Keshav Goyal

Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: a retrospective analysis of 95 cases.

BACKGROUND Surgical procedures for correction of craniosynostosis are often performed in pediatric patients who have a small blood volume; it represents major surgery. Literature is scarce on factors affecting blood loss, intensive care unit (ICU) and hospital stay in these patients. OBJECTIVES To identify the factors which directly affect the outcome of craniosynostosis surgery. MATERIALS AND METHODS A detailed review of records pertaining to preanesthetic evaluation, associated anomalies, intraoperative course, and postoperative follow-up was done for patients who underwent craniosynostosis surgery between June 2000 and June 2010. The correlation between different variables was evaluated using Spearmans rank correlation. RESULTS During the study period 95 patients (mean age 29 months, range: 3 months-13 years) underwent corrective surgery for craniosynostosis. Hospital stay was found to be significantly associated with type of surgery and postoperative complications (P<0.001) Factors such as number of associated medical conditions, number of postoperative complications, type of induction of anesthesia, duration of surgery, type of recovery affected the ICU stay in these patients (P = 0.01). CONCLUSION The outcome of patients undergoing craniosynostosis in terms of ICU and hospital stay is affected by the number of medical and postoperative conditions, type of anesthesia induction, duration of surgery and type of recovery.

Comparison of propofol versus sevoflurane on thermoregulation in patients undergoing transsphenoidal pituitary surgery: A preliminary study

Purpose: General anesthesia causes inhibition of thermoregulatory mechanisms. Propofol has been reported to cause more temperature fall, but in case of deliberate mild hypothermia, both sevoflurane and propofol were comparable. Thermoregulation is found to be disturbed in cases of pituitary tumors. We aimed to investigate which of the two agents, sevoflurane or propofol, results in better preservation of thermoregulation in patients undergoing transsphenoidal excision of pituitary tumors. Methods: Twenty-six patients scheduled to undergo transsphenoidal removal of pituitary adenomas were randomly allocated to receive propofol or sevoflurane anesthesia. Baseline esophageal temperature was noted. Times for temperature to fall by 1°C or 35°C and to return to baseline were also comparable (P>0.05). After that warmer was started at 43°C and time to rise to baseline was noted. Duration of surgery, total blood loss, and total fluid intake were also noted. If any, side effects such as delayed arousal and recovery from muscle relaxant were noted. Results: The demographics of the patients were comparable. Duration of surgery and total blood loss were comparable in the two groups. The time for temperature to fall by 1°C or 35°C and time to return to baseline was also comparable (P>0.05). No side effects related to body temperature were noted. Conclusion: Both propofol and sevoflurane show similar effects in maintaining thermal homeostasis in patients undergoing transsphenoidal pituitary surgery.

Asystole during posterior fossa surgery: Report of two cases

Asystole during posterior fossa neurosurgical procedures is not uncommon. Various causes have been implicated, especially when surgical manipulation is carried out in the vicinity of the brain stem. The trigemino-cardiac reflex has been attributed as one of the causes. Here, we report two cases who suffered asystole during the resection of posterior fossa tumors. The vago-glossopharyngeal reflex and the direct stimulation of the brainstem were hypothesized as the causes of asytole. These episodes resolved spontaneously following withdrawal of the surgical stimulus emphasizing the importance of anticipation and vigilance during critical moments of tumor dissection during posterior fossa surgery.

Application of indigenous continuous positive airway pressure during one lung ventilation for thoracic surgery

During one lung ventilation (OLV) hypoxemia may occur due to ventilation-perfusion mismatch. It can be prevented with application of ventilation strategy that prevents atelectasis while minimally impairing perfusion of the dependant lung. Here, two cases are reported who required OLV and in whom hypoxemia could be prevented with the application of continuous positive airway pressure to the deflated or non-dependant lung, using an indigenous technique. We suggest use of this technique which is easy to be employed during the intraoperative period.

Anaphylactic reaction after autologous blood transfusion: A case report and review of the literature.

Autologous blood transfusion as a cause of intraoperative anaphylaxis is very rare. We encountered one such life-threatening event in a 72-year-old patient undergoing laminectomy and pedicle screw fixation. The probable cause identified was the floseal mixed autologous blood transfusion. Review of literature has been done, and measures to avoid such an event in the future are discussed.

Management of aspirated tooth in an adult head injury patient: Report of two cases

Aspiration of foreign bodies is common in a pediatric age group but adults can also be at risk. We describe management of two adult trauma victims with aspirated tooth. In the first case, foreign body went missing for sometime by intensive care physician and detected by radiologist while it was obvious in the second case. Both the patients were managed with the help of rigid bronchoscopy. Tooth should be removed as soon as possible or it may result in complete airway obstruction or lung collapse.

Anesthetic management of craniosynostosis repair in patient with Apert syndrome

Apert syndrome is an autosomal dominant disease characterized by craniosynostosis, midface hypoplasia and syndactyly. In general, patients present in early childhood for craniofacial reconstruction surgery. Anesthetic implications include difficult airway, airway hyper-reactivity; however, possibility of raised intracranial pressure especially when operating for craniosynostosis and associated congenital heart disease should not be ignored. Most of the cases described in literature talk of management of syndactyly. We describe the successful anesthetic management of a patient of Aperts syndrome with craniosynostosis posted for bicornual strip craniotomy and fronto-orbital advancement in a 5-year-old child.

High altitude cerebral edema with a fatal outcome within 24 h of its onset: Shall acclimatization be made compulsory?

1. Sen S, Chini EN, Brown MJ. Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin Proc 2005;80: 783-95. 2. Joshi G, tobias Jd. intentional use of intra-arterial medications when venous access is not available. Paediatr anaesth 2007;17:1198-202. 3. Weiss M, Gerber a. the substitute for the intravenous route. anesthesiology 2001;95:1040. 4. tobias J. author’s reply. Paediatr anaesth 2008;18:895-6. Access this article online

Neurogenic pulmonary edema after rupture of intracranial aneurysm during endovascular coiling

Neurogenic pulmonary edema (NPE) is a well-known entity, occurs after acute severe insult to the central nervous system. It has been described in relation to different clinical scenario. However, NPE has rarely been mentioned after endovascular coiling of intracranial aneurysms. Here, we report the clinical course of a patient who developed NPE after aneurysmal rupture during endovascular surgery. There was significant cardiovascular instability possibly from stimulation of hypothalamus adjacent to the site of aneurysm. This case highlights the predisposition of minimally invasive procedures like endovascular coiling to life-threatening complications such as NPE.

Intraoperative hyperthermia: Can surgery itself be a cause?

Hyperthermia is defined as the body temperature of >37.5°C due to failed thermoregulation.[1] Body temperature is controlled by the hypothalamus and even minor deviations from normal can be manifested as cellular and tissue dysfunction.[2] Causes of perioperative hyperthermia include dehydration, fever, premedication with anticholinergic drugs, excessive surgical draping, malignant hyperthermia, thyroid storm, neuroleptic syndrome, septicaemia, allogenic blood transfusion and excessive heat delivery from the radiant warmers. Acute hyperthermia lasting for hours during excision of sellar-suprasellar mass has never been reported before. We report a case of intraoperative hyperthermia in patients with sellar-suprasellar mass.