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2007| March-April | Volume 51 | Issue 2
March 20, 2010
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Emergency anaesthetic management of cardio-thoracic & abdominal injury
Vishal Panchamia, Neelam Thaker, Chetana Jadeja, BJ Shah
March-April 2007, 51(2):131-131
A 40 years old male presented with multiple stab injuries over left side of chest& abdomen with unstable hemodynamic status was taken for emergency exploratory laprotomy. Anesthetic management of this patient is discussed here.
Anaesthesia management of a patient with hypertrophic obstructive cardiomyopathy undergoing Morrow's septal myectomy
Naresh Kumar Agarwal, Poonam Malhotra Kapoor, Shiv Chaudhary, Usha Kiran
March-April 2007, 51(2):134-134
Hypertrophic obstructive cardiomyopathy (HOCM) is a rare disorder. There is paucity of literature on anaesthetic management of this disorder. Aim of this case report is to highlight the anaesthetic problems encountered during management of such patients. A thirty-five year old male was admitted with atypical chest pain for last one year. X-ray chest revealed cardiomegaly (CT ratio 0.6). Electrocardiographic findings were left axis deviation with left ventricular hypertrophy. On echocardiography, there was moderate mitral regurgitation (MR), systolic anterior motion (SAM) of anterior mitral leaflet and prominent systolic narrowing of left ventricle cavity. Transoesophageal echocardiography (TOE) also showed an anomalous muscle bundle stretching into LV causing obstruction. Preload was kept high. Systemic vascular resistance (SVR) was maintained, avoiding use of vasodilators and inotropes. Morrow's septal myectomy was done. Anomalous muscle bundle was excised. On postoperative TOE, there was no MR and no obstruction. Optimal anaesthetic management in such patients involves maintaining adequate preload, systemic vascular resistance and minimal outflow obstruction. Other considerations are to maintain haemodynamic stability, sinus rhythm and afterload. Transoesophageal echocardiography is an extremely useful monitoring device in such patients.
Sequential combined spinal epidural anaesthesia for caesarean section in peripartum cardiomyopathy
Kumari Indira, Kumar Sanjeev, Gupta Sunanda
March-April 2007, 51(2):137-137
Peripartum cardiomyopathy (PPCM) is defined as the onset of acute heart failure without demonstrable cause in the last trimester of pregnancy or within the first 6 months after delivery.We report a case of PPCM (LVEF<25%) requiring caesarean section who was successfully managed with sequential combined spinal epidural anaesthesia.
Caesarean section in a patient with varicella: Anaesthesia considerations and clinical relevance
Nandini M Dave, Sachin P Sasane, HR Iyer
March-April 2007, 51(2):140-140
A primigravida with chicken pox was posted for an emergency caesarean section. General anaesthesia was administered. Key issues in anaesthesia management and the clinical implications are discussed.
Laparoscopic Bilateral Adrenalectomy in a patient of Cushing syndrome: A Challenge for the Anaesthesiologist
Uma K Dahanukar, Kedar S Joshi, Vishakha Desai, Usha D Padhye, Arun D Joshi, AM Deshpande
March-April 2007, 51(2):143-143
We present a case of Cushing syndrome who underwent laparoscopic bilateral adrenalectomy and discuss her intraoperative management and postoperative course in ICU, especially pulmonary oedema, that occurred within 3 hours after resection (half life of cortisol is 80-110 minutes).
She was diagnosed to have bilateral adrenal hyperplasia with no pituitary involvement on CT scan. Preoperative workup revealed hypokalemia, anaemia, hypertension and hyperglycemia. She was posted for laparoscopic bilateral adrenalectomy. She received general anaesthesia; we did not give epidural analgesia as the patient had fracture of body of L1 vertebrae. Her intra-operative course was uneventful. Post-operative concerns included acute adrenal insufficiency, hypoglycaemia, hypotension and hyperkalemia, which were successfully managed in ICU. Patient was then given oral corticosteroids. One month later she was reassessed and was in better health.
Anaesthetic management of a patient with haemophilia
Prashanth Mallya, Padmanabha Kaimar, R Jithesh, RK Ranjan, M Ambareesha
March-April 2007, 51(2):145-145
A is a bleeding disorder that has a spectrum of manifestations ranging from persistent bleeding after minor trauma to spontaneous haemorrhage.
We report a case of a male patient with haemophilia A, who received general anesthesia for exploration of right hernial sac. Shortly before surgery he received 2500 units of factor VIII. There was no excessive blood loss intraoperatively. Postoperatively the patient was supplemented with factor VIII. Rest of the postoperative course was uneventful. The literature on the management of patient with haemophilia A is reviewed and considerations are presented concerning preoperative preparation and anaesthetic management of haemophiliac patient for minor and major surgery.
Cricothyrotomy can be hazardous in a difficult airway scenario
March-April 2007, 51(2):148-148
Difficult and compromised airway poses a significant challenge to the anaesthesiologist. The following is a report of management of a case of difficult airway caused by injury of a prior deliberate acid ingestion. A previous uneventful anaesthetic course gave us a false sense of security while proceeding with the next surgical procedure under anaesthesia. After administration of neuromuscular blocking agent, mask ventilation became increasingly difficult and under direct laryngoscopy, visualization of glottis revealed gross fibrosis with no opening visible at all. It was a 'cannot intubate, cannot ventilate (CICV)' scenario. Percutaneous transtracheal jet ventilation (PTJV) also could not be set up as canula could not be negotiated. Surgical ('stab') cricothyroidotomy allowed rapid restoration of ventilation and oxygenation in this CICV situation but not without its complications and compromised airway was imminent. Surgical airway in the form of definite tracheostomy offered the only solution and complications averted.
Unusual migration of pulmonary artery catheter
Sanjay Kuravinakop, Rachel Rouse
March-April 2007, 51(2):151-151
Pulmonary artery catheter is widely used in intensive care. Distal migration of the catheter is a know complication. Diagnosis of such a migration is made by both clinical criteria and radiographs. A 55 year old septic lady was admitted to the intensive care unit. Pulmonary artery catheter introduced for cardiac output monitoring migrated from right lung to left lung. Diagnosis was made following a chest radiograph the following day of insertion with the clinical criteria remaining unaltered. Migration of pulmonary artery catheter can occur not only distally but from one lung to another. Clinical criteria alone cannot rule out migration. Chest radiographs form an important part in monitoring the position of the pulmonary artery catheter.
Influence of multi-level anaesthesia care and patient profile on perioperative patient satisfaction in short-stay surgical inpatients: A preliminary study
Amarjeet Singh, Amitabh Dutta, Jayshree Sood
March-April 2007, 51(2):106-106
Background and goals of study:
Patient satisfaction in relation to perioperative anesthesia care represents essential aspect of quality health-care management. We analyzed the influence of multi-level anesthesia care exposure and patient profile on perioperative patient satisfaction in short-stay surgical inpatients.
120 short-stay surgical inpatients who underwent laparoscopic surgery have been included in this prospective study. Pertaining to demographic parameters (age, gender, education, profession), duration of stay (preoperative room, recovery room), various patient problems and patient satisfaction (various levels, overall) were recorded by an independent observer and analyzed. Overall, adults, male and uneducated patients experienced more problems. Conversely, elderly, females and educated patients were more dissatisfied. Female patients suffered more during immediate postoperative recovery room stay and were more dissatisfied than their male counterparts (p<0.05). However, patient's professional status had no bearing on the problems encountered and dissatisfaction levels. Preoperative and early postoperative period accounted for majority of the problems encountered among the study population. There was a positive correlation between problems faced and dissatisfaction experienced at respective levels of anesthesia care (p<0.05).
Patient's demographic profile and problems faced during respective level of anesthesia care has a correlation with dissatisfaction. Interestingly, none of the above stated factors had any effect on overall satisfaction level.
Evaluation of intranasal midazolam for preanasthetic sedation in paediatric patients
Pradipta Bhakta, BR Ghosh, Manjushree Roy, Gouri Mukherjee
March-April 2007, 51(2):111-111
Most of the preschool children suffer from severe anxiety and apprehension before operation. This can largely affect the smooth conductance and emergence from anaesthesia. Above all this can lead to development of maladaptive behavioral responses in later part of life. Midazolam in current time has emerged as an ideal premedicant having all the desirable properties in this regard. It has been used by several routes for premedication. Each has its own advantage and disadvantage. The search for an ideal route and dose still exists. So the current study was planned to find out the efficacy of midazolam intranasally. Forty five paediatric patients of 2-5 years of age belonging to ASA I& II, scheduled for minor elective surgery were selected for this study. Patients were divided in three equal groups to receive normal saline (Group I), 0.2 mgkg
midazolam (Group II), or 0.3mgkg
midazolam (Group III) intranasally. Vital parameters and level of sedation (using a sedation scale) were assessed before administering the drug and at 5 min interval up to induction of anaesthesia. Standard anaesthesia technique was used intraoperatively. Recovery parameters were assessed in the recovery area using a recovery scale. A statistically significant change in the level of sedation was found at 5 min in group II and at 10 min in group III compared to control group. Parental separation was significantly easier in midazolam groups. Mask acceptance rate was also found to be significantly higher in midazolam groups. There was no statistical difference in recovery parameters in any group. No major adverse effect was seen in any midazolam group. No major advantage was found with higher dose of midazolam. Therefore we conclude that 0.2 mgkg
intranasal midazolam is an effective method of producing anxiolysis and sedation in paediatric patients.
A comparative study of volume and pH of gastric fluid after ingestion of water and sugar-containing clear fluid in children
Gojendra Rajkumar, MK Mehta
March-April 2007, 51(2):117-117
A prospective randomised study on 90 children aged 1-10 year was undertaken to evaluate and compare the gastric fluid volume and pH following ingestion of water and sugar-containing clear fluid given at 2, 4 and 8 hours before elective surgery. Although not diminishing the risk of aspiration, 2mlkg
body wt. of clear fluids given 2 hours before surgery appear to add no additional risk for aspiration of gastric contents and it may also alleviate the unpleasant pre-operative experience due to prolonged fast.
Haemodynamic and central venous pressure changes in transurethral resection of prostate during general, spinal and epidural anaesthesia: A comparative study
Parul Jindal, Gurjeet Khurana, UC Sharma, JP Sharma, Gaurav Chopra, S Lal
March-April 2007, 51(2):121-121
During transurethral resection of prostate (TURP) both intravascular and extra vascular absorption of irrigating fluid may lead to adverse cardiovascular effects and myocardial damage. This prospective study is aimed to compare central venous pressure and haemodynamic changes with different techniques of anaesthesia and to find the best possible technique. We randomly allocated 90 elderly patients (ASA I, II III) into three equal groups receiving either general anaesthesia (Group A), spinal anaesthesia (Group B) or epidural anaesthesia (Group C) for transurethral resection of prostate (TURP). It was observed that the MAP increased by 11% from preinduction values to the completion of surgery in group A while a decrease of 11.2% was observed in group B but only minimal changes in group C. There was decrease in heart rate of 14% and 17% in group A& C respectively but maximum decrease was in group B of 21%. CVP was raised from basal value up to 77%, 44% and 42% and in group A, B and C respectively. Thus, patients who received epidural anaesthesia had minimal changes in haemodynamics.
Lumbar plexus block for post-operative analgesia following hip surgery: A comparison of "3 in 1" and psoas compartment block
Uma Srivastava, Aditya Kumar, Surekha Saxena, Anjum Naz, Vineeta Goyal, Roli Mehrotra
March-April 2007, 51(2):127-127
We used a single shot lumbar plexus block by posterior approach (Psoas compartment block- PCB) or anterior approach ('3in1' block) for postoperative analgesia in the patients of hip fractures operated under spinal anaesthesia. The blocks were given at the end of operation with 0.25% of bupivacaine and pain was assessed using Verbal Rating scale at 1,6,12 and 24 hours postoperatively both during rest and physiotherapy. We also noted time for first analgesic, need of supplemental analgesics and quality of analgesia during 24 hours. The mean time for first demand of analgesia was 12.4 ±7.9 and 10.7±6.4 hrs in groups PCB and '3 in 1' respectively (p>0.05). Requirement of supplemental analgesics was considerably reduced and more than 80% patients in both groups needed only single injection of diclofenac in 24 hrs. It was concluded that both approaches of lumbar plexus block were effective in providing post operative analgesia after hip surgery.
EVIDENCE BASED DATA
Regional anaesthesia versus general anaesthesia: Is there an impact on outcome after major surgery?
March-April 2007, 51(2):153-153
BEARs are the summary of the evidences pertaining to a specific clinical dilemma encountered in the day today anaesthetic practice. They are not the systematic reviews but rather contain the best evidence (highest level) available to any practicing anaesthesiologist. The search strategies adopted will not be discussed in detail.
HIV and anaesthesia
S Parthasarathy, M Ravishankar
March-April 2007, 51(2):91-91
The pandemic of AIDS (Acquired Immuno Deficiency Syndrome) is virtually creating a panic among health workers which include and medical and paramedical staff. Out of the global 40 million Human immunodeficiency virus (HIV) infections, an estimated 5.2 millions are in India. With the advancement of the management techniques, the life span of infected patients is on the increase so that more patients will come for surgical procedures in the future. There is little information on the risk of anaesthesia in HIV infected patients. A detailed preoperative examination and investigations to unmask multisystem disorders caused either by HIV or drugs is essential. General anaesthesia is acceptable but drug interactions and multisystem disease caused by HIV should be considered preoperatively. Regional anaesthesia is safe but one must take into consideration the presence of local infections, bleeding problems and neuropathies. Routine preoperative testing for HIV is acceptable but strict adherence to universal precautions is mandatory.
Trauma in pregnancy
A Rudra, A Ray, S Chatterjee, C Bhattacharya, J Kirtania, P Kumar, T Das, V Ray
March-April 2007, 51(2):100-100
Trauma is the most common non-obstetrical cause of death in pregnant women. Pregnancy must always be suspected in any female trauma patient of childbearing age until proved otherwise. Unique changes in anatomy and physiology that takes place during pregnancy alter the pathophysiology and location of maternal injuries in pregnancy, which may be significantly different from the non-pregnant state. Trauma from road traffic accidents, falls and domestic violence are the most common causes of abdominal blunt trauma. As pregnancy progresses, the change of accidental injury increases. Head and neck injuries, respiratory failure, and hypovolemic shock constitute the most frequent causes of trauma related maternal death in pregnancy. Even the pregnant woman with minor injuries should be carefully observed. Initial management is directed at resuscitation and stabilization of the mother that takes precedence over that of the fetus, unless vital signs cannot be maintained and perimortem cesarean section decided upon. Fetal monitoring should be maintained after satisfactory resuscitation and stabilization of the mother. Preventive measures include proper seat belt use and identifying and counseling victims of suspected domestic violence.
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