Jyotsna Punj

Hemodynamic changes during robotic radical prostatectomy

Background: Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy (RALRP) in steep Trendelenburg position (45°) with high-pressure CO2 pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO2 pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo™1.10. Methods: After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl (2 μg/kg) and thiopentone (4–7 mg/kg), and tracheal intubation was facilitated by vecuronium bromide (0.1 mg/kg). The patients right internal jugular vein was cannulated and the Pre Sep™ central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO2 pneumoperitoneum, position of the patient was gradually changed to 45° Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure (CVP), stroke volume (SV), stroke volume variation (SVV), cardiac output (CO), cardiac index (CI) and central venous oxygen saturation (ScvO2). Results: After induction of anesthesia, heart rate (HR), SV, CO and CI were decreased significantly from the baseline value (P>0.05). SV, CO and CI further decreased significantly after creating pneumoperitoneum (P>0.05). At the 45° Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45° Trendelenburg position (P=0.001). HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value (P>0.05) during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45° Trendelenburg position (after 5 and 20 min) compared with the baseline postinduction value (P>0.05). All these parameters returned to baseline after deflation of CO2 pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO2 throughout the study period. Conclusions: The steep Trendelenburg position and CO2 pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output.

Comparison of performance and efficacy of air-Q intubating laryngeal airway and flexible laryngeal mask airway in anesthetized and paralyzed infants and children.

Flexible laryngeal mask airway is a commonly used supraglotic airway device (SAD) during ophthalmic surgeries. Air‐Q intubating laryngeal airway (ILA) is a newer SAD used as primary airway device and as a conduit for intubation as well. Available literature shows that air‐Q performs equal or better than other SADs in children and adults. However, limited data is available using air‐Q in infants and small children <10 kg. So, our aim was ‘To compare the performance and efficacy of these two devices in infants and small children’. Our hypothesis is that air‐Q due to its improved cuff design will yield better airway seal pressures and improved laryngeal alignment as compared to flexible laryngeal mask airway.

Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns.

Background Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy. Patients and methods The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry. In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered. Results Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 ± 2 to 28 ± 2.7 cmH2O and central venous pressure increased from 12.9 ± 1 to 19.2 ± 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice. Summary Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.

Sensorineural hearing loss after general anaesthesia: 52 cases reported until now!

We read with interest the recent description of unilateral sensorineural hearing loss (SSNHL) after general anaesthesia [1]. The authors highlighted a case of profound and persistent unilateral SSNHL after general anaesthesia. The authors state that the scarcity of reported cases and lack of detail in many of the reports to date make definite conclusions impossible and leave the apparent connection between anaesthesia and SSNHL conjectural. They further state that reporting of additional cases should be encouraged, promoting further understanding of this rare complication. Sudden sensorineural hypoacusis in non-otological surgery under general anesthesia is most frequently associated with cardiopulmonary bypass surgery [1]. Hearing loss following general anaesthesia for non-bypass surgery does not appear to have a uniform prognosis. If a specific aetiology can be identified, treatment maybe effective. Otherwise, any recovery appears to be independent of any type of treatment. Warltier et al. [2] reviewed the possible causes of SSNHL after general anaesthesia for non-bypass surgery. They analysed 35 cases reported in the English literature up 2003. However, in addition to these cases, our literature search revealed eight additional cases reported before 2003 of which five are in non-English literature (one report describes two cases) [3–9]. Since this review article, there are seven more reported cases [1, 10–14]. One case report describes two cases. Thus making the total number of cases reported 52 to date!

Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy?: A randomized control trial

STUDY OBJECTIVE To compare the incidence of postoperative nausea and vomiting (PONV) during perioperative administration of 5% dextrose and normal saline in laparoscopic cholecystectomy. DESIGN Prospective, randomized, double-blind trial. SETTING Operating rooms in a tertiary care hospital of Northern India. PATIENTS One hundred patients with American Society of Anesthesiologists status I to II undergoing laparoscopic cholecystectomy were enrolled in this study. INTERVENTIONS Patients were randomized into two groups [normal saline (NS) group and 5% dextrose (D) group]. Both the groups received Ringer acetate (Sterofundin ISO) intravenously as a maintenance fluid during intraoperative period. Besides this, patients of group NS received 250ml of 0.9% normal saline and patients of group D received 5% dextrose @ 100ml/h started at the time when gall bladder was taken out. It was continued in the postoperative period with the same rate till it gets finished. MEASUREMENTS Incidence of PONV, Apfel score, intraoperative opioids used and consumption of rescue antiemetics. MAIN RESULTS Demographic data was statistically similar. Out of total 100 patients, 47 patients (47%) had PONV. In group D, 14 patients (28%) had PONV while in group NS, 33 patients (66%) had PONV within 24h of surgery (p value 0.001). The incidence of PONV was reduced by 38% in group D which is significantly lower when compared with that of group NS (p value 0.001). The consumption of single dose of rescue antiemetics in group D was also reduced by 26% when compared to that of group NS (p value 0.002). CONCLUSIONS Perioperative administration of 5% dextrose in patients undergoing laparoscopic surgery can reduce PONV significantly and even if PONV occurs, the quantity of rescue antiemetics to combat PONV is also reduced significantly.

An atypical presentation of fentanyl rigidity following administration of low dose fentanyl in a child during intraoperative period

1 Ko YP, Huang CJ, Hung YC et al. Premedication with low-dose oral midazolam reduces the incidence and severity of emergence agitation in pediatric patients following sevoflurane anesthesia. Acta Anaesthesiol Sin 2001; 39: 169–177. 2 Abu-Shahwan I. Effect of propofol on emergence behavior in children after sevoflurane general anesthesia. Paediatr Anaesth 2008; 18: 55–59. 3 Abu-Shahwan I, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Paediatr Anaesth 2007; 17: 846–850.

Comparison of air-Q and Ambu Aura-i for controlled ventilation in infants: a randomized controlled trial

The air‐Q is a new supraglottic airway device (SAD) and has been increasingly used as a primary airway device and as a conduit for tracheal intubation in children as well as in adults. This device has either performed equally or better than other SADs in children. The Ambu Aura‐i is a commonly used SAD in children undergoing various short surgical procedures. However, limited literature is available evaluating the safety and efficacy of the air‐Q and the Ambu Aura‐i in small children. We, therefore, conducted this study to compare the clinical performance of these two airway devices in infants weighing up to 10 kg. Our hypothesis is that air‐Q, due to its improved and larger cuff design will yield better airway seal pressures as compared with the Ambu Aura‐i.

Lowe's syndrome with Fanconi syndrome for ocular surgery: perioperative anesthetic considerations.

Lowes syndrome is a rare inherited metabolic disorder characterized by mental retardation, kidney malfunction, and abnormalities of the eyes and bones. A 4 month-old child with Lowes and Fanconis syndrome, undergoing bilateral congenital cataract surgery, is presented. Preoperative electrolyte imbalance was corrected by potassium, calcium, magnesium, phosphate, and bicarbonate supplementation. Anesthesia was administered uneventfully using appropriate anesthetic agents and monitoring. Adequate preoperative evaluation and optimization, along with selection of anesthetic agents and fluid and electrolyte management with appropriate perioperative monitoring, is key to a successful outcome.

Congenital erythropoietic porphyria: anesthetic implications

Congenital erythropoietic porphyria is a rare error of heme metabolism. Derangement of heme metabolism leads to disfiguration, phototoxicity, and the precipitation of porphyric crises. This case report discusses the myriad perioperative considerations in a patient with congenital erythropoietic porphyria.

Use of saline infusion instead of gel for ultrasound-guided (USG) central venous cannulation

1. Pedersen KR, Povlsen JV, Christensen S et al. Risk factors for acute renal failure requiring dyalisis after surgery for congenital heart disease in children. Acta Anaesthesiol Scan 2007; 51: 1344–9. 2. Lema G, Meneses G, Urzua J et al. Effects of extracorporeal circulation on renal function in coronary surgical patients. Anesth Analg 1995; 81: 446–51. 3. Lema G, Vogel A, Canessa R et al. Renal function and cardipulmonary bypass in pediatric cardiac surgical patients. Paediatr Nephrol 2006; 21: 1446–51. 4. Doberneck RC, Reiser MP, Lillehei CW. Acute renal failure after open-heart surgery utilizing extracorporeal circulation and total body perfusion. Analysis of 1000 patients. J Urol Nephrol 1962; 43: 441–52.