Recently, balanced sedation has commonly been used during procedural sedation. Dexmedetomidine is known for its relative safety to cause “conscious sedation” with little respiratory depression but has some limitations such as frequent awakening and hemodynamic instability during surgery. To facilitate sedation, a small dose of midazolam can be co-administered rather than escalating the dose of dexmedetomidine, especially in elderly patient. Despite the respiratory safety profile of dexmedetomidine, the overall safety of co-administration has not been clarified. We describe the first case of fatal pulmonary aspiration that developed in an elderly patient during balanced sedation with spinal anesthesia for elective femur fracture surgery.
Aged ; Anesthesia, Spinal ; Conscious Sedation ; Dexmedetomidine ; Femur ; Hemodynamics ; Humans ; Midazolam ; Respiratory Aspiration of Gastric Contents ; Respiratory Insufficiency

Pulmonary aspiration of gastric contents is one of the most frightening complications during anesthesia. Although pulmonary aspiration of gastric contents in general surgical patients is not common and resulting long-term morbidity and mortality are rare, severe hypoxemia and other sequelae of pulmonary aspiration continue to be reported. We report a case of massive aspiration of gastric contents during induction of general anesthesia, resulting in cardiac arrest due to severe pulmonary hypertension and myocardial infarction. Sustained cardiac arrest and shock that did not respond the conventional resuscitation was successfully treated using milrinone. The patient was discharged without complications in 20 days.
Anesthesia ; Anesthesia, General ; Anoxia ; Heart Arrest ; Humans ; Hypertension, Pulmonary ; Milrinone* ; Mortality ; Myocardial Infarction ; Respiratory Aspiration of Gastric Contents ; Resuscitation ; Shock ; Shock, Cardiogenic*

OBJECTIVE: To assess cough reflex sensitivity using the simplified cough test (SCT) and to evaluate the usefulness of SCT to screen for silent aspiration. METHODS: The healthy control group was divided into two subgroups: the young (n=29, 33.44+/-9.99 years) and the elderly (n=30, 63.66+/-4.37 years). The dysphagic elderly group (n=101, 72.95+/-9.19 years) consisted of patients with dysphagia, who suffered from a disease involving central nervous system (ischemic stroke 47, intracerebral hemorrhage 27, traumatic brain injury 11, encephalitis 5, hypoxic brain damage 3, and Parkinson disease 8). The SCT was performed using the mist of a 1% citric acid from a portable nebulizer. The time from the start of the inhalation to the first cough was measured as the cough latency. All the dysphagic patients underwent the videofluoroscopic swallowing study. RESULTS: The cough latency was more significantly prolonged in the healthy elderly group than in the healthy young group (p<0.001), and in the dysphagic elderly group than in the healthy elderly group (p<0.001). The sensitivity and specificity of SCT were 73.8% and 72.5% for detecting aspiration in the dysphagic patients, and 87.1% and 66.7% for detecting silent aspiration in the aspirated patients. CONCLUSION: Cough latency measured with the SCT reflects the impairment of cough reflex in healthy elderly and dysphasic subjects. The results of this study show that the SCT test can be a valuable method of screening aspiration with or without cough in dysphasic patients.
Aged ; Brain Injuries ; Central Nervous System ; Cerebral Hemorrhage ; Citric Acid ; Cough* ; Deglutition ; Deglutition Disorders ; Diagnosis ; Encephalitis ; Humans ; Hypoxia, Brain ; Inhalation ; Mass Screening* ; Nebulizers and Vaporizers ; Parkinson Disease ; Reflex* ; Respiratory Aspiration of Gastric Contents ; Sensitivity and Specificity ; Stroke