A blood pressure cuff that is too small, tight-fitting sleeves that are not removed, or a brachial artery that is noncompressible because of calcification sometimes seen in the elderly can cause falsely elevated readings. Apnea Obstructive sleep apnea OSA , a repetitive mechanical obstruction of the upper airway during sleep, is an independent risk factor for hypertension. A formal sleep study usually is needed for diagnosis of OSA and determination of corrective interventions. Aldosteronism Primary hyperaldosteronism is defined as overproduction of aldosterone independent of its usual regulator, the renin-angiotensin system.
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Nazia Nazir, Shruti Jain, Shipra Singh Online First: August 30, Succinylcholine used for difficult airway lead to difficult airway- a case report Nazia Nazir, Shruti Jain, Shipra Singh Succinylcholine Sch is usually given for intubation in suspected difficult airway due to its fast onset and short duration of action.
A healthy, 40 year old female weighing 85 kg was posted for laparoscopic cholecystectomy. She was Mallampatti grade III, mouth opening 4. She had no medical illness, no previous exposure to anaesthetic agents or family history of myopathy with normal investigations. In operating room OR , difficult intubation cart was kept ready. Pre-medication was done with glycopyrrolate 0. On confirming adequacy of bag and mask ventilation, Sch mg IV was given. Laryngoscopy was attempted once Sch induced fasciculations were over.
However, teeth were tightly clenched and it was impossible to open the mouth to allow advancement of the laryngoscope. Again, after few moments, attempt to open the mouth failed. There was no disproportionate increase in EtCO2 or body temperature during this period. After 5 minutes, jaw started relaxing and patient resumed spontaneous respiration. She was sent to the ICU for observation without surgery being performed. Patient remained afebrile throughout with clear urine.
Next day, patient was discharged with a special note regarding not to use Sch and counselling for risk of malignant hyperthermia MH in future anaesthesia. Muscle biopsy for halothane caffeine test was advised. The case was done at a later date under Total intravenous anaesthesia uneventfully. Our patient presented with difficult airway on account of Mallampati III, increased body weight and neck circumference.
In our institute, Sch is routinely used in suspected difficult airway cases as newer short acting non depolarizing muscle relaxants NDMR are not available. A rare adverse effect of Sch is MMR which can occur in isolation or can be an early indicator of malignant hyperthermia MH. MMR causes difficult or impossible laryngoscopy leading to difficult or failed intubation.
In our patient, though Sch triggered MMR leading to difficult intubation, we were able to ventilate the patient with bag and mask. Surgery was abandoned and patient monitored as there is a possibility of development of MH even after a lag of 20 min 4.
To summarize, this case highlights that Sch may produce isolated MMR leading to difficult laryngoscopy and intubation. In such patients, trigger factors of MH should be avoided during maintenance of anaesthesia and availability of dantrolene in OR ensured. We also suggest that the use of Sch is fraught with too much potential for a disastrous outcome and should not be relied upon in cases where difficult intubation is suspected.
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E-mail: moc. This article has been cited by other articles in PMC. Abstract Pheochromocytoma is a rare tumor arising from chromaffin cells in adrenal medulla or other paraganglia in the body, which may be associated with many genetic syndromes and mutation. The role of endocrinologist is in biochemical diagnosis of suspected cases; its anatomic and functional localization with the help of imaging like CT, MRI, and nuclear scanning; preoperative control of hypertension; and postoperative follow-up of cases that have undergone surgical resection. Familial and genetic screening of cases and their family is important to detect occult cases. Endocrinologist will also play a role in cases with malignant pheochromocytoma in assessment of metastasis, control, chemoradiotherapy, and follow-up.
Medical management of pheochromocytoma: Role of the endocrinologist
Endothelin Adrenomedullin, erythropoietin, neuropeptide Y. Hypertension, frequently sustained but often paroxysmal, especially during surgery or delivery. Elevated urinary catecholamines or their metabolites. Normal serum T4 and TSH. Vasomotor changes during an attack cause mottled cyanosis and facial pallor; as the attack subsides, facial flushing may occur as a result of reflex vasodilation. Epinephrine secretion may cause episodic tachyarrhythmias, hypotension, or syncope. Anginal attacks may occur.
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