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   2009| November-December  | Volume 53 | Issue 6  
    Online since March 3, 2010

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Regional & Topical Anaesthesia of Upper Airways
Nibedita Pani, Shovan Kumar Rath, Nibedita Pani, Shovan Kumar Rath
November-December 2009, 53(6):641-648
A combination of techniques are required to adequately anaesthetise upper airway structures for awake intubation . The widest coverage is provided by the inhalational technique. This technique, however, does not always provide a dense enough level of anaesthesia for all patients. Supplementation of this technique with any of the specific nerve blocks is an excellent way to accomplish efficacious anaesthesia for awake inubation. Anaesthetising upper airway is not a difficult skill to master and should be in the armamentarium of all practising anaesthetist.
  8,983 85 -
Efficacy and Safety of Tranexamic Acid in Control of Bleeding Following TKR: A Randomized Clinical Trial
PN Kakar, Nishkarsh Gupta, Pradeep Govil, Vikram Shah
November-December 2009, 53(6):667-671
Total knee arthroplasty (TKA) is generally carried out using a tourniquet and blood loss occurring mainly post operatively is collected in drains. Tranexamic acid is an antifibrinolytic agent which decreases the total blood loss. Patients had unilateral / bilateral cemented TKA using combined spinal and epidural anaesthesia. In a double-blind fashion, they received either placebo (n=25) or tranexamic acid (n=25)10 mg.kg -1 i.v., just before tourniquet inflation, followed by 1 mg kg -1 h -1 i.v. till closure of the wound. The postoperative blood loss, transfusion requirement, cost effectiveness and complications were noted. The groups had similar characteristics. The mean volume of drainage fluid was 270 ml and 620 ml for unilateral(U/L) and bilateral(B/L) TKR patients in placebo group. Whereas it was 160ml and 286 ml respectively in unilateral(U/L) and bilateral(B/L) TKR patients who received tranexamic acid. This was considered statistically significant. Control group patients received 26 units of PRBC as compared to 4 units in tranexamic acid groups (p<0.001). This was again statistically significant. None of the patients in any of the groups developed deep vein thrombosis. Tranexamic acid decreased total blood loss by nearly 54% in B/L TKR and 40% in U/L TKR and drastically reduced (> 80%) blood transfusion.
  3,788 817 -
Patient Controlled Epidural Analgesia during Labour: Effect of Addition of Background Infusion on Quality of Analgesia & Maternal Satisfaction
Uma Srivastava, Amrita Gupta, Surekha Saxena, Aditya Kumar, Saroj Singh, Namita Saraswat, Abhijeet R Mishra, Ashish Kannaujia, Sukhdev Mishra
November-December 2009, 53(6):649-653
Patient controlled epidural analgesia (PCEA) is a well established technique for pain relief during labor. But the inclusion of continuous background infusion to PCEA is controversial. The aim of this study was to assess whether the use of continuous infusion along with PCEA was beneficial for laboring women with regards to quality of analgesia, maternal satisfaction and neonatal outcome in comparison to PCEA alone. Fifty five parturients received epidural bolus of 10ml solution containing 0.125% bupivacaine +2 ìg.ml-1 of fentanyl. For maintenance of analgesia the patients of Group PCEA self administered 8 ml bolus with lockout interval of 20 minutes of above solution on demand with no basal infusion. While the patients of Group PCEA + CI received continuous epidural infusion at the rate of 10 ml.hr-1 along with self administered boluses of 3 ml with lockout interval of 10 minutes of similar epidural solution. Patients of both groups were given rescue boluses by the anaesthetists for distressing pain. Verbal analogue pain scores, incidence of distressing pain, need of supplementary/rescue boluses, dose of bupivacaine consumed, maternal satisfaction and neonatal Apgar scores were recorded. No significant difference was observed between mean VAS pain scores during labor, maternal satisfaction, mode of delivery or neonatal Apgar scores. But more patients (n=8) required rescue boluses in PCEA group for distressing pain. The total volume consumed of bupivacaine and opioid was slightly more in PCEA + CI group. In both the techniques the highest sensory level, degree of motor block were comparable& prolongation of labor was not seen. It was concluded that both the techniques provided equivalent labor analgesia, maternal satisfaction and neonatal Apgar scores. PCEA along with continuous infusion at the rate of 10 ml/ hr resulted in lesser incidence of distressing pain and need for rescue analgesic. Although this group consumed higher dose of bupivacaine, it did not affect maternal or neonatal safety.
  2,444 701 -
Comparative Study of Greater Palatine Nerve Block and Intravenous Pethidine for Postoperative Analgesia in Children Undergoing Palatoplasty
Manjunath R Kamath, Sripada G Mehandale, US Raveendra
November-December 2009, 53(6):654-661
Greater palatine nerve block anaesthetizes posterior portions of the hard palate and its overlying soft tissues. This study compared the efficacy, safety, and ease of the nerve block for cleft palate surgeries in children with i.v. pethidine for postoperative pain management. A prospective, double blind, randomized trial, enrolled 50 children aged below 10 years scheduled for palatoplasty and were alternatively allocated to two groups. Group A received intravenous pethidine 1mg.kg-1, whereas Group B, bilateral greater palatine nerve block with bupivacaine 0.25%, 1ml on each side, before the surgical stimulation. Modified Aldrete Scoring System, Children's Hospital Eastern Ontario Pain Scale (CHEOPS) and Brussels Sedation Score were employed to assess recovery, quality of analgesia and sedation respectively, by the nursing staff. Whenever pain score was >8, 0.5mg.kg-1 of pethidine was given intravenously for rescue analgesia in both groups. Recovery scores were better in Group B (p=0.007). In the immediate postoperative period, pain score was more in Group A (number of patients with pain score >8, 44% v/s 12%, p= .0117). Requirement for rescue analgesia was more in Group A (60 times v/s 7). The average sedation scores were similar. There was a higher incidence of agitation in Group A (66 vs. 30). The incidence of deep sedation was nearly half in Group B (34 Vs 63). Greater palatine nerve block was considered successful in 88% of cases. Greater palatine nerve block produces more effective, consistent and prolonged analgesia than pethidine.
  2,494 446 -
Cervical Epidural Anaesthesia for Radical Mastectomy and Chronic Regional Pain Syndrome of Upper Limb - A Case Report
Ashok Jadon, Prashant S Agarwal
November-December 2009, 53(6):696-699
A 47-yrs-female patient presented with carcinoma right breast, swelling and allodynia of right upper limb. radical mastectomy with axillary clearance and skin grafting was done under cervical epidural anaesthesia through 18G epidural catheter placed at C6/C7 level. Postoperative analgesia and rehabilitation of affected right upper limb was managed by continuous epidural infusion of 0.125% bupivacaine and 2.5 µg/ml -1 clonidine solution through epidu­ral catheter for 5 days and physiotherapy. This case report highlights the usefulness of cervical epidural analgesia in managing a complex situation of carcinoma breast with associated periarthitis of shoulder joint and chronic regional pain syndrome (CRPS) of right upper limb.
  2,315 481 -
Capnography Guided Awake Nasal Intubation in a 4 Month Infant with Pierre Robin Syndrome for Cleft Lip Repair-A Better Technique
Pramod Patra
November-December 2009, 53(6):692-695
This four-month-old Pierre Robin child was admitted for cleft lip repair with history of two failed attempts at intubation and subsequent cancellation of surgery. The capnography guided awake nasal intubation was considered as the child's parents were desperate to get the surgery done. A modified cuffless endotracheal tube was used with a capnography sampling tube placed within it. With the capnograph guidance the expiratory gas flow was followed to successfully intubate the child.This technique was found to be very convenient and helpful. The use of this technique in an infant has not been reported so far.
  2,426 348 -
Comparison of Midazolam and Propofol for BIS-Guided Sedation During Regional Anaesthesia
Priyanka Khurana, Ankit Agarwal, RK Verma, PK Gupta
November-December 2009, 53(6):662-666
Regional anaesthesia has become an important anaesthetic technique. Effective sedation is an essential for regional techniques too. This study compares midazolam and propofol in terms of onset& recovery from sedation, dosage and side effects of both the drugs using Bispectral Index monitoring. Ninety eight patients were randomly divided into two groups,one group recieved midazolam infusion while the other recieved propofol infusion until BIS reached 75. We observed Time to reach desired sedation, HR, MABP, time for recovery, dose to reach sedation and for maintenance of sedation and side effects if any. The time to reach required sedation was 11 min in Midazolam group(Group I) while it was 6 min in Propofol group(Group II) (p=0.0). Fall in MABP was greater with propofol. Recovery in with midazolam was slower than with propofol (18.6 ± 6.5 vs 10.10±3.65 min) (p=0.00). We concluded that both midazolam and propofol are effective sedatives, but onset and offset was quicker with propofol, while midazolam was more cardiostable.
  2,196 566 -
Cardio Cerebral Resuscitation: Is it better than CPR ?
TVSP Murthy, Bhavna Hooda
November-December 2009, 53(6):637-640
The guidelines for cardiopulmonary resuscitation (CPR) have been in place for decades; but despite their international scope and periodic updates, there has been little improvement in survival rates in out-of-hospital cardiac arrest for patients who did not receive early defibrillation. Instituting the new cardio cerebral resuscitation protocol for managing prehospital cardiac arrest improved survival of adult patients with witnessed cardiac arrest and an initially shockable rhythm.
  2,158 598 -
Anaesthetic Management of A Child with Multiple Congenital Anomalies Scheduled for Cataract Extraction
Kalpana Kulkarni, Sunetra Deshpande, Ismail Namazi
November-December 2009, 53(6):683-687
In infants& children variety of conditions and syndromes are associated with difficult Airway. Anaesthetic management becomes a challenge if it remains unrecognized until induction and sometimes results in disaster, leading to oropharyngeal trauma, laryngeal oedema, cardiovascular& neurological complications. A 4-month-old child with multiple congenital anomalies was posted for cataract extraction for early and better development of vision. He had history of post birth respiratory distress, difficulty in feeding, breath holding with delayed mile stones. He was treated as for Juvenile asthma. This child was induced with inhalation anaesthesia. There was difficulty in laryngoscopic intubation and could pass much smaller size of the tube than predicted. He developed post operative stridor and desaturation. The problems which we faced during the anaesthetic management and during postoperative period are discussed with this case.
  2,212 333 -
Congenital Cervical Teratoma: Anaesthetic Management (The EXIT Procedure)
Ferruh Bilgin, Nedim Cekmen, Yavuz Ugur, Ercan Kurt, Sadettin Gungor, Cuneyt Atabek
November-December 2009, 53(6):678-682
Ex utero intrapartum treatment (EXIT) is a procedure performed during caesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anaesthesia for EXIT in a fetus with cervical teratoma. A 30-year-old woman, 70 kg, 160 cm, gravida 2, para 1, was followed because of polyhydramniosis diagnosed at 24 weeks' gestation. During a routine ultrasonographic examination at 35 weeks' gestation, it was noticed that the fetus had a tumoral mass on the anterior neck, the mass had cystic and calcified components and with a size of was 10 x 6 x5 cm. The patient with physical status ASA I, was submitted to caesarean section under general anaesthesia with mechanically controlled ventilation for exutero intrapartum treatment (EXIT). Anaesthesia was induced in rapid sequence with fentanyl, propofol and rocuronium and was maintained with isoflurane in 2.5 at 3 % in O 2 and N 2 O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intuba­tion. The infant was intubated with an uncuffed, size 2.5 endotracheal tube. Excision of the mass was performed under general anaesthesia. After surgical intervention, on the fourth postoperative day, the infant was extubated and the newborn was discharged to the pediatric neonatal unit and on the seventh day postoperatively to home without complications. Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling. We report one case of cervical teratoma managed successfully with EXIT procedure.
  1,946 396 -
Myotonic Dystrophy: An Anaesthetic Dilemma
N Gupta, KN Saxena, Asish Kumar Panda, Raktima Anand, Anil Mishra
November-December 2009, 53(6):688-691
Myotonic dystrophy (dystrophia myotonica, DM) is a chronic, slowly progressing, highly variable inherited multisystemic disease that can manifest at any age from birth to old age. We present a 32-year-old female with adenexal mass posted for exploratory laparotomy. She was a known case of dilated cardiomyopathy (DCMP).The ECG suggested incomplete RBBB& LAHB& the ECHO revealed mild mitral regurgitation, tricuspid regurgitation, pulmonary artery hypertension with severe left ventricular dysfunction (ejection fraction of 30-35 %). General anaes­thesia (GA) with epidural anaesthesia was planned. The patient was haemodynamically stable through out the surgi­cal procedure. The patient was reversed and shifted to post anaesthesia care unit. On the 2nd postoperative day patient developed respiratory distress and hypotension. ABG revealed Type 1 respiratory failure. Since the patient didn't improve with oxygen therapy and nebulisation, she was intubated and shifted to ICU. Patient was tolerating the tube without sedation and relaxants so, consultant anaesthesiologist asked for neurologist referral to rule out myotonic dystrophy. Subsequent muscle biopsy and genetic analysis was suggestive of myotonic dystrophy. Despite all possible efforts we were unable to wean her off the ventilator for 390 days. Patients with myotonic dystrophy are a challenge to the attending anaesthesiologist. These patients can be very well managed with preoperative optimized medical treatment and well-planned perioperative care.
  1,836 442 -
Injury Patterns In Low Intensity Conflict
V Saraswat
November-December 2009, 53(6):672-677
Injury patterns and their outcome has been the subject of interest in all kinds of military conflicts. This retrospective study was conducted in a tertiary care hospital (Level I trauma centre) to find out the trends in injuries in low intensity conflict, adequacy of pre hospital treatment, mortality patterns and adequacy of treatment after reaching tertiary care hospital. 418 patients were treated over a period of two years. All were male and 76% younger than 30 years of age. 61% patients reported directly from the site of incident and 39% were transferred from other trauma centre. Two-third of patients (73.9%) reported with at least one limb injury and 44.9% with extremity injury alone. Multiple injuries were most common injury (29%). Head and neck injuries were seen in 20% patients and Thoracic and abdominal injuries were seen in 2.6% and 3.4% patients only. Most common mode of injury was Gunshot wound (41.4%), followed by splinter injuries (39.2%) and Road traffic accident(RTA) (19.4%). Overall mortality was 3.8% and inpatient mortality of 1.4%. Head and neck injuries were leading cause of death followed by thoracic injuries.
  1,592 269 -
Liver - Assisting Devices
Pramila Bajaj
November-December 2009, 53(6):635-636
  1,321 381 -
The Value of An Audit
Pramila Bajaj
November-December 2009, 53(6):700-701
  1,063 326 -