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Potential health hazards from waste anesthetic gases (WAGs) have been a concern since the introduction of inhalational anesthetics into clinical practice. The potential to exceed recommended exposure levels (RELs) in the postanesthesia care unit (PACU) exists. The aim of this pilot study was to assess sevoflurane WAG levels while accounting for factors that affect inhalational anesthetic elimination. In this pilot study, 20 adult day surgery patients were enrolled with anesthesia maintained with sevoflurane. Following extubation, exhaled WAG from the patient breathing zone was measured 8 inches from the patient's mouth in the PACU. Maximum sevoflurane WAG levels in the patient breathing zone exceeded National Institute for Occupational Safety and Health (NIOSH) RELs for every 5-minute time interval measured during PACU Phase I. Observed WAGs in our study were explained by inhalational anesthetic pharmacokinetics. Further analysis suggests that the rate of washout of sevoflurane was dependent on the duration of anesthetic exposure. This study demonstrated that clinically relevant inhalational anesthetic concentrations result in sevoflurane WAG levels that exceed current RELs. Evaluating peak and cumulative sevoflurane WAG levels in the breathing zone of PACU Phase I and Phase II providers is warranted to quantify the extent and duration of exposure.

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This case report illustrates the importance of proper assessment, management, and creation of an emergent surgical airway. Assessment after the establishment of surgical airways should include confirmation of correct surgical site and appropriate location and depth of tracheostomy, tracheal tube, or catheter placement within the trachea. Supraglottic surgical airway access, as occurred in this case, can lead to laryngotracheal and esophageal injury. Early recognition and appropriate management of this complication can increase the likelihood of preservation of voice and airway function and minimize the extent of esophageal injury.

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T HIS image demonstrates a complex C1 fracture reduced via excessive occipital-C1 flexion via halo vest immobilization (fig. A). Note arrow indicating slit-like oropharyngeal space originating below the soft palate. Halo vest immobilization occurred 30 min before emergent surgery for treatment of open femur fractures after a 15-foot fall. Shortly thereafter, the patient became tachypnic, dyspneic, and required supplemental oxygen to maintain oxygen saturations in the mid 90% range. Heart rate, blood pressure, skin examination, and A-a gradient were normal. General anesthesia with laryngeal mask-assisted endotracheal tube placement was planned. Upon insertion, the laryngeal mask developed an extremely flexed position, producing clear bilateral breath sounds but minimal chest excursion with consistently increased end-tidal carbon dioxide. Routine measures to alleviate upper airway obstruction were ineffective. Fiberoptic examination revealed proximal laryngeal mask angulation that encumbered bronchoscope advancement and revealed only soft tissue. Oxygen saturations remained 100% throughout. Given the brief predicted surgical time and otherwise normal vital signs, the laryngeal mask was left in situ for surgical duration. Postoperative halo vest immobilization realignment (fig. B) resulted in rapid dyspnea resolution with normal respiratory mechanics and ventilation. Note arrow indicating the expanded oropharyngeal space below the soft palate. Intraoperative surgical fusion or halo vest immobilization has resulted in upper airway obstruction and difficulty in airway reestablishment. 1,2 This case, however, illustrates the importance of preoperative halo vest immobilization and oropharyngeal space assessment before definitive airway management. Anesthetic management considerations may include preoperative halo vest repositioning, awake fiberoptic intubation, and postoperative intubation for 2-3 days. 3

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