Hi, Good case you have as a brain teaser.
Not used to this kind of cases, yet it is always easy to advise someone.
You think a tracheal stenting can help?  It certainly will open up the lumen to over 60 % size, providing the nodule is soft and can get compressed. The tube that you can use now will be much bigger than an MLS tube.
Not sure if it can work, but gives ideas.
Regards and best wishes. Do let us know how you succeeded in managing and also post pictures of the nodule.

    My observation in past few cases show, that when CO2 Narcosis takes place, the patient takes quite some time to sattle down, because the cerebral edema also takes its own time to go down. It takes nearly 6 to 8 hours to become normal even after the PCO2 has come back to normal.
  I am sure, other effects like Acidotic cardio myopathy also must be coming in picture to reduce cardiac function.
Thanks for the reply,
Regards, Yogen Bhatt

I presented this case in a local state chapter 3 day conference as a paper reading. Incidentally atleast 3 anaesthesioloists got up to say, that now retrospectivly they think that they had lost one case each, but under spinal anaesthesia.They thought it was spinal hypotension that killed the pt but, now they think that the pt died of gas embolism. Hydrogen Peroxide was used in their cases.

     Thanks for a quick reply. Actually I missed you all for almost a month. No body had posted any thing in a month. So I posted this case.
     ETCO2 monitor has a very important role to play, but the anaesthetist had a better role to play. The reversal was given purely on assumption that it is an hour since Pancuronium was given ( few ppl still use pancuronium here.) TOF-Watch is also never used. After this, I am wondering why LMA was removed and mask ventillation was going on? The pt was hardly attempting breathing. I think some ppl really need to be more watchfull while reversing.
Eagerly waiting for your reply on sequele of events in CO2 Narcosis.

Recently I was called by an anaethesiologist as the patient was not coming out. A case of TKR where Epidural did not work and GA was given. Intubation was not possible and LMA was used. Patient did not come out of GA after reversal.  LMA was removed and mask ventilltion was going on.
     On reaching there I realised that ETCO2 was 90plus( we have a portable Capnogram of our own).These monitors are still not used as a routine over here. We intubated over a guide wire. ABG showed PCO2 of 86. We noticed convulsions on facial muscles. We just kept on ventillating with a venti for an hour and a half and she came out completely. Tube was removed and was shifted to ICU for observation.
     Many things were wrong in management.
     I want members to throw light on what all happens in CO2 narcosis, if they have seen one. and also the pathophysiology.

Being from India I know what it means to manage this kind of cases. PACU is an unheard word. Let us not discuss tirtiary care centers of Mumbai of Chennai. Over all the scene is same all over. Drugs still remain unavailable even in Mumbai( very rigid Narcotic dept).
Overall a very well managed scene in given situation. But the very fact, that the SPO2 was 75% preop, meant that there is real gross problem. Either a PH or high CVP due to anything. GA is real bad if you do not have support, as every one wants to balme you for death du to GA. Yes, retrospective wisdom says, that If we use Narcotics, or even Ketmin Midaz in spinal, it could have been ok. Epidural in slow increaments may be ok, but it takes time and that too if you are not used to giving it in lateral position. Yes, a continuous intrathecal is a best choice along with intra thecal narcotics or even Ketamine would have been best. We have to use only an 18G epidural cath for continuous spinal, as special sets are not easy to acquire. As suggested, now it looks more like a praganecy related cardiomyopathy. But it woukd have been bad either way.
I will add to this by saying that I thought GA should be a better option, so I gave GA in a tight mitral with PH, she came out very well, but every time I would extubate her she would arrest in next about 15 - 20 mins. It happerned thrice over next 15 days. She was fully conscious, but venti depenent. Eventually she had to undergo em. valve replacement, but succumbed to all this in next 15 days time, when they tried to extubate her in the best hospital of Mumbai.

Can some one please translate this article or reply in English? At least in India I do not understand this language, which ever it must be. I certainly would like to know the article.

Hi,
That was a good study conducted and produced. Logically it sounds very right, spicially for very high risk patients with compromised resp reserves. I will certainly give it a try on my next 100 cases and compare the results in our set up in small time private practice in Mumbai, India.

Again PDPH remains ununderstandable, and unexplainable. Off late we see more of Meningism due to chemical irritation of meninges due to drugs we inject. I will quote an incidence. I was called to do a CSF manometry for a pt of Cavernous Synous Thrombosis. His pressure was about 1.25 meters. The physician used to request me to drain out some CSF to reduce his severe headache. I used to remove a lot of CSF. Almost every day he requested me to remove some CSF. I used to use a 20 G needle to drain it and deliberately I used to poke the needle in  dura 5-6 times, hoping that he will have a leak there. But he used to get pain again in nest 2-3 hours. He used to bang his head on the wall as the headache was unbearable. In short, does a few more dura punctures really give a PDPH due to CSF leak? Specially as we now a days use needles which are 27G or Pencil point.

Was called by a fellow anaesthesiologist recently to resuscitate a pt of Medazolam induced resp depression. On reaching we found that patient was better after the hospital staff ventillated the pt with Ambu bag for a while. But still unconscious and deep. The gynaecologist thought he can perform a D & C without an anaesthesiologist, under mild sedation. He gave Medazolam 2 mg( 2ml). and the pt went in resp failure, as shown by the SpO2 monitor.
They later found that it was not Medaz but Succinyle choline of some companey with an exactly simillar lable. Patient was lucky, and after a brief stay ( 48 hrs) in ICU with venti support, recovered and went home. As humans even we can make an error. So it is better, they do not fiddle with our drugs. Our drugs are lethal in pharmacological doses, if one does not know how to use them.

Ha, I see your prejudice showing off for a surgeon, never make it that obvious. Do I take it that it is  for a general surgeon? or an over all experience? I organize bi monthly meet of our association of 140 members. I invariably invite a few surgeons, of various branches, pertaining to the topic of discussion. This prevents ppl from making any adverse comments on our surgeeon friends. Not that I disagree with your article. It is best to work with an obstetrician, you can fool them any time and teach them any thing. 
Regards. Dr. Yogen Bhatt, on your side, ever.

Hi, In Mumbai, India, some of our surgeons do preffer to do under prone position. One place, where they did not get their regular Anaesthesiologist, they had called me to do a Piles surgery in prone position. I did give a saddle block with pt sitting for 12-15 mins. The surgeon actually gives, not a prone position but a Jack Knife( Knee Chest) position. This offers them a very good view. This position is really dangerous, as the drug can so easily seep upwards in to the thoracic or even higher level.
All went well, but when I commented that this is a bad and dangerous position for a surgery, the surgeon says that he has already had two problem events and they had to make the pt supine urgently and treat the hypotension and resp arrest.
I have seen a CD called "Glass Spine", where some one has made an excellant effort to make a glass tube into a spine shaped tube , filled with Fluid of CSF density and he injects a  red dye which has a density of Bupivacain Heavy. He shows how the drug flows, in what position and after how much time. Just imagine this and then work.

Hi,
Sorry for a delayed responce. If an intrathecal cath is accpeted by us in labour analgesia, we inject on demand dose. It is needed almost every one hourly. Only problem we have encountered is an occasional severe tonic contraction leading to severe foetal brady which ended up in a section. On detailed inqueiry I was told by a few friends who have been in labour analgesia for some time in institution, I was told that it is due to circulating Catecholamines due to sever pains, as you give intrathecal and suddenly cut off pain, the catecholamines work on the uterus and give tonic contractions which give a continuous pressure on baby and give bradycardia. Treatment is to give Terbutaline or NTG to relieve the tonic contraction.

Hi, Amit, I have conducted Lap choles under Spinal/ Epidural. Well, as you read even our senior colleague Jafo1964, true name not known, I was also not happy with the technique. Some recommend sprey of Xylocain on Diaphram, but I was not happy with that too. Actually when patient is uncomfortable and in pain we take it as a defeat, and also surgeon also is not happy. I have also given up.
but , lower abdomenal and pelvic surgeries, we were quite happy. We use to think that sedation will reduce respiratory efforts or volume, but the capno gram and SpO2 were very steady. There was no hypertension and no tachycardia.
Well, We have stopped breaking our head with that too. We are back to standard GA.
I have even come to believe that tachy and hypertension and raised ETCO2 are due to pain from improper analgesics, which increase stress.
I know that is will give me lots of corrections, because it is a belief and not a study.

Dear Amarkatira '
Hi , read your note about using air in all Epidurals. I attended a CME lecture some time back, and was shocked to hear a statement made by the speaker. She mentioned about a study conducted with air, and it was proved that when they placed Transe Esophagial Probe of ultra sound, they realised that almost 90 % patients had air embolism. In a small child even 5 ml of Air can be very dangerous, if this study is anywhere near right.
The speaker was Dr. Laxmi Vaz, a very famous Paediatric Anaesthesiologist, now only in pain management in Mumbai. I really  do not know the refference of the article, but if it is true, I think, you start using NS. You will get used to it in the first case only.