Anil P Singh

Spinal cord injury without radiographic abnormality

Spinal cord injury without radiological abnormality is rare in adults. Below we present a case report of 20 yrs old male with isolated cervical cord injury, without accompanying vertebral dislocation or fracture involving the spinal canal rim. He fell down on plain and smooth ground while carrying 40 kg weight overhead and developed quadriparesis with difficulty in respiration. Plain radiographs of the neck revealed no fractures or dislocations. MRI showed bulky spinal cord and an abnormal hyper intense signal on the T2W image from C2 vertebral body level to C3/4 intervertebral disc level predominantly in the anterior aspect of the cord The patient was managed conservatively with head halter traction and invasive ventilatory support for the initial 7 days period in the ICU. In our patient recovery was good and most of the neurological deficit improved over 4 weeks with conservative management.

Ultrasonography: A novel approach to central venous cannulation

Background: Portable ultrasound machines are highly valuable in ICUs, where a patients condition might not permit shifting the patient to the USG department for imaging. Traditionally central lines are put blindly using anatomical landmarks, which often result in complications such as difficulty in access, misplaced lines, pneumothorax, bleeding from inadvertent arterial punctures, etc. Ultrasonography provides “real time” imaging, i.e., the needle can be visualized entering the vein. Aims: We performed a study to compare USG guided central venous cannulation (CVC) and conventional anatomical landmark approach to CVC, in terms of ease of cannulation, time consumed, and associated complications. Settings and Design: The study was performed in a 16-bed open ICU. Eighty patients were randomly divided in two groups. Materials and Methods: The right internal jugular vein (IJV) was cannulated in all. In Group I, a portable ultrasound machine was used during cannulation. The vessels were visualized in the transverse section with the internal carotid artery (ICA) identified as a circular pulsatile structure, while the IJV as a lateral, oval nonpulsatile structure). The needle was inserted perpendicular to the skin under visualization on the US screen. Central venous line was then inserted by the Seldinger technique. In Group II, CVC was performed by the conventional landmark approach. The parameters studied included time for insertion, attempts required, and complications encountered. Statistical Analysis: The database of all parameters was analyzed using SPSS software version 10.5. Results: The mean time to successful insertion was 145 and 176.4 sec in groups I and II, respectively (p = 0.00). An average of 1.2 attempts per cannulation was required for group I, while 1.53 for group II (p = 0.03): 10% witnessed arterial puncture and 2.5% pneumothorax in group I and none in group II. Conclusion: USG-guided CVC is thus easier, quicker, and safer than landmark approach.

Cervical Epidural Anesthesia: A Safe Alternative to General Anesthesia for Patients Undergoing Cancer Breast Surgery

BackgroundGeneral anesthesia (GA) is the standard anesthesia for patients undergoing modified radical mastectomy (MRM) for breast cancer. Cervical epidural anesthesia (CEA) is practiced less often because of its reported complications. This prospective study aimed to evaluate the safety and efficacy of CEA as an anesthetic technique for MRM.Patients and MethodsFifty breast cancer patients with ASA (American Society of Anesthesiologists) grade I or II underwent MRM under CEA from September 2004 to January 2006. Anesthesia was induced with 10 ml of 1% lignocaine; adrenaline was administered through an 18-gauge catheter in C6–C7 or C7–T1 epidural space. Postoperative analgesia was maintained with 0.125% bupivacaine through the epidural catheter.ResultsIn 49 (98%) patients surgery was conducted smoothly under CEA with good analgesia. 44 patients were awake during surgery. Five patients had to be given intravenous sedation with midazolam, and in one case the procedure was terminated after accidental dura puncture. There were no clinically significant variations in perioperative pulse and respiratory rate, and there was no fall in mean arterial blood pressure during the procedure. The mean preoperative anesthesia time and total cost of the procedure was 20.36 + 2.75 minutes and 12.19 + 2.2£, respectively. All patients were started on a liquid diet and mobilized 4 hours after surgery.ConclusionsCervical epidural anesthesia is a safe alternative to GA and was preferred by our patients because of its lower cost and reduced perioperative morbidity.

Comparative Evaluation of Oxygen-Ozone Therapy and Combined Use of Oxygen-Ozone Therapy with Percutaneous Intradiscal Radiofrequency Thermocoagulation for the Treatment of Lumbar Disc Herniation

Aim:  To compare the efficacy of oxygen‐ozone therapy and the combined use of oxygen‐ozone therapy with percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) for the treatment of contained lumbar disc herniation.

Nebulised fentanyl for post-operative pain relief, a prospective double-blind controlled randomised clinical trial.

Background and Aim: Intravenous (IV) route for fentanyl administration is the gold standard for post-operative pain relief, but complications such as respiratory depression, bradycardia and hypotension have limited this route. The aim of this randomised controlled trial was to compare the efficacy of nebulised fentanyl with IV fentanyl for post-operative pain relief after lower abdominal surgery. Methods: In the post-operative care unit, at the time of first onset of pain (visual analogue scale- VAS score > 4) patients were randomised into three groups and fentanyl was administered either IV 2 μg/kg or by nebulisation of solution containing 3 or 4 μg/kg fentanyl over 8 min in 90 patients divided into three groups of 30 each. Observation were made for pain relief by visual analogue scale score 0-10. Adverse effects such as respiratory depression, bradycardia and hypotension were also recoded. Statistical analysis was performed using Medcalc software version 12, 2012. (MedCalc Software, Ostend, Belgium). Results: In the nebulisation group, it was observed that the analgesic efficacy of fentanyl was dose dependent with a delayed onset of analgesia (10 min vs. 5 min). Nebulisation with 4 μg/kg fentanyl produced analgesia at par to 2 μg/kg IV fentanyl with prolonged duration (90 min vs. 30 min) and with significantly less adverse effects. Conclusions: This study shows that nebulisation with 4 μg/kg fentanyl may be used as an alternative to IV 2 μg/kg fentanyl for adequate post-operative pain relief.

A comparative study of continuous versus pulsed radiofrequency discectomy for management of low backache: Prospective randomized, double-blind study

Background: Radiofrequency (RF) is a minimally invasive target-selective technique that has been used with success for many years in the treatment of different pathologies, such as low back pain, trigeminal neuralgia, and others. Aim: The aim of this study is to compare different mode of RF - continuous RF (CRF) versus pulsed RF (PRF) along with steroid in the management of low back pain of discogenic origin. Setting and Design: Prospective, randomized, double-blind trial. Materials and Methods: Forty patients with chronic discogenic low back pain were randomized to receive CRF plus intradiscal triamcinolone 40 mg (Group 1) or to receive PRF plus intradiscal triamcinolone 40 mg (Group 2). Outcome measured includes immediate as well as long-term pain relief using visual analog scale, the Oswestry Disability Index and straight leg raising test. Statistical Analysis: The continuous variables were compared by one-way analysis of variance test. Discrete variables were compared by Fishers exact test/Chi-square test/Students t-test, whichever appropriate. The value of P< 0.05 was considered statistically significant. Results: There was a significant decrease in pain score after CRF without any added side effect. Pain relief after PRF was insignificant. Conclusion: CRF with steroid seems to be better for treatment of chronic discogenic low back pain than PRF with steroid.

Efficacy of ultrasound-guided mandibular block in predicting safer anesthetic induction

Background: Mandibular nerve block reverses the trismus caused by pain and muscle spasm, thereby allowing for selection of a safer intubation technique. Aims: As ultrasonographic imaging has added newer dimensions to clinical anesthesia practice, we utilized this tool in performing mandibular nerve block and evaluated its efficacy in segregating trismus patients on etiological basis, to predict safer anesthetic induction. Settings and Design: Prospective, randomized controlled, outcome assessor blinded trial. Materials and Methods: Sixty-eight patients with unilateral mandibular fracture, acute pain, and trismus were randomized to receive mandibular nerve block by Vazirani-Akinosi approach (Group V) or the ultrasound-guided (USG) technique (Group U) before the general anesthetic induction for corrective surgery. Visual Analog Scale (VAS) score and inter-incisor distance was measured at intervals. Primary outcome measure was blocked failure (continued pain [VAS > 30] after the block procedure). Statistical Analysis Used: Mann–Whitney U-test and Wilcoxon signed rank test. Results: There was a significant decrease in pain score following the block procedure, except for six patients (block failure) in Group V. Inter-incisor distance increased to near-maximal levels after the nerve blockade, except for nine patients in Group V (including all block failures) and four in Group U having continued limited mouth opening. General anesthetic induction increased the inter-incisor gap in block failures (Group V) only. Conclusion: USG mandibular block appears to relieve reversible trismus more reliably, thereby allowing for a precise decision on a safer intubation technique.

Postoperative analgesic efficacy of epidural tramadol as adjutant to ropivacaine in adult upper abdominal surgeries

Background: Postoperative pain control after major abdominal surgery is the prime concern of anesthesiologist. Among various methodologies, epidural analgesia is the most preferred technique because of the excellent quality of analgesia with minimum side-effects. Aim: The present study was designated to compare postoperative analgesic efficacy and safety of epidural tramadol as adjuvant to ropivacaine (0.2%) in adult upper abdominal surgery. Settings and Design: Prospective, randomized-controlled, double-blinded trial. Materials and Methods: Ninety patients planned for upper abdominal surgery under general anesthesia were randomized into three equal groups to receive epidural drug via epidural catheter at start of incisional wound closure: Group R to receive ropivacaine (0.2%); Group RT1 to receive tramadol 1 mg/kg with ropivacaine (0.2%); and RT2 to receive tramadol 2 mg/kg with ropivacaine (0.2%). Duration and quality of analgesia (visual analog scale [VAS] score), hemodynamic parameters, and adverse event were recorded and statistically analyzed. Statistical Analysis: One-way analysis of variance test, Fishers exact test/Chi-square test, whichever appropriate. A P < 0.05 was considered significant. Results: Mean duration of analgesia after epidural bolus drug was significantly higher in Group RT2 (584 ± 58 min) when compared with RT1 (394 ± 46 min) or R Group (283 ± 35 min). VAS score was always lower in RT2 Group in comparison to other group during the study. Hemodynamic parameter remained stable in all three groups. Conclusion: We conclude that tramadol 2 mg/kg with ropivacaine (0.2%) provides more effective and longer-duration analgesia than tramadol 1 mg/kg with ropivacaine (0.2%).

Neonate with omphalocele and dextrocardia: Anaesthetic goals and challenges

Omphalocele and gastroschisis are the two common congenital malformations of the anterior abdominal wall. Omphalocele can be associated with other congenital anomalies such as cardiac anomalies. Association of omphalocele with dextrocardia has been reported in few literatures previously. We describe here such a rare association of omphalocele, dextrocardia with patent ductus arteriosus with a brief review on the anesthetic challenges in the perioperative period.

Comparative evaluation of cost effectiveness and recovery profile between propofol and sevoflurane in laparoscopic cholecystectomy.

Background : Anesthetic agents should be chosen not only on the basis of safety-efficacy profile, but also on the economic aspect. Propofol and sevoflurane are commonly utilized anesthetic agent for general anesthesia. Aim: The present study was designated to compare cost-effectiveness and recovery profile between propofol and sevoflurane for induction, maintenance or both. Settings and Design: Randomized controlled, participant and data operator blinded trial. Materials and Methods: Ninety patients undergoing laparoscopic cholecystectomy were randomized into three equal groups to receive: Group P to receive injection propofol for both induction and maintenance; Group PS to receive injection propofol for induction and sevoflurane for maintenance; and Group S to receive sevoflurane for both induction and maintenance of general anesthesia, respectively. Cost analysis, hemodynamic parameter, and recovery profile were compared between these groups. Statistical Analysis: One-way analysis of variance test or Fisher′s exact test/Chi-square test whichever appropriate. Results: Total cost of anesthesia was highest in Group P and lowest in Group S. Mean time to extubation and time to follow verbal commands was lowest in Group S than Group P or Group P/S. Hemodynamic parameter was more stable in Group S. Conclusion: We conclude that sevoflurane appears to be better anesthetic agents in terms of cost-effectiveness and recovery profile.