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   2007| November-December  | Volume 51 | Issue 6  
    Online since March 20, 2010

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Scoliosis and anaesthetic considerations
Anand H Kulkarni, M Ambareesha
November-December 2007, 51(6):486-495
Scoliosis may be of varied etiology and tends to cause a restrictive ventilatory defect, along with ventilation-perfusion mismatch and hypoxemia. There is also cardiovascular involvement in the form of raised right heart pressures, mitral valve prolapse or congenital heart disease. Thus a careful pre-anaesthetic evaluation and optimization should be done. Intraoperatively temperature and fluid balance, positioning, spinal cord integrity testing and blood conservation techniques are to be kept in mind. Postoperatively, intensive respiratory therapy and pain management are prime concerns.
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The discovery of modern anaesthesia-contributions of Davy, Clarke, Long, Wells and Morton
Sukumar P Desai, Manisha S Desai, Chandrakant S Pandav
November-December 2007, 51(6):472-478
While many may argue as to who deserves the most credit for the discovery of modern anaesthesia, events in the late 18 th and early 19 th centuries led to the introduction and development of modern anaesthetic techniques. English physicist and chemist Humphry Davy [1778-1829] first became aware of the sedative and analgesic properties of nitrous oxide in 1795. Although he never experimented with the drug during a surgical procedure, he was the first to suggest that it would be beneficial in relieving pain during surgical procedures. The mind-altering properties of nitrous oxide and ether were often abused for recreational purposes, and the term 'ether frolics' was coined to describe such use. While physician William Crawford Williamson Long [1815-1878] first used ether during general surgery, medical student William Edward Clarke [1819-1898] was the first to use ether for dental extraction in 1842. Dr. Long neglected to publicize his findings until 1849, thereby denying himself much of the credit he deserved. Dentist Horace Wells [1815-1848] successfully used nitrous oxide for dental procedures, but a public demonstration which he held in January 1845 turned out to be a fiasco. Medical student William Thomas Green Morton [1819-1868] was the first to publicly demonstrate the effectiveness of ether for general surgery on October 16, 1846. This article seeks to give rightful credit to each of these individuals for their unique contributions to the discovery of modern anaesthesia.
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Anaesthesia for liver transplantation: an update
TVSP Murthy
November-December 2007, 51(6):464-471
A significant progress has been made in the last two decades in the field of orthotopic liver transplantation since it was first performed in 1967. It now stands as a standard therapy for many patients with acute and chronic liver disease. The success in this field is due to the advancements and innovations which evolved - in the form of better pre and post transplant care, improved anaesthesia, innovative surgical strategies, early detection of complications and progress in the field of immunosuppression. Liver transplantation is now a routine procedure in numerous medical centers throughout the world. The issues involved in the conduct of anaesthesia in this novel procedure are highlighted.
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Post operative analgesia after caesarean section: an experience with intrathecal buprenorphine
Sunil Dixit
November-December 2007, 51(6):515-518
Buprenorphine is a mixed agonist-antagonist narcotic with high affinity at both µ and k opiate receptors. The aim of the study was to compare intrathecal bupivacaine (0.5%) and buprenorphine (60µg) with bupivacaine (0.5%) for postoperative analgesia in caesarean section. Sixty parturients undergoing elective lower segment caesarean section (LSCS) were randomly selected after dividing into two groups of 30 each. Control group (C) received 1.70ml (8.5mg) of bupivacaine (0.5%) while patients of Study group (S) received 1.70ml (8.5mg) bupivacaine 0.5% + 60µg buprenorphine. Onset of analgesia was 5.35± 1.79 min in Control group, while 1.85 ± 1.39 min in Study group (P<0.001). The total duration of analgesia was prolonged from145.16 ± 25.86 min in Control group to 491.26 ± 153.97min in Study group. We conclude that intrathecal buprenorphine is a suitable drug for postoperative analgesia after caesarean section with no effects on neonatal Apgar scores with minimal side effects.
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Malignant hyperthermia -a case report
Kirti N Saxena, CK Dua
November-December 2007, 51(6):534-535
A twenty-eight year old female was scheduled to undergo excisional reconstruction and plating of the mandible following a diagnosis of ameloblastoma on incisional biopsy under local anaesthesia. On preanaesthetic evaluation, there was no significant finding except restricted mouth opening and a swelling over the mandible. On attempting laryngoscopy the patient was found to have masseteric spasm following administration of succinylcholine. After one hour it was noted that the EtCO2 was being maintained at 47 -48 mmHg inspite of slight hyperventilation. Within half an hour EtCO2 rose gradually to 60 mm Hg and then suddenly to 80 mm Hg .The patient's pulse rate rose gradually to 130 beats per minutes and then suddenly to 160 beats per minutes .At this time the patient was found to have nasopharyngeal temperature of 106.50 F. Aprovisional diagnosis of malignant hyperthermia was made and the patient was treated accordingly. Further the patient was investigated to rule out other conditions and clinch the diagnosis of MH. This is probably the first case report of this disease from India.
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A case of severe ankylosing spondylitis posted for hip replacement surgery
Nalini Kotekar, NV Nagalakshmi, Gururaj , Mujeeb Rehman
November-December 2007, 51(6):546-549
A 50-year-old male patient with history of ankylosing spondylitis (AS) for 30 years presented for hip replacement surgery. Airway management in ankylosing spondylitis patients presents the most serious array of intubation and airway hazards imagin­able, which is secondary to decrease in cervical spine mobility and possible temporo-mandibular joint disease. Literatures support definitive airway management and many authors consider regional anaesthesia to be contraindicated. The reasons cited include inability to gain neuraxial access and the need for urgent airway control in case of complication of regional anaesthesia.
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Antiemetic effects of granisetron versus dexamethasone in clonidine premedicated children undergoing strabismus surgery
Indu Sen, GS Brar, P Chari
November-December 2007, 51(6):510-514
In a prospective, double blind, randomized trial, 120 children, aged 3-8 years,ASAI-II, undergoing strabismus repair were randomly divided into three groups (n = 40 each). Oral clonidine premedication (4gg.kg-1) was administered to all the patients two hours prior to surgery. Soon after induction of anaesthesia, Group G patients were administered intravenous granisetron (40gg.kg­1 ), Group D intravenous dexamethasone (150gg.kg-1) and group S received 4ml normal saline. Postoperatively, children were continuously monitored and assessed half-hourly till discharge and then after 24 hours for vomiting and pain. The overall incidence of postoperative emesis was lower (15.4%) in the Group G compared with the Group D (21.6%) in the first 24 hours (P>0.05). The Group S had a highest incidence of postoperative vomiting ((37%) P value < 0.0324 compared to group G). The frequency of early vomiting was highest in the S group. Both G and D groups showed better control of delayed emetic episodes. We observed that in children who were premedicated with clonidine, both IV granisetron or dexamethasone were efficacious in reducing the incidence and severity of POV in day-care strabismus surgery.
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Pramila Bajaj
November-December 2007, 51(6):550-551
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End points in trauma management
N Ganapathy
November-December 2007, 51(6):479-485
Fluid resuscitation following traumatic haemorrhage has historically been instituted as soon after injury as possible. Patients suffering from haemorrhagic shock may receive several liters of crystalloid, in addition to colloid solutions, in order to normalize blood pressure, heart rate, urine output and mental status, which are the traditional endpoints of resuscitation. Current theory and recent investigations have questioned this dogma. Resuscitation goals may be different when the patient is actively haemorrhaging and once bleeding has been controlled. Newer markers of tissue and organ system perfusion may allow a more precise determination of adequate resuscitation
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Bacterial colonization and infection of epidural catheters: a prospective study of incidence and risk factors in surgical patients
Uma Srivastava, Parul Chandra, Surekha Saxena, Aditya Kumar, Ashish Kannaujia, Shiv Pratap Singh Rana, Hompriya Issar
November-December 2007, 51(6):496-500
Infection of the epidural space is a rare but serious complication of catheter placement. The purpose of the present study was to determine the incidence of bacterial colonization of epidural catheters, the co-relation between colonization and infection and to identify the risk factors associated with colonization.Aprospective observational trial was carried out on 272 adult patients receiving epidural catheterization for anaesthesia and post-operative analgesia. Patients undergoing a variety of surgical proce­dures (abdominal, thoracic, urological, orthopaedic, gynaecological and obstetric) both elective and emergency were recruited. The tips of epidural catheters after removal were sent aseptically for culture. Of 261 tips sent for culture 11 (4.2%) showed positive culture, the most prevalent microorganism being Staphylococcus epidermidis. None of the patients had signs and symptoms of local or epidural space infection. Twelve potential risk factors were entered in the step-wise logistic regression analysis to identify factors associated with catheter colonization. Out of these only the duration of catheterization (P<0.01, odd ratio 3.39, 95% confidence interval 0.12-1.5) was found to be significant. Summarizing the results, the incidence of bacterial colonization was 4.2% with no case of epidural space infection. The chances of colonization increased with duration of placement beyond 96 hours and this was found to be a potential risk factor for colonization but not infection. The positive cultures did not equate with infection.
  2,427 357 -
Hereditary sensory autonomic neuropathy and anaesthesia - a case report
Nandini Dave, Anil Sonawane, Sachin Chandolkar
November-December 2007, 51(6):528-530
The hereditary sensory and autonomic neuropathies are a rare group of disorders characterized by progressive loss of function that predominantly affects the peripheral sensory nerves. Autonomic dysfunction is present to a variable degree and can have several implications for anaesthesia. We report the case of a patient with Hereditary sensory and autonomic neuropathy who was posted for a below knee amputation and discuss the anaesthesia management.
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Depth of anaesthesia: clinical applications
Pramila Bajaj
November-December 2007, 51(6):461-463
  1,575 662 -
Lumbar epidural anaesthesia for fixation of intertrochanteric fracture in a 108 year old elderly patient
Simant Kumar Jha, Rahul DebDas, Mukesh Kumar, Shanti Prakash
November-December 2007, 51(6):538-540
Perioperative morbidity and mortality in elderly patients continues to be an important problem.As the patient was 108 year old, it was a rare case to be reported. Seeing his age & compromised cardiac function we planned for epidural anaesthesia. Epidural anaesthesia has a distinct advantage over general anaesthesia in terms of improved pulmonary & myocardial function, less chances of thromboembolism due to early mobilization, less blood loss due to lowered MAP & lastly postoperative analgesia provided through catheter, reduces perioperative morbidity and mortality. So elderly patients can have good quality of life even this age & choice of anaesthesia plays a very important role.
  1,897 316 -
Open heart surgery for cyanotic heart disease in a child with immune thrombocytopenic purpura:a case report
Minati Choudhury, Nirvik Pal, Usha Kiran
November-December 2007, 51(6):541-545
Acute immune thrombocytopenic purpura in children, though a benign self limiting condition, at times complicated with life threatening haemorrhage. In spite of bleeding episode it is inevitable that surgical procedure will be performed on patients with this disease. The anaesthetic implications therefore need to be addressed. Although few reports describing the perioperative management of patients with chronic idiopathic thrombocytopenic purpura are available, literature regarding open heart surgery for cyanotic heart disease is lacking. We describe the management course and raise some anaesthetic considerations for a two year old child with acute immune thrombocytopenic purpura and tetralogy of Fallot's who underwent emergency surgical correction of the cardiac problem under extracorporeal circulation.
  1,915 247 -
A retrospective study of anaesthetic management of foreign bodies in airway- a two & half years experience
Jyoti V Kulkarni, HP Bhagat
November-December 2007, 51(6):501-504
A retrospective analysis of medical records of 76 children of suspected foreign bodies (FB) in airway posted for rigid bronchoscopy under general anaesthesia was done. Patients were 9 months to 11 years old. Seventy eight percent patients were between the age of 9 months to 4 years & 22% patients were above the age of four years. Seventy one percent patients were male and 29% patients were female. In 16% (n=12) patients no FB was found while in 82.7% (n=63) patients vegetative FB like peanut, custard apple, gram and turdal, tamarind seed, garlic, chilli, coconut piece and non-vegetative foreign body i.e. ear-ring was found in 1 case. In 17 % patients foreign body was located in subglottic region, in 59 % patients FB was in right main bronchus and in 24% patients it was in left main bronchus. In 33 % patients bronchoscopy was done within 72 hours of appearance of symptoms while in 51% patients bronchoscopy was done after 72 hours to one week of appearance of symptoms. In 16% patients bronchoscopy was done after one week. Twenty percent patients required tracheostomy and 3% patients required bronchodilators, nebuliza­tion and ventilatory support in immediate post operative period. All patients were managed under general anaesthesia using ketamine, suxamethonium, oxygen and halothane. All patients were ventilated through side arm of ventilating bronchoscope.All patients were discharged from hospital & no death was reported.
  1,598 336 -
Correlation of serum oestrogen level with duration of post operative analgesia
Pramod Kumar, K Jaspreet, Jigisha Pujara, JS Anand
November-December 2007, 51(6):519-524
Sixty female patients ofASAstatus I and II posted for routine surgical procedures like abdominal hysterectomy, exploratory laparotomy, pyelolithotomy, laparoscopic cholecystectomy etc. were studied for correlation of serum oestrogen level and post operative analgesia. The patients were divided into 3 groups, each consisting of 20 patients. Group-I consisted of female patients in Ist phase of menstrual cycle, Group-II of female patients in II nd phase of menstrual cycle& Group-III of female patients in IIIrd phase of menstrual cycle.All patients were premedicated with glycopyrrolate 4μg.kg -1 and midazolam 0.02 mg.kg -1 intravenously just before induction. All patients were given general anaesthesia with sodium thiopentone 5 mg.kg -1 and succinylcholine 1.5 mg.kg -1 and maintained with O 2 + N 2 O=30:70, fentanyl 1 μg.kg -1 pancuronium 0.08mg.kg -1 bolus and .02 mg.kg -1 given in intermit­tent doses. Patients were reversed with neostigmine 50 μg.kg -1 and glycopyrrolate 8 μg.kg -1 given intravenously slowly. All patients were monitored for pulse, BP, SpO2, RR, tidal volume and minute volume. After recovery of patient, when patient complained of pain, buprenorphine 4μg.kg -1 was given intravenously. Additional supplements of diclofenac sodium were given if needed after the effect of buprenorphine was over upto 24 h. Before induction of anaesthesia, 5ml of patient's venous blood was collected to measure serum oestrogen level by ELISA method and analgesia after buprenorphine was assessed by VAS score. The results analysed showed that there was a clinically significant but statistically non significant reduction in 24hr VAS score in Group I& III patients than Group II patients who had a high oestrogen level. A negative correlation between serum oestrogen and mean duration of analgesia further support this, indicating that low serum oestrogen level decreases pain sensitiv­ity and high serum oestrogen level increases pain sensitivity.
  1,659 235 -
Cricoid pressure: a survey of its practice in India
BS Krishnan, DA Sanjib, D Harikrishna, B Rajlakshmi, Unnikrishnan , Grace Korula
November-December 2007, 51(6):505-509
Cricoid pressure (CP) application is performed by most anaesthesiologists during a rapid sequence intubation as a day to day routine; but very few anaesthetists have adequate knowledge or have been given proper instructions of the technique. We conducted a survey of knowledge and practice regarding cricoid pressure application in 360 anaesthesiologists who attended the Annual Scientific meeting of the Indian Society of Anaesthesiologists in 2003. There was a uniform lack of knowledge in most participants with widely varying practices being followed. Participants had experienced a high incidence of regurgitation (30%) and difficulty in tracheal intubation (57%) during application of cricoid pressure during their practice. We concluded that a proper technique of application of CP must be emphasized and demonstrated during the training programme for anaesthesiologists and an equal importance in training must be given to the non anaesthetic assistant who performs the maneuver in most instances in our country.
  1,534 292 -
Anaesthetic management for paraneoplastic pemphigus
ST Dave, V Chandrashekhar, SK Kamath, LV Dewoolkar
November-December 2007, 51(6):525-527
The article sums up the anaesthetic management of a patient with paraneoplastic pemphigus, undergoing excision of a retroperitoneal tumor. General anaesthesia with tracheal tube was administered, with perioperative steroid cover.All precautions to prevent exacerbation of pemphigus were taken.
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Severe venous air embolism in a paediatric patient undergoing neurosurgical procedure
Naresh Dua, Jayashree Sood
November-December 2007, 51(6):531-533
Venous air embolism (VAE) is a well-recognized complication and twice much common in children undergoing neurosurgical operations. A case of catastrophic presentation of venous air embolism during perioperative period is hereby reported. Early detection by adequate vigilant monitoring techniques and appropriate management of VAE as well as massive blood transfusion to replace the severe blood loss made the successful outcome.
  1,352 307 -