Difficult airway due to cervical haemorrhage caused by spontaneous rupture of a parathyroid adenoma: A case report

BACKGROUND Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise.CASE SUMMARY A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications.CONCLUSION Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction.Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.

Low-dose Simvastatin Increases Skeletal Muscle Sensitivity to Caffeine and Halothane

Objective To determine whether the myotoxic side effects of statin simvastatin affect skeletal muscle's sensitivity to caffeine and halothane. Methods Primary cultured neonate rat skeletal myotubes were treated with 0.01-5.0 μmol/L simvastatin for 48 hours. MTT was used to evaluate cellular viability. The gross morphology and microstructure of the myotubes were observed with a light and electron microscope, respectively. The intracellular calcium concentrations([Ca^(2+)]i) at rest and in response to caffeine and halothane were investigated by fluorescence calcium imaging. Data were analyzed by analysis of variance(ANOVA) test. Results Simvastatin(0.01-5.0 μmol/L) decreased myotube viability, changed their morphological features and microstructure, and increased the resting [Ca^(2+)]i in a dose-dependent manner. Simvastatin did not change myotube's sensitivity to low doses of caffeine(0.625-2.5 mmol/L) or halothane(1.0-5.0 mmol/L). In response to high-dose caffeine(10.0 mmol/L, 20.0 mmol/L) and halothane(20.0 mmol/L, 40.0 mmol/L), myotubes treated with 0.01 μmol/L simvastatin showed a significant increase in sensitivity, but those treated with 1.0 μmol/L and 5.0 μmol/L simvastatin showed a significant decrease. The sarcoplasmic reticulum Ca^(2+) storage peaked in the myotubes treated with 0.01 μmol/L simvastatin, but it decreased when cells were treated with higher doses of simvastatin(0.1-5.0 μmol/L).Conclusions The myotoxic side effect of simvastatin was found to change the sensitivity of myotubes in response to high-dose caffeine and halothane. When dose was low, sensitivity increased mainly because of increased Ca^(2+) content in the sarcoplasmic reticulum, which might explain why some individuals with statin-induced myotoxic symptoms may show positive caffeine-halothane contracture test results. However, when the dose was high and the damage to the myotubes was severer, sensitivity was lower. It is here supposed that the damage itself might put individuals with statin-induced myotoxic symptoms at greater risks of presenting with rhabdomyolysis during surgery or while under anesthesia.

Anesthesia and perioperative management for giant adrenal Ewing’s sarcoma with inferior vena cava and right atrium tumor thrombus:A case report

BACKGROUND Ewing’s sarcoma of the adrenal gland with inferior vena cava(IVC)and right atrium thrombus is extremely rare.Here,we report a case of giant adrenal Ewing’s sarcoma with IVC and right atrium tumor thrombus and summarize the anesthesia and perioperative management.CASE SUMMARY A young female was admitted to the Department of Urology with intermittent pain under the right costal arch for four months.Enhanced abdominal computed tomography revealed a large retroperitoneal mass(22 cm in diameter),which may have originated from the right adrenal gland and was closely related to the liver.Transthoracic echocardiography showed a strong echogenic filling measuring 70 mm extended from the IVC into the right atrium and ventricle.After preoperative preparation with cardiopulmonary bypass,sufficient blood products,transesophageal echocardiography and multiple monitoring,tumor and thrombus resection by IVC exploration and right atriotomy were successfully performed by a multidisciplinary team.Intraoperative hemodynamic stability was the major concern of anesthesiologists and the status of tumor thrombus and pulmonary embolism were monitored continuously.During transfer of the patient to the intensive care unit(ICU),cardiac arrest occurred without external stimulus.Cardiopulmonary resuscitation was performed immediately and cardiac function was restored after 1 min.In the ICU,extracorporeal membrane oxygenation(ECMO)and continuous renal replacement therapy(CRRT)were provided to maintain cardiac,liver and kidney function.Histopathologic examination confirmed the diagnosis of Ewing’s sarcoma.After postoperative treatments and rehabilitation,the patient was discharged from the urology ward.CONCLUSION An adrenal Ewing’s sarcoma with IVC and right atrium thrombus is extremely rare,and its anesthesia and perioperative management have not been reported.Thus,this report provides significant insights in the perioperative management of patients with adrenal Ewing’s sarcoma and IVC tumor thrombus.Intraoperative circulation fluctuations and sudden cardiovascular events are the major challenges during surgery.In addition,postoperative treatments including ECMO and CRRT provide essential support in critically ill patients.Moreover,this case report also highlights the importance of multidisciplinary cooperation during treatment of the disease.

Shikani Optical Stylet versus Macintosh Laryngoscope for Intubation in Patients Undergoing Surgery for Cervical Spondylosis： A Randomized Controlled Trial

Background： Airway management is critical in patients with cervical spondylosis, a population with a high incidence of difficult airway. Intubation with Shikani Optical Styler （SOS） has become increasingly popular in difficult airway. We compared the effects ofintubation with SOS versus Macintosh laryngoscope （MLS） in patients undergoing surgery for cervical spondylosis. Methods： A total of 270 patients scheduled for elective surgery for cervical spondylosis of spinal cord and nerve root type from August 2012 to January 2016 were enrolled and randomly allocated to the MLS or SOS group by random numbers. Patients were evaluated for difficult airway preoperatively, and Cormack-Lehane laryngoscopy classification was determined during anesthesia induction. Difficult airway was defined as Cormack-Lehane Grades IlI IV. Patients were intubated with the randomly assigned intubation device. The success rate, intubation time, required assistance, immediate complications, and postoperative complaints were recorded. Categorical variables were analyzed by Chi-square test, and continuous variables were analyzed by independent samples t-test or rank sum test. Results： The success rate of intubation among normal airways was 100% in both groups. In patients with difficult airway, the success rates in the MLS and SOS groups were 84.2% and 94.1%, respectively （P = 0.605）. lntubation with SOS took longer compared with MLS （normal airway： 25.1 ± 5.8 s vs. 24.5 ± 5.7 s, P = 0.426; difficult airway： 38.5± 8.5 s vs. 36.1 ±8,2 s, P = 0.389）. Intubation with SOS required less assistance in patients with difficult airway （5.9% vs. 100%, P 〈 0.001 ）. The frequency of postoperative sore throat was lower in SOS group versus MLS group in patients with normal airway （22.0% vs. 34.5%, P =0.034）. Conclusions： SOS is a sale and effective airway management device in patients undergoing surgery for cervical spondylosis. Compared with MLS, SOS appears clinically beneficial for intubation, especially in patients with difficult airway. Trial Registration： Chinese Clinical Trial Registry, ChiCTR-IOR- 16007821 ; http：//www.chictr.org.cn/showproj.aspx？proj-13203.

Massive Pulmonary Embolism in Recovery Period of General Anesthesia： Rapid Diagnosis and Successful Rescue by the Guidance of Transthoracic Echocardiography

Massive pulmonary embolism （PE）, an uncommon event in the perioperative period, is a major challenge to anesthesia management. Massive PE is often associated with an unexpected hemodynamic collapse and severe desaturation without other characteristic changes. It is difficult to make a rapid diagnosis during the perioperative period, especially under general anesthesia. We present a rare case of massive PE diagnosed with transthoracic echocardiography （TTE） in the recovery period of general anesthesia.

Reply to ＂Comparing Shikani Optical Stylet and Macintosh Laryngoscope for Orotracheal Intubation＂

To the Editor： We thank Dr. Wang, et al. for the comments in our article. With regard to the flint comment point, we agreed with them that Connack-Lehane grades 34 with Macintosh laryngoscope should be defined as difficult laryngoscopy. The definition of difficult airway in our paper should be difficult laryngoscopy, not difficult airway.

Duration-dependent regulation of autophagy by isoflurane exposure in aged rats

Current evidence suggests a central role for autophagy in many inflammatory brain disorders, including Alzheimer＇s disease （AD）. Furthermore, it is also well accepted that some inhalation anesthetics, such as isoflurane, may cause AD- like neuropathogenesis and resultant postoperative cognitive dysfunction, especially in the elderly population. However, the impact of inhalation anesthetics on autophagic components in the brain remains to be documented. Hence, our objective was to investigate the effects of different durations of isoflurane exposure on hippocampus-dependent learning and hippocarnpal autophagy in aged rats. Aged Sprague-Dawley rats （20 months old） were randomly exposed to 1.5% isoflurane or 100% oxygen for 1 or 4 h. Animals were then trained in the Morris water maze （4 trials/day for 5 consecutive days）. Hippocampal phagophore formation markers, beclin 1 and protein microtubule-associated protein 1 light chain-3B （LC3B）, as well as p62, an indicator of autophagic flux, were quantified by western blotting. There was no significant difference in the escape latencies and time spent in the target quadrant, as well as hippocampal expression of beclin 1, LC3B- II, and p62 at 24 h post-anesthesia between the 1-h isoflurane-exposed rats and their controls （P 〉0.05）. Four-hour exposure to isoflurane resulted in spatial learning and memory deficits, as evidenced by prolonged escape latencies on days 4 and 5 post- anesthesia and less time spent in the target quadrant than sham-exposed animals （P 〈0.05）. These events were accompanied by a decline in hippocampal expression of LC3B-I, LC3B-II, and beclin 1 24 h after isoflurane （P 〈0.01 and P 〈0.05）. Nevertheless, no significant change in p62 expression was found. Further kinetics study of autophagic changes induced by 4 h of isoflurane showed a transient upregulation of LC3B-I, LC3B-II, and beclin 1 at the end of exposure and a subsequent striking decrease within 12-24 h post-anesthesia （P 〈0.05）. Hippocampal p62 peaked at 6 h but subsequently resolved. These results from our pilot in vivo study support a duration- dependent relationship between 1.5% isoflurane exposure, and spatial cognitive function as well as hippocampal phagophore formation.