Gaurav Chauhan

Comparison of clinical performance of the I-gel with LMA proseal

Aim: To compare insertion characteristics of 2 different supraglottic devices [I-gel and Proseal laryngeal mask airway (PLMA)] and to observe any associated complications. Study Design: This prospective, randomized study was conducted in 80 patients [Group I - I-gel insertion (n = 40) and Group P - LMA Proseal insertion (n =40)] of ASA grades I/II, of either sex in the age group 18-65 years. Both groups were compared with respect to ease of insertion, insertion attempts, fiberoptic assessment, airway sealing pressure, ease of gastric tube placement, and other complications. Materials and Methods: All patients were asked to fast overnight. Patients were given alprazolam 0.25 mg orally at 10 p.m. the night before surgery and again 2 hours prior to surgery with 1-2 sips of water. Glycopyrrolate 0.2 mg, metoclopramide 10 mg, and ranitidine 50 mg were administered intravenously to the patients 45 minutes prior to the surgery. Once adequate depth of anesthesia was achieved either of the 2 devices, selected using a random computerized table, was inserted by an experienced anesthesiologist. In group I, I-gel was inserted and in patients of group P, PLMA was inserted. Statistical Analysis: Student t-test and Mann-Whitney test were employed to compare the means; for categorical variables, Chi-square test was used. Result: Mean insertion time for the I-gel (11.12 ± 1.814 sec) was significantly lower than that of the PLMA (15.13 ± 2.91 sec) (P = 0.001). I-gel was easier to insert with a better anatomic fit. Mean airway sealing pressure in the PLMA group (29.55 ± 3.53 cm H2O) was significantly higher than in the I-gel group (26.73 ± 2.52 cm H2O; P = 0.001). Ease of gastric tube insertion was significantly higher in the I-gel group (P = 0.001). Incidence of blood staining of the device, sore throat and dysphagia were observed more in PLMA group. No other complications were observed in either of the groups.

Parsonage-Turner syndrome after interscalene block for diagnostic arthroscopic surgery of shoulder joint

leading to hypersensitivity of the damaged nerves to stretching or pressure.[1] This syndrome can present with sudden-onset pain radiating from the shoulder to the upper arm, followed by weakness and numbness. Subsequently, there is generally a phase in which there is no pain while resting but, with specific movements or positions, sudden sharp shooting pain can occur, which subsides within a couple of hours. Affected muscles become weak and atrophied, and in advanced cases, paralyzed.[2] The most common presentation is involvement of nerves of brachial plexus, but the nerves of upper and lower legs and feet, diaphragm or the vocal cords, skin and muscles of the abdomen, muscles of the face and ear and organ of Corti can also be affected.[3] Surgery, trauma, or exhausting exercise, infection, vaccinations, and treatments with blood products or immunotherapy could be predisposing factors. Although it is a well-documented entity with autosomal dominant variant, to our knowledge, there are few reported cases of PTS precipitated by interscalene block in a healthy adult in anesthesia literature. Tetzlaff et al.[4] have reported a case of idiopathic brachial plexitis after total shoulder replacement for osteoarthritis with interscalene brachial plexus block in a 65-year-old hypothyroid patient. Provisional diagnosis is based on thorough history and examination and appearance of a sudden and severe shoulder and upper arm pain, paralysis, and amyotrophy. Accurate diagnosis can be challenging, but nerve conduction velocity and imaging studies assist in the evaluation.[5] Although the mechanisms of this injury are unclear, the potential preexisting occult pathology of the peripheral nervous system may have predisposed him to development of a peripheral autoimmune injury leading to a brachial neuritis. Treatment is symptomatic and requires combination of a long-acting nonsteroidal anti‐inflammatory drug (NSAID) with long‐acting opioids for acute phase. A short therapy of oral prednisone along with immunoglobulin therapy has a favorable effect in some cases.[6] Later on, during the chronic phase of the disease, patient may require psychotherapy to cope with psychological trauma of chronic pain and chiropractic care or physiotherapy to regain function in the limb and to prevent contractures. Patients and physicians may misunderstand the persistence of pain and paresthesias in the early postoperative period to be a reflection of poor surgical sequelae or anesthetic complication. Sir,

Intra-operative Tako-tsubo cardiomyopathy during carotid body tumor excision: An indication for therapeutic use of Levosimendan

Dear Editor, An 80 kg, 52-year-old woman, in American Society of Anesthesiologists class 2, was scheduled for excision of a chemodectoma. Pre-anesthetic examination and relevant investigations were unremarkable, and vital parameters recorded were within normal limits. In the operating room, patient was administered cefuroxime 1.5 g, ranitidine 50 mg, and metoclopramide 10 mg intravenous (IV). General anesthesia was induced with midazolam 1.5 mg, fentanyl 120 mcg, and propofol 160 mg IV. Neuromuscular blockade was achieved with vecuronium 7 mg IV. Anesthesia was maintained as per standard protocol of our institution. One hour into surgery as the tumor was manipulated, the patient developed asystole. Cardiopulmonary resuscitation was initiated immediately according to advanced cardiac life support (ACLS) protocol and after 2 cycles of cardio-pulmonary resuscitation (CPR), the heart was revived. Electrokardiogram (EKG) showed deep T-wave inversion, and central venous pressure was 26 cms of H2O. Vasopressor and inotropic support (dopamine, dobutamine, and adrenaline) was administered to maintain blood pressure within optimum limits.

Effect of intraoperative intravenous crystalloid infusion on post-operative nausea and vomiting after diagnostic gynaecological laparoscopy: Comparison of 30 ml/kg and 10 ml/kg and to report the effect of the menstrual cycle on the incidence of post-operative nausea and vomiting.

Aim: Primary To compare effect of 30 ml/kg and 10 ml/kg crystalloid infusion on post-operative nausea and vomiting after diagnostic gynaecological laparoscopy. Secondary To correlate incidence of post-operative nausea and vomiting associated with different phases of menstrual cycle. Study Design: This prospective, randomized, double blinded study was conducted in 200 patients [Group I - 10 ml.kg-1 crystalloid infusion (n = 100) and Group II - 30 ml.kg-1 crystalloid infusion (n = 100)] of ASA grades I/II, of either sex in the age group 20-40 years undergoing ambulatory gynaecological laparoscopic surgery. Both groups were compared with respect to post-operative nausea vomiting, hemodynamic parameters and incidence of post-operative nausea and vomiting associated with different phases of menstrual cycle. Statistical Analysis: Data for categorical variables and continuous variables are presented as proportions and percentages and mean ± SD, respectively. For normally distributed continuous data, the Student t test was used to compare different groups. Categorical data were tested with the Fisher exact test. Pearson or Spearman correlation coefficients for data normally distributed and not normally distributed, respectively, were used to evaluate the relation between 2 variables. P values < 0.05 were considered statistically significant. Results: In the first 4 h after anaesthesia, the cumulative incidence of nausea and vomiting in Group I was 66% as compared to 40% in Group II (P value = 0.036, *S). Anti-emetic use was less in the group II as compared to Group I (13% vs. 20%, P = 0.04). Female patients in the menstrual phase experienced nausea and vomiting in 89.48% of cases as compared to 58.33% and 24.24% during proliferative and secretory phases of menstrual cycle, respectively.

Metoclopramide-induced akathisia

Intraoperative venous gas embolism is a dreaded complication that can have catastrophical consequences. It produces the characteristic ‘Mill-Wheel’ murmur, but can be more accurately diagnosed by precordial Doppler or transthoracic and transesophageal echocardiography. However, they may not be immediately available and precious time may be lost in procuring them. The hypoxia and desaturation, which usually accompanies air or carbon dioxide embolism, may not be seen in the case of oxygen embolism as the oxygen microbubbles that mix with the venous blood in the right atrium and ventricle may produce mechanism of gas exchange similar to that seen in bubble type oxygenators used for cardio-pulmonary bypass machine.[5] We feel that H2O2 is being used with little knowledge of its inherent risks.[5] In view of possible oxygen embolism, H2O2 should be used cautiously and the patient should be monitored to detect early gas embolism.

Anesthetic management of patient with systemic lupus erythematosus and thrombocytopenia for vaginal hysterectomy

We report a case of a female having systemic lupus erythematosus, who was on steroid therapy and was scheduled for vaginal hysterectomy. She presented with breathlessness on mild exertion, a characteristic facial malar rash, and a platelet count 56,000 cells/cu mm. The patient was given a subarachnoid block with 2.8 ml 0.5% bupivacaine heavy in L3–L4 intervertebral space. Inj. Hydrocortisone 25 mg was given I.V. intraoperatively and repeated every 6 hours for 24 hours. Anesthetic management included considerations of systemic organ involvement, thrombocytopenia, and perioperative steroid replacement. Spinal block can be given with platelet count > 50,000/cumm. Strict asepsis should be maintained for invasive procedures. Maintenance of normothermia decreases the impact of Raynauds phenomenon.