SummaryThe relationship between internal jugular vein diameter as measured with an ultrasound imaging machine (SiteRite, Dymax) and external jugular vein diameter was studied in 50 anaesthetised patients undergoing elective cardiac surgery. There was an inverse correlation between external jugular vein diameter and internal jugular vein diameter (r = -0.47, p < 0.001). All patients with an external jugular vein diameter of 7 mm or greater had an internal jugular vein diameter of less than 15 mm. No patient with an external jugular vein diameter of less than 7 mm had an internal jugular vein diameter of less than 20 mm. No other patient dimension (height, weight, body mass index, neck circumference) predicted internal jugular vein size. These results suggest that a large external jugular vein (i.e. 7 mm or greater in external diameter) may be associated with a small internal jugular vein. A size 5.0-mm internal diameter tracheal tube may be used to provide a rapid assessment of external jugular vein diameter.
Patients with a laryngectomy pose a challenge when they require cardiac surgery. Dissection of the manubrium and sternal notch from surrounding soft tissues can be hazardous, as it may result in troublesome bleeding and inadvertent tracheal injury, especially in those patients, in whom the trachea is displaced anteriorly, or lies close to the sternal notch, as a result of a 'low' tracheal stoma. Performing a median sternotomy in such patients is believed to substantially increase the risk of sternal wound complications, mediastinitis, stoma necrosis and tracheal injuries, leading to several modifications of conventional median sternotomy, including bilateral thoracotomy incisions and limited median sternotomy approaches. There is only one case reported in the literature wherein cardiac surgery was done in such a patient, through a full sternotomy. This report describes a successful coronary artery bypass grafting through a complete median sternotomy, with no complications. This approach permitted adequate operative exposure and separated the stoma from the operative field. We also review alternative modalities of access, in these patients.
SummaryWe report a case df profound hypotension, after induction of Key wormComplications; cardiac tamponade, bradycardia. Case historyA 25-year-old male student was admitted as an emergency after transfer by mountain rescue RAF helicopter over a distance of 60 miles. He had fallen some 30 metres on to scree while hill-walking in the Scottish Highlands.He was pale in appearance, drowsy but conscious and orientated, on arrival in the Accident and Emergency Department. He gave a history of a few seconds loss of consciousness but no retrograde amnesia. On examination, there were multiple superficial abrasions over legs, buttocks, chest, back, arms and face, and a large haematoma over his forehead with a laceration at the hair line. His back was tender over the upper lumbar vertebrae and there was a compound fracture dislocation of the right elbow. Sternal tenderness was noted but rib springing was pain free. Pupils were equal and reacting to light and there were no focal neurological signs. His core temperature was 32°C increasing to 3 5 T , and his arterial blood pressure was 90 mmHg systolic on admission. For this reason he had received 400 ml of plasma protein solution and 1 unit of SAG-M blood. These had been administered into a central vein cannula inserted via a low right supraclavicular approach. Arterial blood pressure was subsequently recorded as 120/56 mmHg, and pulse as 80/minute, sinus rhythm. Air entry on chest auscultation was equal on both sides with no added sounds. Abdominal palpation revealed neither tenderness nor distension.Chest and skull X rays were normal in appearance but abdominal films showed evidence of ileus, as well as some free peritoneal fluid. Dorsal spine X ray revealed a compression wedge fracture of the body of the first lumbar vertebra. A right elbow dislocation and separated fracture of the medial epicondyle were noted.White cell count was raised at 42.5 x 109/litre, haemoglobin was 120 g/litre, platelets 400 x 109/litre. Electrolytes were normal and the urea was 8.7 mmol/litre. Arterial blood gas analysis (no2, 0.5) showed a pH of 7.1 I , Pco2 6.3 kPa, Po2 24 kPa, and a base deficit of 13.5 mmol/litre. The orthopaedic surgeons wished to proceed with internal fixation urgently, in view of the compound dislocation fracture of the elbow, accompanied by lavage and dressing of the various lacerations and abrasions. Arrangements for theatre were made, since the patient was apparently stable.Peripheral venous access was established with an intravenous 16-gauge cannula inserted into a left forearm vein, after arrival in the anaesthetic room. Blood was already being given slowly via the internal jugular cannula. Anaesthesia was induced, after 5 minutes pre-oxygenation, with intravenous alfentanyl 1 mg, thiopentone 150 mg and suxamethonium 100 mg, and cricoid pressure was applied. A 9-mm cuffed oral tracheal tube was inserted and the lungs were ventilated using a Manley Pulmovent ventilator, set to deliver a minute volume of 9 litres of 50% nitrous oxide in oxygen with isoflurane 0.5-...
A case is described of a patient who presented for closure of atrial septal defect (ASD) in whom a coexisting phaeochromocytoma was first suspected during induction of anaesthesia.
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