Abhishek Karnwal

Stellate ganglion block for postoperative analgesia in patients with upper extremity orthopaedic injuries

htm;jsessionid=2DD4749FA 5D7C11DE1DEA1A63DD04D17? year=2005&index=11&absnum= 1575 (accessed 20 ⁄ 08 ⁄ 2011). 4 Bantel C, Trapp S. The role of the autonomic nervous system in acute surgical pain processing – what do we know? Anaesthesia 2011; 66:

Utilization of Intraoperative Real-time Three-Dimensional Transoesophageal Echocardiography to Objectively Assess Improvement in Synchronization and Regional Wall Motion after Coronary Reperfusion

It is well known that myocardial ischemia leads to Regional Wall Motion Abnormalities (RWMAs) and reversible depression of Left Ventricular (LV) systolic function. Transoesophageal Echocardiography (TEE) is an established tool for early diagnosis of new RWMAs. However, evaluation of RWMAs by echocardiography is largely qualitative and relies on visual assessment of wall segments. Evaluation of LV systolic function and Ejection Fraction (EF) is more reproducible and accurate with Real-Time 3D Echocardiography (RT3DE) as compared with two-dimensional and M-mode techniques. Primary advantages for RT3DE are fast and largely automated volumetric analysis of LV function and LV volumes, without geometric assumptions and risk of underestimating volumes in foreshortened views. This case illustrates the use of intraoperative RT3DE during coronary artery bypass surgery to objectively assess: LV systolic function with LV volumes and RWMAs and improvement in cardiac synchronization following coronary reperfusion.

The anesthetic technique of choice for better outcomes in high-risk elderly patients undergoing endovascular repair of aortic aneurysms

To the Editor: We read with great interest the recent article by Asakura et al. [1] and wish to comment on their retrospective study of an anesthetic technique for patients undergoing endovascular repair of aortic aneurysms (EVAR), which has improved patient outcomes. Their review of 31 patients points out that ‘‘locoregional’’ anesthesia was well tolerated and has advantages over general anesthesia. We concur with their findings, as their retrospective analysis of patient’s corroborates with our results [2–4]. Based on our studies involving more than 500 patients with aortic abdominal and thoracic aneurysms, dissections, and transections [2–4], monitored anesthesia care (MAC) technique consisting of an opioid (fentanyl) and local anesthetic infiltration of the groin area with an adjunctive ilioinguinal/iliohypogastric nerve block has positive outcomes in this high-risk population with multiple comorbidities. The advantages of this technique include shorter intensive care unit (ICU) stays and faster hospital discharges, thus significantly cutting cost. Patients experience better pain control leading to reduced use of perioperative opioids. Avoidance of airway instrumentation and inhalational agents provides smoother intraoperative hemodynamics, resulting in less cardiopulmonary complications [2–4]. In addition, an awake, responsive patient is readily treated in case of adverse reactions (namely, to contrast material) due to early detection of signs and symptoms than in a patient under general anesthesia [5]. Use of the ultrasound-guided nerve blocks by Asakura et al. [1] was the only remarkable difference from our approach. Although the authors’ references are recent and do not site information from years past, their study substantiates what we have stressed over the years in the anesthesia and surgical literature. In conclusion, the efficacy of local anesthesia with MAC plus the adjunctive use of groin nerve blocks is an excellent alternative to general anesthesia and has previously been established in larger prospective clinical trials.

Amelanotic melanoma presenting with cervical lymphadenopathy

We present a rare case of an amelanotic melanoma of unknown primary presenting with cervical lymphadenopathy. A 20-year-old man presented with large left sided neck lump, associated dysphagia and weight loss. Examination revealed a hard mass in the left posterior triangle of neck and sacral sensory loss. Fine needle aspiration cytology of the mass suggested a poorly differentiated carcinoma. Computed tomography showed a left sided, 8×13 cm cervical mass with liver, lung and bony metastases. Histological examination of the lymph nodal mass confirmed the diagnosis of a metastatic amelanotic melanoma. The patient was treated with glucocorticoids, radiation therapy for the sacral bony deposit, and chemotherapy. Despite an initial reduction of his target lesions, his condition subsequently deteriorated and he died 4 months after diagnosis.