Anjolie Chhabra

Anesthetic techniques and postoperative emesis in pediatric strabismus surgery

Background and Objectives: Postoperative emesis after pediatric strabismus surgery continues to be a problem, despite the use of antiemetics. The purpose of this study was to identify an anesthetic technique associated with the lowest incidence of vomiting after pediatric strabismus surgery. Methods: A prospective, randomized, double-blind study was conducted to evaluate the effect of intravenous fentanyl, meperidine, or peribulbar block with propofol infusion on emesis in 105 pediatric patients undergoing strabismus surgery. Anesthesia was maintained with nitrous oxide, oxygen, and propofol infusion. Ketorolac 1.0 mg/kg−1 intramuscular was administered to all patients after induction. Patients were given either a peribulbar block, intravenous fentanyl 2 μg/kg−1, or intravenous meperidine 1mg/kg−1 for perioperative analgesia. The emesis scores were observed for the first 24 hours postoperatively. Results: The incidence of emesis was significantly lower (1 of 35; 2.9%) in the peribulbar group compared with the meperidine group (9 of 35; 25.6%) (P < .01) in the first 24 hours. The fentanyl group had a higher incidence of postoperative vomiting (4 of 35; 11.4%) than did the peribulbar group; the difference, however, was not statistically significant. Conclusion: Among the three techniques, peribulbar block with propofol-based anesthesia is the technique with the lowest incidence of postoperative emesis. Fentanyl-propofol is an equally acceptable alternative; however, meperidine-propofol is associated with a high incidence of postoperative emesis.

A fulminant case of acute respiratory distress syndrome associated with Mycoplasma pneumoniae infection

Acute respiratory distress syndrome (ARDS) caused by mycoplasmas is very rare. This report describes a severe case of atypical pneumonia due to M. pneumoniae in a formerly healthy young woman who developed high grade fever and cough leading to severe disseminated lung disease and finally to fatal ARDS. This case came into picture when killer atypical pneumonia, namely, SARS (severe acute respiratory syndrome), spread very fast from South-Asian countries to the rest of the world. Moreover, the clinical presentation and radiologic features of SARS bear resemblance to the syndrome of atypical pneumonia, which lead us to investigate this case into detail. We suggest that M. pneumoniae infections should be included in the differential diagnosis of pathogens causing ARDS, establishing an early diagnosis may have important therapeutic implications.

Transversus abdominis plane block for laparoscopic inguinal hernia repair: a randomized trial

BACKGROUND Pain after laparoscopic inguinal hernia surgery can be moderate to severe, interfering with return to normal activity. The study aimed to assess the efficacy of bilateral ultrasound-guided (USG) transversus abdominis plane (TAP) block for relieving acute pain after laparoscopic hernia repair as T10-L1 nerve endings are anesthetized with this block. METHODS Seventy-one American Society of Anesthesiologists I to II patients, aged 18 to 65 years, undergoing unilateral/bilateral laparoscopic hernia repair were randomized to port site infiltration (control, 36) and TAP block groups (35). All patients received general anesthesia (fentanyl 2 μg/kg intravenously at induction, 0.5 μg/kg on 20% increase in heart rate or mean blood pressure) and paracetamol 6 hourly. Postintubation, TAP group received bilateral USG TAP block (15-20 mL 0.5% ropivacaine, maximum 3 mg/kg) with 18-G Tuohy needle. Control group had 20 to 30 mL 0.5% ropivacaine infiltrated preincision, at port sites from skin to peritoneum. Postoperative patient-controlled analgesia fentanyl was provided for 6 hours; pain was assessed using 0- to 100-mm visual analog scale (VAS) at 0, 1, 2, 4, 6, and 24 hours and telephonically at 1 week and 3 months. RESULTS Demographic profile of the 2 groups was comparable. Significantly more number of patients required intraoperative fentanyl in the control group (24/36) than in the TAP group (13/35); VAS at rest was lower in TAP than control patients in postanesthesia care unit at 0, 2, 6, and 24 hours (median VAS TAP group: 0, 0, 0, and 0; control: 10, 20, 10, and 10; P= .002, P= .001, P= .001, and P= .006, respectively); P< .01 was considered statistically significant. TAP group had significantly lower VAS on deep breathing at 6 hours and on knee bending and walking at 24 hours and lesser patient-controlled analgesia fentanyl requirement. No significant difference in pain scores was observed at 1 week and 3 months. CONCLUSION TAP block reduced postoperative pain up to 24 hours after laparoscopic hernia repair.

The evaluation of efficacy and safety of paravertebral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy

Background: Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery. Methods: Fifty patients were included in this prospective randomized study and allocated to two groups: Group A (25 patients) receiving general anesthesia alone and Group B (25 patients) receiving nerve-stimulator–guided bilateral thoracic Paravertebral Block (PVB) at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl (0.5 μg/kg) based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia (PCA) morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups. Results: Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A (17.6 μg and 38.6 μg, respectively, P =0.001). PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A (4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P <0.0001 at all intervals). Conclusion: Pre-induction PVB resulted in improved analgesia for 24 hours following laparoscopic cholecystectomy in this study, along with a significant reduction in perioperative opioid consumption and opioid-related side effects.

Atropine-induced lens extrusion in an open eye surgery

A 2‐month‐old male baby undergoing penetrating keratoplasty (PKP) under general anesthesia developed bradycardia and a decrease in heart rate to 53 b·min−1 when stay sutures were taken through the superior and inferior rectii. A bolus of 0.1 mg intravenous atropine resulted in tachycardia of up to 180–220 b·min−1, which persisted for 35 min. After corneal trephination was performed the eyeball seemed to pulsate with the heartbeat. Spontaneous extrusion of the lens and vitreous occurred, which necessitated a lensectomy and vitrectomy in addition to PKP. The role of atropine in corneal transplant surgery is discussed here.

Entropy monitoring decreases isoflurane concentration and recovery time in pediatric day care surgery ‐a randomized controlled trial

Aim:  To assess if titrating anesthesia with entropy would result in faster awakening in children undergoing day care surgery.

Comparison of topical lignocaine gel and fentanyl for perioperative analgesia in children undergoing cataract surgery.

Background:  Opioids continue to remain the primary analgesics in children undergoing ophthalmic surgery, and their use may be associated with adverse effects like vomiting and respiratory depression. Topical anesthesia avoids these adverse effects and also complications of regional blocks. We designed this study to verify whether topical anesthesia with lignocaine gel is a feasible alternative to intravenous (IV) fentanyl for pediatric cataract surgery.

Postoperative cyanotic breath-holding spells in a child with Worster-Drought syndrome.

We report multiple cyanotic spells in the postoperative period in a child with Worster–Drought syndrome. A male child, 3.5 years old, 12 kg, who had experienced drooling of saliva since birth, was accepted for bilateral submandibular duct translocation and sublingual gland excision. He had delayed milestones (sat at 15 months and walked at 3 years). Difficulty in swallowing resulted in frequent vomiting during feeding and recurrent upper respiratory tract infections (URI). He was fed by his parents and could mainly swallow liquids or semi-solids. He did not require a nasogastric tube or gastrostomy for feeding. There was no history of epigastric pain or discomfort following feeds that would suggest a gastroesophageal reflux disorder. He was unable to protrude his tongue despite there being no tongue-tie. He could not speak despite normal hearing (normal brainstem auditory evoked responses) and communicated with signs. There was no history of seizures. Head noncontrast computerized tomography (NCCT) showed a paucity of periventricular white matter with prominent ventricles, gliotic areas, and bilateral frontoparietal volume loss. Other systems were normal. Before surgery, the patient did not have an URI, and no adventitious sounds were heard on auscultation. In the operating room, after instituting routine monitoring, anesthesia was induced with sevoflurane in oxygen and an IV access was secured. Following the administration of fentanyl and vecuronium, nasotracheal intubation was accomplished using a 4-mm-ID uncuffed endotracheal tube and the oropharynx packed. Paracetamol suppositories (250 ? 170 mg) were inserted rectally. Anesthesia was maintained with oxygen, nitrous oxide, isoflurane, and supplemental doses of fentanyl and vecuronium. The intraoperative period was uneventful, and at the end of surgery, which lasted for 2 h, a nasogastric tube was inserted to facilitate feeding the child after the oral surgery. Neuromuscular blockade was reversed and the trachea extubated once the patient was fully awake and breathing regularly. As he was being shifted out, he sat up and started crying. He held his breath, desaturated, and became cyanosed. Saturation improved on bag-mask ventilation with 100% oxygen. Two similar episodes of desaturation occurred. After the third, a conscious effort was made to avoid any stimulation that could precipitate crying, and he was gently shifted to his mother in the post anesthesia care unit (PACU). On retrospective questioning, the parents admitted that if they force-fed the child, he would have prolonged crying with breath-holding spells; however, there was no history suggestive of cyanosis during these episodes. Worster–Drought syndrome (WDS) is a phenotypically distinct but underdiagnosed form of cerebral palsy first described in 1956 [1]. Patients share features with bilateral congenital perisylvian syndrome, a type of childhood-onset epilepsy [1]. Worster–Drought syndrome is characterized by weakness of the orofacial and bulbar muscles, leading to difficulty in feeding, swallowing, and voluntary lip, tongue, and palate movements. Attempts at feeding can cause choking and A. Chhabra D. K. Baidya Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Seizure disorder leading to apnea and bradycardia in a 9‐year‐old child in immediate postoperative period

Editor’s Note: Pediatric Anesthesia is keen to encourage correspondence and we have a large body of very active letter writers in our specialty. During 2008 a large backlog of letters has accumulated which has led to delay in publication for some authors. Priority is given to letters commenting on previous articles and subsequent author’s replies. In order to be fair to all our correspondents a word limit of 800 words including a maximum of 5 references will be used by the editor as space for the correspondence section is somewhat limited. My aims are to ensure that the letters section remains fresh and interesting and encourages debate. I hope to continue to allow early reporting of innovations, alert readers to unusual adverse events, encourage sharing of good practice and highlight learning points from a broad sweep of clinical practice across the world. Neil S. Morton Editor-in-Chief

Esophageal polyp as a posterior mediastinal mass: Intraoperative dynamic airway obstruction requiring emergency tracheostomy.

Anesthesia in the presence of a mediastinal mass is difficult and challenging as the mass can involve or compress the heart, great vessels, tracheo-bronchial tree and the surrounding structures. We describe a case of severe tracheo-bronchial obstruction requiring emergency tracheostomy during the intraoperative period after an uneventful induction of anesthesia in a patient with a large esophageal polyp presenting as a posterior mediastinal mass.