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General anesthesia for a patient with multiple system atrophy.

Jang MS, Han JH, Park SW, Kang JM, Kang WJ - Korean J Anesthesiol (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea. ; Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea.

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We report a case of successful general anesthesia in a MSA patient... In operating room, routine monitoring devices for electrocardiography, pulse oximetry, and non-invasive blood pressure, and a noninvasive cardiac output monitor showing cardiac output, cardiac index (CI), and stroke volume variation (SVV) were set up... At 25 min after induction of anesthesia, the BP abruptly fell from 160/85 to 80/50 mmHg... This was managed successfully with rapid fluid administration and a phenylephrine bolus dose of 40 µg intravenously... In contrast, Cohen reported a successful case of general anesthesia after failure of epidural anesthesia, induction with thiopental and succinylcholine, and maintenance with N2O and methoxyflurane... Ketamine was reported as a successful anesthetic in a MSA patient without hypotension in 1983, because ketamine causes central sympathetic stimulation primarily through parasympathetic inhibition... We decided on general anesthesia for several reasons: noncooperation, the possibility of procedural failure due to involuntary movements, and regional anesthesia not being suitable for laparoscopic surgery... The preoperative hemodynamic state of our patient was stable; however, realizing that MSA patients have a damaged sympathetic system, we decided to use etomidate with its minimal cardiovascular effects... We also used remifentanil, which has been reported to effectively suppress cardiovascular reactions and myoclonus after endotracheal intubation with etomidate... If a preoperative evaluation is impossible, preventative measures should be used... Although no case has been reported of awake bronchoscopic intubation in MSA patients, it is worth considering in patients who are suspected to have difficult airways if the patients are cooperative.

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Related in: MedlinePlus

Hemodynamic changes during anesthesia. (A) Indicates the changes in blood pressure and heart rate. There is an abrupt decrease in blood pressure to 80/50 mmHg at 25 min after induction, but almost no change in the heart rate. Similarly, a sudden drop in blood pressure to 80/50 mmHg occurs when there is a little change in heart rate, 70-75 beats/min; moreover, phenylephrine is effective in stabilizing the cardiovascular system. (B) Shows the fluctuation in CVP, CI, and SVV. There is a slight decrease in CVP and CI during the hypotension events with slight increases in SVV. SBP: systolic blood pressure (mmHg), DBP: diastolic blood pressure (mmHg), HR: heart rate (beats/min), CVP: central venous pressure (cmH2O), CI: cardiac index (L/min/m2), SVV: stroke volume variation (%).
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Figure 1: Hemodynamic changes during anesthesia. (A) Indicates the changes in blood pressure and heart rate. There is an abrupt decrease in blood pressure to 80/50 mmHg at 25 min after induction, but almost no change in the heart rate. Similarly, a sudden drop in blood pressure to 80/50 mmHg occurs when there is a little change in heart rate, 70-75 beats/min; moreover, phenylephrine is effective in stabilizing the cardiovascular system. (B) Shows the fluctuation in CVP, CI, and SVV. There is a slight decrease in CVP and CI during the hypotension events with slight increases in SVV. SBP: systolic blood pressure (mmHg), DBP: diastolic blood pressure (mmHg), HR: heart rate (beats/min), CVP: central venous pressure (cmH2O), CI: cardiac index (L/min/m2), SVV: stroke volume variation (%).

Mentions: General anesthesia was induced with etomidate 0.4 mg/kg intravenously. With good mask ventilation, 40 mg of rocuronium was injected intravenously, and we tried laryngoscopic intubation. Because of poor mouth opening even after full relaxation with the rocuronium, moving the laryngoscope forward was impossible. So, we performed a bronchoscopic intubation. Anesthesia was maintained with sevoflurane 1.5-2 vol% and intravenous remifentanil 0.05 µg/kg/min in an O2-air mixture at a 1 : 1 ratio. The operation lasted about 4 h and anesthesia was maintained appropriately with BIS at 35-50. At 25 min after induction of anesthesia, the BP abruptly fell from 160/85 to 80/50 mmHg. This was managed successfully with rapid fluid administration and a phenylephrine bolus dose of 40 µg intravenously. HR hardly changed, from 82 to 90 beats/min. However, systolic blood pressure dropped again to 80 mmHg during awakening despite the irritating sensation of the endotracheal tube. Phenylephrine 20 µg raised the BP to 100/60 mmHg again with little change in HR, 70-75 beats/min (Fig. 1). Finally, gentle extubation was tried, and no respiratory event occurred. He was transferred to the surgical intensive care unit, and has been cardiovascularly stable since then. He was returned to the ward next day.


General anesthesia for a patient with multiple system atrophy.

Jang MS, Han JH, Park SW, Kang JM, Kang WJ - Korean J Anesthesiol (2014)

Hemodynamic changes during anesthesia. (A) Indicates the changes in blood pressure and heart rate. There is an abrupt decrease in blood pressure to 80/50 mmHg at 25 min after induction, but almost no change in the heart rate. Similarly, a sudden drop in blood pressure to 80/50 mmHg occurs when there is a little change in heart rate, 70-75 beats/min; moreover, phenylephrine is effective in stabilizing the cardiovascular system. (B) Shows the fluctuation in CVP, CI, and SVV. There is a slight decrease in CVP and CI during the hypotension events with slight increases in SVV. SBP: systolic blood pressure (mmHg), DBP: diastolic blood pressure (mmHg), HR: heart rate (beats/min), CVP: central venous pressure (cmH2O), CI: cardiac index (L/min/m2), SVV: stroke volume variation (%).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4295972&req=5

Figure 1: Hemodynamic changes during anesthesia. (A) Indicates the changes in blood pressure and heart rate. There is an abrupt decrease in blood pressure to 80/50 mmHg at 25 min after induction, but almost no change in the heart rate. Similarly, a sudden drop in blood pressure to 80/50 mmHg occurs when there is a little change in heart rate, 70-75 beats/min; moreover, phenylephrine is effective in stabilizing the cardiovascular system. (B) Shows the fluctuation in CVP, CI, and SVV. There is a slight decrease in CVP and CI during the hypotension events with slight increases in SVV. SBP: systolic blood pressure (mmHg), DBP: diastolic blood pressure (mmHg), HR: heart rate (beats/min), CVP: central venous pressure (cmH2O), CI: cardiac index (L/min/m2), SVV: stroke volume variation (%).
Mentions: General anesthesia was induced with etomidate 0.4 mg/kg intravenously. With good mask ventilation, 40 mg of rocuronium was injected intravenously, and we tried laryngoscopic intubation. Because of poor mouth opening even after full relaxation with the rocuronium, moving the laryngoscope forward was impossible. So, we performed a bronchoscopic intubation. Anesthesia was maintained with sevoflurane 1.5-2 vol% and intravenous remifentanil 0.05 µg/kg/min in an O2-air mixture at a 1 : 1 ratio. The operation lasted about 4 h and anesthesia was maintained appropriately with BIS at 35-50. At 25 min after induction of anesthesia, the BP abruptly fell from 160/85 to 80/50 mmHg. This was managed successfully with rapid fluid administration and a phenylephrine bolus dose of 40 µg intravenously. HR hardly changed, from 82 to 90 beats/min. However, systolic blood pressure dropped again to 80 mmHg during awakening despite the irritating sensation of the endotracheal tube. Phenylephrine 20 µg raised the BP to 100/60 mmHg again with little change in HR, 70-75 beats/min (Fig. 1). Finally, gentle extubation was tried, and no respiratory event occurred. He was transferred to the surgical intensive care unit, and has been cardiovascularly stable since then. He was returned to the ward next day.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea. ; Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

We report a case of successful general anesthesia in a MSA patient... In operating room, routine monitoring devices for electrocardiography, pulse oximetry, and non-invasive blood pressure, and a noninvasive cardiac output monitor showing cardiac output, cardiac index (CI), and stroke volume variation (SVV) were set up... At 25 min after induction of anesthesia, the BP abruptly fell from 160/85 to 80/50 mmHg... This was managed successfully with rapid fluid administration and a phenylephrine bolus dose of 40 µg intravenously... In contrast, Cohen reported a successful case of general anesthesia after failure of epidural anesthesia, induction with thiopental and succinylcholine, and maintenance with N2O and methoxyflurane... Ketamine was reported as a successful anesthetic in a MSA patient without hypotension in 1983, because ketamine causes central sympathetic stimulation primarily through parasympathetic inhibition... We decided on general anesthesia for several reasons: noncooperation, the possibility of procedural failure due to involuntary movements, and regional anesthesia not being suitable for laparoscopic surgery... The preoperative hemodynamic state of our patient was stable; however, realizing that MSA patients have a damaged sympathetic system, we decided to use etomidate with its minimal cardiovascular effects... We also used remifentanil, which has been reported to effectively suppress cardiovascular reactions and myoclonus after endotracheal intubation with etomidate... If a preoperative evaluation is impossible, preventative measures should be used... Although no case has been reported of awake bronchoscopic intubation in MSA patients, it is worth considering in patients who are suspected to have difficult airways if the patients are cooperative.

No MeSH data available.


Related in: MedlinePlus