Aortic stenosis is a stenotic valvular heart disease with a fixed cardiac output state. The patients with such illness can come for non-cardiac surgeries. They pose significant challenges to the attending anesthesiologist. Here, we report a 45-year-old 65 kg female with significant aortic stenosis posted for myomectomy. She was a known case of significant aortic stenosis with an orifice of 1 sq.cm. She was symptomatic with NYHA class three symptoms. The patient had a difficult airway with Mallampatti class IV with stiff temporomandibular joints. The pulse rate was 70 / minute and regular with a blood pressure of 110/70mmHg. After explaining the pros and cons of General and regional anaesthesia, the patient accepted for a regional technique. A bilateral TAP block was administered with 20 ml of 0.25 % bupivacaine on each side. She was administered intrathecal fentanyl 50 µg with 0.5 ml of 0.5 % hyperbaric bupivacaine. Surgical anaesthesia was obtained and myomectomy was completed within 45 minutes. The blood loss was approximately 500 ml which was replaced. After an uneventful early postoperative period of six hours, she became hypotensive with a heart rate of 122/minute. An emergency ultrasound scan revealed a collection. A passive leg rising test was positive. She was again administered two more units of compatible blood. The rest of the postoperative period was uneventful and discharged on the seventh day. This case is reported for its extreme rarity and successful management.
Achalasia cardia is among the conditions that pose a high risk of aspiration during induction of anaesthesia. This report is about a case of 23-year-old male patient, where regurgitation and pulmonary aspiration occurred in a patient with achalasia cardia despite Rapid Sequence Induction (RSI). The risk of aspiration in conditions that cause stasis in the oesophagus is much higher due to the anaesthetic induced relaxation of the upper oesophageal sphincter and the proximity of the pooled contents to the oropharynx. The lower oesophageal sphincter being pathological in achalasia cardia does not relax. In this article, even though it is a case report of such an incidence, the various techniques that can be adopted to negate the risk have been explored. Preinduction oesophagoscopy and suctioning, video-laryngoscope guided intubation and ultrasound confirmation of Tracheal Tube (TT) position before initiating ventilation can be adopted in addition to head up positioning and RSI as an infallible technique to abolish the aspiration risk in patients with achalasia cardia. The case report is highlighted in the way to focus on describing safe ways of induction of anaesthesia where there is a high risk of aspiration.
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