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   2014| July-September  | Volume 30 | Issue 3  
    Online since July 22, 2014

 
 
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REVIEW ARTICLES
Current concepts of optimal cerebral perfusion pressure in traumatic brain injury
Hemanshu Prabhakar, Kavita Sandhu, Hemant Bhagat, Padmaja Durga, Rajiv Chawla
July-September 2014, 30(3):318-327
DOI:10.4103/0970-9185.137260  PMID:25190937
Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO 2 ), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.
  33 6,631 2,073
ORIGINAL ARTICLES
Benefits of intravenous lidocaine on post-operative pain and acute rehabilitation after laparoscopic nephrectomy
Patrick Tauzin-Fin, Olivier Bernard, Musa Sesay, Matthieu Biais, Philippe Richebe, Alice Quinart, Philippe Revel, Francois Sztark
July-September 2014, 30(3):366-372
DOI:10.4103/0970-9185.137269  PMID:25190945
Background and Aims: Intravenous (I.V.) lidocaine has analgesic, antihyperalgesic and anti-inflammatory properties and is known to accelerate the return of bowel function after surgery. We evaluated the effects of I.V. lidocaine on pain management and acute rehabilitation protocol after laparoscopic nephrectomy. Materials and Methods: A total of 47 patients scheduled to undergo laparoscopic nephrectomy were included in a two-phase observational study where I.V. lidocaine (1.5 mg/kg/h) was introduced, in the second phase, during surgery and for 24 h post-operatively. All patients underwent the same post-operative rehabilitation program. Post-operative pain scores, opioid consumption and extent of hyperalgesia were measured. Time to first flatus and 6 min walking test (6MWT) were recorded. Results: Patient demographics were similar in the two phases (n = 22 in each group). Lidocaine significantly reduced morphine consumption (median [25-75% interquartile range]; 8.5 mg [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] vs. 25 mg [19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] ; P < 0.0001), post-operative pain scores (P < 0.05) and hyperalgesia extent on post-operative day 1-day 2-day 4 (mean ± standard deviation (SD); 1.5 ± 0.9 vs. 4.3 ± 1.2 cm (P < 0.001), 0.6 ± 0.5 vs. 2.8 ± 1.2 cm (P < 0.001) and 0.13 ± 0.3 vs. 1.2 ± 1 cm (P < 0.001), respectively). Time to first flatus (mean ± SD; 29 ± 7 h vs. 48 ± 15 h; P < 0.001) and 6MWT at day 4 (189 ± 50 m vs. 151 ± 53 m; P < 0.001) were significantly enhanced in patients with i.v. lidocaine. Conclusion: Intravenous (I.V.) lidocaine could reduce post-operative morphine consumption and improve post-operative pain management and post-operative recovery after laparoscopic nephrectomy. I.V. lidocaine could contribute to better post-operative rehabilitation.
  18 4,408 793
Analgesic efficacy of transversus abdominis plane block in providing effective perioperative analgesia in patients undergoing total abdominal hysterectomy: A randomized controlled trial
Sulagna Bhattacharjee, Manjushree Ray, Tapas Ghose, Souvik Maitra, Amitava Layek
July-September 2014, 30(3):391-396
DOI:10.4103/0970-9185.137274  PMID:25190950
Background and Aims: Transversus abdominis plane (TAP) block has been shown to provide postoperative pain relief following various abdominal and inguinal surgeries, but few studies have evaluated its analgesic efficacy for intraoperative analgesia. We evaluated the efficacy of TAP block in providing effective perioperative analgesia in total abdominal hysterectomy in a randomized double-blind controlled clinical trial. Materials and Methods: A total of 90 adult female patients American Society of Anesthesiologists physical status I or II were randomized to Group B (n = 45) receiving TAP block with 0.25% bupivacaine and Group N (n = 45) with normal saline followed by general anesthesia. Hemodynamic responses to surgical incision and intraoperative fentanyl consumption were noted. Visual analog scale (VAS) scores were assessed on the emergence, at 1, 2, 3, 4, 5, 6 and 24 h. Time to first rescue analgesic (when VAS ≥4 cm or on demand), duration of postoperative analgesia, incidence of postoperative nausea-vomiting were also noted. Results: Pulse rate (95.9 ± 11.2 bpm vs. 102.9 ± 8.8 bpm, P = 0.001) systolic and diastolic BP were significantly higher in Group N. Median intraoperative fentanyl requirement was significantly higher in Group N (81 mcg vs. 114 mcg, P = 0.000). VAS scores on emergence at rest (median VAS 3 mm vs 27 mm), with activity (median 8 mm vs. 35 mm) were significantly lower in Group B. Median duration of analgesia was significantly higher in Group B (290 min vs. 16 min, P = 0.000). No complication or opioid related side effect attributed to TAP block were noted in any patient. Conclusion: Preincisional TAP block decreases intraoperative fentanyl requirements, prevents hemodynamic responses to surgical stimuli and provides effective postoperative analgesia.
  17 4,652 863
A comparison of effect of preemptive use of oral gabapentin and pregabalin for acute post-operative pain after surgery under spinal anesthesia
Usha Bafna, Krishnamoorthy Rajarajeshwaran, Mamta Khandelwal, Anand Prakash Verma
July-September 2014, 30(3):373-377
DOI:10.4103/0970-9185.137270  PMID:25190946
Background and Aims: Preemptive analgesia is an antinociceptive treatment that prevents establishment of altered processing of afferent input. Pregabalin has been claimed to be more effective in preventing neuropathic component of acute nociceptive pain of surgery. We conducted a study to compare the effect of oral gabapentin and pregabalin with control group for post-operative analgesia Materials and Methods : A total of 90 ASA grade I and II patients posted for elective gynecological surgeries were randomized into 3 groups (group A, B and C of 30 patients each). One hour before entering into the operation theatre the blinded drug selected for the study was given with a sip of water. Group A- received identical placebo capsule, Group B- received 600mg of gabapentin capsule and Group C - received 150 mg of pregabalin capsule. Spinal anesthesia was performed at L3-L4 interspace and a volume of 3.5 ml of 0.5% bupivacaine heavy injected over 30sec through a 25 G spinal needle. VAS score at first rescue analgesia, mean time of onset of analgesia, level of sensory block at 5min and 10 min interval, onset of motor block, total duration of analgesia and total requirement of rescue analgesia were observed as primary outcome. Hemodynamics and side effects were recorded as secondary outcome in all patients. Results: A significantly longer mean duration of effective analgesia in group C was observed compared with other groups (P < 0.001) .The mean duration of effective analgesia in group C was 535.16 ± 32.86 min versus 151.83 ± 16.21 minutes in group A and 302.00 ± 24.26 minutes in group B. The mean numbers of doses of rescue analgesia in the first 24 hours in group A, B and C was 4.7 ± 0.65, 4.1 ±0.66 and 3.9±0.614. (P value <0.001). Conclusion: We conclude that preemptive use of gabapentin 600mg and pregabalin 150 mg orally significantly reduces the postoperative rescue analgesic requirement and increases the duration of postoperative analgesia in patients undergoing elective gynecological surgeries under spinal anesthesia
  15 4,700 1,199
Prospective randomized comparison between ultrasound-guided saphenous nerve block within and distal to the adductor canal with low volume of local anesthetic
Areti Adoni, Tilemachos Paraskeuopoulos, Theodosios Saranteas, Tatiana Sidiropoulou, Dimitrios Mastrokalos, Georgia Kostopanagiotou
July-September 2014, 30(3):378-382
DOI:10.4103/0970-9185.137271  PMID:25190947
Background and Aims: The anatomic site and the volume of local anesthetic needed for an ultrasound-guided saphenous nerve block differ in the literature. The purpose of this study was to examine the effect of two different ultrasound-guided low volume injections of local anesthetic on saphenous and vastus medialis nerves. Materials and Methods: Recruited patients (N = 48) scheduled for orthopedic surgery were randomized in two groups; Group distal adductor canal (DAC): Ultrasound-guided injection (5 ml of local anesthetic) distal to the inferior foramina of the adductor canal. Group adductor canal (AC): Ultrasound-guided injection (5 ml local anesthetic) within the adductor canal. Following the injection of local anesthetic, block progression was monitored in 5 min intervals for 15 min in the sartorial branches of the saphenous nerve and vastus medialis nerve. Results: Twenty two patients in each group completed the study. Complete block of the saphenous nerve was observed in 55% and 59% in Group AC and DAC, respectively (P = 0.88). The proportion of patients with vastus medialis weakness at 15 min in Group AC, 36%, was significantly higher than in Group DAC (0/22), (P = 0.021). Conclusions: Low volume of local anesthetic injected within the adductor canal or distally its inferior foramina leads to moderate success rate of the saphenous nerve block, while only the injection within the adductor canal may result in vastus medialis nerve motor block.
  9 3,294 605
Efficacy of intraarticular dexamethasone for postoperative analgesia after arthroscopic knee surgery
Dhurjoti Prosad Bhattacharjee, Chaitali Biswas, Purba Haldar, Sujata Ghosh, Gautam Piplai, Jati Sankar Rudra
July-September 2014, 30(3):387-390
DOI:10.4103/0970-9185.137273  PMID:25190949
Background and Aims: In an attempt to improve the recovery and early rehabilitation after arthroscopic knee surgery, various medications have been administered via intra-articular route to prolong the duration and improve the quality of postoperative analgesia. Among the potentially effective substances, steroids like dexamethasone could be of particular interest. Materials and Methods: Fifty patients undergoing elective knee arthroscopy were randomly assigned to one of the following groups containing 25 patients each. Group D patients received 8 mg (2 mL) of dexamethasone added to 18 mL of 0.25% levobupivacaine intra-articularly, (total volume 20 mL). Group L patients received 18 mL of 0.25% levobupivacaine and 2 mL of isotonic saline (20 mL in total) intra-articularly. Analgesic effect was evaluated by measuring pain intensity visual analogue scale score and duration of analgesia. Results: A longer delay was observed between intra-articular injection of study medication and first requirement of supplementary analgesic in Group D (10.24 ± 2.8 hours) compared with Group L (5.48 ± 1.6 h). Total consumption of diclofenac sodium in first 24 h in postoperative period was significantly less in Group D. No significant side effects were noted. Conclusion: Dexamethasone, used as adjunct to levobupivacaine in patients undergoing arthroscopic knee surgery, improves the quality and prolongs the duration of postoperative analgesia.
  9 2,348 453
Safety profile of fast-track extubation in pediatric congenital heart disease surgery patients in a tertiary care hospital of a developing country: An observational prospective study
Mohammad Irfan Akhtar, Mohammad Hamid, Fauzia Minai, Amina Rehmat Wali, Anwar-ul-Haq , Muneer Aman-Ullah, Khalid Ahsan
July-September 2014, 30(3):355-359
DOI:10.4103/0970-9185.137267  PMID:25190943
Background and Aims: : Early extubation after cardiac operations is an important aspect of fast-track cardiac anesthesia. In order to reduce or eliminate the adverse effects of prolonged ventilation in pediatric congenital heart disease (CHD) surgical patients, the concept of early extubation has been analyzed at our tertiary care hospital. The current study was carried out to record the data to validate the importance and safety of fast-track extubation (FTE) with evidence. Materials and Methods: A total of 71 patients, including male and female aged 6 months to 18 years belonging to risk adjustment for congenital heart surgery-1 category 1, 2, and 3 were included in this study. All patients were anesthetized with a standardized technique and surgery performed by the same surgeon. At the end of operation, the included patients were assessed for FTE and standard extubation criteria were used for decision making. Results: Of the total 71 patients included in the study, 26 patients (36.62%) were extubated in the operating room, 29 (40.85%) were extubated within 6 h of arrival in cardiovascular intensive care unit and 16 (22.54%) were unable to get extubated within 6 h due to multiple reasons. Hence, overall success rate was 77.47%. The reasons for delayed extubation were significant bleeding in 5 (31.3%) cases, hemodynamic instability (low cardiac output syndrome) in 4 (25%) cases, respiratory complication in 2 (12.5%), bleeding plus hemodynamic instability in 2 (12.5) cases, hemodynamic instability, and respiratory complication in 2 (12.5%) cases and triad of hemodynamic instability, bleeding and respiratory complication in 1 (6.5%) case. There was no reintubation in the FTE cases. Conclusion: On the basis of the current study results, it is recommended to use FTE in pediatric CHD surgical patients safely with multidisciplinary approach.
  8 3,318 677
REVIEW ARTICLES
Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage
Sandeep Kundra, Vidhi Mahendru, Vishnu Gupta, Ashwani Kumar Choudhary
July-September 2014, 30(3):328-337
DOI:10.4103/0970-9185.137261  PMID:25190938
Aneurysmal subarachnoid hemorrhage is associated with high mortality. Understanding of the underlying pathophysiology is important as early intervention can improve outcome. Increasing age, altered sensorium and poor Hunt and Hess grade are independent predictors of adverse outcome. Early operative interventions imposes an onus on anesthesiologists to provide brain relaxation. Coiling and clipping are the two treatment options with increasing trends toward coiling. Intraoperatively, tight control of blood pressure and adequate brain relaxation is desirable, so that accidental aneurysm rupture can be averted. Patients with poor grades tolerate higher blood pressures, but are prone to ischemia whereas patients with lower grades tolerate lower blood pressure, but are prone to aneurysm rupture if blood pressure increases. Patients with Hunt and Hess Grade I or II with uneventful intraoperative course are extubated in operation theater, whereas, higher grades are kept electively ventilated. Postoperative management includes attention toward fluid status and early management of vasospasm.
  7 12,677 2,984
CASE REPORTS
Transversus abdominis plane block as the primary anesthetic for laparotomy
Julie T Vuong, Patrick M McQuillan, Evangelos Messaris, Sanjib Das Adhikary
July-September 2014, 30(3):419-421
DOI:10.4103/0970-9185.137284  PMID:25190958
Elderly patients undergoing emergency intra-abdominal surgery are at high risk for morbidity and mortality. The risks and side-effects associated with intubation and mechanical ventilation or neuraxial anesthesia must be balanced against the need to maintain hemodynamic stability while maximizing pain control. Providing anesthesia and analgesia without either of these techniques can be a difficult prospect. We present three cases of ultrasound guided transversus abdominis plane (TAP) block as the primary anesthetic for laparotomy in elderly patients with multiple comorbidities. We have demonstrated the efficacy of and recommend the use of TAP blocks as the primary surgical anesthetic in a selected group of patients undergoing laparotomy.
  6 2,803 459
ORIGINAL ARTICLES
Perioperative management and complications in patients with obstructive sleep apnea undergoing transsphenoidal surgery: Our institutional experience
Eiman Rahimi, Ramamani Mariappan, Suresh Tharmaradinam, Pirjo Manninen, Lashmi Venkatraghavan
July-September 2014, 30(3):351-354
DOI:10.4103/0970-9185.137266  PMID:25190942
Background and Aims: Patients with endocrine diseases such as acromegaly and Cushing's disease have a high prevalence of obstructive sleep apnea (OSA). There is controversy regarding the use of continuous positive airway pressure (CPAP) following transsphenoidal surgery. The aim of this study was to compare the perioperative management and complications, in patients with or without OSA undergoing transsphenoidal surgery. Materials and Methods: After Research Ethics Board approval, we retrospectively reviewed the charts of all patients who underwent transsphenoidal surgery in our institution from 2006 to 2011. Information collected included patients' demographics, pathology of lesion, history of OSA, anesthetic and perioperative management and incidence of perioperative complications. Patients with sleep study proven OSA were compared with a control group, matched for age, sex and pathology of patients without OSA. Statistical analysis was performed using t-test and Chi-square test and the P < 0.05 was considered to be significant. Results: Out of a total 469 patients undergoing transsphenoidal surgery, 105 patients were found to be at risk for OSA by a positive STOP-BANG scoring assessment. Preoperative sleep study testing was positive for OSA in 38 patients. Post-operative hypoxemia (SpO 2 < 90) occurred in 10 (26%) patients with OSA and was treated with high-flow oxygen through face mask (n = 7) and by CPAP mask (n = 3). In the OSA-negative group, 2 patients had hypoxemia and were treated with low-flow oxygen using face mask. There were no differences between the groups with respect to post-operative opioid use, destination, hospital stay or other complications. Conclusions: Post-operative hypoxemia in patients with OSA following transsphenoidal surgery can be treated in most but not all patients with high flow oxygen using the face mask. We were able to safely use CPAP in a very small number of patients but caution is needed to prevent complications. Further prospective studies are needed to determine the safe use of CPAP in patients after transsphenoidal surgery.
  6 3,455 583
CASE REPORTS
Entropy as an indicator of cerebral perfusion in patients with increased intracranial pressure
James Khan, Ramamani Mariappan, Lashmi Venkatraghavan
July-September 2014, 30(3):409-411
DOI:10.4103/0970-9185.137280  PMID:25190955
Changes in electroencephalogram (EEG) patterns correlate well with changes in cerebral perfusion pressure (CPP) and hence entropy and bispectral index values may also correlate with CPP. To highlight the potential application of entropy, an EEG-based anesthetic depth monitor, on indicating cerebral perfusion in patients with increased intracranial pressure (ICP), we report two cases of emergency neurosurgical procedure in patients with raised ICP where anesthesia was titrated to entropy values and the entropy values suddenly increased after cranial decompression, reflecting the increase in CPP. Maintaining systemic blood pressure in order to maintain the CPP is the anesthetic goal while managing patients with raised ICP. EEG-based anesthetic depth monitors may hold valuable information on guiding anesthetic management in patients with decreased CPP for better neurological outcome.
  4 2,059 279
ORIGINAL ARTICLES
Evaluation of endotracheal intubating conditions without the use of muscle relaxants following induction with propofol and sevoflurane in pediatric cleft lip and palate surgeries
Sunil Rajan, Priyanka Gotluru, Susamma Andews, Jerry Paul
July-September 2014, 30(3):360-365
DOI:10.4103/0970-9185.137268  PMID:25190944
Background and Aims: Children with facial clefts are usually difficult to intubate and it is considered safer to keep them spontaneously breathing while securing the airway. This prospective comparative study was conducted to evaluate endotracheal intubating conditions in pediatric patients undergoing cleft surgeries, without the use of muscle relaxants following induction with propofol and sevoflurane. Materials and Methods: Sixty patients aged 1month to 3 years, were randomly allocated into two equal groups. Anesthesia was induced with sevoflurane 8% in oxygen in group 1 and with propofol 3 mg/kg in group 2. Laryngoscopy and intubation were attempted 150 s after induction in both groups and ease of laryngoscopy, position of vocal cords, degree of coughing, jaw relaxation, and limb movements were assessed and scored. Total score of 5 was considered excellent, 6-10 good, 11-15 poor, and 16-20 bad. Total score ≤ 10 was considered clinically acceptable, and >10 as clinically unacceptable. Chi-square and Wilcoxon Mann-Whitney tests were used to analyze data. Results: There was no significant difference between groups when ease of laryngoscopy was compared. Sevoflurane induced patients had significantly better position of vocal cords at intubation and the propofol group had significantly more episodes of coughing. Significantly less number of patients had limb movements in sevoflurane group. There was no significant difference in degree of jaw relaxation between groups. The sevoflurane group had significantly better total scores and clinically acceptable intubating conditions. Conclusion: Sevoflurane 8% in oxygen provides clinically acceptable intubating conditions without use of muscle relaxants in pediatric cleft patients.
  4 3,270 630
A prospective controlled study to assess the antiemetic effect of midazolam following intragastric balloon insertion
Sherif A Abdelhamid, Mohamed Samir Kamel
July-September 2014, 30(3):383-386
DOI:10.4103/0970-9185.137272  PMID:25190948
Background and Aims: Obesity is a chronic disease with considerable morbidity and mortality. The intragastric balloon appears attractive for a group of patients who do not respond to medical therapy and who are not surgical candidates. Postoperative nausea and vomiting (PONV) are distressing adverse effects for these patients. Midazolam has been used as an antiemetic, both as a preventive or rescue medication.The study aims at studying effect of combined use of ondansetron and midazolam to decrease the PONV following intragastric balloon insertion. Materials and Methods: The study was conducted on 54 patients presented for intragastric balloon insertion during the period between 1 st of January 2012 and 31 December 2012. Patients were randomly allocated into two groups; Ondansetron group and ondansetron/midazolam group. Patients were assessed for the incidence of nausea and vomiting, nausea and vomiting score, degree of sedation and occurrence of adverse effects during the first 24 h after the operation. Results: Incidence of nausea and/or vomiting during the first 24 h postoperatively was 66% in the ondansetron group, while 34.5% among the ondansetron-midazolam group. There was significant reduction of nausea and/or vomiting in the second group. Degree of postoperative sedation was also significantly different between the two groups in the immediate postoperative period and 30min postoperatively. Conclusion: Use of midazolam combined with ondansetron provides significant reduction and therefore better outcome regarding nausea and vomiting following intragastric balloon insertion.
  4 2,525 338
EDITORIAL
Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery?
Sudhakar Subramani, Anurag Tewari
July-September 2014, 30(3):313-315
DOI:10.4103/0970-9185.137258  PMID:25190935
  3 5,237 799
ORIGINAL ARTICLES
A comparative study evaluating the prophylactic efficacy of oral clonidine and tramadol for perioperative shivering in geriatric patients undergoing transurethral resection of prostate
Anurag Tewari, Ira Dhawan, Vidhi Mahendru, Sunil Katyal, Avtar Singh, Navneet Narula
July-September 2014, 30(3):340-344
DOI:10.4103/0970-9185.137264  PMID:25190940
Background and Aims: Perioperative shivering, in geriatric patients undergoing urological surgery under central neuraxial blockade is a common complication. Prophylactic measures to reduce shivering are quintessential to decrease the morbidity and mortality. Believing that oral formulation will bring down the cost of treatment, we decided to compare the efficacy of oral clonidine and tramadol, as premedication, in prevention of shivering in patients undergoing transurethral resection of prostate (TURP) under spinal anesthesia in a prospective and double-blind manner. Materials and Methods: The patients were randomly allocated into three groups (40 patients each). Group I received oral clonidine 150 μg, Group II received oral tramadol 50 mg, while Group III received a placebo. Number of patients having shivering, their grades and duration, hemodynamic changes, and side-effects in the form of sedation were recorded. Data were analyzed using analysis of variance, Student's t-test, Z test as and when appropriate. Results: In group I and II, 38 patients (95%) and 37 patients (92.5%) did not shiver, respectively. Although in the group III, 24 patients (60%) exhibited no grade of shivering, the shivering was of significantly severe intensity and lasted for a longer duration. No, clinically significant collateral effects were observed in patients who were administered clonidine or tramadol. Conclusions: Oral clonidine and tramadol were comparable in respect to their effect in decreasing the incidence, intensity, and duration of shivering when used prophylactically in patients who underwent TURP under subarachnoid blockade.
  3 2,872 539
CASE REPORTS
Eisenmenger's syndrome in pregnancy: Use of epidural anesthesia and analgesia for elective cesarean section
Lipi Mishra, Nibedita Pani, Ramesh Samantaray, Kalyani Nayak
July-September 2014, 30(3):425-426
DOI:10.4103/0970-9185.137286  PMID:25190960
We describe a case of a pregnant patient with a large ventricular septal defect (VSD) and pulmonary artery hypertension, presented to the hospital and underwent elective cesarean section under epidural anesthesia and postoperative analgesia. The procedure was uneventful till the patient was discharged on 10th day.
  2 2,168 441
Permissive hypotension in traumatic brain injury with blunt aortic injury: How low can we go?
Santvana Kohli, Naveen Yadav, Gyaninder Pal Singh, Hemanshu Prabhakar
July-September 2014, 30(3):406-408
DOI:10.4103/0970-9185.137279  PMID:25190954
With an ever-increasing incidence of high impact collisions, polytrauma is becoming increasingly common. Patients with traumatic brain injury (TBI) may require urgent surgical intervention along with maintenance of an adequate mean arterial pressure (MAP) to maintain cerebral perfusion. On the other hand, patients who sustain blunt aortic injuries (BAI) have a high mortality rate, many of them succumbing to their injury at the site of trauma. Surgery has been the mainstay of the management strategy for the remaining survivors. However, in recent years, the paradigm has shifted from early operative management to conservative treatment with aggressive blood pressure and heart rate control, serial imaging, and close clinical monitoring. When TBI and BAI coexist in a patient, it becomes crucial to maintain the MAP within a narrow range to prevent secondary insult to the brain as well as to prevent aortic rupture. We present the management of a case of TBI with traumatic aortic pseudoaneurysm, which required stringent monitoring and maintenance of hemodynamics during decompressive craniectomy.
  2 2,377 425
LETTERS TO EDITOR
Anesthesia in a patient with multiple allergies
Sanhita J Kulkarni, Vasanti P Kelkar, Prabha P Nayak
July-September 2014, 30(3):433-434
DOI:10.4103/0970-9185.137291  PMID:25190964
  2 1,618 308
Tongue bite injury after use of transcranial electric stimulation motor-evoked potential monitoring
Aparna Williams, Georgene Singh
July-September 2014, 30(3):439-440
DOI:10.4103/0970-9185.137297  PMID:25190968
  2 1,685 231
Use of picture archiving and communication system for imaging of radiological films in cardiac surgical intensive care unit
Dheeraj Arora, Yatin Mehta
July-September 2014, 30(3):447-448
DOI:10.4103/0970-9185.137306  PMID:25190974
  2 4,226 244
CASE REPORTS
Importance of transesophageal echocardiography in peripartum cardiomyopathy undergoing lower section cesarean section under regional anesthesia
Poonam Malhotra Kapoor, Sameer Goyal, Kalpana Irpachi, Barya Smita
July-September 2014, 30(3):427-429
DOI:10.4103/0970-9185.137287  PMID:25190961
Peripartum cardiomyopathy is a relatively rare but life threatening disease. The etiology and pathogenesis of peripartum cardiomyopathy is generally centered upon viral and autoimmune mechanism. This case report describes the anesthetic management of a patient with term pregnancy suffering from dilated peripartum cardiomyopathy planned for cesarean section , successfully managed with epidural anesthesia after precipitate labour.
  1 1,806 330
Fat embolism syndrome: Case report of a clinical conundrum
Roneeta Nandi, Pradeep Marur Venkategowda, Dnyaneshwar Mutkule, Surath Manimala Rao
July-September 2014, 30(3):412-414
DOI:10.4103/0970-9185.137281  PMID:25190956
Fat embolism syndrome is a rare clinical condition associated with trauma, particularly of long bones. FES after fracture of neck of femur or head of humerus is uncommon. We report a case of FES following fracture in neck of femur and head of humerus in a man with history of mitral valve replacement, on long-term oral anticoagulant therapy, with an alleged history of convulsions. Our dilemma in clinical diagnosis is discussed.
  1 3,183 402
Convulsions in a critically ill patient on hemodialysis: Possible role of low dose colistin
Kanwalpreet Sodhi, Rahul Kohli, Basjinder Kaur, Sidhartha Garg, Anupam Shrivastava, Manender Kumar
July-September 2014, 30(3):415-418
DOI:10.4103/0970-9185.137282  PMID:25190957
The increasing prevalence of multi-drug resistant Gram-negative pathogens in intensive care units has led to the revival of colistin. Colistin had gone into disrepute in early 1970s because of numerous reports of adverse renal and neurological effects. The renewed interest in colistin has also revived the discussion about its toxicity. The neurotoxicity reported in literature is usually with higher doses of colistin. We present a case report of seizures in a critically ill-patient, possibly with low dose colistin. A 47-year-old hypertensive female with chronic kidney disease-5 with sepsis on colistimethate sodium 1 million units (80 mg), intravenous once daily, developed paresthesias and seizures on 12 th day of therapy, which were subsequently controlled after withdrawl of the drug. To conclude, colistin should be considered as a cause of convulsions in critically ill-patients with renal failure, even when given in low dose and patient receiving intermittent hemodialysis, when other obvious causes have been ruled out. When possible, cessation of therapy may be considered.
  1 2,225 400
Anesthetic management of a parturient with glioma brain for cesarean section immediately followed by craniotomy
Tina Khurana, Bharti Taneja, Kirti N Saxena
July-September 2014, 30(3):397-399
DOI:10.4103/0970-9185.137275  PMID:25190951
The anesthetic management of a parturient with an intracranial tumor can be quite challenging for the anesthetist as it requires a fine balance of both maternal and fetal safety. The literature pertaining to anesthetic management of such cases is limited. We describe the anesthetic management and peri-operative concerns of this unusual case of a parturient aged 25 years with 8 months amenorrhea and a high grade glioma in the left temporo-parietal region who underwent cesarean section under general anesthesia immediately followed by craniotomy. Anesthetic management was tailored keeping in mind maternal safety and fetal considerations.
  1 2,217 343
Spinal anesthetic for emergency cesarean section in a parturient with uncorrected tetralogy of Fallot, presenting with abruptio placentae and gestational hypertension
Sethuramachandran Adinarayanan, Satyen Parida, Jayaram Kavitha, Hemavathi Balachander
July-September 2014, 30(3):400-402
DOI:10.4103/0970-9185.137276  PMID:25190952
A subarachnoid block is an effective way of providing anesthesia for cesarean sections. However, it can be considered relatively contra-indicated in parturients with uncorrected tetralogy of Fallot (TOF). We report a case of a 22-year-old female patient with TOF and gestational hypertension, who presented for an emergency cesarean section for placental abruption. The surgery was successfully conducted under a spinal anesthetic with a combination of low dose bupivacaine and fentanyl. Fentanyl combined with small-dose bupivacaine in the subarachnoid space can be considered as an alternative technique to general anesthesia, in selected parturients with uncorrected TOF presenting for cesarean section, especially in cases where the risks of administering a general anesthetic are deemed high.
  1 2,517 372
LETTERS TO EDITOR
Interdisciplinary intraoperative communication and collaboration needed for optimal neuromuscular blockade management
Mark D Welliver, William H Jones
July-September 2014, 30(3):442-443
DOI:10.4103/0970-9185.137300  PMID:25190970
  1 1,116 161
Transient brain stem ischemia following cervical spine surgery: An unusual cause of delayed recovery
Nirmala Jonnavithula, Kavya Cherukuri, Padmaja Durga, Dilip Kumar Kulkarni, Vijayasaradhi Mudumba, Gopinath Ramachandran
July-September 2014, 30(3):432-433
DOI:10.4103/0970-9185.137290  PMID:25190963
  1 1,143 251
Successful tracheal stent placement for central airway obstruction using dexmedetomidine and regional airway anesthesia
Samarjit Dey, Prithwis Bhattacharyya, Jayanta Medhi, Adarsha Karadi Nellappa
July-September 2014, 30(3):438-439
DOI:10.4103/0970-9185.137296  PMID:25190967
  1 1,355 195
Ipsilateral paralysis of hypoglossal nerve following interscalene brachial plexus block
Saswata Bharati, Manas Karmakar, Sujata Ghosh
July-September 2014, 30(3):446-447
DOI:10.4103/0970-9185.137304  PMID:25190973
  1 1,283 203
CASE REPORTS
Perioperative management of a patient of Rubinstein-Taybi syndrome with ovarian cyst for laparotomy
Vanlal Darlong, Ravinder Pandey, Rakesh Garg, Deepak Pahwa
July-September 2014, 30(3):422-424
DOI:10.4103/0970-9185.137285  PMID:25190959
Rubinstein-Taybi syndrome (RTS) is a multisystem involvement disease. These children may present for various surgeries of different systems. Due to multisystem involvement, perioperative management of such patients poses peculiar challenges for the anesthesiologists. We report the successful anesthetic management of a patient with RTS with tonsillar hypertrophy grade III scheduled for ovarian cystectomy.
  - 2,036 284
Successful anesthetic management for microsurgical excision of ruptured cerebellar arteriovenous malformation with trapped endovascular microcatheter
Shruti Redhu, B Madhusudhana Rao, Vinay Byrappa, KR Madhusudan Reddy
July-September 2014, 30(3):403-405
DOI:10.4103/0970-9185.137277  PMID:25190953
Microsurgical excision and good anesthetic management of arteriovenous malformation (AVM) that ruptures during endovascular embolization can ensure good outcome despite per-procedural catastrophe. This case report illustrates the successful anesthetic management of microsurgical excision of ruptured AVM with entrapped microcatheter and highlights the role of the anesthesiologist in careful monitoring of the patient's hemodynamic status and communicating any changes to the radiology team to facilitate check angiography to diagnose the intracranial complication. This case highlights the need for anticipating and defining a catastrophe plan in advance of each interventional neuroradiology procedure as complications are rapid and require good multidisciplinary communication to ensure safe and successful outcomes.
  - 2,015 268
COMMENTARY
Antishivering premedication: Can it improve outcome?
Medha Mohta
July-September 2014, 30(3):338-339
PMID:25190939
  - 2,220 524
EDITORIAL
World cup football… in the theatres now, everyday
Rakhee Goyal
July-September 2014, 30(3):316-317
DOI:10.4103/0970-9185.137259  PMID:25190936
  - 1,487 235
LETTERS TO EDITOR
"x" descent of CVP: An indirect measure of RV dysfunction ?
Monish S Raut, Arun Maheshwari
July-September 2014, 30(3):430-431
DOI:10.4103/0970-9185.137289  PMID:25190962
  - 5,545 314
Displacement of optimally placed subclavian central venous catheter by dialysis catheter - retrospection after radiography
Arun Kumar, Souvik Chaudhuri, Shaji Mathew, Kush Goyal
July-September 2014, 30(3):435-436
DOI:10.4103/0970-9185.137293  PMID:25190965
  - 1,818 172
Another alternative to universal certodyn adaptor
Manila Singh, Kapil Chaudhary, Rajeev Uppal
July-September 2014, 30(3):436-438
DOI:10.4103/0970-9185.137294  PMID:25190966
  - 1,324 165
In response: Interdisciplinary intraoperative communication and collaboration needed for optimal neuromuscular blockade management
Joseph F Answine, James J Lamberg
July-September 2014, 30(3):443-444
DOI:10.4103/0970-9185.137302  PMID:25190971
  - 877 138
Subarachnoid space needle manipulations for successful block
Deepak Gupta
July-September 2014, 30(3):444-446
DOI:10.4103/0970-9185.137303  PMID:25190972
  - 1,408 267
Induction and intubation in a Kleeblattschadel syndromic child with posterior cranial distractors
Sunil Rajan, Jerry Paul, Susamma Andrews
July-September 2014, 30(3):440-442
DOI:10.4103/0970-9185.137299  PMID:25190969
  - 1,239 174
ORIGINAL ARTICLES
Efficacy and outcomes of perioperative anesthetic management of extracranial to intracranial bypass for complex intracranial aneurysm in the absence of advanced neurological monitoring
Padmaja Durga, Sudhakar Kinthala, Barada Prasad Sahu, Manas Kumar Panigrahi, Srinivas Mantha, Gopinath Ramachandran
July-September 2014, 30(3):345-350
DOI:10.4103/0970-9185.137265  PMID:25190941
Background and Aims: Anesthetic management of extracranial to intracranial (EC-IC) bypass for complex intracranial aneurysms is challenging as the goals involve balancing the cerebral perfusion during parent artery clamping and avoiding factors that predispose to rupture of the unsecured aneurysm. There is very sparse literature available on anesthetic management for this procedure. Materials and Methods: A retrospective review of the records of 20 patients undergoing EC-IC bypass was performed with an objective of assessing the efficacy and outcomes of anesthetic management in the absence of advanced neurological monitoring. Results: A total of 20 patients underwent EC-IC bypass as an adjunct cerebral revascularization in the management of complex intracranial aneurysms. Intraoperatively normotension and normocarbia were maintained. During the EC-IC bypass, when the temporary clamp was applied, mild hypertension (increase from baseline by 20%) and hypervolemia (central venous pressure increased to 12 mmHg) were maintained. Cerebral protection during temporary clipping of intracranial vessel was provided using moderate hypothermia to 34°C and intravenous thiopentone. Temporary clip time ranged from 15 min to 54 min (mean-25 min). All patients except one were extubated post-operatively (19/20 = 95%). None of the patients had rupture of aneurysm in the peri-operative period. Three patients developed neurologic events (3/20 = 15%). One patient had cerebral vasospasm and two patients developed cerebral infarction. Two patient subsequently improved and one succumbed to the neurological deterioration (mortality 1/20 = 5%). Conclusion: Adherence to the principal goals for the procedure, avoidance of hemodynamic fluctuations such as hypotension and hypertension, maintenance of normocarbia, and cerebral protection, result in favorable neurological outcome even in the absence of advanced neuromonitoring.
  - 2,174 393
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