKGROUND: Postanesthetic shivering develops in as many as one half of patients recovering from isoflurane anesthesia. Cholinergic stimulation of the hypothalamic-pituitary-adrenal axis and adrenal medulla by physostigmine enhances secretion of arginine vasopressin, epinephrine, and norepinephrine. Because the hypothalamus is the dominant thermoregulatory controller in mammals, and these neurotransmitters may be involved in body temperature control, physostigmine administration may influence the incidence of shivering. Accordingly, the authors tested the hypothesis that physostigmine administration inhibits postanesthetic shivering. Its efficacy was compared with that of saline (negative control) and meperidine and clonidine (positive controls). METHODS: Sixty patients having surgery of the ear or nose were tested. General anesthesia was induced with 2 mg/kg propofol, 0.1 mg/kg vecuronium, and 1.5 microg/kg fentanyl and maintained with isoflurane (1.5 +/- 0.4%) in 70% nitrous oxide. At the end of surgery, the patients were randomly assigned to receive an intravenous bolus of 0.04 mg/kg physostigmine, isotonic saline, 0.5 mg/kg meperidine, or 1.5 microg/kg clonidine. Heart rate, mean arterial blood pressure, oxygen saturation, visual analog pain score, temperature, and postanesthetic shivering were measured during recovery. RESULTS: Postanesthetic shivering occurred in 6 of 15 (40%) patients given saline. In contrast, postanesthetic shivering was significantly reduced in physostigmine-treated patients (1 of 15, or 7%) and was absent in patients given clonidine or meperidine. CONCLUSIONS: Physostigmine inhibited shivering as well as did two established treatments, meperidine and clonidine. These data suggest that cholinergic systems contribute to the genesis and control of postanesthetic shivering.
Adult↗
Non-thermoregulatory shivering in patients recovering from isoflurane or desflurane anesthesia.
BACKGROUND: Although cold-induced shivering is an obvious source of postanesthetic tremor, other causes may contribute. Consistent with this theory, the authors had previously identified an abnormal clonic component of postoperative shivering and proposed that it might be nonthermoregulatory. A subsequent study, however, failed to identify spontaneous muscular activity in normothermic volunteers. These data suggested that the initial theory was erroneous or that a yet-to-be identified factor associated with surgery might facilitate shivering in patients after operation. Therefore, the authors tested the hypothesis that some postoperative tremor is nonthermoregulatory. METHODS: One hundred twenty patients undergoing major orthopedic operation were observed. They were grouped randomly to receive maintenance anesthesia with nitrous oxide and isoflurane (0.8 +/- 0.4%) or desflurane (3.4 +/- 1.1%). Twenty patients in each group were allowed to become hypothermic, whereas normal body temperatures were maintained in the others (tympanic membrane temperature exceeding preinduction values). Arteriovenous shunt vasoconstriction was evaluated using forearm-minus-fingertip skin-temperature gradients; gradients less than 0 degrees C identified vasodilation. Postanesthetic shivering was graded by a blinded investigator. Tremor in patients who were normothermic and vasodilated was considered nonthermoregulatory. RESULTS: Thermoregulatory responses were similar after isoflurane or desflurane anesthesia. Approximately 50% of the unwarmed patients shivered. Shivering was observed in 27% of the patients who were normothermic; 55% of this spontaneous muscular activity occurred in vasodilated patients. Among the normothermic patients, 15% fulfilled the authors' criteria for nonthermoregulatory tremor. CONCLUSIONS: The incidence of postoperative shivering is inversely related to core temperature. Therefore, it was not surprising that shivering was most common among the hypothermic patients. The major findings, however, were that shivering remained common even among patients who were kept scrupulously normothermic and that many shivered while they were vasodilated. Thus, postoperative patients differ from nonsurgical volunteers in demonstrating a substantial incidence of nonthermoregulatory tremor.
Adult↗
Transcranial Doppler sonography mean flow velocity during infusion of ultrapurified bovine hemoglobin.
A number of studies have shown that polymerized bovine hemoglobin (HBOC-201) does not cause clinically significant side effects. This has been demonstrated in spite of the fact that a primary increase in oxygen extraction ratio has been associated with an increase in systemic vascular resistance (SVR) and a decrease in cardiac index (CI). The current study investigated the effects of HBOC-201 on cerebral circulation. Middle cerebral artery mean flow velocity (Vm) was measured using Transcranial Doppler sonography. After institutional review board approval and informed consent were obtained, 12 patients (mean age 59+/-10 years), scheduled for hepatic resection, were enrolled. Anesthesia during the induction period consisted of etomidate (0.3 mg/kg), fentanyl (3 mcg/kg), and vecuronium (0.1 mg/kg). Anesthesia during the maintenance period consisted of isoflurane (0.64-0.8 vol%)/O2/N2O (FiO2=0.3), fentanyl, and vecuronium. End-tidal carbon dioxide partial pressure (PetCO2), arterial carbon dioxide partial pressure (PaCO2), mean arterial blood pressure (MAP), CI, SVR, mean flow velocity, and pulsatility index were measured in each patient. Hemodilution was performed in all patients, followed by randomized assignment to two groups: Group 1 (n=6) received 0.4 g/kg HBOC-201, Group 2 (n=6) received a corresponding volume of hydroxyethyl starch (mw 70,000). Measurements were taken at six points (PMs): before hemodilution (PM 1); following hemodilution (PM2); and at 3, 10, 20, and 30 minutes (PM 3-6) after infusion of HBOC-201 or starch. Systemic vascular resistance rose in Group 1 as compared with Group 2, with significant differences at PM 3-6. The greatest difference was at PM 6 (Group 2=1071 dyne x s x cm(-5); Group 1=2154 dyne x s x cm(-5)). Cardiac indices were significantly lower in Group 1 (1.7-1.8 l/minute x m(-2)) than in Group 2 (2.4-2.7 l/minute x m(-2)) after PM 3. After hemodilution, mean flow velocity showed an insignificant increase in both groups, ranging from 39 to 46 cm/second. Although SVR increased significantly following HBOC-201 -infusion, the results of this study did not reveal changes in cerebral blood flow that establish significant group-to-group differences.
Adult↗
Subarachnoid and intravenous PCA versus bolus administration for postoperative pain relief in orthopaedic patients.
BACKGROUND: Patient-controlled analgesia (PCA) with intravenous piritramide and subarachnoid bupivacaine was studied during postoperative pain management in comparison with nurse-administered bolus injections. METHODS: Following general anaesthesia (n = 60) patients randomly received either 3.75-7.5 mg i.v. piritramide on demand (group P-Bolus) or via PCA (group P-PCA; initial bolus: 3.75 mg i.v. piritramide, baseline rate: 1 mg/h, demand-dose 1.5 mg, lockout time: 20 min). Following continuous spinal anaesthesia (n = 60; CSA; 28-G spinal catheter) patients randomly received a subarachnoid injection of 1.5 ml bupivacaine 0.25% every 2-4 h (group B-Bolus) or a baseline infusion of 0.5 ml/h bupivacaine 0.125% plus 0.5 ml bupivacaine 0.125% on demand via PCA (group B-PCA; lockout time: 30 min). Pain ratings were assessed hourly by patients using a visual analogue scale (0 = no pain, 100 mm = unbearable pain). STATISTICS: multivariate analysis of variance. RESULTS: While pain scores did not differ between group P-Bolus and P-PCA, group B-PCA showed the lowest pain ratings (18 +/- 22 mm) differing significantly from group B-Bolus (41 +/- 32 mm; P < 0.001). Group P-PCA required more piritramide than group P-Bolus (46 +/- 15 mg vs. 31 +/- 13 mg, P = 0.001). In contrast group B-PCA required less bupivacaine than group B-Bolus (18 +/- 4 vs. 23 +/- 7 mg, P = 0.002). CONCLUSION: PCA with CSA was more effective than nurse-administered bolus-administration of bupivacaine, while the present study failed to show superiority of i.v. PCA over i.v. bolus-administration of piritramide. PCA using the subarachnoid route is a promising concept for treatment of postoperative pain in orthopaedic patients, while the PCA piritramide regime of this study warrants improvement.
Aged↗
[Single-dose spinal anesthesia with a mixture of isobaric bupivacaine 0.5% and hyperbaric mepivacaine 4%].
BACKGROUND: Single-dose spinal anaesthesia with hyperbaric local anaesthetic provides profound analgesia and motor blockade and allows exact assessment of the analgesic level. The present prospective, randomised study compares a mixture of plain 0.5% bupivacaine and hyperbaric 4% mepivacaine with hyperbaric 0.5% bupivacaine with regard to onset time of analgesia and duration of the sensory and motor blockade. METHODS: One hundred and twenty-two orthopaedic patients (69 m/53 f, aged 20-91 years) scheduled for elective lower limb surgery under spinal anaesthesia were randomly allocated to one of two groups. In group 1, 67 patients received a 1:1 mixture of plain 0.5% bupivacaine and hyperbaric 4% mepivacaine (density: 1,015 kg/m3, 37 degrees C). In group 2, 55 patients received hyperbaric 0.5% bupivacaine (density: 1,021). The lumbar puncture was performed between L3 and L5 using a 26 G Quincke needle through a 20 G introducer with the patients either in the sitting or lateral position. The local anaesthetic was administered with an injection speed of 1 ml per 5 s. Patients with a body height < 160 cm received 2.0 ml, those 160-180 cm 3.0 ml, and those > 180 cm 4.0 ml. The level of analgesia was registered every minute by pin-prick until the maximal analgesic level was reached. The time of regression of analgesia to the level of T 12 and regression of the motor block to Bromage scale 3 was registered. The data were analysed using Student's t-test with P < 0.05 considered as significant. RESULTS: Demographic data did not differ between groups. In group 1, the onset time of analgesia was faster than in group 2 (8 +/- 3 vs. 14 +/- 5 min, P < 0.001). While in group 1 the onset time of analgesia was faster in patients injected sitting compared to those in the lateral position (p < 0.05), there was no position-related difference in group 2. The groups also did not differ with respect to the maximal level of analgesia and the duration of sensory and motor blockade. CONCLUSIONS: The local anaesthetic mixture may be preferred to hyperbaric 0.5% bupivacaine in patients requiring a fast onset of analgesia associated with a 2-3 h duration of sensory and motor block.
Adult↗
[Preoperative hemodilution with bovine hemoglobin. Acute hemodynamic effects in liver surgery patients ].
UNLABELLED: Haemoglobin solutions can be an alternative to allogeneic red-cell transfusions because they combine colloid osmotic with oxygen transport properties. Since severe toxic side effects have been overcome by ultrapurification, clinical interest has been focused on haemodynamics changes during application of haemoglobin preparations. The present clinical study examines changes of haemodynamic and oxygen transport parameters during and after haemodilution with ultrapurified polymerized bovine haemoglobin (HBOC-201) in comparison to hydroxyethyl starch (HES). METHODS: After approval of the Ethics Committee, 12 patients (6 males and 6 females, mean age 59 +/- 10 years, ASA 1-2) undergoing elective liver resection were randomly allocated to receive either 3 ml.kg-1 6% HES 70,000/0.5 (group 1) or 0.4 g.kg-1 HBOC-201 (group 2) within 30 min following autologous blood donation of 1 l and substitution with 2 l Ringer's lactate. Measurements of blood gases, haemodynamics, and oxygen transport parameters were performed after induction of general anaesthesia, prior to and after blood donation, during and after infusion, at the beginning of surgery, and in the intensive care unit. RESULTS: Demographic characteristics did not differ between groups. In contrast to the HES group, mean arterial pressure increased by 18% over baseline measurements in group 2. While pulmonary vascular resistance showed a trend to higher values in group 2, systemic vascular resistance increased to a maximum of 42% over baseline in group 2 and was twice as high as in the HES group. The cardiac index was lower in the HBOC-201 group than in the HES group. During and after HBOC-201 infusion, mixed-venous oxygen saturation and content and calculated oxygen delivery were lower in group 2 in comparison to group 1, while the oxygen extraction ratio was higher in group 2. Free haemoglobin reached a maximal concentration of 1.0 +/- 0.2 g.dl-1 30 min after the HBOC-201 infusion was started, but was not detectable in urine over time. The mean intravascular half-life of HBOC-201 was 8.5 h. CONCLUSIONS: Patients did not show any severe complications during and after infusion of HBOC-201. However, vasoconstrictive side effects resulted in increased systemic but not pulmonary resistance. Ongoing studies with higher doses of HBOC-201 applied in a larger number of patients will probably reveal potential clinical consequences of the demonstrated haemodynamic changes.
Adult↗
[Continuous spinal anesthesia vs. combined spinal-epidural anesthesia in emergency surgery. The combined spinal-epidural anesthesia technique does not offer an advantage of spinal anesthesia with a microcatheter].
UNLABELLED: In this prospective study we investigated the efficacy of microcatheter spinal anaesthesia in comparison with a combined spinal-epidural technique in trauma patients. METHODS: After institutional approval 60 patients undergoing urgent lower-limb surgery randomly received either CSA (22 G Sprotte needle, 28 G nylon catheter) in group 1 or CSE (18 G Tuohy needle, 22 G epidural catheter and 25 G pencil-point needle) in group 2. An initial subarachnoid bolus of 2 ml of plain bupivacaine 0.5% was injected in both groups. Difficulties with the lumbar puncture or catheter insertion, the time required for performance of either technique and the onset of analgesia at T12 were documented. If analgesia did not reach T12 within 20 min, supplemental bupivacaine was injected either intrathecally or epidurally up to a maximum of 5 ml in the CSA group or 16 ml in the CSE group. RESULTS: The number of lumbar punctures (CSA: n = 1.8 +/- 1.5; CSE: n = 2.6 +/- 1.8; P = 0.05) and the incidence of technical problems (CSA: 13%, CSE: 47%; P = 0.012) was higher in the CSE group. In contrast to CSA, performance of CSE was more time consuming (CSA: 8 +/- 3 min, CSE: 15 +/- 8 min; P = 0.0003), and the total dose of local anaesthetics was higher in the CSE group (CSA: 3.2 +/- 1 ml, CSE: 9.7 +/- 5 ml; P < 0.0001). CONCLUSIONS: Because of the higher incidence of technical problems, more time was required for the performance of CSE. As a consequence, microcatheter CSA might be preferred over CSE in trauma patients.
Aged↗
Bovine hemoglobin increases skeletal muscle oxygenation during 95% artificial arterial stenosis.
BACKGROUND: This study investigates the effect of a stroma-free ultrapurified bovine hemoglobin solution (HBOC) on skeletal muscle tissue oxygenation in comparison with hetastarch during nearly complete arterial stenosis. METHODS: Fourteen foxhounds were intravenously anesthetized and mechanically ventilated with 30% oxygen in air. Catheters were inserted into the right femoral artery and vein for measurements of hemodynamic parameters and blood gas sampling. Arterial blood flow of the left popliteal artery was measured by means of an electromagnetic flow probe. Skeletal muscle tissue oxygen tension (tpO2) was measured in the left gastrocnemius muscle by using a stepwise driven polarographic needle probe creating histograms from 200 single tpO2 measurements. After isovolemic hemodilution with Ringer's lactate solution to a hematocrit of 25%, a 95% artificial stenosis of the popliteal artery was established. The animals then randomly received two applications of either 50 ml HBOC (molecular weight, 32,000 to 500,000; hemoglobin, 13 +/- 1 gm/dl-1) or 200 ml 6% hetastarch 200,000/0.5. Variables were measured at baseline, after hemodilution, 30 minutes after stenosis, and 15 minutes after two applications of the respective compound. RESULTS: Demographic data, muscle temperature, and arterial blood gases did not differ between groups. With the exception of higher mean arterial and mean pulmonary artery pressures in HBOC-treated animals, hemodynamics did not differ between groups. In both groups oxygen delivery and oxygen consumption of the muscle decreased in parallel to the decreasing blood flow during arterial stenosis. In contrast, oxygen extraction ratio increased after infusion of HBOC and was higher after the second application when compared with hetastarch-treated animals (p < 0.05). During stenosis tpO2 was decreased in both groups when compared with baseline (p < 0.001). Mean tpO2 remained at decreased levels after administration of hetastarch but increased to nearly baseline values after HBOC treatment (p < 0.001). CONCLUSIONS: The data suggest that increased oxygen extraction in the HBOC group is associated with improved skeletal muscle tissue oxygenation during severe arterial stenosis.
Animals↗
[Acute theophylline intoxication as differential diagnosis of pneumothorax in an asthma patient].
The ambulance was called to a known asthmatic patient. On arrival, the team found a massively dyspnoeic, diaphoretic, non-cyanotic and somnolent patient. His medication consisted of oral theophylline (unknown dosage), fenoterol (metered-dose inhaler), as well as 8 mg oral prednisolone. On the day of emergency, the patient had been treated by two physicians who applied two doses of i.v. theophylline and one dose of s.c. terbutaline because of bronchoconstriction (dosage not documented). The patient's pulse was frequent with 200 beats/min, the blood pressure not measurable. Careful i.v. titration of metoprolol was started to decrease the patient's heart rate and increase diastolic filling and stroke volume. However, the patient showed a progressive circulatory collapse. Following diagnostic thoracocentesis to rule out a left-side pneumothorax, the patient required intubation and mechanical ventilation because of increasing cardiovascular instability. A tension pneumothorax developed immediately after mechanical ventilation and required rapid treatment with a chest tube. Nevertheless, CPR and intravenous infusion of catecholamines were necessary before the patient was referred to a medical intensive care unit where he died the same day in cardiogenic shock. Clinical signs and symptoms associated with an elevated theophylline plasma level make theophylline toxicity the probable causative event for the patient's emergency condition of acute theophylline intoxication.
Administration, Oral↗
[Special anesthesiological aspects in patients with Niikawa-Kuroki ("Kabuki Make-Up") syndrome].
The Niikawa-Kuroki ("Kabuki Make-up") syndrome (NKS) is a rare disease with a characteristic array of multiple congenital anomalies. The syndrome is characterised by distinct craniofacial dysmorphias, moderate mental retardation, skeletal abnormalities, cardiovascular and urogenital disorders, growth retardation and skeletal muscle abnormalities. The inheritance of NKS is not completely clear. However, the available data are compatible with an autosomal dominant mutation with variable expressivity. There is no specific treatment for NKS. The patients require intensive support for the development of their mental and physical capabilities. Furthermore, therapy includes operative correction of the multiple anomalies. The risk of anaesthesia is increased in these patients because of a possible difficult airway, cardiovascular and urogenital diseases, and abnormalities of the skeletal muscles. Special problems associated with the anaesthetic management in patients with NKS are discussed in this case report.
Abnormalities, Multiple↗
[Hyperplasia of the lingual tonsil as an unexpected intubation obstruction in a preschool child].
Case report of a five year-old boy who was admitted for elective squint surgery. The medical history revealed some delay in his behavioural and mental development as well as an unspecific dysmorphic syndrome with suspected muscular weakness. Tonsillectomy and adenotomy have been performed six months prior to admission. During examination on the day before surgery, the child presented only mild symptoms of a subsiding upper respiratory infection. Because of the uncooperativeness of the child the pharyngeal inspection was not performed. On the day of surgery total intravenous anaesthesia was induced by injection of sufentanil, propofol and atracurium. Ventilation with 100% oxygen via facemask was uneventful. However, laryngoscopy for endotracheal intubation was impossible due to a massive lingual tonsillar hyperplasia. A size 2 laryngeal mask with flexible spiral-tubing was inserted and anaesthesia was maintained using continuous propofol infusion. The surgical procedure was finished after 30 min and the laryngeal mask was removed. The following postoperative course was uneventful and the child was discharged from the hospital two days later. The present case report demonstrates the importance of preoperative pharyngeal inspection prior to elective endotracheal intubation and the possibility of unexpected difficult airway management by the laryngeal mask.
Child, Preschool↗
[Anesthesia in general surgery and urology].
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Anesthesiology↗