Is a history of severe anesthesia emergence ballism a risk for complications during a Bilateral Inferior Petrosal Sinus Sampling (BIPSS) procedure?

Anesthesia Emergence Ballism and BIPSS: Risk Assessment and Management

Patients with a history of severe anesthesia emergence ballism are at increased risk for complications during Bilateral Inferior Petrosal Sinus Sampling (BIPSS) procedures, particularly airway management difficulties and potential neurological complications. Careful planning and specific management strategies are essential to mitigate these risks.

Understanding Emergence Ballism and Its Implications

• Emergence ballism (violent, uncontrolled movements during emergence from anesthesia) should be considered an "at-risk" extubation scenario that requires special precautions and planning 1
• These movements may represent a form of emergence delirium that can compromise patient safety during the critical transition from controlled to uncontrolled airway management 1
• Patients with previous emergence ballism may have underlying neurological conditions or abnormal responses to anesthetic agents that could complicate BIPSS procedures 1

Pre-Procedure Risk Assessment

• BIPSS is an invasive diagnostic procedure requiring careful anesthetic management, with potential complications including airway compromise and neurological sequelae 2, 3
• Prior to BIPSS, thoroughly evaluate:
  • Previous anesthesia records documenting the nature and severity of emergence ballism 1
  • Presence of sleep-disordered breathing or obstructive sleep apnea, which may exacerbate emergence complications 1
  • Potential difficult airway characteristics that could be complicated by ballistic movements 1

Anesthetic Management Recommendations

Medication Selection

• Use short-acting anesthetic agents (sevoflurane or desflurane) to allow rapid emergence and return of protective reflexes 1
• Consider total intravenous anesthesia (TIVA) with propofol for smoother emergence, though this may increase vasopressor requirements 1
• Implement multimodal opioid-sparing analgesia to reduce the risk of respiratory depression and emergence delirium 1
• Avoid long-acting opioids which may contribute to delayed emergence or exacerbate ballistic movements 1

Monitoring Considerations

• Utilize depth of anesthesia monitoring (BIS or other processed EEG) to avoid excessive anesthetic depth, particularly in patients over 60 years 1
• Ensure complete neuromuscular blockade reversal with quantitative monitoring before emergence 1
• Implement standard monitoring plus continuous end-tidal CO2 monitoring throughout the procedure 1

Emergence Strategy

• Consider using remifentanil infusion for controlled emergence:
  • Maintain the infusion during emergence while discontinuing other anesthetics
  • Allow the patient to awaken with the infusion running at a low rate
  • Discontinue the infusion only after confirming adequate spontaneous respiration 1
• Position the patient in a head-up position during emergence to optimize airway patency 1
• Consider inserting a nasopharyngeal airway before emergence to mitigate partial airway obstruction 1

Airway Management Strategies

• Develop a clear extubation strategy before the procedure begins, following Difficult Airway Society guidelines 1
• Consider using an airway exchange catheter (AEC) during extubation to maintain airway access in case reintubation becomes necessary 1
• Ensure the patient has return of airway reflexes and adequate tidal volumes before extubation 1
• Perform extubation with the patient awake and in a sitting position 1

Post-Procedure Management

• Plan for extended post-anesthesia monitoring, particularly observing for delayed emergence which could indicate neurological complications 4, 5
• Be prepared for potential VP shunt dysfunction if the patient has one, as positioning during BIPSS could affect shunt function 4
• Consider level-2 care (step-down or high-dependency unit) for patients with significant risk factors 1
• Monitor oxygen saturations until the patient is fully mobile 1

Special Considerations for BIPSS

• Regional anesthesia techniques may be preferable when possible, though BIPSS typically requires general anesthesia 1
• Ensure the procedure room is properly equipped for managing potential airway emergencies 1
• Optimize workspace ergonomics with equipment and monitors in the direct line of sight of the anesthesiologist 1
• Have immediate access to emergency drugs, staff, and equipment in case of complications 1

By implementing these specific strategies, the risks associated with severe anesthesia emergence ballism during BIPSS can be significantly mitigated, improving patient safety and procedural outcomes.