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2011| January-March | Volume 5 | Issue 1
Online since
February 5, 2011
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ORIGINAL ARTICLES
Palonosetron: A novel approach to control postoperative nausea and vomiting in day care surgery
Sukhminderjit Singh Bajwa, Sukhwinder Kaur Bajwa, Jasbir Kaur, Veenita Sharma, Amarjit Singh, Anita Singh, SPS Goraya, SS Parmar, Kamaljit Singh
January-March 2011, 5(1):19-24
DOI
:10.4103/1658-354X.76484
PMID
:21655011
Background:
Postoperative nausea and vomiting (PONV) is one of the complications which hamper the successful implementation of day care surgical procedure in spite of the availability of so many antiemetic drugs and regimens for its prevention. The aim was to compare the prophylactic effects of intravenously (IV) administered ondansetron and palonosetron on PONV prevention in patients undergoing laparoscopic gynecological surgery under general anesthesia.
Methods:
A prospective double-blind study comprised of 60 ASAI/II female patients between the age group of 25 and 40 years was carried out in the Departments of Anesthesiology and Obstetrics and Gynecology of our institute. Patients were randomly divided into two groups of 30 patients each in a double-blind manner. Group I received 8 mg of inj. ondansetron IV while group II received inj. palonosetron 0.075 mg IV 5 minutes before the induction of anesthesia. The need for rescue antiemetics, episodes of PONV and other side effects were observed for 6 hours in the postanesthesia care unit and thereafter complaints were received on phone after the discharge. At the end of study, results were compiled and statistical data was subjected to statistical analysis using Student two-tailed 't' and c
2
test and value of
P
<0.05 was considered significant.
Results:
The demographical profile of the patients was comparable. Twenty and 13.33% of the patients in group I had nausea and vomiting episodes postoperatively as compared to 6.67% and 3.33%, respectively, in group II which was statistically significant (
P
<0.05). Twenty percent of the patients in group I experienced significant post-op headache as compared to 6.67% in group II. The mean rescue dose of antiemetic was significantly higher (10.6 mg) in the group I as compared to group II (6.4 mg) (
P
=0.036). The rest of parameters were comparable and statistically nonsignificant.
Conclusions:
Palonosetron is a comparatively better drug to prevent the PONV in patients undergoing day care surgical procedures as compared to ondansetron as it has got a prolonged duration of action and favorable side-effects profile.
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1,041
CASE REPORTS
Inadvertent intrathecal injection of tranexamic acid
Olfa Kaabachi, Mongi Eddhif, Karim Rais, Mohamed Ali Zaabar
January-March 2011, 5(1):90-92
DOI
:10.4103/1658-354X.76504
PMID
:21655027
Some factors have been identified as contributing to medical errors such as labels, appearance, and location of ampules. In this case report, inadvertent intrathecal injection of 80 mg tranexamic acid was followed by severe pain in the back and the gluteal region, myoclonus on lower extremities and agitation. General anesthesia was induced to complete surgery. At the end of anesthesia, patient developed polymyoclonus and seizures needing supportive care of the hemodynamic, and respiratory systems. He developed ventricular tachycardia treated with Cordarone infusion. The patient's condition progressively improved to full recovery 2 days after. Confusion between hyperbaric bupivacaine and tranexamic acid was due to similarities in appearance between both ampules.
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ORIGINAL ARTICLES
A comparative study of efficacy of esmolol and fentanyl for pressure attenuation during laryngoscopy and endotracheal intubation
Shobhana Gupta, Purvi Tank
January-March 2011, 5(1):2-8
DOI
:10.4103/1658-354X.76473
PMID
:21655008
Objective:
To compare the effectiveness of single bolus dose of esmolol or fentanyl in attenuating the hemodynamic responses during laryngoscopy and endotracheal intubation.
Methods:
Ninety adult ASA I and ASA II patients were included in the study who underwent elective surgical procedures. Patients were divided into three groups. Group C (control) receiving 10 ml normal saline, group E (esmolol) receiving bolus dose of esmolol 2 mg/kg and group F (fentanyl) receiving bolus dose of fentanyl 2 μg/kg intravenously slowly. Study drug was injected 3 min before induction of anesthesia. Heart rate, systemic arterial pressure and ECG were recorded as baseline and after administration of study drug at intubation and 15 min thereafter.
Results:
Reading of heart rate, blood pressure and rate pressure product were compared with baseline and among each group. The rise in heart rate was minimal in esmolol group and was highly significant. Also the rate pressure product at the time of intubation was minimal and was statistically significant rate 15 min thereafter in group E.
Conclusion:
Esmolol 2 mg/kg as a bolus done proved to be effective in attenuating rises in heart rate following laryngoscopy and intubation while the rise in blood pressure was suppressed but not abolished by bolus dose of esmolol.
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Dexmedetomidine versus propofol for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia
Ashraf Ghali, Abdul Kader Mahfouz, Tapio Ihanamäki, Ashraf M. El Btarny
January-March 2011, 5(1):36-41
DOI
:10.4103/1658-354X.76506
PMID
:21655014
Purpose:
The purpose of this study was to evaluate the hemodynamic, respiratory effects, the recovery profile, surgeons, and patients satisfaction with dexmedetomidine sedation compared with those of propofol sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia.
Methods:
Sixty patients were enrolled in this prospective, single-blind, randomized study. The patients were divided into two groups to receive either dexmedetomidine (group D) or propofol (group P). Sedation level was titrated to a Ramsay sedation scale (RSS) of 3. Hemodynamic and respiratory effects, postoperative recovery time, analgesic effects, surgeons and patients satisfaction were assessed.
Results:
Both groups provided a similar significant reduction in heart rate and mean arterial pressure compared with baseline values. The respiratory rate values of the dexmedetomidine group were significantly higher than those in the propofol group. The oxygen saturation values of the dexmedetomidine group were significantly higher than those of the propofol group. The expired CO
2
was similar in both groups. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both groups. Dexmedetomidine patients have significantly lower visual analog scale for pain than propofol patients. The surgeon satisfaction with patients' sedation was similar for both groups. The patients' satisfaction was higher in the dexmedetomidine group.
Conclusion:
Dexmedetomidine at similar sedation levels with propofol was associated with equivalent hemodynamic effects, maintaining an adequate respiratory function, similar time of discharge from PACU, better analgesic properties, similar surgeon's satisfaction, and higher patient's satisfaction. Thus, dexmedetomidine may prove to be a valuable adjuvant for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia.
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A clinical comparison of etomidate-lipuro, propofol and admixture at induction
Fatma Saricaoglu, Sennur Uzun, Oguzhan Arun, Funda Arun, Ulku Aypar
January-March 2011, 5(1):62-66
DOI
:10.4103/1658-354X.76509
PMID
:21655019
Objective:
The purpose of this study was to compare etomidate-lipuro and propofol and 50%, (1:1) admixture of these agents at induction with special reference to injection pain, hemodynamic changes, and myoclonus.
Methods:
Ninety patients were assigned at random to three groups in which induction was performed with either etomidate-lipuro, propofol or etomidate-lipuro−propofol admixture. After monitorization with bispectral index (BIS) all agents were given with infusion with a perfuser at a constant rate of 200 ml/min till the BIS values decreased to 40. Blood pressure and heart rate were measured every 30 s at this period. Patients were asked for pain at the injection site and observed visually for myoclonus. The time BIS values decreased to 40 (BIS 40 time) and total amounts of induction doses were measured.
Results:
BIS 40 time measurements were P > E > PE (199.4 ± 40.9, 176.9 ± 31.6, 163.5 ± 20.6 s). The hemodynamic (systolic, diastolic and mean blood pressures, heart rate) changes were minimal in group PE than other two groups (
P
= 0.017). The intensity of myoclonus was graded as mild in 9, moderate in 12, and severe in 5 patients in the group E (76.3%). Myoclonus was not observed in group PE and group P. There were no injection pain in group PE as the incidence were (83.8%) in group P and in (63.2%) group E.
Conclusion:
Incidence of hemodynamic changes, myoclonus, and injection pain is significantly lower in group PE. BIS 40 times is least in group PE. We concluded that 1:1 admixture of etomidate-lipuro and propofol is a valuable agent for induction.
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Comparative study of attenuation of the pain caused by propofol intravenous injection, by granisetron, magnesium sulfate and nitroglycerine
Dhananjay Kumar Singh, Parul Jindal, Gaurav Singh
January-March 2011, 5(1):50-54
DOI
:10.4103/1658-354X.76511
PMID
:21655017
Background:
Propofol has the disadvantage of causing pain or discomfort on injection. The aim of the study was to assess the efficacy of pretreatment with various drugs to alleviate the propofol injection pain.
Methods:
One hundred American Society of Anesthesiology (ASA) I and II adults, scheduled for various elective surgical procedures under general anesthesia (GA), were included in the study. They were randomly divided into four groups having 25 patients in each group. Group A received pretreatment with intravenous (i.v.) magnesium sulfate, group B received i.v. granisetron, group C received i.v. nitroglycerine and group D was the control group. One-fourth of the total calculated induction dose of propofol was administered over a period of 5 seconds. The patients were asked about the pain on injection. The intensity of pain was assessed using verbal response. A score of 0-3 which corresponds to no, mild, moderate and severe pain was recorded.
Results:
All the three drugs reduced the incidence and intensity of pain on propofol injection but the order of efficacy in attenuation of pain on the propofol injection was granisetron > nitroglycerine > magnesium sulfate > control.
Conclusion:
Granisetron was the most effective followed by nitroglycerine and magnesium sulfate in attenuating pain on propofol intravenous injection.
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CASE REPORTS
Symptomatic sinus bradycardia: A rare adverse effect of intravenous ondansetron
Md Shahnawaz Moazzam, Farah Nasreen, Shahjahan Bano, Syed Hussain Amir
January-March 2011, 5(1):96-97
DOI
:10.4103/1658-354X.76492
PMID
:21655029
Ondansetron is a serotonin receptor antagonist which has been used frequently to reduce the incidence of post-operative nausea and vomiting in laparoscopic surgery. It has become very popular drug for the prevention of post-operative nausea and vomiting due to its superiority in-terms of efficacy as well as lack of side effects and drug interactions. Although cardiovascular adverse effects of this drug are rare, we found a case of symptomatic sinus bradycardia in a 43-year-old female patient, going for laparoscopic cholecystectomy, who developed the same after she was given intravenous ondansetron in operation theater during premedication. Hence, we report this case, as the rare possibility of encountering bradycardia effect after intravenous administration of ondansetron should be born in mind.
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ORIGINAL ARTICLES
Effect of magnesium infusion on thoracic epidural analgesia
Sampa Dutta Gupta, Koel Mitra, Maitreyee Mukherjee, Suddhadeb Roy, Aniruddha Sarkar, Sudeshna Kundu, Anupam Goswami, Uday Narayan Sarkar, Prakash Sanki, Ritabrata Mitra
January-March 2011, 5(1):55-61
DOI
:10.4103/1658-354X.76512
PMID
:21655018
Introduction:
Patients of lung volume reduction surgery (LVRS) having an ASA status III or more are likely to be further downgraded by surgery to critical levels of pulmonary function.
Aim:
To compare the efficacy of thoracic epidural block with (0.125%) bupivacaine, fentanyl combination and (0.125%) bupivacaine, fentanyl combination with adjunctive intravenous magnesium infusion for the relief of postoperative pain in patients undergoing LVRS.
Methods:
Patients were operated under general anesthesia. Thirty minutes before the anticipated completion of skin closure in both groups, (Group A and Group B) 7 ml of (0.125%) bupivacaine calculated as 1.5 ml/thoracic segment space for achieving analgesia in dermatomes of T4, T5, T6, T7, and T8 segments, along with fentanyl 50 ΅g (0.5 ml), was administered through the catheter, activating the epidural block, and the time was noted. Thereafter, in patients of Group A, magnesium sulfate injection 30 mg/kg i.v. bolus was followed by infusion of magnesium sulfate at 10 mg/kg/hr and continued up to 24 hours. Group B was treated as control.
Results and Analysis:
A significant increase in the mean and maximum duration of analgesia in Group A in comparison with Group B (
P
<0.05) was observed. Total epidural dose of fentanyl and bupivacaine required in Group A was significantly lower in comparison with Group B in 24 hours.
Discussion:
Requirement of total doses of local anesthetics along with opioids could be minimized by magnesium infusion; therefore, the further downgradation of patients of LVRS may be prevented.
Conclusion:
Intravenous magnesium can prolong opioid-induced analgesia while minimizing nausea, pruritus, and somnolence.
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A retrospective study of the outcome of cesarean section for women with severe pre-eclampsia in a third world setting
Obinna V Ajuzieogu, Humphrey Azubuike Ezike, Adaobi Obianuju Amucheazi, Jamike Enwereji
January-March 2011, 5(1):15-18
DOI
:10.4103/1658-354X.76480
PMID
:21655010
Objective:
To compare the outcome of subarachnoid block (spinal anesthesia) and general anesthesia in Cesarean delivery for women with severe pre-eclampsia.
Methods:
A retrospective study of women with severe pre-eclampsia requiring Cesarean section from January 2005 to June 2009 was carried out. Maternal age, parity, gestational age at delivery, booking status, Apgar scores, maternal and perinatal mortality of the sub-arachnoid block group were compared with those of general anesthesia group using c
2
, Student t-test and Fischer exact test.
Results:
There were no significant difference between the two groups in overall maternal mortality (5.4% vs. 11.9%,
P
=0.5) and perinatal mortality (2.7% vs. 11.9%,
P
=0.15). The general anesthesia group had significantly more birth asphyxia than the spinal group (55.9% vs. 27.0%,
P
=0.0006).
Conclusion:
There was no significant difference in the maternal and perinatal mortality outcome of cesarean delivery between women with severe pre-eclampsia who had regional anesthesia and those that had general anesthesia. There was significantly higher proportion of birth asphyxia in babies of women who received general anesthesia.
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Evaluation of analgesic effects of intrathecal clonidine along with bupivacaine in cesarean section
Nikhil Kothari, Jaishri Bogra, Ajay K Chaudhary
January-March 2011, 5(1):31-35
DOI
:10.4103/1658-354X.76499
PMID
:21655013
Aims and Context:
The objective of the present study was to evaluate the analgesic and adverse effects of intrathecal clonidine with hyperbaric bupivacaine in spinal anesthesia.
Settings and Design
: Randomized single blind trial.
Methods:
210 ASA I-II pregnant females undergoing emergency cesarean section were randomized in a single-blind fashion to one of the three groups. In group I (n=70) patients received 12.5 mg of 0.5% hyperbaric bupivacaine intrathecally. In group II (n=70) patients received intrathecal mixture of 0.5% hyperbaric bupivacaine (8 mg) and clonidine 50 μg. In group III (n=70)
,
patients received 0.5% hyperbaric bupivacaine (10 mg) intrathecally along with 50 μg of clonidine.
Statistical Analysis Used:
Groups were compared using one-way ANOVA with the Bonferroni multiple comparison
post hoc
test. The proportion of adverse events was compared using the chi-square test (χ
2
=57.2410).
Results:
On adding 50 μg clonidine, we were able to reduce intrathecal dose of bupivacaine for cesarean section to 8 mg. Patients receiving intrathecal clonidine along with bupivacaine had significantly long lasting analgesia with lower bupivacaine dose [246.21±5.15 min. (group II) vs 146.0±4.55 min (group I),
P
=0.021; 95% confidence interval: 238.01-257.40, group II and 134.99-157.0 group I].
Conclusions:
Addition of intrathecal clonidine causes some sedation in the postoperative period, but it provides adequate analgesia and motor paralysis at lower dose of bupivacaine. It also significantly prolongs postoperative pain relief.
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901
Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases
Chetan B Raval, Mohd. Rashiduddin
January-March 2011, 5(1):9-14
DOI
:10.4103/1658-354X.76476
PMID
:21655009
Background:
Airway management in maxillofacial injuries presents with a unique set of problems. Compromised airway is still a challenge to the anesthesiologist in spite of all modalities available. Maxillofacial injuries are the result of high-velocity trauma arising from road traffic accidents, sport injuries, falls and gunshot wounds. Any flaw in airway management may lead to grave morbidity and mortality in prehospital or hospital settings and as well as for reconstruction of fractures subsequently.
Methods:
One hundred and seventy-seven patients of maxillofacial injuries, operated over a period of one and half years during July 2008 to December 2009 in Al-Nahdha hospital were reviewed. All patients were reviewed in depth with age related type of injury, etiology and techniques of difficult airway management.
Results:
The major etiology of injuries were road traffic accidents (67%) followed by sport (15%) and fall (15%). Majority of patients were young in the age group of 11-30 years (71 %). Fracture mandible (53%) was the most common injury, followed by fracture maxilla (21%), fracture zygoma (19%) and pan-facial fractures (6%). Maxillofacial injuries compromise mask ventilation and difficult airway due to facial fractures, tissue edema and deranged anatomy. Shared airway with the surgeon needs special attention due to restrictions imposed during surgery. Several methods available for securing the airway, both decision-making and performance, are important in such circumstances. Airway secured by nasal intubation with direct visualization of vocal cords was the most common (57%), followed by oral intubation (17%). Other methods like tracheostomy and blind nasal intubation was avoided by fiberoptic bronchoscopic nasal intubation in 26% of patients.
Conclusion:
The results of this study indicated that surgically securing the airway by tracheostomy should be revised compared to other available methods. In the era of rigid fixation of fractures and the possibility of leaving the patient without wiring an open mouth and alternative techniques like fiberoptic bronchoscopic intubation, it is unnecessary to carry out tracheostomy for securing the airway as frequently as in the past.
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875
CASE REPORTS
An unusual cause of post-operative orbital edema in a child after general anesthesia
Joseph D Tobias, Narasimhan Jagannathan, Amod Sawardekar, Tarun Bhalla
January-March 2011, 5(1):105-107
DOI
:10.4103/1658-354X.76500
PMID
:21655032
We present an unusual ocular complication during the perioperative period, bilateral orbital edema in an otherwise healthy child after an outpatient surgical procedure. Ocular complications under general anesthesia remain a rare event. When periorbital edema is present, the appropriate work-up includes ruling out the potential for an allergic event by reviewing the medications administered and serum tryptase testing. Ophthalmology consultation should be considered to exclude pathology native to the eye itself. An allergist may assist in confirming a diagnosis and for allergic testing, if indicated. In our patient, the eventual diagnosis of exclusion was that of a localized reaction to the cellophane-based eye tape.
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263
ORIGINAL ARTICLES
Efficacy of ultrasound-guided obturator nerve block in transurethral surgery
Ahmed Thallaj, Dany Rabah
January-March 2011, 5(1):42-44
DOI
:10.4103/1658-354X.76507
PMID
:21655015
Background:
During transurethral resection surgery (TUR), accidental stimulation of the obturator nerve can cause violent adductor contraction, leading to serious intraoperative complications. General anesthesia with muscle relaxation is currently the preferred technique for TUR surgery. Spinal anesthesia combined with obturator nerve block has also been used for TUR surgery in geriatric population. Blind, anatomical methods for identifying the obturator nerve are often unsatisfactory. Therefore, we conducted this prospective study to validate the efficacy of ultrasound-guided obturator nerve block (USONB) during TUR procedures.
Methods:
Eighteen male patients undergoing TURP surgery under spinal anesthesia were included in the study. Bilateral USONB with maximum 20 ml of 1% lidocaine per patient was performed. An independent observer was present to monitor any adduction movements during the operation and to record patient and surgeon satisfactions.
Results:
In all patients, obturator nerve was visualized from the first attempt, requiring an average of 4.3 min for blocking of each side. USONB was successful (97.2%) in preventing an adductor spasm in all except one patient. Patient's and surgeon's satisfaction were appropriate. In all patients, adductor muscle strength recovered fully within 2 h following the surgical procedure.
Conclusions:
USONB is safe and effective during TUR surgery. It provides optimal intra-and postoperative conditions.
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394
Combined parecoxib and I.V. paracetamol provides additional analgesic effect with better postoperative satisfaction in patients undergoing anterior cruciate ligament reconstruction
Zeinab Ahmed Elseify, Salwa Omar El-Khattab, Ahmed Metwally Khattab, Eman Mohammed Atta, Layal Fares Ajjoub
January-March 2011, 5(1):45-49
DOI
:10.4103/1658-354X.76510
PMID
:21655016
Background
: Adequacy of postoperative analgesia is one of the most important factors that determine early hospital discharge and patients' ability to resume their normal activities postoperatively. The optimal non-opioid analgesic technique for postoperative pain management would reduce pain and enhance patient satisfaction, and it also facilitates earlier mobilization and rehabilitation by reducing pain-related complications after surgery. The aim of this study was to evaluate the analgesic efficacy of intravenous paracetamol and parecoxib when used alone, or in combination.
Methods
: Sixty American Society of Anesthesiology (ASA) physical status I and II adult patients who were scheduled for anterior cruciate ligament reconstruction were included in this study. Patients were allocated into three groups: group I patients received 1g intravenous paracetamol after induction and another 1 g 4 h later, group II received 40 mg parecoxib after induction, while group III received combination of both drugs (paracetamol 1 g and parecoxib 40 mg). Pain during rest and mobility was assessed in the immediate postoperative period, 2 h and 8 h successively using visual analog scale (VAS). Patient satisfaction was rated according to satisfaction score.
Results
: Total morphine requirements were lower in group III patients (6.9±2.7 mg) in comparison to group I patients (12.6±3.6 mg) or group II patients (9.8±2.8 mg). The least VAS scores were recorded during knee movement (3.8±1.1) in group III patients compared to group I (6.0±1.8) and group II patients (4.8±1.9). Eight hours postoperatively, group III patients were more satisfied regarding the postoperative pain management.
Conclusion
: Combination of intravenous paracetamol and parecoxib provided better analgesia and higher patient satisfaction than each drug when used separately.
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Anesthesia for patients undergoing transsternal thymectomy for juvenile myasthenia gravis
Lianne Stephenson, Igor Tkachenko, Robert Shamberger, Christian Seefelder
January-March 2011, 5(1):25-30
DOI
:10.4103/1658-354X.76490
PMID
:21655012
Background:
Juvenile myasthenia gravis (JMG) is the rare form of myasthenia gravis presenting in childhood and adolescence. When medical management fails, thymectomy is offered for these patients. Complete resection of the thymus is best achieved through transsternal thymectomy. Anesthetic management of patients with JMG is challenging, particularly in regards to the goals of postoperative pain control, respiratory function, and extubation.
Methods:
We retrospectively reviewed the medical records of 13 patients, ranging in age from 6 to 22 years, who underwent transsternal thymectomy for JMG. Information on patient demographics, characteristics of their disease and treatment, anesthetic management, and postoperative course were collected.
Results:
All patients had undergone multiple treatment modalities and presented for surgery because of inadequate symptom control with medical management. As expected for a pediatric population, anesthesia induction was age dependent. 40% of the patients underwent an inhalation induction and 60% underwent an intravenous induction. Anesthesia was maintained with a low-dose inhalation agent in all patients, supplemented in 84% of patients with a remifentanil infusion, and in 69% of patients with an epidural infusion. Muscle relaxants were avoided in all patients. With this regimen, 92% of patients could be extubated successfully in the operating room.
Conclusion:
We found that avoidance of muscle relaxants and use of remifentanil with a low-dose hypnotic agent provided a stable intraoperative course, facilitated rapid emergence, and allowed early extubation in patients with JMG undergoing transsternal thymectomy. Epidural analgesia reduced the need for intra- and postoperative intravenous opioids and did not have an adverse effect on respiratory strength.
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CASE REPORTS
Mismatched transfusion of 8 AB0-incompatible units of packed red blood cells in a patient with acute intermittent porphyria
Burkard Rudlof, Burkhard Just, Robert Deitenbeck, Thomas Ehmann
January-March 2011, 5(1):101-104
DOI
:10.4103/1658-354X.76497
PMID
:21655031
We report on a patient with acute intermittent porphyria, who received 8 AB0 incompatible units of packed red blood cells in an emergency situation. She never showed any signs of severe intravascular haemolysis. The patient died after four weeks because of a multi-organ failure caused from the malpractice of the porphyria. The problems of bedside testing, mixing field reaction, fresh frozen plasma and molecular-genetic determination of bloodgroup were discussed.
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3
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309
Reported survival with severe mixed acidosis and hyperlactemia after toluene poisoning
Amr S Omar, Masood ur Rahman, Said Abuhasna
January-March 2011, 5(1):73-75
DOI
:10.4103/1658-354X.76474
PMID
:21655021
Lactic acidosis is a recognized complication of the inhalant abuse such as toluene, especially in patients with renal insufficiency. We report a case of severe metabolic acidosis and hyperlactemia due to toluene sniffing. The favorable outcome, despite extremely poor clinical symptoms, signs, laboratory and radiological findings, was unexpected. Specific aspects of the clinical course are addressed. Toluene sniffing should be considered in evaluating sever metabolic acidosis. Favorable outcome could be achieved with early diagnosis and proper interventions.
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2
4,779
244
Continuous positive airway pressure ventilation during whole lung lavage for treatment of alveolar proteinosis -A case report and review of literature
Abdelazeem El-Dawlatly, Waseem Hajjar, Sami Alnassar, Reem Alsafar, Ahmed Abodonya
January-March 2011, 5(1):76-78
DOI
:10.4103/1658-354X.76475
PMID
:21655022
Pulmonary alveolar proteinosis (PAP) is a rare disease that affects young population usually in the age group of 20-40 years, characterized by the deposition of lipoproteinacious material in the alveoli secondary to abnormal processing of surfactant by macrophages. We report a case of a 15-year-old female who had history of cough with sputum for 3 days along with fever. She was seen in another hospital and was treated as a case of pneumonia where she received antibiotic but with no improvement. Computerized tomography (CT) chest showed diffuse interlobular septal thickening in the background of ground glass opacity giving a picture of crazy paving pattern which was consistent with the diagnosis of PAP. The patient was scheduled to undergo, first right-sided whole lung lavage (WLL) under general anesthesia. Endobronchial intubation using left sided 37 Fr double lumen tube. Continuous positive airway pressure (CPAP) as described in our previously published report was connected to the right lumen of the endobronchial tube. CPAP ventilation was used during the suctioning of lavage fluid phase in order to improve oxygenation. WLL was done using 5 L of warm heparinized saline (500 i.u/litre). The same procedure was repeated on the left side using 6 L of heparinized normal saline solution. In conclusion, anesthesia in alveolar proteinosis for patients undergoing WLL is challenging to the anesthesiologist. It requires meticulous preoperative preparation with antibiotics, mucolytics and chest physiotherapy. Also it requires careful intraoperative monitoring and proper oxygenation especially during the suctioning phase of the lavaged fluid. With this second case report of successful anesthetic management using the modified CPAP system we recommend with confidence the application of CPAP ventilation to improve oxygenation during WLL.
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6,011
307
Delayed recovery due to exaggerated acid, base and electrolyte imbalance in prolonged laparoscopic repair of diaphragmatic hernia
Rakesh Garg, Jyotsna Punj, Ravindra Pandey, Vanlal Darlong
January-March 2011, 5(1):79-81
DOI
:10.4103/1658-354X.76477
PMID
:21655023
The acid, base and electrolyte changes are usually observed in the perioperative settings. We report a case of prolonged laparoscopic repair of left-sided diaphragmatic hernia which involved a lot of tissue handling and fluid replacement leading to acid, base and electrolyte imbalance. A 42-year-old male underwent prolonged laparoscopic repair under general anesthesia. Intraoperatively, surgeon reported that contents of hernia includes bowel along with mesentery, spleen and lot of fatty tissue The blood loss was about 2 L which was replaced with 1 L of colloid and 7.5 L of lactated ringer. Near the end of surgery arterial blood gas analysis revealed metabolic acidosis, hyperkalemia, and hypocalcemia leading to delayed recovery. We conclude prolonged laparoscopic surgery involving lot of tissue handling including gut and fat should be monitored for acid, base, electrolyte imbalance and corrected timely to have uneventful rapid recovery.
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4,432
299
Anesthetic management of a patient with sickle β
+
thalassemia
Saswata Bharati, Subhabrata Das, Prasenjit Majee, Subrata Mandal
January-March 2011, 5(1):98-100
DOI
:10.4103/1658-354X.76496
PMID
:21655030
Sickle cell disease is a congenital condition and its most common clinical manifestation is anemia due to chronic hemolysis. Persistent and accelerated hemolysis associated with multiple transfusions is a recognized risk factor for the development of cholelithiasis. The occurrence of gallstones is one of the most important manifestations of sickle cell disease in the digestive tract. Most gallstones are pigmented and characteristically occur at younger ages and the prevalence of cholelithiasis increases progressively with age, affecting 50% of young adults. Cholecystectomy is the most common surgical procedure performed in sickle cell disease patients. Anesthesia in this population of patients for major surgeries deserves special attention due to various complications particularly silent infarctions of end organs are common. We are reporting a 14-year-old girl diagnosed with sickle cell anemia and β
+
thalassemia with cholelithiasis went for cholecystectomy under general anesthesia. Although the patient has both β
+
thalassemia and sickle cell disease component, the latter is of more concern for anesthesia.
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7,146
473
LETTERS TO EDITOR
Use of heat and moisture exchanger in intubated patients reduces the blockage in gas sampling tube of the mass spectrometer
Nataraj Madagondapalli Srinivasan
January-March 2011, 5(1):112-113
DOI
:10.4103/1658-354X.76469
PMID
:21655036
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2,647
204
Oxygen desaturation following methylene blue injection: Not always spurious
Uma Hariharan, Rajesh Sood, Arindam Choudhury, Rakesh Garg, Jaswinder Kaur
January-March 2011, 5(1):113-114
DOI
:10.4103/1658-354X.76471
PMID
:21655037
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3,164
239
CASE REPORTS
Cardiac arrest after anesthetic management in a patient with hereditary sensory autonomic neuropathy type IV
Yakup Ergül, Baris Ekici, Sabiha Keskin
January-March 2011, 5(1):93-95
DOI
:10.4103/1658-354X.76486
PMID
:21655028
Hereditary sensory autonomic neuropathy type IV is a rare disorder with an autosomal recessive transmission and characterized by self-mutilation due to a lack in pain and heat sensation. Recurrent hyperpyrexia and anhydrosis are seen in patients as a result of a lack of sweat gland innervation. Self-mutilation and insensitivity to pain result in orthopedic complications and patients undergone recurrent surgical interventions with anesthesia. However, these patients are prone to perioperative complications such as hyperthermia, hypothermia, and cardiac complications like bradycardia and hypotension. We report a 5-year-old boy with hereditary sensory autonomic neuropathy type IV, developing hyperpyrexia and cardiac arrest after anesthesia.
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189
Anesthetic and airway management of a child with a large upper-lip hemangioma
Sukhminderjit Singh Bajwa, Aparajita Panda, Sukhwinder Kaur Bajwa, Amarjit Singh, SS Parmar, Kanwalpreet Singh
January-March 2011, 5(1):82-84
DOI
:10.4103/1658-354X.76479
PMID
:21655024
An 11-month-old male child weighing 8 kg was brought to the plastic surgery out-patient department by his parents with chief complaints of sudden increase in size of a swelling over the upper lip and difficulty in feeding for the last 7 days. It was diagnosed as a case of hemangioma of the upper lip. All the routine and special investigations including coagulation profile of the child were normal. The child was planned for ablation of feeding vessels along with intralesional steroid injection. Airway management of the child posed the challenge for us as the size and site of the lesion carried the risk of difficult intubation and possible risk of extensive hemorrhage. All the requisite equipment for difficult airway management was made ready. We were able to intubate the child with miller number-2 blade from the left angle of mouth without putting much pressure on the swelling. The surgical and postoperative period was uneventful and the child was discharged the next day to be followed up after 2 weeks.
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314
Anesthetic management of a child with Apert syndrome
Yavor Metodiev, Nadezhda Gavrilova, Atanas Katzarov
January-March 2011, 5(1):87-89
DOI
:10.4103/1658-354X.76483
PMID
:21655026
In this paper, the authors describe an anesthetic technique for a child with Apert syndrome, presenting to the operating room for a syndactyly separation. The anesthetic approach is innovative for the clinic and is a combination of intravenous anesthesia and two regional techniques (axillary block and transversus abdominis plane block, respectively). They were performed under ultrasound guidance and provided analgesia in the two body regions, which were to be operated.
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ORIGINAL ARTICLES
Evaluating ranitidine, pantoprazole and placebo on gastric pH in elective surgery
Tapas Bhattacharyya, Debabrata Sarbapalli, Ranabir Pal, Ujjal Sarkar, Sumit Kar, Kanak Kanti Kundu, Forhad Akhtar Zaman
January-March 2011, 5(1):67-72
DOI
:10.4103/1658-354X.76508
PMID
:21655020
Background and Aim:
Concern about the grim nature of postoperative acid aspiration syndrome grew among the anesthesiologist over the years warranting the need for pre-emptive intervention. The aim of the study is to compare the effects of preoperative oral ranitidine versus pantoprazole given in regulating gastric pH in elective surgery.
Methods:
This prospective, parallel group, controlled, randomized, single-blind study was conducted at a tertiary care postgraduate teaching institute at Kolkata, involving 120 participants of either sex, aged 18-60 years of American Society of Anesthesiologists physical status I and II, who were scheduled for elective surgery under general anesthesia lasting for more than 2 h. The participants were divided into three groups. In group A (n=40) participants received placebo tablet, in group B (n=40) participants received ranitidine tablet while in group C (n=40), participants received pantoprazole tablet and their gastric pH estimated serially.
Results:
The participants in the three groups were comparable in terms of age, sex, body weight, duration of surgery and type of surgery distribution. In regard to changes in gastric pH trends, there was no statistically significant difference between serial pH values in group A (Friedman test;
P
>0.05) and group C participants. (
P
>0.05). However, the mean preoperative gastric pH values (7.140±.7652) were significantly lower than mean pH values (7.253±.7514) after 2 h postoperatively in group B participants (
P
<0.05).
Conclusion:
From the observations and analyses of the present study, it can be inferred that ranitidine is more effective than pantoprazole to raise the gastric pH for prevention of aspiration pneumonitis.
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CASE REPORTS
Intubation with Airtraq
TM
laryngoscope in a morbidly obese patient
Pratik Tantia, Sunny Malik, Shahin Jamil, Rajiv Samal
January-March 2011, 5(1):85-86
DOI
:10.4103/1658-354X.76482
PMID
:21655025
In the present study, we report a case of successful endotracheal intubation using Airtraq
TM
Laryngoscope (AQL) in a morbidly obese patient. A 35-year-old woman, morbidly obese (weight, 105 kg; height, 160 cm; BMI, 41 kg/m
2
), known hypertensive and diabetic, was admitted in the operating room for total abdominal hysterectomy under general anesthesia. The preoperative airway assessment anticipated both difficult bag-mask ventilation and intubation. Tracheal intubation using AQL was attempted after induction with propofol and relaxation with succinylcholine. Successful tracheal intubation was accomplished within 12 seconds of insertion of AQL into the oral cavity. The minimal hemodynamic response during this maneuver was advantageous in our patient.
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EDITORIAL
Anesthesia for thymectomy
Abdelazeem El-Dawlatly
January-March 2011, 5(1):1-1
DOI
:10.4103/1658-354X.76465
PMID
:21655007
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3,702
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LETTERS TO EDITOR
Pseudo loss of resistance in epidural space localization: A complication of subcutaneous emphysema or simply a faulty technique
Amit Jain
January-March 2011, 5(1):108-109
DOI
:10.4103/1658-354X.76464
PMID
:21655033
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3,182
223
Novel technique in difficult percutaneous tracheostomy
Babita Gupta, Manpreet Kaur, Nita D'souza, Chandni Sinha
January-March 2011, 5(1):109-110
DOI
:10.4103/1658-354X.76466
PMID
:21655034
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3,444
256
Life-threatening arrhythmias due to faulty microdebrider during nasal sinus surgery
Rakesh Garg, Anjan Trikha, Preet M Singh, PK Nishad
January-March 2011, 5(1):110-112
DOI
:10.4103/1658-354X.76468
PMID
:21655035
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2,896
206
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