Delayed recovery from anaesthesia poses a challenge to the anaesthesiologists. We report a case of 45-year-old lady, a known diabetic on oral hypoglycaemics posted for buttress plating for fracture tibia. On patient's request general anaesthesia was administered. She was haemodynamically stable throughout the procedure. At the end of the procedure, patient was apnoeic and unresponsive. She was investigated thoroughly and a diagnosis of severe hypothyroidism was made with low free T4 and T3 and high TSH levels. The patient was successfully resuscitated after treating with oral T4, gradual rewarming, and inotropic support.
A 45-year-old male, a known patient of ankylosing spondylitis (AS), suffering from significant restriction of neck and trunk movements for the past 15 years presented with a complain of neck pain for the past 15 days following a trivial trauma. On examination, he could hardly move his neck. Neurological examination was normal. X-ray of cervical spine [ Figure 1a] showed completely fused vertebral bodies with C5-C6 subluxation. Magnetic resonance imaging (MRI) confirmed the same with significant compromise in canal diameter [ Figure 1b]. Computed tomography (CT) cervical spine [Figures 1cand d] showed ossified anterior longitudinal ligament, calcified inter vertebral disc with fused vertebrae (all three columns) with fracture subluxation at C5-C6 disc level. The ankylosed spine became like a bamboo with increased brittleness so that even a trivial trauma resulted in a horizontal fracture at C5-C6 level involving both anterior and posterior elements [ Figure 1c] hence called as carrot-stick fracture. [1] These are highly unstable as the movement of the spine can occur only at the fracture segment requiring surgical immobilization. [2] However, our patient refused surgery. Nonetheless, attention toward this type of imaging in AS is imperative due to the involvement of all three columns that simultaneously require global fusion. Figure 1: (a) X-ray of cervical spine showing fused cervical vertebrae with fracture at C5-C6 level. (b) MRI of cervical spine showing significant canal compromise. (c) CT of cervical spine showing ossified anterior longitudinal ligament and calcified inter vertebral disc with C5-C6 fracture subluxation. (d) The fracture extending to involve posterior elements as well (arrow) d c b a
BACKGROUND During the induction of general anaesthesia (GA), laryngoscopy and endotracheal intubation produce significant nociceptive stimuli, which frequently results in inadvertent activation of the sympathetic nervous system. To blunt this pressor response, many drugs are successfully used. However, administration of an additional drug might cause adverse haemodynamic effects or might unnecessarily increase the depth of anaesthesia. Hence, a non-pharmacological measure to reduce the response is preferred. In this study, we wanted tocompare haemodynamic responses between clinical assessment-guided tracheal intubation and neuromuscular block monitoring-guided tracheal intubation. METHODS An observational study was conducted on 62 patients aged 18 – 60 years old belonging to American Soceity of Anaesthesiologist (ASA) I & II posted for surgeries under general anaesthesia were allotted to 2 groups of 31 each. In Group C patients, the trachea was intubated after the clinical judgment of jaw muscle relaxation. In Group M patients, the trachea was intubated after train of four counts became zero in adductor pollicis muscle. Changes in heart rate [HR], mean arterial blood pressure [MAP], Krieg’s intubation score, time between the administration of a neuromuscular blocking agent and endotracheal intubation were recorded. The collected data was analysed by mean, standard deviation, frequency, percentage, ttest and chi square test. RESULTS HR and mean arterial pressure were significantly higher in Group C as compared to Group M after laryngoscopy and tracheal intubation (P < 0.05). The mean time required for intubation was significantly shorter in Group C compared to Group M (179.52 ± 2 s vs. 358.19 ± 55 s). Excellent and good intubation conditions were observed in all Group M patients, whereas 24 out of 31 patients (77 %) in Group C showed excellent and good intubation conditions. CONCLUSIONS Haemodynamic responses to laryngoscopy and tracheal intubation can be significantly attenuated if tracheal intubation is performed following complete paralysis of laryngeal muscles, detected by neuromuscular monitoring of adductor pollicis muscle. KEY WORDS Laryngoscopy, Intubation, Haemodynamic Responses, Stress Response, Neuromuscular Monitor.
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