Discussion

DiscussionDiscussionDiscussionDiscussion

黃尹宬黃尹宬 B85401077B85401077

Clinical Issues about This PatientClinical Issues about This Patient

Hyponatremia & HypokalemiaHyponatremia & Hypokalemia AnemiaAnemia Infection and Drug InteractionInfection and Drug Interaction Ankylosing Spondylitis – major one!Ankylosing Spondylitis – major one!

Electrolyte ProblemsElectrolyte ProblemsHyponatremiaHyponatremia

<135 mEq/L<135 mEq/Lsevenfold to sixtyfold increase in mortality (association)sevenfold to sixtyfold increase in mortality (association)consciousness change, nausea and vomiting, when <120 mEq/Lconsciousness change, nausea and vomiting, when <120 mEq/Ldifferentiation: serum osmolaritydifferentiation: serum osmolarity

HypokalemiaHypokalemia<3.5 mEq/L<3.5 mEq/Lneuromuscular changeneuromuscular changemay potentiate cardiac arrhythmia: ventricular escape activity, may potentiate cardiac arrhythmia: ventricular escape activity, reentrant phenomena, ectopic tachycardia, and delayed reentrant phenomena, ectopic tachycardia, and delayed conduction.conduction.differentiation: excessive Kdifferentiation: excessive K++ loss or intracellular redistribution loss or intracellular redistribution

AnemiaAnemia34 % - 56 % surgical p’t may have preoperative anemia 34 % - 56 % surgical p’t may have preoperative anemia ( (http://www.anemia.org/http://www.anemia.org/))Effects:Effects:

Increase morbidity and mortalityIncrease morbidity and mortalityDecreased ODecreased O22 saturation saturation

Destablizing hemodynamic of the patientDestablizing hemodynamic of the patientTransfusion complicationTransfusion complication

Immunological: GVHD, for exampleImmunological: GVHD, for exampleElectrolyte imbalanceElectrolyte imbalanceAcid-base effectsAcid-base effectsInfectionInfection

Infection and Drug InteractionInfection and Drug InteractionSome CephalosporinsSome Cephalosporins

Those with Those with NN-methylthiotrazole and methylthiotrazole side -methylthiotrazole and methylthiotrazole side chain:chain:e.g. moxalactam, cefmenoxine, cefoperazone, cefotetan, e.g. moxalactam, cefmenoxine, cefoperazone, cefotetan, cefamandole, and cefazolincefamandole, and cefazolinLong-term use → hypoprothrombinemiaLong-term use → hypoprothrombinemiaInhibition of Vit. K- dependent hepatic enzyme epoxide Inhibition of Vit. K- dependent hepatic enzyme epoxide reductasereductase

The well-known aminoglycoside effect The well-known aminoglycoside effect prolongation of neuromuscular blockadeprolongation of neuromuscular blockade

Anesthesia about AS PatientsAnesthesia about AS PatientsAnesthesia about AS PatientsAnesthesia about AS Patients

Anesthesia about AS PatientsAnesthesia about AS Patients

Difficult IntubationDifficult Intubation Breath ChangesBreath Changes Spinal and Epidural anesthesiaSpinal and Epidural anesthesia Miscellaneous ProblemsMiscellaneous Problems


Difficult IntubationDifficult Intubation Cervical spine rigidity and fragilityCervical spine rigidity and fragility

Flexion: unable to place the sniffing positionFlexion: unable to place the sniffing position→ increasing difficulty of direct laryngoscopy→ increasing difficulty of direct laryngoscopy

Subluxation of atlantoaxial joint: Subluxation of atlantoaxial joint: DANGER!DANGER!→More mobile spine; easy damage to spinal →More mobile spine; easy damage to spinal cordcord

Temporomandibular joint involvementTemporomandibular joint involvementLimitation of Mouth OpeningLimitation of Mouth OpeningPartial limitation, tenderness, and CrepitusPartial limitation, tenderness, and Crepitus


Difficult IntubationDifficult Intubation Cricoarytenoid joint involvement Cricoarytenoid joint involvement

(Cricoarytenoid arthritis)(Cricoarytenoid arthritis)S/S: fullness or tightness in the throat, foreign body S/S: fullness or tightness in the throat, foreign body

sensation, hoarseness, stridor, dysphagia, odynophagia, sensation, hoarseness, stridor, dysphagia, odynophagia, dyspnea, and pain radiating to earsdyspnea, and pain radiating to ears

Diagnosis: direct laryngoscopyDiagnosis: direct laryngoscopy-- arytenoid mucosa is red / edematous / thick-- arytenoid mucosa is red / edematous / thick

Effect on Anesthesia: Effect on Anesthesia: Narrow glottic opening‧Narrow glottic opening‧normal appearing vocal cord but bow in the middle‧normal appearing vocal cord but bow in the middle‧ during inspiration during inspiration


Difficult IntubationDifficult Intubation SuggestionSuggestion

A Difficult Intubation PlanA Difficult Intubation Plan┌──────┬──────┐┌──────┬──────┐

mask and mask and artificial airway artificial airway

tracheal tracheal intubationintubation

tracheostomy under local tracheostomy under local anesthesiaanesthesia

┌──────┴──────┐┌──────┴──────┐

blind techniquesblind techniques direct visiondirect vision

┌────┴────┐┌────┴────┐classic blind classic blind nasalnasal

guided blind guided blind techniquestechniques

┌───┴───────┐┌───┴───────┐

┌──┴──┐┌──┴──┐

laryngoscopiclaryngoscopic fiberopticfiberoptic

retrograde wire via cricothyroidotomyretrograde wire via cricothyroidotomy stylette with tube mounted overstylette with tube mounted over



Breath ChangesBreath Changes


Breath ChangesBreath Changes Keep the thoracic cage in the position Keep the thoracic cage in the position

of inspirationof inspiration Increase FRC & RVIncrease FRC & RV Mainly depends on Mainly depends on DIAPHRAGMDIAPHRAGM

Vulenable in P’t undergoing upper abdominal Vulenable in P’t undergoing upper abdominal or thoracic surgeryor thoracic surgery

Prolonged ventilatory supportProlonged ventilatory support


Breath ChangesBreath Changes SuggestionSuggestion AvoidAvoid

place DIAPHRAGM in mechanical place DIAPHRAGM in mechanical disadvantage: lung hyperinflationdisadvantage: lung hyperinflation

increase DIAPHRAGM workload: small increase DIAPHRAGM workload: small endotracheal tube, bronchospasm, retained endotracheal tube, bronchospasm, retained endobronchial secretion, or abdominal biningendobronchial secretion, or abdominal bining

decrease Odecrease O22 supply and metabolic substrate: low supply and metabolic substrate: low cardiac output, anemia, hypoxemia, or cardiac output, anemia, hypoxemia, or starvationstarvation



Anesthesia about AS PatientsAnesthesia about AS Patients Spinal and Epidural anesthesia (SA & EA)Spinal and Epidural anesthesia (SA & EA) Ossification of interspinous ligamentsOssification of interspinous ligaments Ossification of bony bridges between vertebrae Ossification of bony bridges between vertebrae

(syndesmophyte, aka ossified soft tissue)(syndesmophyte, aka ossified soft tissue) Limited flexion of lumbar spine: makes SA or EA Limited flexion of lumbar spine: makes SA or EA

difficult or impossibledifficult or impossible Wittman & Ring:Wittman & Ring:

SA & EA are SA & EA are contraindicatedcontraindicatedOssification makes the placement of a needle very Ossification makes the placement of a needle very

difficultdifficultHigher risk of a vertebral fracture / severe neurological Higher risk of a vertebral fracture / severe neurological

deficitdeficit


Spinal and Epidural anesthesia (SA & EA)Spinal and Epidural anesthesia (SA & EA) SuggestionSuggestion Pre-op X-ray of sacrumPre-op X-ray of sacrum Case reportsCase reports

Lower limb surgery: Lateral approach to SALower limb surgery: Lateral approach to SAHip surgery: caudal approachHip surgery: caudal approach



Anesthesia about AS PatientsAnesthesia about AS Patients Miscellaneous ProblemsMiscellaneous Problems Scarring or the aorta and aortic valve cuspsScarring or the aorta and aortic valve cusps

-- aortitis & aortic insufficiency-- aortitis & aortic insufficiency Stokes-Adams attacksStokes-Adams attacks

-- pacemaker requirement-- pacemaker requirement Cauda equina syndromeCauda equina syndrome Spinal cord compressionSpinal cord compression Vertebrobasilar insufficiencyVertebrobasilar insufficiency Atlantooccipital subluxation or dislocationAtlantooccipital subluxation or dislocation

-- from minor trauma-- from minor trauma The most serious array of intubation and airway hazardsThe most serious array of intubation and airway hazards

= Cricoarytenoid arthritisCricoarytenoid arthritis+ Cervical spine limitationCervical spine limitation+ Atlantooccipital fragilityAtlantooccipital fragility

ReviewReview Difficult IntubationDifficult Intubation

Cervical spine rigidity and fragilityCervical spine rigidity and fragilityTemporomandibular joint involvementTemporomandibular joint involvementCricoarytenoid joint involvementCricoarytenoid joint involvement

Breath ChangesBreath ChangesDiaphragm!!!Diaphragm!!!

Spinal and Epidural anesthesiaSpinal and Epidural anesthesiaOssification of interspinous ligamentsOssification of interspinous ligamentsOssification of bony bridgesOssification of bony bridgesContraindicated?Contraindicated?

Miscellaneous ProblemsMiscellaneous Problems

Major ReferenceMajor Reference

1.1. Anesthesia & Perioperative ComplicationsAnesthesia & Perioperative ComplicationsJ L Benumof & L J Saidman J L Benumof & L J Saidman 1999 Mosby 1999 Mosby ISBN 0-8151-2619-0ISBN 0-8151-2619-0

2.2. Anesthesia & Uncommon DiseasesAnesthesia & Uncommon DiseasesJ L Benumof & Lesley Day, J L Benumof & Lesley Day, 4th Ed4th Ed 1998 W B Saunders 1998 W B Saunders ISBN 0-7216-8673-7ISBN 0-7216-8673-7

END OF DATA

Documents

Discussion