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Moyamoya Disease Defined!The National Institute ofNeurological Disorders and Strokedefines Moyamoya disease as arare, progressive cerebrovasculardisorder caused by blockedarteries at the base of the brain inan area called the basal ganglia.!The name “moyamoya” means“puff of smoke” in Japanese anddescribes the look of the tangle oftiny vessels formed to compensatefor the blockage.!It primarily affects children, but itcan also occur in adults.

Symptoms of MoyamoyaDisease! In children, the first symptom is often stroke, orrecurrent transient ischemic attacks,accompanied by muscular weakness or paralysisaffecting one side of the body, and/or seizures.! Adults usually experience a hemorrhagic strokedue to recurring blood clots in the affected brainvessels.(The National Institute of Neurological Disordersand Stroke)

Case Study #2! All routine preoperative checks were performed on theDrager Apollo anesthesia machine without incident,including the machine’s automated self-test and leaktest.! No abnormalities are found.

Case Study #2! During preoxygenation a normal capnograph tracing isobserved.! The pt is given muscle relaxant and intubated with a7.0 cuffed ett secured at 23 cm at the lip.! Correct position of the Ett is confirmed both by ETCO2and B/L auscultation of breath sounds.

Case Study #2! Subsequently, an abnormalcapnograph waveformwith a single humpmidplateau was noted.! Vitals at this time:! ETCO2 36 mmHg,! tidal volume 513 ml,! peak inspiratory pressure30 cm H2O,! respiratory rate 10,! inspiratory to expiratoryratio 1:4.

Case Study #2! The author notes that:! “There was no obvious cause for this unique waveform,but we thought that it may be related to a leak in thesampling system.”! Tightening the sample line connections resulted in nochange.

Case Study #2! They then replaced theentire sample line with anew 10-foot sample lineand observed thefollowing:

SO WHAT’S THE CAUSE?

It’s A Trap!!! Next, the water trap wasinspected and crackswere seen

Case Study #2! Because a new water trap wasnot available, the crackedwater trap was wrapped with a3M Tegaderm dressing andreinstalled; resulting in a normalappearing waveform.

The Dromedary Sign! This sign occurs as a result of an ‘increaseddyssynchrony between the positive pressure phaseof mechanical ventilation and the arrival of endtidal gas.”! During expiration, negative pressure at the crack inthe water trap allowed room air to dilute thesample leading to a decrease in ETCO2concentration.

! Because of the cracks in the water trap,the positive pressure exerted by theventilator contributes to an increase indead space in the sample line as well.TheDromedarySign! Therefore, the transit time delay causedby the additional dead space in thesample line combined with a crackedwater trap resulted in the appearance ofthe Dromedary sign.

Case Study #3As reported by: Kinghorn, K. MD; et. alAnesthesiology

Case Study #3!A 60-yr-old, 104-kg, 71-inch-tall manpresented for a left total kneearthroplasty for degenerative jointdisease.!Medical history: hypertension,chronic obstructive pulmonarydisease, gout, and a 40-pack-yearsmoking history.!Home medications: naproxen,atenolol, and allopurinol.!Naproxen had been discontinued 1week before surgery.

Case Study #3Results ofpreoperative neurologicexam werenormal.Examinationby theorthopedicsurgeonnoted theabsence ofa valgusdeformity orflexioncontracture.

Case Study #3! Before placement of theblocks, 100 mcg fentanyland 2 mg midazolam wereadministered intravenously.! In the preoperative holdingarea, sciatic and femoralnerve catheters wereplaced for postoperativepain management.

Case Study #3! The patient was transferred to the operating room,where a subarachnoid block was performed forsurgical anesthesia using a 25-gauge Whitacre pencilpoint spinal needle through which 1.2 ml hyperbaricbupivacaine (0.75%) was injected.! A T10 level of anesthesia was attained. The patient waspositioned supine for surgery, and a tourniquet wasapplied to the left thigh.(Kinghorn; et. Al2012)

Case Study#3! Before surgicalincision, thetourniquet wasinflated to apressure of 250mmHg. The surgerywas completeduneventfully.! Total tourniquet timewas 46 min.

! In the recovery room, infusions in eachcatheter were begun immediately aftersurgeryCaseStudy #3! The catheters were test dosed with nointravenous symptoms, and bupivacaine(0.25%) infusion was begun in eachcatheter at a rate of 7 ml/h.

POD 1! On the morning of postoperative day 1, the local anestheticinfusions were discontinued, and both catheters wereremoved! On the afternoon of postoperative day 1, physical exam bythe hospital’s pain service was noted a left lower extremitymotor strength score of 3 of 5 (Medical Research Councilscale) and an absence of ankle dorsiflexion! The patient reported no pain or tenderness.! No ecchymosis was seen at the sites of nerve block injection

! The patient reported pain on the plantarsurface of the left foot, pain over theposterior left thigh, and a left foot dropwas noted.POD #2! The patient continued physical therapyfor the remainder of his inpatient stay andwas discharged home on postoperativeday 4, without improvement in motorexamination.

Case Study #3! An outpatient appointment was made with neurologyduring the week after discharge, but the patient failedto appear.! Despite several telephone call reminders, he did notfollow up.

Case Study #3! Three and one half weeks later, the patientpresented to the emergency departmentreporting pain and weakness in the left leg andfoot.! Physical exam revealed a warm left lowerextremity with mild swelling, absent dorsiflexion,and decreased sensation over both the medialand lateral aspect of the foot.

Case Study #3! A complex regional pain syndrome type one wasconsidered; gabapentin was prescribed, andplans were made for the patient to follow up witha neurologist the next week! At the neurologist’s appointment, the patient stillhad unresolved lower extremity symptoms, theplantar surface foot pain had been replaced bynumbness over the dorsum of the foot andoccasional shooting pains up the posterior aspectof the leg and thigh

! Decreased sensation to pinprick on thedorsum of the foot, weakness of both footdorsiflexion (score 0 of 5) and plantarflexion (score 3 of 5), mild weakness (score4of 5) of the hamstrings, and absence ofthe left ankle deep tendon reflex.At theNeurologist’s! Electrodiagnostic testing demonstratedabsent left sural and superficial peronealsensory responses, and absent leftperoneal (extensor digitorum brevis andtibialis anterior recording) and tibial motorresponses.! The right sural sensory response wasnormal.

Case Study#1! There was no sciaticnerve abnormality,but there was anabnormal signal inthe mid- to distalfemur that wasconsistent with abone infarct

! Foot drop is a term that aptly describesthe most striking physical finding ofperoneal nerve injury.Foot Drop! Compensation for weakness of footdorsiflexion results in the characteristichigh-stepping gait used to preventtripping over the toes.

Foot Drop! Weakness of foot eversion and toe extension is alsopresent.! This clinical picture can be caused by a lesionanywhere along the course of the L5 nervefascicles, from the anterior horn cells to theperoneal nerve itself.! Damage to the sciatic nerve can result in footdrop if there is injury to the lateral trunk becausethis trunk becomes the peroneal nerve.

Foot Drop! Peroneal nerve injury causing foot drop is a wellknown complication of total knee arthroplasty.! Injury in this setting can be caused bycompression, ischemia, traction, crush, orlaceration.! The incidence of this injury based on more recentobservations is estimated to be 0.79%

Nerve Injury Etiology! Most commonly suggested risk factors is a valgusdeformity of the joint greater than or equal to 10degrees! Intraoperative correction of the deformity results intraction on the nerve.

! preoperative flexion contracture of the knee alsoincreases stretch on the nerve after surgery and isa predisposing factor.! baseline neuropathy increases risk, andpreoperative neurologic evaluation has beenrecommended so that surgical technique can beadjusted if a known underlying neuropathy ispresent

Other PredisposingFactors 1.Tourniquet time longer than 120 min2.Rheumatoid arthritis3.constrictive dressings4.postoperative bleeding,5.previous lumbar laminectomy.6.tourniquet pressures greater than 400 mmHg

! The numerous factors that influence therisk of nerve injury after knee arthroplastycan make the determination of a singlecause of injury challenging.CaseStudy #3! It is likely that a combination of thesefactors explains the much higherincidence of nerve injury after total kneearthroplasty than is associated withregional nerve block or tourniquet usealone

! Like other peripheral nerve blocks, cancause neurologic injury from needletrauma, intraneural injection of localanesthetic, neuronal ischemia, andneurotoxicity of local anesthetic.SciaticNerveBlockade! True symptoms of neuropathy, (allodynia,hyperpathia, and hyperesthesia) must bedistinguished from perceived nerve injuryresulting in paresthesia.

! Lack of pain on injection is not a reliableindicator of safetySciaticNerveBlockade! Resistance on injection has beensuggested to be more indicative ofintraneural placement of the needle.

! An epidural in place has been implicatedas a risk factor for peroneal nerve injuryafter total knee arthroplasty.InSummary! It has been proposed that the sensoryand proprioceptive deficits of thistechnique may result in patient toleranceof either unsafe leg position or overlyconstrictive dressings.! Epidural anesthesia is also suspected ofdelaying the diagnosis of nerve injury ofother etiologies.

CaseStudy #4As reported by: Gilles A.Orliaguet, M.D., Ph.D; etalAnesthesiology

! A 10-month-old boy (8.5 kg body weight)was taken to the operating room (at11:00 PM), without premedication, foremergency surgery of an abscess of thesecond fingertip on the right hand.CaseStudy #4! Past medical history: unremarkableexcept for an episode of upperrespiratory tract infection 4 weeks ago.! The mother volunteered that he wasexposed to passive smoking in the home.

Case Study #4! Preoperative evaluation was normal (85/50 mmHg,heart rate 115 beats/min, [SpO2] 99% on room air).! The procedure was expected to be very short, andgeneral anesthesia with inhalational induction andmaintenance, without tracheal intubation

! The pt was induced by a resident under the directsupervision of a senior anesthesiologist withinhaled sevoflurane in a 50/50% mixture of oxygenand nitrous oxide.CaseStudy #4! Two min after loss of eyelash reflex, a first episodeof airway obstruction with inspiratory stridor andsuprasternal retraction was successfully managedby jaw thrust and manual positive pressureventilation.! An IV line was obtained while the child wasmanually ventilated.! Anesthesia was then maintained by facemaskwith 2.0% expired sevoflurane in a mixture ofoxygen and nitrous oxide 50/50%.

! About 5 minutes into the case; aninspiratory stridulous noise was notedagain.CaseStudy #4! Manual facemask ventilation becamedifficult with an increased resistance toinsufflation and SpO2dropped rapidlyfrom 98% to 78%, associated with adecrease in heart rate from 115 to 65beats/min.! Laryngospasm was immediatelysuspected.

! Despite a jaw thrust maneuver, positivepressure ventilation with 100% O2, andadministration of two bolus doses (5 mg) ofIV propofol (0.6 mg/kg), the obstructionwas not relieved and SpO2 decreased to52%.CaseStudy #4! A 0.2-mg IV bolus dose of atropine wasinjected and IV succinylcholine was givenat a dose of 16 mg, followed by trachealintubation.! Thereafter, surgery was quickly completed,while tracheal extubation andpostoperative recovery were uneventful.

! Laryngospasm is an anestheticemergency that is still responsible forsignificant morbidity and mortality inpediatric patients.Laryngospasm! Frequent complication that occurs withvarying frequency dependent on multiplefactors.

Laryngospasm! According to recent research, childrenare more prone to laryngospasm thanadults, with laryngospasm being reportedmore commonly in children (17.4/1,000)than in the general population

! Many factors may increase the risk oflaryngospasm.! These risk factors can be related to the:RiskFactors1.Patient2.Procedure3.Anesthesia

! Personal history! Male! Upper respiratory tract infection presentthe day of surgery or within the past 2weeksPatientRiskFactors! Wheezing at exercise or more than threetimes in past 12 months! Nocturnal dry cough! Eczema present or in the past 12 months! Family history! History of at least two family membershaving asthma, atopy (rhinitis, eczema),or smoking

! Age.PatientRiskFactors! Young age is one of the most importantrisk factors.! The highest incidence (more than 2%)was found in preschool age groups.

Upper Respiratory TractInfection.! Upper respiratory tract infection is associated with atwofold to fivefold increase in the risk of laryngospasm.! Children with URI are prone to develop airway (upperand bronchial) hyperactivity that lasts beyond theperiod of viral infection.! Whereas epithelial damage heals in 1–2 weeks, virusinduced sensitization of bronchial autonomic efferentpathways can last for up to 6–8 weeks.

SmokeExposure! Household exposure to tobacco smokewas shown to increase the incidence oflaryngospasm from 0.9% to 9.4% inchildren scheduled for otolaryngologyand urologic surgery.

! The highest incidence of laryngospasm isfound in procedures involving surgery andmanipulations of the pharynx and larynx.ProcedureRelatedRiskFactors! The incidence of laryngospasm, aftertracheal extubation, has already beenreported to exceed 20% and be as highas 26.5% in pediatric patients who haveundergone tonsillectomy.! Urgent procedures also carry a higher riskof laryngospasm than electiveprocedures.

! Insufficient depth of anesthesia is one ofthe major causes of laryngospasm.! Any stimulation in the area supplied by thesuperior laryngeal nerve, during a lightplane of anesthesia, may producelaryngospasm.AnesthesiaRelatedRisk Factors! Common triggers of reflex laryngealresponse during anesthesia are secretions,blood, insertion of an oropharyngealairway suction catheter, and laryngoscopy.! Inexperience of the anesthetist is alsoassociated with an increased incidence oflaryngospasm and perioperativerespiratory adverse events.

! Some factors are associated with a lowerrisk of laryngospasm:! IV inductionA LowerRisk! Airway management with facemask,! inhalational maintenance of anesthesia.! Induction and emergence fromanesthesia are the most critical periods

! Identifying and removing the offendingstimulus,Prevention ofLaryngospasm! Applying airway maneuvers to open theairway,! Administering anesthetic agents if theobstruction is not relieved.

! A detailed history should be taken toidentify the risk factors.! For children with URI, cancellation ofelective procedures for a period of 4–6weeks was traditionally the rule.PreoperativeManagement! However, children younger than 3 yr maydevelop 5–10 URI episodes per year.! Thus, the potential window for safeadministration of general anesthesia isfrequently very short.

! Rescheduling patient 2–3 weeks after anURI episode appears to be a safeapproach.PreoperativeManagement! Premedication with anticholinergicagents may decrease secretions but hasno demonstrated influence on theincidence of laryngospasm.

Questions?

References! Olsson GL. Bronchospasm during anaesthesia. A computer-aidedincidence study of 136,929 patients. Acta Anaesthesiol Scand 1987;31: 244-52.! Pepe PE, Marini JJ. Occult positive end-expiratory pressure inmechanically ventilated patients with airflow obstruction: the autoPEEP effect. Rev Respir Dis 1982; 126: 166-70.! Westhorpe RN, Ludbrook GL, Helps SC. Crisis management duringanaesthesia: bronchospasm. Qual Saf Health Care 2005; 14: e7.! Department of Health 2004. Protecting the Breathing Circuit inAnaesthesia--Report to the Chief Medical Officer of an Expert Groupon Blocked Anaesthetic Tubing Available from: www.dh.gov.uk

References! Szczeklik A, Stevenson D. Aspirin-induced asthma: Advances inpathogenesis, diagnosis, and management. J Allergy Clin Immunol2003; 111: 913–21.! Dudzińska K, Mayzner-Zawadzka E. Tobacco smoking and theperioperative period. Anestezjol Intens Ter 2008; 40: 108-13.! Nandwani N, Raphael JH, Langton JA. Effects of an upper respiratorytract infection on upper airway reactivity. Br J Anaesth 1997; 78: 352-5.! Kim ES, Bishop MJ. Endotracheal intubation, but not laryngeal maskairway insertion, produces reversible bronchoconstriction.Anesthesiology 1999; 90: 391-4.

References! Looseley, Alex. Management of bronchospasm during generalanesthesia. Update in Anaesthesia 2010; 17-21.! Verhagen E, Sauer PJ: The Groningen protocol: Euthanasia inseverely ill newborns. N Engl J Med 2005; 352:959 – 62! Martínez MA, Ballesteros S, Almarza E: Anesthesiologist suicidewith atracurium. J Anal Toxicol 2006; 30:120! Curfman GD, Morrissey S, Drazen JM: Physicians andexecution. N Engl J Med 2008; 358:403– 4

References! Kirby RR, Colaw JM, Douglas MM: Death from propofol: Accident,suicide, or murder? Anesth Analg 2009; 108:1182–4! Risse M, Erdmann F, Schutz H, Weiler G: Multiple homicides as aresult of chloroform poisoning: Case report and experimentalstudy. Forensic Sci Internat 2001; 124:209 –13! Furbee RB: Criminal poisoning: Medical murderers. Clin Lab Med2006; 26:255–73! Shepherd G, Ferslew B: Homicidal poisoning deaths in the UnitedStates 1999 –2005. Clin Toxicol 2009; 47:342–7! Kliff S: The new doctor death. Newsweek. 2010, Mar 15

References! Bromiley M. Have you ever made a mistake? Royal College ofAnaesthetists Bulletin 2008; 48: 2442–5.! DeAnda A, Gaba DM. Unplanned incidents duringcomprehensive anesthesia simulation. Anesthesia andAnalgesia 1990; 71: 77–82.! Rudolph JW, Morrison JB, Carroll JS. The dynamics of actionoriented problem solving: linking interpretation and choice.Academy of Management Review 2009; 34: 733–56.! E. Fioratou et al. Æ No simple fix for fixation errors Anaesthesia,2010, 65, pages 61–69

References! Carter JA. Checking anaesthetic equipment and the ExpertGroup on Blocked Anaesthetic Tubing (EGBAT). Anaesthesia 2004;59: 105–7.! Duncker K. On problem solving. Psychological Monographs 1945;58: Whole No. 270.! DeBono E. The Use of Lateral Thinking. New York: Penguin, 1967.! MacGregor JN, Ormerod TC, Chronicle EP. Information processingand insight: a process model of performance on the nine-dot andrelated problems. Journal of Experimental Psychology: Learning,Memory and Cognition 2001; 27:176–201.

References! Fioratou E., Flin R., and Glavin R. No simple fix for fixation errors:cognitive processes

adequate depth of anesthesia before airway instrumentation reduces the risk of bronchospasm. ! The use of an LMA (in suitable patients) has been shown to reduce the incidence of bronchospasm compared to tracheal intubation. ! Regional techniques where appropriate can also avoid the need for general anesthesia and intubation.