Discussion

2. Discussion 黃尹宬 B85401077

3. Clinical Issues about This Patient • Hyponatremia & Hypokalemia • Anemia • Infection and Drug Interaction • Ankylosing Spondylitis – major one!

4. Electrolyte Problems • Hyponatremia • <135 mEq/L • sevenfold to sixtyfold increase in mortality (association) • consciousness change, nausea and vomiting, when <120 mEq/L • differentiation: serum osmolarity • Hypokalemia • <3.5 mEq/L • neuromuscular change • may potentiate cardiac arrhythmia: ventricular escape activity, reentrant phenomena, ectopic tachycardia, and delayed conduction. • differentiation: excessive K+ loss or intracellular redistribution

5. Anemia • 34 % - 56 % surgical p’t may have preoperative anemia (http://www.anemia.org/) • Effects: • Increase morbidity and mortality • Decreased O2 saturation • Destablizing hemodynamic of the patient • Transfusion complication • Immunological: GVHD, for example • Electrolyte imbalance • Acid-base effects • Infection

6. Infection and Drug Interaction • Some Cephalosporins • Those with N-methylthiotrazole and methylthiotrazole side chain:e.g. moxalactam, cefmenoxine, cefoperazone, cefotetan, cefamandole, and cefazolin • Long-term use → hypoprothrombinemia • Inhibition of Vit. K- dependent hepatic enzyme epoxide reductase • The well-known aminoglycoside effect • prolongation of neuromuscular blockade

7. Anesthesia about AS Patients

8. Anesthesia about AS Patients • Difficult Intubation • Breath Changes • Spinal and Epidural anesthesia • Miscellaneous Problems

9. Anesthesia about AS Patients • Difficult Intubation • Cervical spine rigidity and fragility • Flexion: unable to place the sniffing position→ increasing difficulty of direct laryngoscopy • Subluxation of atlantoaxial joint: DANGER!→More mobile spine; easy damage to spinal cord • Temporomandibular joint involvement • Limitation of Mouth Opening • Partial limitation, tenderness, and Crepitus

10. Anesthesia about AS Patients • Difficult Intubation • Cricoarytenoid joint involvement (Cricoarytenoid arthritis) • S/S: fullness or tightness in the throat, foreign body sensation, hoarseness, stridor, dysphagia, odynophagia, dyspnea, and pain radiating to ears • Diagnosis: direct laryngoscopy-- arytenoid mucosa is red / edematous / thick • Effect on Anesthesia: ‧Narrow glottic opening‧normal appearing vocal cord but bow in the middle during inspiration

11. Anesthesia about AS Patients • Difficult Intubation • Suggestion A Difficult Intubation Plan ┌──────┬──────┐ mask and artificial airway tracheal intubation tracheostomy under local anesthesia ┌──────┴──────┐ blind techniques direct vision ┌────┴────┐ ┌──┴──┐ guided blind techniques classic blind nasal laryngoscopic fiberoptic ┌───┴───────┐ retrograde wire via cricothyroidotomy stylette with tube mounted over

12. Anesthesia about AS Patients • Difficult Intubation • Breath Changes • Spinal and Epidural anesthesia • Miscellaneous Problems

13. Breath Changes

14. Anesthesia about AS Patients • Breath Changes • Keep the thoracic cage in the position of inspiration • Increase FRC & RV • Mainly depends on DIAPHRAGM • Vulenable in P’t undergoing upper abdominal or thoracic surgery • Prolonged ventilatory support

15. Anesthesia about AS Patients • Breath Changes • Suggestion • Avoid • place DIAPHRAGM in mechanical disadvantage: lung hyperinflation • increase DIAPHRAGM workload: small endotracheal tube, bronchospasm, retained endobronchial secretion, or abdominal bining • decrease O2 supply and metabolic substrate: low cardiac output, anemia, hypoxemia, or starvation

16. Anesthesia about AS Patients • Difficult Intubation • Breath Changes • Spinal and Epidural anesthesia • Miscellaneous Problems

17. Anesthesia about AS Patients • Spinal and Epidural anesthesia (SA & EA) • Ossification of interspinous ligaments • Ossification of bony bridges between vertebrae (syndesmophyte, aka ossified soft tissue) • Limited flexion of lumbar spine: makes SA or EA difficult or impossible • Wittman & Ring:SA & EA are contraindicated • Ossification makes the placement of a needle very difficult • Higher risk of a vertebral fracture / severe neurological deficit

18. Anesthesia about AS Patients • Spinal and Epidural anesthesia (SA & EA) • Suggestion • Pre-op X-ray of sacrum • Case reports • Lower limb surgery: Lateral approach to SA • Hip surgery: caudal approach

19. Anesthesia about AS Patients • Difficult Intubation • Breath Changes • Spinal and Epidural anesthesia • Miscellaneous Problems

20. Anesthesia about AS Patients • Miscellaneous Problems • Scarring or the aorta and aortic valve cusps-- aortitis & aortic insufficiency • Stokes-Adams attacks-- pacemaker requirement • Cauda equina syndrome • Spinal cord compression • Vertebrobasilar insufficiency • Atlantooccipital subluxation or dislocation-- from minor trauma • The most serious array of intubation and airway hazards • Cricoarytenoid arthritis • Cervical spine limitation • Atlantooccipital fragility

21. Review • Difficult Intubation • Cervical spine rigidity and fragility • Temporomandibular joint involvement • Cricoarytenoid joint involvement • Breath Changes • Diaphragm!!! • Spinal and Epidural anesthesia • Ossification of interspinous ligaments • Ossification of bony bridges • Contraindicated? • Miscellaneous Problems

22. Major Reference Anesthesia & Perioperative ComplicationsJ L Benumof & L J Saidman 1999 Mosby ISBN 0-8151-2619-0 Anesthesia & Uncommon DiseasesJ L Benumof & Lesley Day, 4th Ed1998 W B Saunders ISBN 0-7216-8673-7

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