Arvind Chaturvedi

Effect of preemptive gabapentin on postoperative pain relief and morphine consumption following lumbar laminectomy and discectomy: a randomized, double-blinded, placebo-controlled study.

Synergism between gabapentin and morphine in treating incisional pain has been demonstrated in animal experiments and clinical studies. The efficacy of gabapentin for treatment of perioperative pain remains controversial. This study was designed to detect the influence of gabapentin premedication on morphine consumption in the immediate postoperative period in patients undergoing lumbar laminectomy and discectomy. Either gabapentin 800 mg (in two equally divided doses) or placebo was given preoperatively to 60 adult patients undergoing elective lumbar laminectomy or discectomy in a double-blinded, placebo-controlled, randomized study. Standard general anesthesia was given to all the patients. Morphine was administered via patient-controlled analgesia pump in the immediate postoperative period for first 8 hours. Pain at rest and on movement was assessed using a Verbal Rating Scale (VRS) every 2 hours for the first 8 postoperative hours. There were no differences in demographics or surgical duration between the two groups. The amount of fentanyl administered in the intraoperative period was similar between the two groups. In the postoperative period, the VRS score for pain at 0, 2, 4, 6, and 8 hours was not significantly different between the two groups. Highest median VRS score was recorded at 0 hours postoperatively in both groups (VRS: rest = 6, movement = 8 in placebo group; rest = 6, movement = 8 in gabapentin group). Total morphine consumption and side effects were similar in the two groups. Gabapentin does not decrease the morphine requirement or morphine side effects in the immediate postoperative period following lumbar laminectomy and discectomy.

Catheter malplacement during central venous cannulation through arm veins in pediatric patients.

For successful catheter placement, central venous cannulation (CVC) through internal jugular vein and subclavian vein has been recommended in both adult and pediatric patients. But it carries a risk of serious complications, such as pneumothorax, carotid, or subclavian artery puncture, which can be life-threatening, particularly in critically ill children. So a prospective study was carried out to determine the success rate of correct catheter tip placement during CVC through antecubital veins in pediatric neurosurgical patients. A total of 200 pediatric patients (age 1-15 years) of either sex were studied. Basilic or cephalic veins of either arm were selected. All the patients were cannulated in the operation room under general anesthesia. Single lumen, proper size catheters (with stillete) were used for cannulation. The catheter was inserted in supine position with the arm abducted at right angle to the body and neck turned ipsilaterally. The length of insertion was determined from cubital fossa to the right second intercostal space. The exact position of the tip of the catheter was confirmed radiologically in ICU. Correct catheter tip placement was achieved in 98 (49%) patients. Multivariate logistic regression analysis of data shows that there was no statistically significant difference among correct and incorrect catheter tip placement in relation to factors including sex, side of cannulation (left or right), and type of vein (basilic or cephalic). The analysis of correct catheter tip placement in relation to age showed that the highest success rate was achieved in children of age group 6 to 10 years (60.2%) followed by 30.6% in the 11 to 15 year group. The lowest success rate of tip placement of only 9.2% was observed in younger children of age 1 to 5 years, which is statistically significant (P = 0.001). Of 102 incorrect placements reported, 37% were in 1 to 5 year age group versus 9.2% correct tip placements. The most common unsatisfactory placements were either in the ipsilateral internal jugular vein (N = 38, 37.2%) or in the ipsilateral subclavian vein (N = 27, 26.4%). In 10 patients the catheter crossed over to the opposite subclavian vein, in 16 patients the catheter tips were found in the axillary vein, and in 10 patients each the catheter tip was observed in right atrium and right ventricle. No major complication during and following CVC was observed. To conclude, CVC using single orifice catheter through arm veins in pediatric patients is easy to perform, but the proper catheter tip placement is highly unreliable, particularly in younger children 1 to 5 years of age.

Rupture of aorta and inferior vena cava during lumbar disc surgery

SummaryMajor vascular injury during lumbar disc surgery has been recognized as an unusual but well described complication. A potentially fatal outcome can be avoided by a high index of suspicion and an early diagnosis.We present a rare case of aortic and inferior vena caval injury in a 50-year-old female patient undergoing intervertebral disc surgery at lumbar one and two levels. A quick diagnosis and prompt management resulted in a favourable outcome for the patient.

Comparative incidence of cardiovascular changes during venous air embolism as detected by transesophageal echocardiography alone or in combination with end tidal carbon dioxide tension monitoring

The objective of our study was to compare the incidences of cardiovascular disturbance during venous air embolism (VAE) episodes detected using transesophageal echocardiography (TEE) and end tidal carbon dioxide (ETCO(2)) tension monitoring. We retrospectively analyzed the anesthesia records of patients who underwent posterior fossa surgery while in the sitting position and who were simultaneously monitored using both TEE and ETCO(2) tension monitoring. Data on the occurrence of VAE and the cardiovascular changes associated with it were recorded. Patients were divided into the ETCO(2)-positive group (both TEE and ETCO(2) tension monitoring indicated VAE) and the ETCO(2)-negative group (TEE alone indicated VAE, no significant drop in ETCO(2)). No instances of cardiovascular disturbance were detected in the ETCO(2)-negative group, whereas the incidences of tachycardia and hypotension were 20% and 30%, respectively, in the ETCO(2)-positive group. None of the episodes of VAE detected by TEE (without a fall in ETCO(2)) were clinically significant. We conclude that ETCO(2) monitoring is sensitive enough to detect hemodynamically significant VAE episodes.

Both clonidine and metoprolol modify anesthetic depth indicators and reduce intraoperative propofol requirement

PurposeBeta-blockers have been used in the past to decrease the depth of anesthesia, but the results are conflicting. However, beta-blockers are known to suppress electroencephalographic activities. This study was carried out to assess the effect of metoprolol on anesthetic depth indicators. We also compared the effect of metoprolol in reducing propofol requirements.MethodsNinety healthy adult patients undergoing peripheral nerve injury repair were enrolled in three groups to receive either: a tablet containing clonidine 200 μg, a tablet containing metoprolol tartrate 100 mg, or a placebo; 1 h prior to surgery. Standard anesthesia technique was followed. The bispectral index was monitored to guide propofol infusion and was maintained between 40 and 60. The total duration of anesthesia and surgery, and the total propofol consumption, were noted.ResultsDemographic variables were comparable in all three groups. Significantly less propofol was consumed by patients in the clonidine and metoprolol groups in comparison to that in the placebo group (P < 0.001). Heart rate and mean blood pressure values differed significantly in the placebo group in comparison to the values in the other two groups.ConclusionOur study showed that, like clonidine, metoprolol attenuated the hemodynamic response to intraoperative stimuli and also had a sparing effect on the propofol dose requirement.

Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: a retrospective analysis of 95 cases.

BACKGROUND Surgical procedures for correction of craniosynostosis are often performed in pediatric patients who have a small blood volume; it represents major surgery. Literature is scarce on factors affecting blood loss, intensive care unit (ICU) and hospital stay in these patients. OBJECTIVES To identify the factors which directly affect the outcome of craniosynostosis surgery. MATERIALS AND METHODS A detailed review of records pertaining to preanesthetic evaluation, associated anomalies, intraoperative course, and postoperative follow-up was done for patients who underwent craniosynostosis surgery between June 2000 and June 2010. The correlation between different variables was evaluated using Spearmans rank correlation. RESULTS During the study period 95 patients (mean age 29 months, range: 3 months-13 years) underwent corrective surgery for craniosynostosis. Hospital stay was found to be significantly associated with type of surgery and postoperative complications (P<0.001) Factors such as number of associated medical conditions, number of postoperative complications, type of induction of anesthesia, duration of surgery, type of recovery affected the ICU stay in these patients (P = 0.01). CONCLUSION The outcome of patients undergoing craniosynostosis in terms of ICU and hospital stay is affected by the number of medical and postoperative conditions, type of anesthesia induction, duration of surgery and type of recovery.

Locked-in syndrome during stellate ganglion block

Intra-arterial injection of a local anaesthetic during stellate ganglion blockade may cause life-threatening complications. The usual complications are apnoea, unconsciousness and seizures. However, occasionally an unusual complication, ‘locked-in’ syndrome, has also been reported. In this syndrome the patients remain conscious despite their inability to move, breathe or speak. Here we describe a patient who developed features akin to the locked-in syndrome along with severe hypotension and bradycardia, after an injection of only 2 ml of lignocaine during a stellate ganglion block.

Effect of cerebrospinal fluid return on success rate of percutaneous retrogasserian glycerol rhizotomy

Background and Objective Trigeminal neuralgia is a painful syndrome, which has been commonly treated with percutaneous retrogasserian glycerol rhizotomy (PRGR). This study was performed to evaluate the effect of cerebrospinal fluid (CSF) return on the success rate of PRGR. Methods In this retrospective, nonrandomized, observational case series, 100 cases underwent 140 PRGRs under fluoroscopic guidance and were followed up for 6 to 36 months. The results were compared in the presence or absence of CSF return before PRGR. Results The PRGR was successful in 115 procedures (82.1%). CSF return was present in 84 procedures (60%) and, among these, 76 PRGRs (90.5%) produced pain relief. More than 1 year of pain relief without medications was present in 60 of 84 procedures (71.4%). CSF return before PRGR was absent in 56 procedures (40%) and success resulted in 39 procedures (69.6%). Pain relief for more than 1 year without medications was present in 19 procedures (33.9%). The success rate and duration of pain relief was greater in the presence of CSF return compared with absence of CSF return (P ≤ .005). The incidence of complications such as facial dysesthesia (40%), corneal anesthesia (2.8%), herpes simplex (3.5%), and nonbacterial meningitis (0.7%) was not significantly different in 2 groups (P > .05). Conclusion The presence of CSF is an important factor in determining the success rate and duration of pain relief of PRGR.

Transient cardiac asystole in transsphenoidal pituitary surgery: a case report.

Unlike other cardiac arrhythmia, asystole during neurosurgical procedures is not reported in the literature. We describe such a case during transsphenoidal pituitary surgery in a patient who was not having any history of associated cardiac problems. Its possible cause in relation to the perioperative sequence of events has been discussed.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases.

Background and Aims: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Methods: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Results: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1-14 days) and mean hospital stay was 7.0 ± 5.0 day (3-30 days). Conclusions: ′Conscious sedation′ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.