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   2008| November-December  | Volume 52 | Issue 6  
    Online since March 19, 2010

 
 
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CLINICAL INVESTIGATIONS
Preemptive Gabapentin vs Pregabalin for Acute Postoperative Pain after Surgery under Spinal Anaesthesia
V Saraswat, Vishal Arora
November-December 2008, 52(6):829-829
Gabapentin and Pregabalin have been used in treatment of neuropathic pain as well as postoperative pain with good results. However there is paucity of studies in comparison with each other. This study was designed to compare their efficacy with respect to increase in duration of analgesia, reduction in total post- operative require­ments of analgesics and study side effects and complications. Sixty patients of either sex in ASA grade I and II were randomly allocated to one of the two groups of thirty each. Patients in Group G were given single dose of gabapentin 1200mg, whereas in Group P were administered pregabalin 300mg one hour prior to administration of spinal anaesthesia. Pain was assessed by Visual Analogue Scale immediate postoperatively and every two hourly thereafter. Time since spinal anaesthesia to first dose of analgesic (diclofenac) and total dose of analgesic in first 24 hours was recorded. The total postoperative analgesic time was 8.98h in Group G whereas 14.17h in Group P (HS, P < 0.001). Total dose of analgesics in first 24h was 62.5mg in Group P and 72.5mg in Group G and was not significant (P>.05). Dizziness and somnolence were the only side effects noticed in both groups. Gabapentin and pregabalin, both have been effective in prolongation of post-spinal analgesia, Pregabalin more than Gabapentin and either can be used as part of multimodal therapy if not as sole analgesic.
  5,904 1,093 -
SPECIAL ARTICLES
Psychosocial Aspects of Pain Management
Mary Korula
November-December 2008, 52(6):777-777
Pain and psychological disorders with associated disability still remains a major issue in management of chronic pain. The subjective nature and reliance on self-report makes pain the most challenging of all symptoms to treat. Mental and physical functions are not separate from each other, they are interrelated - the 'mind-body' concept. Pain causes significant suffering and distress, is feared by patients, is often poorly understood, and hence poorly managed by clinicians. Philosophy of mind deals with mentality and its properties and understanding this is important not only for the pain relievers but for all those interested in understanding pain. This article is a brief review on what we know regarding these so far, the social and psychological implications and their impact on adult pain management.
  5,102 578 -
EDITORIAL
Renal Replacement Therapy
Pramila Bajaj
November-December 2008, 52(6):753-753
  3,853 1,580 -
CASE REPORTS
Anaesthetic Management of Nephrectomy for Emphysematous Pyelonephritis
N Dua, AB Upadhyay, PK Pradhan, Jayashree Sood
November-December 2008, 52(6):840-840
Emphysematous pyelonephritis (EPN) is a serious and often life threatening infection of the renal and perirenal tissues. The characteristic feature of this infection is the presence of gas within the kidney and perinephric tissues. The triad of symptoms of fever, flank pain and pyuria, especially in a diabetic female patient which did not respond promptly to conventional antibiotic therapy raised the possibility of EPN. CT scan established the diagnosis and the line of management. After failing medical management, uncontrolled frustrating hyperglycemia with fear of septice­mia, nephrectomy was done in life threatening fulminant infection of the kidney.
  4,780 401 -
Anaesthetic Management of Caesarean Section in an Achondroplastic Dwarf
Kirti N Saxena, Dheeraj Kapoor, Bharti Taneja, Lalit Maini, Shallu Hora
November-December 2008, 52(6):844-844
Achondroplasia is the commonest form of dwarfism which results from abnormal cartilage formation at epiphyseal growth plates .It is also known as short-limbed dwarfism. Anaesthetic management of caesarean section in these patients requires a deep understanding of this condition. A twenty year old parturient with short stature presented to the hospital in early labour. An elective lower segment caesarean section(LSCS) was planned in view of cephalopelvic disproportion. She had papers which suggested that she had been diagnosed as a case of achondroplasia though details were not available. Combined spinal epidural(CSE) anaesthesia was planned in the patient in view of the death of her first baby following caesarean section under general anaesthesia. Repeatedly dry taps were achieved on attempting dural puncture. Dural puncture was abandoned and an 18 G epidural catheter was threaded via the Tuohy needle. Sensory block till T 6 was achieved with 6ml of local anaesthetic solution. The patient was stable during the intraoperative and postoperative period.
  4,288 596 -
Anaesthetic Considerations in A Child with Bilateral Hydatid Cysts of Lung
Harsimran Singh, Harjinder Kohli, Anju Grewal, Sushil Budhiraja
November-December 2008, 52(6):849-849
Bilateral hydatid cyst of lung in a child is a challenge to anaesthesiologist. The benefits of one lung versus two lung ventilation is still a question. A 9-yr-old male child presented with respiratory distress. The chest X-ray showed the presence of two cysts bilaterally in the lung fields. A possibility of bilateral hydatid cyst in lung was considered. The child was taken up for emergency single stage bilateral thoracotomy under general anaesthesia. Two lung ventilation technique was used. Postoperatively the child was kept on controlled ventilation in the paediatric intensive care unit. The child was weaned off from ventilatory support and extubated 48 hours after the surgery.
  3,782 508 -
CLINICAL INVESTIGATIONS
Comparison of Haemodynamic and Cardiovascular Effects of VIMA with Sevoflurane Versus TIVA with Propofol in Patients Undergoing Coronary Artery Bypass Surgery
Neerja Bharti, Pramila Chari, Shyam K S Thingnam, Suman Arora
November-December 2008, 52(6):805-805
Sevoflurane provides protection against myocardial ischaemia during bypass surgery. This prospective, random­ized study was conducted to compare the haemodynamic and cardiovascular effects of sevoflurane induction& maintenance of anaesthesia(VIMA) with a standard total intravenous technique using propofol(TIVA) during coro­nary artery bypass graft (CABG) surgery. Thirty adult patients undergoing elective CABG surgery were randomly allocated to receive either sevoflurane (S group) or propofol (P group) for induction and maintenance of anaesthesia. In both groups, analgesia was supple­mented with fentanyl and muscle relaxation with vecuronium. Patients' heart rate, systemic and pulmonary pressures, cardiac index and mixed venous oxygen saturation were measured at following time intervals: pre-induction, post­induction, post-intubation, skin incision, post sternotomy, chest closure, and 1 hr after surgery, at spontaneous respira­tion and post extubation. The type and duration of inotropic support, duration of postoperative ventilation and ICU stay, perioperative complications and outcome were assessed. Patients' characteristics and demographic data were similar for both groups. Induction of anaesthesia was rapid and smooth in all patients. Compared to sevoflurane group more patients in the propofol group required nitroglycerine(NTG) to control blood pressure during prebypass period. Patients receiving sevoflurane had higher cardiac index (P<0.05) and required less inotropic support during post-operative period as compared to propofol treated patients. Duration of postoperative ventilation and ICU stay was similar in both groups. The incidence of postoperative complications and outcome were comparable between groups. In conclusion, sevoflurane provided better perioperative haemodynamic control and cardiovascular profile than propofol during elective CABG surgery.
  3,640 607 -
SPECIAL ARTICLES
Basic Statistical Concepts for Sample Size Estimation
Vithal K Dhulkhed, MG Dhorigol, Rajesh Mane, Vandana Gogate, Pavan Dhulkhed
November-December 2008, 52(6):788-788
For grant proposals the investigator has to include an estimation of sample size .The size of the sample should be adequate enough so that there is sufficient data to reliably answer the research question being addressed by the study. At the very planning stage of the study the investigator has to involve the statistician. To have meaningful dialogue with the statistician every research worker should be familiar with the basic concepts of statistics. This paper is concerned with simple principles of sample size calculation. Concepts are explained based on logic rather than rigorous mathematical calculations to help him assimilate the fundamentals.
  3,324 890 -
REVIEW ARTICLES
Pain Management: Medico-Legal Issues
Gaurab Maitra, A Rudra, Saikat Sengupta
November-December 2008, 52(6):768-768
Freedom from pain has now emerged as a fundamental human right. Pain has long been under treated and physicians have been accused for poor pain management. There are many reasons for failure of physicians to properly manage pain. Joint Commission on Accreditation of Health Care Organizations (JCAHO) made pain assess­ment and proper management mandatory. Many statutory regimens have evolved over the time demanding proper pain management and focusing it as a legal right. Standards of care for pain management have evolved and are well established. Websites have also proliferated to help physicians gain user friendly access to these guidelines. Physi­cians are now bound with legal responsibilities to follow pain practice as per the guidelines and to document every­thing in medical records. Not only the physicians, the hospitals are also liable to it patients if it fails to uphold the standard of care to ensure patient's safety. Though pain management has been slow to progress, a convergence of forces have now made it possible to incorporate quality pain management in medical practice.
  3,284 573 -
CLINICAL INVESTIGATIONS
Use of Classic Laryngeal Mask Airway Inserted in Prone Position for Controlled Ventilation: A Feasibility Study
Vijay Kumar, K Lalitha, Talib Lone
November-December 2008, 52(6):813-813
Traditionally, general anaesthesia for surgical procedures requiring prone position consists of induction and tracheal intubation in supine position on a trolley, and then patient is turned prone on the operation table and positioned carefully. Even though this approach is familiar to most anaesthesiologists, it is time consuming and requires shift of manpower from other tasks to properly position the patient. In the present study as an alternative to the traditional approach, classic laryngeal mask airway has been used successfully in patients who need controlled ventilation during short, moderate and even long duration surgeries in prone position. In this feasibility study involving 100 patients it was found that insertion of laryngeal mask airway in prone position, considerably simplify the management of this group of patients, without compromising the safety.
  3,056 416 -
Controversial Issues in Neuroanaesthesia and Their Current Practice in India-A Questionnaire Survey
Hemanshu Prabhakar, Munish Sharma, Virendra Jain, Zulfiqar Ali, Parmod K Bithal, Hari H Dash
November-December 2008, 52(6):823-823
To address the practice of various controversial issues in neuroanaesthesia practice in India, a questionnaire survey was conducted during the Annual Conference of Indian Society of Neuroanaesthesiology and Critical Care (ISNACC), held in Hyderabad this year in February 2008. The aim of the survey was to assess the views of the neuroanaesthetists on these issues and its influence in their clinical practice. A simple questionnaire comprising of eight questions was prepared related to the various controversies in neuroanaesthesia. Participants were asked to fill the questionnaire and return before the end of conference. All the questionnaires were distributed in hand and collected personally. The response rate was 66.25% from the nearly 160 delegates. The response was received from nearly an equal number of practitioners, both in the government and corporate sectors. Most of the respondents shared a neutral opinion on the controversies in neuroanaesthesia. New challenges are being faced by anaesthetists with evolution of neurosurgical practice. Various controver­sies have led to more research in this field. Although the awareness exists among Indians, the practice continues at many centres. Multi-centric trials to address such issues may prove beneficial.
  2,860 419 -
Effect of Intravenous Magnesium Sulfate and Fentanyl Citrate on Circulatory Changes During Anaesthesia and Surgery: A Clinical Study
Dilip Kothari, Amrita Mehrotra, Bhanu Choudhary, Alok Mehra
November-December 2008, 52(6):800-800
The study was conducted to compare the effects of magnesium sulfate and fentanyl citrate on circulatory variables during anaesthesia and surgery. Sixty patients (ASA-I& II) of either sex, between the age of 25-45 years were given either magnesium sulfate (Group M, n=30) 20mg.kg -1 5 min before induction, 10 mg.kg -1 5 min before skin incision and 10 mg.kg -1 every 30 min interval or fentanyl citrate (Group F, n=30) 1.25 mcg.kg -1 , 0.5 mcg.kg -1 and 0.5 mcg.kg -1 at similar time intervals. Balanced general anaesthesia was maintained with O2:N2O + halothane 0.2% and relaxants throughout the study period with controlled ventilation. Changes in pulse rate (PR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded at various time intervals. A clinically significant rise in pulse rate (+11.3%) was recorded in Group M after initial injection. Statistically insignifi­cant rise in all haemodynamic variables from baseline values were recorded immediately after intubation in both the groups, after which they returned and maintained, nearer to baseline values. No sympatho-somatic responses like tearing, sweating, eye movement etc. were observed during the course of study. In conclusion, the clinical results suggest that magnesium sulfate could be a safe and cheaper alternative analgesic to fentanyl citrate during general anaesthesia.
  2,652 498 -
CASE REPORTS
Takayasu's Arteritis:Anaesthetic Implications and Role of ILMA for Airway Management
Prachi Gaba, Kirti N Saxena, CK Dua
November-December 2008, 52(6):858-858
Takayasu arteritis is a chronic progressive inflammatory vasculitis affecting aorta and its branches. We discuss a 24 year old posted for post partum sterilization. Patient had weak carotid pulsation on right and absent pulsations on left side. We used Intubating Laryngeal Mask Airway(ILMA) #4 to intubate the patient preventing any extension of the neck.
  2,646 412 -
Child With Cystic Fibrosis And Pyopneumothorax For Emergency Thoracotomy For Decortication
Rakesh Garg, Ashwani Kumar, Mridu Paban Nath, Dilip Shende, Rajib Bhattacharyya
November-December 2008, 52(6):866-866
We describe a child of cystic fibrosis for emergency thoracotomy. A 7 year female diagnosed as cystic fibrosis, pyopneumothorax with pneumonia was posted for emergency left thoracotomy. On examination, child had decreased air entry on left side of chest and bilateral crepts. Anaesthesia was induced with fentanyl, propofol, vecuronium and sevoflurane in oxygen/air. Airway was secured with tracheal tube. Central venous line and caudal epidural catheter was placed. There were multiple episodes of desaturation and airway pressures were high. Child was shifted to ICU with tube in situ and put on ventilator and gradually weaned. Epidural infusion was initiated. Child had an uneventful recovery. Patient with cystic fibrosis for emergency thoracotomy requires proper choice of anaesthetic techniques along with perioperative pain relief.
  2,169 277 -
Molar Intubation for Intra Oral Swellings:Our Experience
Meenoti Potdar, RD Patel, LV Dewoolkar
November-December 2008, 52(6):861-861
Molar intubation is a technique of laryngoscopy that can be used for anticipated difficult intubation in cases where standard laryngoscopy technique is difficult due to presence of any intraoral mass that anatomically hampers laryngoscopy or that bleeds on touch. This technique is very easy, reliable and rewarding but should be practiced on normal patients for easy application in actual difficult cases.
  2,051 320 -
CLINICAL INVESTIGATIONS
A Multimodal Approach to Post-Operative Pain Relief in Children Undergoing Ambulatory Eye Surgery
VV Jaichandran, Bhanulakshmi Indermohan, V Jagadeesh, R Sujatha, JJ Kavitha Devi, N Manimaran
November-December 2008, 52(6):794-794
This study was carried to assess the efficacy of multimodal analgesia using ketorolac and fentanyl, for post­operative pain relief in children undergoing ambulatory eye surgery. Total of 161 children, aged 1 to 5 years, were randomly stratified to three different analgesic regimens: Group A Ketorolac 0.75 mg.kg -1 I.M. , Group B Fentanyl 0.75 µg.kg -1 I.V. and Group C Ketorolac 0.50mg.kg -1 I.M. and Fentanyl 0.50µg.kg -1 I.V. Ketorolac I.M. was given 45 minutes before extubation and fentanyl I.V. was given soon after extubation in the respective groups. Post-operative pain was assessed in a double blinded manner using Children's Hospital of Eastern Onatario Pain Scale (CHEOPS) scoring system and by recording the heart rate at 10, 30 and 60 minutes. If the score was above 8, the child was left with the parents. In case the score did not improve and persisted to be greater than 8, fentanyl 0.50µg.kg -1 I.V. was given as the rescue analgesia. The incidence of nausea, vomiting, sleep disturbances or any other complaints were recorded by a staff nurse 24 hours post operatively. Mean CHEOPS score at 10, 30 and 60 minutes and mean heart rate at 10 and 30 minutes were significantly higher for Group A compared with Group C. Mean pain score emerged significantly higher for Group B compared with Group C at 30 and 60 minutes, (P<0.01). Rescue analgesia required was significantly higher in Group A compared to Groups B and C, (P<0.0001). Post-operatively, significant incidence of drowsiness was reported in children in Group B compared to Groups A and C, (P<0.01). A multimodal approach using both ketorolac and fentanyl at low doses produce effective and safe analgesia in children undergoing ambula­tory eye surgery.
  2,011 308 -
REVIEW ARTICLES
Statins-More Than Just Plaque Stabilisation
Ashish K Khanna, Satinder Gombar
November-December 2008, 52(6):756-756
Hydroxymethylglutaryl-CoA reductase inhibitors, better known as statins have come a long way in the recent years, not just in perioperative cardiac protection but also as potential agents for the critically ill patient in intensive care. To review the large body of literature on the pleiotropic effects of statins and to highlight their role not just in the stabilisation of atherosclerotic plaques but also improved outcomes in sepsis. PubMed was searched using "perioperative", "cardiac", "critically ill", "statins" and combinations of these terms as keywords. The reference lists of relevant articles were further reviewed to identify additional citations. Principal findings: The underlying pharmacology, cellular and metabolic responses to statin therapy are elucidated. The duration and timing of statin therapy in terms of perioperative practice is presented along with evidence regarding the utility and safety of peri-operative statin therapy. The indications for peri-operative statin therapy especially for vascular surgical patients and the need for continuation post operatively are highlighted. Potential roles in sepsis and septic shock though in their infancy as of now are reviewed and outcomes presented. Recommendations for peri-operative statin therapy are made with the need for more work before extrapolation to the clinical scenario. Perioperative statin therapy seems to be associated with a survival benefit, with a variable effect on postoperative cardiovascular morbidity. The available evidence also suggests that, there may be a benefit from including statins in the therapy for treatment of sepsis. Larger prospective, randomized clinical trials are needed to confirm these observations and to determine the optimal timing and duration of statin therapy in the perioperative setting.
  1,857 447 -
CASE REPORTS
Transfusion Related Acute Lung Injury -A Case Report
Anamika , Vasanth Nayak, Jose Chacko, G Parameswara
November-December 2008, 52(6):835-835
Transfusion related acute lung injury (TRALI) is a rare but life threatening complication of blood transfusion which is being increasingly recognized. It is caused by cross reaction between donor antibodies and host leucocytes or between donor leucocytes with host antibodies. TRALI usually presents as an Acute Lung Injury (ALI) resulting in pulmonary congestion and edema, often leading to Acute Respiratory Distress Syndrome (ARDS). We report a case of TRALI in a patient who underwent laparotomy for ruptured corpus luteal cyst requiring blood transfusion. She presented with acute pulmonary edema about an hour after commencing a blood transfusion .This was managed conservatively with oxygen, steroids and diuretics. Patient improved rapidly and later discharged without any residual complications.
  1,864 352 -
CLINICAL INVESTIGATIONS
Attitude Amongst Resident Doctors in The Specialty of Anaesthesiology Towards Conferences and Workshops
Nishkarsh Gupta, Anju Gupta, Rakesh Garg, Anju Bhalotra, Amit Kohli, Poonam Bhadoria
November-December 2008, 52(6):818-818
The foundations of quality patient care are laid during training, but awareness of recent developments in medical knowledge is prerequisite to maintain a high level of quality care. Conferences and workshops are held as a part of continuing medical education (CME) under various banners in all specialties worldwide. This audit was carried out among the residents (JR and SR) working in various hospitals in Northern India. A questionnaire (14 questions) was designed to assess the attitude of resident doctors in the specialty of anaesthesiology towards conferences and workshops. Two hundred and fifty residents (110 senior and 150 junior residents) partici­pated in the audit and the information thus collected was analyzed. The audit revealed that all the residents were attending CME programmes whenever possible and major rea­sons cited for attending were to update knowledge (52% SRs and 63% PGs), make a presentation, to meet friends and socialize. The duration of workshop found to be most optimum was 2-3 days (70% residents). Almost all the residents (98% SRs and 96% PGs) were in favor of making a presentation during a conference in order to increase their confidence level, acquire knowledge and improve the resume. The majority preferred an oral presentation (87% SRs and 84% PGs) to a poster presentation as it enhanced their confidence and it was easier to prepare and carry out the material. The audit revealed that most of the residents suggested the making of some form of presentation compulsory during conferences every year (42% SRs and 29% PGs), with financial aid (20% SRs and 25% PGs) and special leaves (25% SRs and 28% PGs) to encourage active participation among the residents.
  1,419 250 -
CASE REPORTS
Cardiac Catheterization in Thoraco-Omphalocardiopagus Twins: A Case Report
Minati Choudhury, Usha Kiran
November-December 2008, 52(6):853-853
The incidence of conjoined twin is rare and anaesthesia for procedures on conjoined twins is a demanding, exacting and meticulous exercise, whether prior to or during separation. literature on the anaesthetic management of these cases is sparse. The following case report details the expert and vigilant anaesthetic management leading to successful diagnostic cardiac catheterization. The report emphasizes the importance of synchronous ventilation, teamwork and communication required in cases such as this. This case report also details the difficulties encountered and how to overcome them during the prolonged procedure.
  1,191 229 -
EVIDENCE BASED DATA
The Child with Sleep Apnea for Adenotonsillectomy
Pramila Bajaj
November-December 2008, 52(6):870-870
  960 291 -