Solutions for management of angiotensin-converting enzyme–induced angioedema in a high risk population: a single center retrospective observational study Background: There is an increasing rate of angiotensin-converting enzyme (ACE) inhibitor-induced angioedema in the United States which has not plateaued since this side effect was first described in 1980. There are no studies reporting a plateau, decrease in the incidence or decrease in the rate of rise in high risk populations. High risk populations are defined as African Americans, female sex, and age older than 65. Objectives: The objective of this manuscript is to determine the incidence of angioedema in a high risk, urban population over a 7-year period, and to determine impactful solutions on its management by anesthesiologists. Methods: PubMed was queried with the keywords angioedema, ACE inhibitor-induced angioedema, and anesthesiology angioedema management. Subset keyword searches included angioedema incidence and high risk populations, and emergency room anesthesiology angioedema management. Our medical center’s data repository was queried to identify the number of emergency department visits between January 2007 and December 2013. We then queried the database to determine the number of cases that were diagnosed as angioedema. A subset of patients was identified that included all patients that presented with angioedema, and who had a current ACE inhibitor prescription. The medical records of the admitted patients were reviewed to determine whether angioedema was induced by an ACE inhibitor or another etiology. The annual occurrence rates of angioedema and ACE inhibitor-induced angioedema were then calculated. Analysis of the medical records also determined the extent of anesthesiology involvement. Results: There were a total of 478 cases of ACE inhibitor-induced angioedema during the 7-year period. The incidence of ACE inhibitor-induced angioedema rose from 0.17 in 2007 to 0.53 in 2013. There is no evidence of plateau for this rise and current rate of rise appears to be exponential. African Americans, female sex, and age 65 and younger were associated with a greater incidence of ACE inhibitor-induced angioedema. One hundred thirty-three patients that presented to the emergency department with ACE inhibitor-induced angioedema were admitted, and 22 of these patients required intubation. Anesthesiology was consulted 23 times, and performed 14 (63.6%) of the intubations.

The value of preoperative endoscopic airway examination in complex airway management of a patient with supraglottic cancer The standard bedside airway assessment tests are poorly predictive for difficult tracheal intubation, and do not assess the presence of the inside pathology of the upper airway, such as base of the tongue lesions, glottic and vallecular lesions, pyriform sinus pathology, supraglottic tumors, etc. The preoperative endoscopic airway examination, also commonly called nasal endoscopy, or nasendoscopy, is the only technique that assesses the upper airway in its entirety, under dynamic conditions prior to induction of anesthesia, and is recommended for routine use by NAP4 even for high acuity cases. We present a case of a patient with a malignant partial upper airway obstruction and largely normal external airway exam where preoperative endoscopic airway examination findings were used in real-time to devise successful ventilation and intubation strategies.

Chronic rhinosinusitis with nasal polyps Chronic rhinosinusitis (CRS) is a complex disease and can present with different stages of disease progression, depending on etiology and comorbidities. One important feature of a specific subset of CRS are nasal polyps (CRSwNP). Medical treatment options for patients with CRSwNP remain limited, often making surgery necessary. Functional endoscopic sinus surgery with navigation is the preferred treatment of CRSwNP, offering the safety of computed tomography guided navigation with minimally invasive resection of the tumors. It is paramount for the anesthesiologist to know the most commonly encountered surgical perioperative complications of functional endoscopic sinus surgery: ethmoidal artery injury (bleeding, optic nerve damage), penetration of the ethmoid roof or lamina papyracea (cerebrospinal leak), nasolacrimal duct damage or direct optic nerve damage. Anticipation of surgical (bleeding, nerve or brain injury) and anesthetic complications (lost airway, hypoxia, and anaphylaxis) is fundamental to patient safety. Anesthesia management for cases with complete nasal airway obstruction relies on a careful preoperative assessment of the patient’s anatomy and symptoms, clinical presentation, and associated comorbidities. Airway compromise can result in a dangerous cannot ventilate/cannot intubate situation, a risk complicated by patient refusal for awake intubation. A proper plan should not only be established for the intubation, but also for the extubation. Important factors in proper anesthesia management are also based on accurate preoperative assessment of the patient, evaluation of associated comorbidities (obstructive sleep apnea, morbid obesity, aspirin-exacerbated respiratory disease, IgE related CRS, fungus, etc.) as well as planning of the procedure with attention to directed management and therapy (controlled hypotension, pain control, airway management, admission status).