Gaurav Singh Tomar

Ketotic hyperglycemia with movement disorder

Chorea, hemichorea-hemiballismus and severe partial seizures may be the presenting features of nonketotic hyperglycemia in older adults with type 2 diabetes, but cases in young adults with type 1 diabetes are rare. We hereby report a very rare case of diabetic ketosis with movement disorder in a young patient.

Intrathecal bupivacaine in comparison with a combination of nalbuphine and bupivacaine for subarachnoid block: a randomized prospective double-blind clinical study.

We performed this randomized, prospective double-blind study to evaluate the effects of 2 different doses of intrathecal nalbuphine (a synthetic opioid agonist–antagonist) on the onset, duration of action, side effects, and complication produced by intrathecal hyperbaric 0.5% bupivacaine in lower abdominal, urologic and lower limb surgeries. Seventy-five patients of ASA grades 1 and 2 of either sex in the age group of 20–60 years were randomly allocated to 1 of 3 groups. Group A (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL sterile water intrathecally; group B (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL (200 &mgr;g) nalbuphine intrathecally; group C (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL (400 &mgr;g) nalbuphine intrathecally. The onsets of sensory and motor blockade, highest level of sensory blockade, 2 segment regression time of sensory blockade, duration of motor blockade and analgesia, visual analog scale score, hemodynamic and respiratory changes, side effects were recorded, tabulated, and analyzed. Onsets of sensory and motor blockade and duration of motor blockade were not affected. Two segment regression time of sensory blockade and duration of analgesia were maximally prolonged in group C (P < 0.05). The visual analog scale scores were in the following order: group A > group B > group C at 90, 120, and 150 minutes after induction (P < 0.05). Hemodynamic and respiratory complications were absent except in 2 patients in groups A and C each, and 1 patient in group B developed bradycardia (P > 0.05). One patient in group A had nausea and vomiting, 2 patients in each group developed shivering (P > 0.05). No other side effect or complication was observed. Nalbuphine hydrochloride (400 &mgr;g) significantly prolongs the duration of sensory blockade and postoperative analgesia without any side effect or complication when introduced intrathecally along with hyperbaric bupivacaine.

Myofascial pain syndrome: an overview.

ABSTRACT Over the last few decades, advances have been made in the understanding of myofascial pain syndromes (MPSs). In spite of its high prevalence in the society, it is not a commonly established diagnosis. MPS is said to be the great imitator. This article puts some light on the various clinical presentations of the syndrome, on the various tools to reach to a diagnosis for commencing the treatment and on the treatment modalities that have been used so far.

Anesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: A case series

Peripartum cardiomyopathy is a rare cause of dilated cardiomyopathy in parturients, occurring in approximately one in 1000 deliveries, manifesting during the last few months or the first 5 months of the postpartum period. It can result in severe ventricular dysfunction during late puerperium. The major concern while managing these patients is to optimize fluid administration and avoid myocardial depression, while maintaining stable intraoperative hemodynamics. We present a case series of five parturients that were posted for elective cesarean section and managed successfully by the epidural volume extension technique.

Supraclavicular approach of central venous catheter insertion in critical patients in emergency settings: Re-visited

The supraclavicular approach was first put into clinical practice in 1965 by Yoffa and is an underused method for gaining central access. It offers several advantages over the conventional infraclavicular approach to the subclavian vein. At the insertion site, the subclavian vein is closer to the skin, and the right-sided approach offers a straighter path into the subclavian vein. Also, this site is often more accessible during CPR and surgical procedures. In patients who are obese, this anatomic area is less distorted and in patient with congestive heart failure and cervical spine instability repositioning is not required.

Anaphylaxis related to fentanyl citrate.

Anaphylaxis is a fulminant, unexpected, immunoglobulin E-mediated allergic reaction that can be triggered by multiple agents. Common causative agents include neuromuscular blocking drugs, latex, antibiotics, colloids, hypnotics, and opioids. Fentanyl citrate, however, is an extremely unusual cause of anaphylaxis. Pulmonary edema, although uncommon in anaphylaxis, can be a prominent feature, as was in one of the patient. An adverse drug reaction is a noxious or unintended reaction to a drug that is administered in standard doses by the proper route for the purpose of prophylaxis, diagnosis, or treatment. Reactions are classified into two major subtypes: type A, which are dose dependent and predictable; and type B, which are not dose dependent and unpredictable. Unpredictable reactions include immune (allergic) or no immune drug hypersensitivity reactions and are related to genetic susceptibilities or undefined mechanisms (formally called idiosyncratic and intolerance reactions). A drug allergy is always associated with an immune mechanism for which evidence of drug-specific antibodies or activated T lymphocytes can be shown. In the last few years, many novel drugs have entered clinical practice (i.e., biologic agents) generating novel patterns of drug hypersensitivity reactions. As old drugs continue to be used, new clinical and biologic techniques enable improvement in the diagnosis of these reactions.

Kounis syndrome resulting from anaphylaxis to diclofenac

“Kounis syndrome” refers to acute coronary syndromes of varying degree (myocardial ischaemia to infarction) induced by mast cell activation as a result of allergic and anaphylactic reactions. ST-segment elevated myocardial infarction is a rare complication that can occur even in patients with normal coronary arteries due to anaphylactic reactions. We present a case that developed acute myocardial infarction following a diclofenac sodium-induced anaphylaxis. The patient did not have any previous coronary artery disease, but there was a temporal relationship with development of the anaphylactic reaction due to diclofenac sodium and the cardiac event. The patient was managed conservatively and the recovery was uneventful.

A Comparative Study of Two Different Doses of Fentanyl Added to Bupivacaine for Intermittent Epidural Labor Analgesia: A Prospective Randomized Double Blind Study

Background: Intermittent technique of labor epidural analgesia has been showing promising results over other techniques. This study was to assess and compare efficacy of two different doses of fentanyl mixed with low doses of bupivacaine in intermittent labor epidural analgesia. Methods: 90 ASA grade I-II parturients in active labor with a cervical dilatation of 3 to 5cm were randomly allocated to three different groups- Group A: 10ml Bupivacaine 0.125% + fentanyl 10μg (1μg/ ml). Group B: 10ml Bupivacaine 0.125% + fentanyl 20μg (2μg/ ml). Group C: 10ml Bupivacaine 0.125% (The control group). All patients were preloaded with 10-15ml/kg Lactated Ringer’s solution. Labor analgesia was maintained by intermittent boluses of the drug combination. Results: The mean time of onset of analgesia was significantly lower (P 0.05). Conclusion: Addition of fentanyl (2μg/ml) to bupivacaine 0.125% decreases the time of onset of analgesia and increases the duration of analgesia and level of maternal satisfaction during labor as compared to fentanyl (1μg).

Role of Clonidine in Fascia Iliaca Compartment Block for Preoperative Analgesia in Post Hip Fracture Patients: A Comparative Study

Background: Fractures around the hip joint are associated with considerable moderate to severe pain. Adequate preoperative analgesia in these patients is difficult to assess and often an overseen aspect of their care. This study was aimed to assess the efficacy of adding clonidine as adjuvant in fascia iliaca compartment block (FICB) in relieving pain and increasing the pain free duration in the preoperative period. Methods: Sixty patients were divided into three groups of 20 each. Patients in group A received 40 ml of 0.25% bupivacaine + 100μg clonidine and patients in group B received 40 ml of 0.25% bupivacaine + 50μg clonidine whereas group C (the control group) patients were given only 40 ml of 0.25% bupivacaine. Changes in heart rate and blood pressure were recorded in each group. Results: There was significant improvement in VAS and Sitting Score in both the groups after the block and the findings of paired t test on VAS at 1Hr, 2Hr, 6Hr was comparable (P>0.05) but showed significant difference the next morning (P<0.05). The patients of group A had a total pain free sleep of more than 12 hrs after the block. Conclusion: The results suggest that 100μg clonidine is superior to 50μg clonidine and the control group and is the appropriate dose in fascia iliaca compartment block and provides significant benefit in terms of pain relief at rest as well as during transportation and more importantly also facilitates positioning required for proper imaging in the preoperative period.

Anaesthesia in a diagnosed VSD with Guillain-Barré paediatric patient for VATS

Guillain-Barrι syndrome with ventricular septal defect is rare finding. Delayed diagnosis,often leading to increased complications. This report describes an Guillain-Barrι syndrome case and the special approaches required during anaesthesia. 4 yrs old male pt with Guillain-Barrι syndrome diagnosed at time of ward admission, submitted to video-assisted thoracic surgery under uneventful general anaesthesia with sevoflurane, without neuromuscular blockers. The case highlights the frequency with which this syndrome so important for anaesthetic practice is diagnosed, adverse events, the best choice for the anaesthetic team and complications of pediatric Guillain-Barrι syndrome.Guillain-Barré syndrome with ventricular septal defect is rare finding. Delayed diagnosis, often leading to increased complications. This report describes an Guillain-Barré syndrome case and the special approaches required during anaesthesia. 4 yrs old male pt with Guillain-Barré syndrome diagnosed at time of ward admission, submitted to video-assisted thoracic surgery under uneventful general anaesthesia with sevoflurane, without neuromuscular blockers. The case highlights the frequency with which this syndrome so important for anaesthetic practice is diagnosed, adverse events, the best choice for the anaesthetic team and complications of pediatric Guillain-Barré syndrome.