Debesh Bhoi

Partial facial nerve paralysis after laparoscopic surgery under general anaesthesia.

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Anaesthesia management of caesarean section in a patient with severe factor XI deficiency

Factor XI deficiency is a rare coagulation disorder associated with bleeding tendency and prolonged APTT. Parturients can have increased bleeding during vaginal delivery or cesarean section. Patients with severe factor XI deficiency should receive prophylactic fresh frozen plasma or factor XI transfusion in the peripartum period to maintain a near normal APTT. Limited evidence based on case reports and series is inconclusive as to the choice of anesthesia technique for cesarean section. We describe the anesthesia management of a parturient with severe factor XI deficiency for cesarean section and discuss the relevant literature.

USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: A report of two cases

The postoperative pain management in open thoracotomy is very crucial as the effective analgesia can prevent respiratory and thrombotic complications and lead to early mobilization and discharge. The thoracic epidural analgesia is the gold standard in such surgeries; however, there are few adverse effects such as hypotension, dural puncture, and contralateral block that always warrants safer alternative. Recently, with the advent of ultrasound, the regional anesthetic techniques are getting more popular to avoid such complications. Erector spinae plane (ESP) block is one of the novel techniques that has been described as a safe thoracic paravertebral block. We are reporting here the continuous ESP block as a primary mode of postoperative analgesia which was continued for 48 h. The intraoperative opioid requirement was very less, and the maximum NRS score in postoperative period was 4 at 12 h, which was well managed with multimodal analgesic regimen along with rescue doses of opioid.

Erector Spinae Block a safe, simple and effective analgesic technique for major hepatobiliary surgery with thrombocytopenia

Abstract Hepatobiliary surgeries are associated with severe pain, and coagulopathy. Adequate pain control is vital and difficult to achieve for these patients. Epidural analgesia is considered the routine standard technique for the management of both somatic and visceral pain from major abdominal surgeries until now. However, it is invasive, blind and carries the risk of dural or vascular puncture. Coagulopathy found in patients posted for hepatobiliary surgery further increases the concerns. We found ultrasound guided erector spinae plane block as a safe, simple yet an effective alternative to epidural analgesia for postoperative pain management of hepatobiliary surgeries.

Early diagnosis of a nearly missed complication made by anatomical landmark guided internal jugular vein canulation

Internal jugular vein (IJV) canulation for central venous pressure monitoring or venous access is a routine procedure in the operation theatre. Among the all-anatomical site, right IJV is the most preferred and technically favorable site because of its straight course.1 However complications are not unusual even with expert hands. Various vascular injuries are possible with blind technique. We are reporting an unusual complication of anatomical landmark guided catheter placement. We did not find similar complication in literature review. A 45-year-old male patient (weight 60 kg height 168 cm) with peripheral vascular diseasewas scheduled for aorto-femoral bypass

Fiberoptic intubation with intraoral digital manipulation may be superior to C‐Mac videolaryngoscope in minimizing hypertensive response in cervical paraganlioma of the parapharyngeal area

SIR—A 15-year-old girl, 53 kg, presented with a history of hypertension, sweating, and throbbing headache for the last 7 months. On examination, her blood pressure was 170/98 mmHg, and her pulse was pulse 88 b min . Other systemic examination was unremarkable. Urinary vanilylmandelic acid was positive. However, urinary and serum catecholamines and all other investigations for secondary hypertension were normal. Computed tomography revealed a 5 9 4.2 9 5.9 cm heterogeneously enhancing soft tissue mass arising from the left parapharyngeal space. The mass was extending from the base of skull to the hyoid bone and was occupying the oropharyngeal lumen causing significant luminal compromise. A provisional diagnosis of paraganglioma was made and excision under general anesthesia was planned. The patient was initially started and titrated on prazosin 2 mg tds and amlodipine 5 mg bd followed by atenolol 25 mg bd. Airway examination revealed a lobulated mass arising from left lateral wall of oropharynx behind soft palate and uvula, crossing the midline (Figure 1). All the antihypertensives were continued and alprazolam premedication was used. In the operating room, after attaching routine monitors, midazolam 2 mg and fentanyl 50 lg were given and left radial artery was cannulated. Anesthesia was induced with fentanyl 200 lg, propofol 160 mg, and vecuronium 6 mg. C-Mac videolaryngoscopy (Karl-Storz Endoscopy, Tuttlingen, Germany) was attempted but the mass could not be bypassed. Moreover, there was a hypertensive response (BP 190/110 mmHg) when the laryngoscope blade touched the mass, which was managed with labetalol 20 mg. Oral fiberoptic bronchoscopy (FOB) revealed the mass filling the oropharynx. The bronchoscope was negotiated through the glottis by intraoral digital manipulation and elevation of the mass by the assistant’s fingers. This did not lead to a significant hypertensive response. Surgery proceeded uneventfully. Cervical paraganglioma of the parapharyngeal area associated with secondary hypertension is rare (1) as most of these tumors are nonhormone secreting (2). Twofold problems of difficult airway coupled with risk of hypertensive response during intubation-related tumor manipulation made this case challenging. CMac videolaryngoscope has been reported to be superior to glidescope and even FOB in large parapharyngeal mass (3). However, a heightened hypertensive response to laryngoscopy perhaps precluded application of increased pressure by the laryngoscopist leading to C-Mac failure in this case. Digital elevation and sideways retraction of the mass by using index and middle fingers of the assistant standing at the side created some space to negotiate the FOB. This digital manipulation did not yield significant hemodynamic response to warrant immediate drug administration. However, labetalol injected during previous laryngoscopy could have been contributory. To conclude, laryngoscopy in a possible hormone secreting parapharyngeal mass may lead to heightened hypertensive response by laryngoscope blade just touching the mass even before application of pressure. Use of FOB with careful and gentle intraoral digital manipulation of mass eases intubation along with less hemodynamic response.