Arvind Khare

Heimlich's maneuver-assisted bronchoscopic removal of airway foreign body

Aspiration of foreign bodies (FBs) by children can lead to serious illness and sometimes even death. Bronchoscopic removal of the FB is necessary to prevent from any catastrophic event. Sometimes bronchoscopic removal is not possible due to the larger size of the FB, sharp FB, or long duration FB. Tracheostomy is normally used for the removal of such FBs. The aim of this case report is to highlight the use of Heimlich maneuver for the removal of such FBs before opting invasive procedures. In the present case, a 5-year-old child was presented with history of FB aspiration 5 h back. After multiple failed bronchoscopic attempts to remove the FB it was decided to use Heimlich maneuver in the supine position. A single attempt of Heimlich maneuver expelled the FB into the oral cavity, which was removed by Magills forceps. On repeated bronchoscope check, there was no remnant of FB. Childs further course of stay in hospital was uneventful. In conclusion, Heimlich maneuver may be useful in patient with failed bronchoscope removal of airway FBs before proceeding for tracheotomy or other invasive procedures.

Anaesthetic management of a patient with Jarcho-Levin syndrome

Sir, Jarcho–Levin syndrome (JLS) is a rare, congenital, inherited costovertebral dysplasia with an estimated global incidence of 1/40,000 births.[1,2] Though exact incidence in Indian context is not known, there are few case reports describing it in Indian population.[3] We report a case of JLS, associated anaesthetic challenges and their management. A 12-month-old male child with JLS presented with left inguinal hernia and was scheduled for herniotomy. The history was significant, with presence of abnormal position of lower limbs, protuberant abdomen at birth, recurrent chest infections and cyanosis on crying. The child had short stature with normal limb length, kyphoscoliosis and shield-like chest. His height was 60 cm, arm span 66 cm, upper segment to lower segment ratio 1.2, weight 6.8 kg, length/age below 3 standard deviation (SD) and weight/height within 1 SD. On examination, there was no upper chest movement and slight (1–1.2 cm) lower chest movement with respiration. Mouth opening was 2 cm with bulky tongue, short neck, and restricted neck mobility. Radiography showed fused cervical vertebrae [Figure 1], crowded ribs (crab-like or fan-like) due to posterior fusion, without any intrinsic rib abnormality [Figure 2a] and hemivertebrae (pebble beach) in thoracolumbar spine [Figure 2b]. Abdominopelvic ultrasonography and two-dimensional echocardiogram were normal. Other investigations were within normal limits. Figure 1 X-ray neck lateral view showing fused cervical vertebrae Figure 2 (a) Chest X-ray PA view showing crowding of ribs characteristic ‘crab-like’ appearance of ribs. (b) X-ray thoracic and lumbar spine showing ‘pebble beach’ appearance due to hemi vertebrae Patient was posted for herniotomy; in view of vertebral anomalies, neuraxial blockade was ruled out, and general anaesthesia was planned. Since difficult intubation was anticipated, difficult airway cart was kept ready. Pre-operative oxygen saturation (SpO2) on room air was 90%, pulse rate 130/min and blood pressure 96/70 mm Hg. Intravenous tramadol 12 mg was given as pre-medication through a 24-gauge cannula already in situ. Patient was pre-oxygenated, and SpO2 of 100% was achieved, followed by inhalational induction with halothane and O2. Laryngoscopy was attempted with spontaneous respiration and Cormack and Lehane grade 3 was noted. Patient could be intubated with a 4 mm uncuffed endotracheal tube using stylet; bilateral air entry and tube placement (by capnography) were confirmed. Patient was kept on volume controlled ventilation, and anaesthesia was maintained with O2 and isoflurane. Injection atracurium was used for muscle relaxation. Intraoperative vitals remained stable. After completion of surgery, patient was reversed with injection neostigmine and glycopyrrolate and extubated after return of airway reflexes and adequate muscle power. Post-operative SpO2 was 100% on oxygen by ventimask. Rest of the post-operative period was uneventful and patient was discharged on 3rd post-operative day. On the follow-up after 2 months patient was healthy. Jarcho–Levin syndrome is skeletal dysplasia with a short trunk. It is of two subtypes, spondylothoracic dysostosis (STD) and spondylocostal dysostosis (SCD). Associated anomalies are hernias, neural tube defects, urogenital and anal anomalies.[4] Patients with STD have vertebral anomalies with a ‘fan-like’ or ‘crab-like’ rib configuration, a higher incidence of neural tube defects and a higher mortality rate and inherited in autosomal recessive manner. SCD patients have vertebral anomalies with marked intrinsic rib abnormalities such as absent ribs, abnormal orientation, irregularity of shape and size, bifurcation, broadening, fusion of ribs, etc. They are often short statured, have higher survival rate, less likely to have associated neural tube defects and inherited in either autosomal recessive or autosomal dominant manner.[5] There is no definitive treatment of this syndrome and management is directed towards prevention of respiratory infection and symptomatic support. Our patient had features of STD. This syndrome may pose multiple challenges to anaesthesiologist such as difficulty in airway management, respiratory compromise and problems posed by associated anomalies. As these patients have recurrent respiratory infections, perioperative assessment and management of these complications is of prime importance.[6] Cyanosis while crying in the absence of cyanotic heart disease may be seen due to collapse of the trachea owing to the absence of tracheal cartilaginous rings.[4] Fusion of cervical vertebra and kyphoscoliosis pose a special challenge during airway management and contribute to intubation difficulty. Supraglottic airway devices can be of great help specially in centres without facility for fiberoptic intubation.[7] As we were able to intubate the patient in first go, we did not use supraglottic device. Inhalational induction is preferred as it allows intubation in spontaneously breathing patients. Pre-operative sedatives and opioid analgesics should not be used to avoid respiratory depression. We avoided the use of nitrous oxide as these patients may have associated pulmonary hypertension.[8] Post-operative mechanical ventilation may be needed because of the presence of kyphoscoliosis and decreased chest wall compliance. The perioperative morbidity and mortality of these patients is mainly related to pulmonary consequences of thoracic skeletal dysplasia and associated anomalies. Adequate care during pre-operative period, anaesthetic management and post-operative period are imperative in successful outcomes in patients with Jarcho–Levin syndrome. [This article is devoted to the memory of Dr. Priya Verma.]

Buprenorphine as an adjuvant to 0.5% ropivacaine for ultrasound-guided supraclavicular brachial plexus block: A randomized, double-blind, prospective study

Context: Ultrasound-guided supraclavicular brachial plexus block is ideal for upper limb surgical procedures. Buprenorphine used as an adjuvant to ropivacaine may prolong analgesia. Aims: The aim is to assess the analgesic efficacy and safety of buprenorphine added to 0.5% ropivacaine solution. Settings and Design: This prospective, double-blind, randomized study was conducted on 60 adult patients of the American Society of Anesthesiologists physical Status I and II undergoing various upper limb surgeries under ultrasound-guided supraclavicular brachial plexus block. Subjects and Methods: Patients were allocated into two groups of 30 each to receive either 30 ml 0.5% ropivacaine with 1 ml buprenorphine (0.3 mg) (Group B) or 30 ml 0.5% ropivacaine with 1 ml normal saline (Group C) for supraclavicular brachial plexus block. Onset, duration, and quality of sensory block and motor block; duration of analgesia and side effects were observed. Results: The mean duration of analgesia was significantly longer in Group B (868.2 ± 77.78 min) than in Group C (439.3 ± 51.19 min). The mean duration of motor and sensory block were significantly longer in Group B (451.8 ± 57.18 min) and (525.8 ± 50 min), respectively, than in Group C (320.5 ± 43.62 min) and (373 ± 53.78 min), respectively (P < 0.05). Conclusions: Addition of buprenorphine to ropivacaine for ultrasound-guided supraclavicular brachial plexus block prolonged the duration of sensory and motor blockade and postoperative analgesia without an increase in side effects.

Anaesthetic management in a case of large plunging ranula with difficult airway: A case report

Abstract Plunging ranula is a mucous retention cyst found on the floor of mouth which arises from the submandibular and sublingual salivary glands extending to lateral aspect of neck, which may often cause potential airway obstruction leading to difficulty in airway management. A forty year old female patient was admitted to our hospital with large, painless swelling in the floor of mouth extending to the lateral part of body of mandible and neck. This intraoral swelling distorted the normal airway anatomy thus making airway management difficult as the patient was planned for excision of swelling under general anaesthesia. So we present a case of successful management of a difficult airway by using awake fibre optic intubation in a patient posted for excision of a large plunging ranula under general anaesthesia.

A comparative study of propofol and N2O versus sevoflurane and N2O with respect to haemodynamic response and ease of laryngeal mask airway insertion: a prospective randomized double blinded study

Background: Laryngeal mask airway (LMA) is an accepted airway device for spontaneous and modest positive pressure ventilation. Propofol is widely used Induction agent. Sevoflurane is a newer pleasant volatile anaesthetic with rapid induction and recovery with stable haemodynamics. The aim of this study was to compare propofol and sevoflurane with respect of haemodynamic changes and conditions for LMA insertion. Methods: This study was done on 60 female patients of ASA I, II grade between 20-60 years of age. Patients were randomized into two groups (n=30). All patients were preoxygenated and received inj. fentanyl 2µg/kg. Induction agent was propofol 2.5mg/kg (group P) or sevoflurane 8% with vital capacity breath (group S). Loss of eyelash reflex was the end point of induction. Induction time, conditions for LMA insertion, number of attempts, time of successful LMA insertion and haemodynamic parameters were noted. Results: time for induction and LMA insertion was significantly faster in propofol group than group S (p<0.05). Successful LMA insertion in first attempt was 100% in group P with excellent conditions (score 18) while in group S, it was 86.7% with excellent to satisfactory conditions (score 16-17). A significant fall in mean arterial pressure (p<0.05) was noted in group P while pulse rates were comparable in both groups. Conclusions: Sevoflurane vital capacity breath inhalational induction can be used as an effective alternative to propofol though it requires greater time for LMA insertion but with better haemodynamic stability.

A prospective randomized study for comparison of haemodynamic changes and recovery characteristics with propofol and sevoflurane anaesthesia during laparoscopic cholecystectomies

Background: Day care laparoscopic surgical procedures are rapidly increasing nowadays. Rapid emergence and early recovery from anaesthesia with minimal complications are desired. Both propofol and sevoflurane meet above criteria and established as agents of choice in laparoscopic surgeries for induction and maintenance of anaesthesia. So this study aimed to compare sevoflurane with propofol for intraoperative haemodynamic changes with postoperative recovery profile in patient’s undergone laparoscopic cholecystectomies under general anaesthesia. Methods: In this prospective randomized study, sixty patients of either sex, 18-60 years with ASA grade 1 and 2 scheduled for laparoscopic cholecystectomies under general anaesthesia were randomly allocated into two groups. In Group S, patients were maintained on sevoflurane anaesthesia (0.5-2.5%) while in Group P, patients were maintained with propofol infusion (75-125 µg/kg/min) along with O 2 (50%) and N 2 O (50%).The intraoperative haemodynamic parameters, recovery characteristics and postoperative nausea and vomiting (PONV) were observed in both groups. Results: The mean baseline haemodynamic parameters (HR, SBP, DBP, MBP, SpO 2 and EtCO 2 ) were comparable in both groups, (P>0.05). No significant difference in HR was at observed any time interval, P>0.05, however, SBP, DBP and MBP were significantly lower in propofol group at different time intervals, P<0.05, but clinically not significant and patients remained haemodynamically stable in both groups. The mean time for all recovery characteristics were significantly shorter in sevoflurane group as compared to propofol group, (P<0.01). However the incidence of PONV was significantly more in sevoflurane group. Conclusions: Sevoflurane can be used as an effective alternative to propofol for maintenance of anaesthesia in day care laparoscopic procedures as it has better recovery profile with stable haemodynamic parameters.

Intraoperative wide bore nasogastric tube knotting: A rare incidence

Nasogastric tubes are commonly used in anesthetic practice for gastric decompression in surgical patients intraoperatively. The indications for its use are associated with a number of potential complications. Knotting of small-bore nasogastric tubes is usually common both during insertion and removal as compared to wide bore nasogastric tubes. Knotting of wide bore nasogastric tube is a rare complication and if occurs usually seen in long standing cases. We hereby report a case of incidental knotting of wide bore nasogastric tube that occurred intraoperatively.

Effect of bispectral index versus end-tidal anesthetic gas concentration-guided protocol on time to tracheal extubation for halothane-based general anesthesia

Background and Aims: Early extubation is a desirable goal after general anesthesia. Very few studies have compared the effect of bispectral index (BIS) monitoring versus standard end-tidal anesthetic gas (ETAG) concentration monitoring on tracheal extubation time for halothane-based anesthesia. The aim of this study was to compare the effect of BIS versus ETAG-guided anesthesia on time to tracheal extubation for halothane-based anesthesia in general surgical setting. Methods: This was a randomized, controlled double-blind study. Sixty patients with the American Society of Anesthesiologists physical status Class 1 or 2, receiving halothane-based general anesthesia were randomized to BIS-guided (n = 30) and ETAG-guided anesthesia (n = 30). Time to tracheal extubation was measured. In BIS group, BIS value was kept between 40 and 60 while in ETAG group; ETAG value was kept between 0.7 and 1.3 minimum alveolar concentration. The two groups were compared using Students t-test, and P< 0.05 was considered statistically significant. Data were processed and analyzed using SPSS version 17 software. Results: Mean time to tracheal extubation was significantly longer in BIS group (9.63 ± 3.02 min) as compared to ETAG group (5.29 ± 1.51 min), mean difference 4.34 min with 95% confidence interval (3.106, 5.982) (P < 0.05). Conclusion: In our study, the extubation time was significantly longer in BIS-guided anesthesia as compared to ETAG-guided anesthesia. ETAG monitoring promotes earlier extubation of patients as compared to BIS monitoring during halothane anesthesia.

Anesthetic considerations in a child with unrepaired D-transposition of great arteries undergoing noncardiac surgery.

D-transposition of great arteries (D-TGA) is the most common cyanotic congenital heart disease diagnosed at birth. There is ventriculoarterial discordance leading to parallel circulation. The postnatal survival depends on intercirculatory mixing of oxygenated and deoxygenated blood at various levels through atrial septal defect, ventricular septal defect or patent ductus arteriosus. The anesthesiologist must have an understanding of concepts of shunting and other long-term consequences of transposition of great arteries (TGA) in order to tailor the anesthetic technique to optimize the hemodynamic variables and oxygenation in the perioperative period. The preoperative evaluation includes echocardiography to delineate the type of TGA, associated lesions and extent and direction of shunts. Oxygen saturation is influenced by the ratio of pulmonary vascular resistance (PVR) to systemic vascular resistance. Thus, care should be taken to avoid an increase in PVR which can lead to decreased pulmonary blood flow leading to hypoxia. We report a case of an 8-year-old child with unrepaired D-TGA, who presented to us for craniotomy for drainage of brain abscess.