Kiran Jangra

Evaluation of the Effect of Aneurysmal Clipping on Electrocardiography and Echocardiographic Changes in Patients With Subarachnoid Hemorrhage: A Prospective Observational Study.

Background: Electrocardiographic (ECG) and echocardiographic changes that are subsequent to aneurysmal subarachnoid hemorrhage (a-SAH) are commonly observed with a prevalence varying from 27% to 100% and 13% to 18%, respectively. There are sparse data in the literature about the pattern of ECG and echocardiographic changes in patients with SAH after clipping of the aneurysm. Hence, we observed the effect of aneurysmal clipping on ECG and echocardiographic changes during the first week after surgery, and the impact of these changes on outcome at the end of 1 year. Materials and Methods: This prospective, observational study was conducted in 100 consecutive patients with a-SAH undergoing clipping of ruptured aneurysm. ECG and echocardiographic changes were recorded preoperatively and every day after surgery until 7 days. Outcome was evaluated using the Glasgow outcome scale at the end of 1 year. Results: Of 100 patients, 75 had ECG changes and 17 had echocardiographic changes preoperatively. The ECG changes observed were QTc prolongation, conduction defects, ST-wave and T-wave abnormalities, tachyarrhythmias, and bradyarrhythmias. The echocardiography changes included global hypokinesia and regional wall motion abnormalities. Both echocardiographic and ECG changes showed significant recovery on the first postoperative day. Patients presenting with both echocardiographic and ECG changes were found to require higher ionotropic support to maintain the desired blood pressure, and were associated with poor outcome (Glasgow outcome scale, 1 to 2) at 1 year after surgery. There was no association of ECG and echocardiographic changes with mortality (both in-hospital or at 1 year). Conclusions: The ECG changes, such as QTc prolongation, bradycardia, conduction abnormality, and echocardiographic changes, recover on postoperative day-1, in most of the cases after clipping. Patients with combined ECG and echocardiographic changes tend to have poor neurological outcome at the end of 1 year.

Anesthesia in pregnancy with heart disease

Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence – for better or for worse – on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.

What is optimal in patients with myasthenic crisis: Invasive or non-invasive ventilation?

Myasthenia gravis is an immune disorder involving the neuromuscular junction. The consequent weakness of respiratory muscles leads to variable disorders of ventilation in patients with myasthenia gravis. This article reviews the options of invasive and non-invasive ventilation in patients with advanced form of the disease.

Neuroanaesthesia and Coexisting Psychiatric Problems

Psychiatric illnesses are on the rise throughout the globe mainly due to enhanced awareness and advanced diagnostic modalities [1]. The actual prevalence is also rising due to the changing environmental factors including increasing population, lesser number of jobs, increasing competition at every step, declining moral and ethical values, job stress, altered lifestyles, lesser time available for self-care, etc. [2]. In India, the reported incidence of psychiatric disorders is much lower than the actual incidence of these diseases [3–6]. Unlike the other central nervous system (CNS) disorders, there are no anatomical defects, but there are only functional imbalances between different areas of the brain. In neurosurgical patients, the organic diseases can manifest as psychiatric disorder [7–9]. Most commonly recognised pathway leading to psychiatric disorders is deficiencies of major neurotransmitters of the brain including dopamine, norepinephrine and serotonin [10]. The pharmacological target for treatment of psychiatric illnesses is to increase the concentration of these neurotransmitters at effect site by either inhibiting the metabolism or reducing the reuptake at nerve ending. These psychotropic medications are associated with serious side effects and drug interactions [11].

Anesthesia for Awake Craniotomy: What Is New?

Purpose of ReviewThe purpose of this article is to review the current evidence on perioperative management for awake craniotomy (AC).Recent FindingsWith the advancement of diagnostic modalities, newer intraoperative monitoring technologies, and safer and shorter-acting anesthetic agents, the indications of AC are expanding beyond epilepsy surgery. Anesthesia techniques including asleep-awake-asleep and monitored anesthesia care are generally safe and without any serious side effects when performed by experienced providers; however, data regarding awake-awake-awake technique is limited. Currently, an α-2 agonist, dexmedetomidine, is gaining popularity both as a sole agent as well as an adjunct for AC as it provides analgesia with minimal respiratory depression and it minimally interferes with electrocorticography and cortical mapping. The use of dexmedetomidine allows reduction of opioid and propofol doses while preserving hemodynamic stability.SummaryThe success of AC is based on the appropriate patient selection, detailed preoperative evaluation, adequate preparation, and prevention, timely detection, and efficient management of the intraoperative complications.

Comparison of quality of the surgical field after controlled hypotension using esmolol and magnesium sulfate during endoscopic sinus surgery

Background and Aims: Most vital aspect of Endoscopic Sinus Surgery (ESS) is an optimal visibility in the surgical field. This invariably requires controlled hypotension to facilitate surgical dissection and to decrease operative time. We used esmolol and magnesium sulfate to achieve controlled hypotension and assessed the quality of the surgical field in ESS. Material and Methods: A total of 30 patients undergoing ESS, were enrolled in three parallel groups of 10 patients each in a prospective randomized double-blind study. “Magnesium Sulfate group” received magnesium sulfate 40 mg/kg intravenously (i.v.) as a bolus over 10 min before induction of anesthesia, followed by 15-30 mg/kg/h through infusion. “Esmolol group” received 0.5 mg/kg i.v. bolus over 10 min after induction followed by 150-300 μg/kg/min infusion and “control group” received normal saline in same volume schedule. The primary aim was to assess the quality of surgical field, using Fromme scale. Category Scale values of all the three groups were compared using Kruskal-Wallis analysis of variance (ANOVA) test. Hemodynamic data was compared using ANOVA test. Results: Quality of the surgical field was better in both magnesium sulfate and esmolol groups as compared to the control group. Durations of anesthesia and surgery were significantly lower in esmolol group as compared to the control group. Blood loss was comparable in all the three groups. Conclusion: Quality of the surgical field was better in esmolol and magnesium sulfate groups as compared to control group. Duration of surgery was significantly less in esmolol group as compared to other two groups.

Postoperative Vision Loss

Abstract Postoperative vision loss is defined as partial or complete loss of vision following nonophthalmic procedures. Though rare, when it occurs it is a devastating complication. The etiopathogenesis, causes, and signs and symptoms are discussed. The treatment and preventive options are also discussed in the chapter.

Partial airway obstruction following manufacturing defect in laryngeal mask airway (Laryngeal Mask SilkenTM)

Laryngeal mask (LM) airway is commonly used for securing airway in day-care surgeries. Various problems have been described while using LM airway. Out of those, mechanical obstruction causing airway compromise is most common. Here, we describe a case report of 4-year-old child who had partial upper airway obstruction due to LM manufacturers defect. There was a silicon band in upper one-third of shaft of LM airway. This band was made up of the same material as that of LM airway so it was not identifiable on external inspection of transparent shaft. We suggest that such as non-transparent laryngeal mask, a transparent LM airway should also be inspected looking inside the lumen with naked eyes or by using a probe to rule out any manufacturing defect before its insertion.