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Based on the data obtained by the authors, formal instruction in difficult airway management is not offered by most residency programs. It is commonly taught as difficult clinical situations arise. Because these difficulties occur sporadically, opportunities for teaching are occasional. Learning based on sporadic and occasional occurrences risks incomplete and nonuniform training of residents.

arkinson's disease afflicts approximately 1 % of the population over 50 yr old (1). Its associated P muscle tremors and rigidity are progressive and become severe enough to debilitate many patients. We summarize a case of advanced Parkinson's disease with an intraoperative exacerbation during regional anesthesia. A discussion of its consequences and treatment follow. Case ReportA 73-yr-old man with Parkinson's disease required anesthesia for repair of a large recurrent left inguinal hernia. His Parkinson's disease was treated with carbidopa 25 mg and levodopa 100 mg five times a day; amantadine 200 mg three times a day; and selegiiine 5 mg each day. Levodopa was administered every 4 h while awake. Delaying or omitting a single dose resulted in severe generalized body tremors and rigidity. He also suffered from congestive heart failure for which he received lanoxin 0.125 mg each day and isordil 20 mg three times a day, as well as sick sinus syndrome for which he had received a permanent pacemaker. Previous anesthetics were limited to one general anesthetic for left inguinal hernia repair and one spinal anesthetic for transurethral resection of the prostate. There were no known anesthetic complications.He had taken his usual morning medications 2 h before the planned surgery. Physical examination 1 h before surgery revealed masklike facies and poor facial expressions. No bradykinesia or resting tremor were noted. There were no active signs and symptoms of congestive heart failure nor sick sinus syndrome.No sedative premedication was given. Field block anesthesia was feared to be inadequate for this large, recurrent hernia and therefore was not performed. Spinal anesthesia was agreed to, and the patient was brought to the operating room where his vital signs were an arterial blood pressure of 140190 mm Hg; heart rate of 70 bpm with a paced rhythm; respiratory rate of 16 breathdmin; and arterial oxygen saturation of 96% while breathing room air. Hyperbaric bupivacaine, 12 mg, plus 10 pg of fentanyl were injected into the cerebrospinal fluid at the L4-5 interspace. Ten minutes later, a T-9 level was achieved and vital signs were

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