Akhilesh Kumar Tiwari

Ketotic hyperglycemia with movement disorder

Chorea, hemichorea-hemiballismus and severe partial seizures may be the presenting features of nonketotic hyperglycemia in older adults with type 2 diabetes, but cases in young adults with type 1 diabetes are rare. We hereby report a very rare case of diabetic ketosis with movement disorder in a young patient.

Intrathecal bupivacaine in comparison with a combination of nalbuphine and bupivacaine for subarachnoid block: a randomized prospective double-blind clinical study.

We performed this randomized, prospective double-blind study to evaluate the effects of 2 different doses of intrathecal nalbuphine (a synthetic opioid agonist–antagonist) on the onset, duration of action, side effects, and complication produced by intrathecal hyperbaric 0.5% bupivacaine in lower abdominal, urologic and lower limb surgeries. Seventy-five patients of ASA grades 1 and 2 of either sex in the age group of 20–60 years were randomly allocated to 1 of 3 groups. Group A (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL sterile water intrathecally; group B (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL (200 &mgr;g) nalbuphine intrathecally; group C (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL (400 &mgr;g) nalbuphine intrathecally. The onsets of sensory and motor blockade, highest level of sensory blockade, 2 segment regression time of sensory blockade, duration of motor blockade and analgesia, visual analog scale score, hemodynamic and respiratory changes, side effects were recorded, tabulated, and analyzed. Onsets of sensory and motor blockade and duration of motor blockade were not affected. Two segment regression time of sensory blockade and duration of analgesia were maximally prolonged in group C (P < 0.05). The visual analog scale scores were in the following order: group A > group B > group C at 90, 120, and 150 minutes after induction (P < 0.05). Hemodynamic and respiratory complications were absent except in 2 patients in groups A and C each, and 1 patient in group B developed bradycardia (P > 0.05). One patient in group A had nausea and vomiting, 2 patients in each group developed shivering (P > 0.05). No other side effect or complication was observed. Nalbuphine hydrochloride (400 &mgr;g) significantly prolongs the duration of sensory blockade and postoperative analgesia without any side effect or complication when introduced intrathecally along with hyperbaric bupivacaine.

β2 Agonist for the Treatment of Acute Lung Injury: A Systematic Review and Meta-analysis

BACKGROUND: The use of β2 agonist as an intervention for acute lung injury (ALI) and ARDS patients is controversial, so we performed a systematic review and meta-analysis of the published randomized controlled trials of using β2 agonists to improve outcomes (mortality and ventilator free days) among patients with ALI/ARDS. METHODS: A comprehensive search of 7 major databases (Ovid MEDLINE In-Process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Cochrane Database of Systematic Reviews, Web of Science, and Scopus) for randomized controlled trials using β2 agonists for ALI from their origin to March 2013 was conducted. The effect size was measured by relative risk for dichotomous outcomes, and mean difference for continuous outcomes, with 95% CI. The statistical heterogeneity between the studies was assessed with the Cochran Q test and I2 statistic. The heterogeneity of > 50% was considered significant for the analysis. The Cochrane risk of bias tool was used to ascertain the quality of the included studies. RESULTS: Out of 219 studies screened, 3 randomized controlled trials reported mortality and ventilator-free days, in 646 ALI/ARDS subjects. Of the 646 subjects, 334 (51.7%) received β2 agonist and 312 (48.3%) received placebo. There was no significant decrease in 28-day mortality or hospital mortality in the β2-agonist group: relative risk 1.04, 95% CI 0.50–2.16, and relative risk 1.22, 95% CI 0.95–1.56, respectively. The ventilator-free days and organ-failure-free days were significantly lower for the ALI subjects who received β2 agonists: mean difference −2.19 days (95% CI −3.68 to −1.99 d) and mean difference −2.04 days (95% CI −3.74 to −0.35 d), respectively. CONCLUSIONS: In subjects with ALI/ARDS, β2 agonists were not only nonbeneficial in improving the survival, but were harmful and increased morbidity (reduced organ-failure-free days and ventilator-free days). The current evidence discourages the use of β2 agonist in ALI/ARDS patients. (International Prospective Register of Systematic Reviews, http://www.crd.york.ac.uk/prospero, 2012:CRD42012002616.)

The effect of tranexamic acid on hemoglobin levels during total knee arthroplasty.

The aim of this study was to evaluate the efficacy of perioperative administration of 1,4-amino-carboxylic acid (tranexamic acid) in reducing the intraoperative and postoperative blood loss in patients undergoing total knee replacement (TKR). Tranexamic acid is an antifibrinolytic agent that is 7–10 times as potent as epsilon aminocaproic acid. We had investigated the effect of tranexamic acid on blood loss intraoperatively and postoperatively during and after TKR thereby significantly preventing a decrease in postop Hb in these patients. This study was a randomized, prospective, observational, double-blinded study on 99 patients, after obtaining ethical committee approval and valid informed consent from patients to be part of the study. In the study group, the drug was administered in 2 doses 1 hour preoperatively and 6 hours postoperatively. The use of tranexamic acid injection in TKR surgeries can be considered as an effective method to control and minimize the blood loss during total knee arthroplasty surgeries.

Anesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: A case series

Peripartum cardiomyopathy is a rare cause of dilated cardiomyopathy in parturients, occurring in approximately one in 1000 deliveries, manifesting during the last few months or the first 5 months of the postpartum period. It can result in severe ventricular dysfunction during late puerperium. The major concern while managing these patients is to optimize fluid administration and avoid myocardial depression, while maintaining stable intraoperative hemodynamics. We present a case series of five parturients that were posted for elective cesarean section and managed successfully by the epidural volume extension technique.

Kounis syndrome resulting from anaphylaxis to diclofenac

“Kounis syndrome” refers to acute coronary syndromes of varying degree (myocardial ischaemia to infarction) induced by mast cell activation as a result of allergic and anaphylactic reactions. ST-segment elevated myocardial infarction is a rare complication that can occur even in patients with normal coronary arteries due to anaphylactic reactions. We present a case that developed acute myocardial infarction following a diclofenac sodium-induced anaphylaxis. The patient did not have any previous coronary artery disease, but there was a temporal relationship with development of the anaphylactic reaction due to diclofenac sodium and the cardiac event. The patient was managed conservatively and the recovery was uneventful.

Anesthetic considerations and airway management in a professional singer: case report and brief review

To the Editor, A 64-yr-old male professional opera singer scheduled to undergo a lumbar laminectomy for spinal stenosis was very anxious about the potential for postoperative voice changes that might threaten his career. His medical history was relatively non-contributory except for gastroesophageal reflux disease (GERD) that was controlled with oral pantoprazole 40 mg. The patient’s airway was normal: Mallampati class 2, a 4-cm mouth opening, and normal neck movement. After standard monitoring was applied, anesthesia was induced with propofol (2 mg kg iv), fentanyl (2 lg kg iv), and rocuronium (0.6 mg kg iv), and following confirmation of complete neuromuscular blockade (absence of train-of-four stimulation), the patient’s trachea was intubated with a size 7.0 mm cuffed endotracheal tube (ETT) using a C-MAC video laryngoscope (Karl Storz & Co, Tuttlingen, Germany). The ETT cuff was inflated with the minimal amount of air (3.5 mL) required to obtain a seal. Endotracheal tube cuff pressure measurement, although ideal, was not done in our case. Anesthesia was maintained using an air/oxygen mixture (FIO2 = 0.50) and 1.0 MAC sevoflurane, and the patient also received intravenous dexamethasone 8 mg for postoperative nausea and vomiting (PONV) prophylaxis and to minimize postoperative airway edema. With the ETT well secured, the patient was turned to the prone position with attention paid to keeping his head and neck in a neutral position to minimize any ETT movement. No further muscle relaxants were used intraoperatively in order to allow electromyographic monitoring. Intraoperative blood loss was minimal and Plasma-Lyte A 800 mL was administered during the two-hour case. Prior to the end of the case, ondansetron (4 mg iv) was administered for further PONV prophylaxis. At the conclusion of the case, the patient was turned to the supine position, and the ETT was removed while the patient was deeply anesthetized and apneic. After gentle suctioning, bag mask ventilation was instituted until recovery of spontaneous respiration, and patientcontrolled analgesia was utilized for postoperative pain control. Postanesthesia follow-up occurred in the immediate postoperative period and on days 1, 2, and 7. Apart from slight hoarseness confined only to the first postoperative day, the patient experienced no noticeable change in voice quality. Dysphonia (i.e., hoarseness) is one of most common postoperative complications after general anesthesia using tracheal intubation, with a reported incidence of 16-55 %. The important risk factors that could potentially lead to an increased risk of postoperative hoarseness include the size of ETT, intubation trauma, pre-existing vocal cord pathology, perioperative coughing and bucking on the tube, insertion of a nasogastric tube, history of GERD, high ETT cuff pressure, and the duration of surgery. Hoarseness is often temporary and rarely requires any specific investigation or treatment. In certain cases, however, it could be permanent or prolonged, lasting up to six months after the surgery. Thus, anxiety concerning its occurrence is not unusual in professional voice users (e.g., singers, actors etc.). Airway management in such professionals presents a challenge for anesthesiologists, particularly as intubation had been linked to hoarseness. Use of regional anesthesia should be carefully considered where appropriate. The type of airway device, i.e., an ETT A. K. Tiwari, MBBS D. T. Wong, MD L. Venkatraghaven, MD (&) Department of Anesthesia, Toronto Western Hospital, Toronto, ON, Canada e-mail: lashmi.venkatraghavan@uhn.on.ca

Effect of oral clonidine, etoricoxib, and gabapentin as premedication on sensory and motor blocks and post operative analgesia in surgeries under subarachnoid block using bupivacaine.

Oral premedicant has better patient compliance since it avoids a potential needle prick, and hence can be considered closest to an ideal premedicant. This was a randomized prospective observational study on 120 patients after obtaining ethical committee approval and valid informed consent from patients to be part of the study. We assessed the onset and duration of both sensory and motor blocks along with postoperative analgesic requirement by the patient in terms of first dose and total dose required over the period of 24 hours. It is recommended that clonidine, etoricoxib, and gabapentin be considered as good premedicants for patients undergoing surgery under spinal anesthesia. However, more research using these drugs needs to be carried out in the field of premedication.

Procedural Sedation and Analgesia in Emergency Department

Balwinder Singh1, Akhilesh Kumar Tiwari3, Sanjay Kumar Verma2, Pedro Whatts4, Dipti Agarwal5 and Subhash Chandra6 1Division of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; 2Department of Anesthesia, All India Instituteof Medical Sciences (A.I.I.M.S.), New Delhi, 3Department of Anesthesia, St. Stephen’s Hospital New Delhi, 4Department of Anesthesia, Saint Luke’s Episcopal Hospital, Ponce, 5Department of Emergency Medicine, Mayo Clinic, Rochester, MN 6Department of Medicine, Greater Baltimore Medical Center, Towson, MD 1,5,6USA 2,3India 4Puerto Rico

Accuracy in blood pressure monitoring: The effect of noninvasive blood pressure cuff inflation on intra-arterial blood pressure values

Context: Both invasive and noninvasive blood pressure (invasive arterial blood pressure [IABP] and noninvasive BP [NIBP]) monitors are used perioperatively; however, they often produce different values. The reason for this discrepancy is not clear, and it is possible that the act of cuff inflation itself might affect the IABP values, especially with the recurrent cycling of NIBP cuff. Aim: The aim of this study was to determine the effect of ipsilateral NIBP cuff inflation on the contralateral IABP values. Settings and Designs: Prospective, observational study. Materials and Methods: One hundred consecutive patients were studied. The NIBP device was set to cycle every 5 min for a total of 6 times. During each cuff inflation cycle, changes in IABP values from the arterial line in the contralateral arm were recorded. A total of 582 measurements were included for data analysis. Statistical Analysis: Chi-square, paired t-test, analysis of variance. Results: Mean (± standard deviation) changes in systolic BP (SBP), diastolic BP, and mean BP with cuff inflation were 6.7 ± 5.9, 2.6 ± 4.0, and 4.0 ± 3.9 mmHg, respectively. We observed an increase of 0–10 mmHg in SBP in majority (73.4%) of cuff inflations. The changes in IABP did not differ between the patients with or without hypertension or with the baseline SBP. Conclusions: This study showed that there is a transient reactive rise in IABP values with NIBP cuff inflation. This is important information in the perioperative and intensive care settings, where both these measurement techniques are routinely used. The exact mechanism for this effect is not known but may be attributed to the pain and discomfort from cuff inflation.