Lakshmi Jayaraman

Laparoscopic approach to pheochromocytoma : Is a lower intraabdominal pressure helpful?

Laparoscopic adrenalectomy is gaining popularity because of its well-documented benefits. The aim of our study was to see if a decreased intraoperative intraabdominal pressure during laparoscopic adrenalectomy would affect the hemodynamic variables and the serum levels of catecholamines. We randomly divided 9 patients into 2 groups, maintaining either an intraabdominal pressure of 15 mm Hg (group A) or 8–10 mm Hg (group B). Norepinephrine and epinephrine blood levels were measured preoperatively, during endotracheal intubation, carboperitoneum, surgical manipulation of tumor just before the ligation of the adrenal vein, and tracheal extubation; the hemodynamic variables were recorded. The introduction of carboperitoneum resulted in an increase in heart rate and mean arterial blood pressure (MAP), although it was statistically insignificant. The norepinephrine levels showed a statistically significant increase in group A as compared with group B (P = 0.0002). Surgical manipulation of the tumor resulted in a significant increase in MAP and norepinephrine levels in group A (P = 0.007 and P = 0.0001, respectively). The epinephrine levels did not change as much because the tumor was probably predominantly norepinephrine-secreting. Norepinephrine levels continued to be high even during tracheal extubation in group A patients (P = 0.027). We conclude that a low intraabdominal pressure of 8–10 mm Hg causes less catecholamine release and fewer hemodynamic fluctuations.

Liposuction: Anaesthesia challenges

Liposuction is one of the most popular treatment modalities in aesthetic surgery with certain unique anaesthetic considerations. Liposuction is often performed as an office procedure. There are four main types of liposuction techniques based on the volume of infiltration or wetting solution injected, viz dry, wet, superwet, and tumescent technique. The tumescent technique is one of the most common liposuction techniques in which large volumes of dilute local anaesthetic (wetting solution) are injected into the fat to facilitate anaesthesia and decrease blood loss. The amount of lignocaine injected may be very large, approximately 35-55 mg/kg, raising concerns regarding local anaesthetic toxicity. Liposuction can be of two types according to the volume of solution aspirated: High volume (>4,000 ml aspirated) or low volume (<4,000 ml aspirated). While small volume liposuction may be done under local/monitored anaesthesia care, large-volume liposuction requires general anaesthesia. As a large volume of wetting solution is injected into the subcutaneous tissue, the intraoperative fluid management has to be carefully titrated along with haemodynamic monitoring and temperature control. Assessment of blood loss is difficult, as it is mixed with the aspirated fat. Since most obese patients opt for liposuction as a quick method to lose weight, all concerns related to obesity need to be addressed in a preoperative evaluation.

A comparative study to evaluate the effect of intranasal dexmedetomidine versus oral alprazolam as a premedication agent in morbidly obese patients undergoing bariatric surgery

Background: Morbidly obese patients with obstructive sleep apnea are extremely sensitive to sedative premedication. Intranasal dexmedetomidine is painless and quick acting. Intranasal dexmedetomidine can be used for premedication as it produces adequate sedation and also obtund hemodynamic response to laryngoscopy and tracheal intubation. Materials and Methods: Forty morbidly obese patients with BMI > 35 were chosen and divided into two groups. Group DEX received intranasal dexmedetomidine 1 mcg/kg (ideal body weight) while other group (AZ) received oral alprazolam 0.5 mg. Sedation scale, heart rate and the mean arterial pressure was assessed in both the groups at 0 hour, 45 minutes, during laryngoscopy and tracheal intubation. Results: The demographic profile, baseline heart rate, means arterial pressure, oxygen saturation and sedation scale was comparable between the two groups. The sedation scores, after 45 min, were statistically significant between the two groups i.e., 2.40 ± 1.09 in the AZ group as compared to 3.20 ± 1.79 in DEX group P value 0.034. The heart rate, mean arterial pressure and oxygen saturation were statistically similar between the two groups, after 45 min. The heart rate was significantly lower in the DEX group as compared to the AZ group. There was no statistical difference in the mean arterial pressure between the two groups either during laryngoscopy or tracheal intubation. Conclusion: Intranasal dexmedetomidine is a better premedication agent in morbidly obese patients than oral alprazolam.

Anaesthesia for caesarean section in a patient with lumbar syringomyelia

BACKGROUND AND OBJECTIVES Syringomyelia is a rare neurological condition characterized by the presence of an expansive cystic cavity in the spinal cord, resulting in several neurologic manifestations. The objective of the present report was to address the safety of general anesthesia in this group of patients. CASE REPORT This is a 28-year old primipara with lumbar syringomyelia scheduled for lower segment cesarean section (LSC). Surgery was performed under general anesthesia without complications. General anesthesia was chosen for this patient to avoid manipulation of the subarachnoid space during neuraxial anesthesia, which could cause changes in intracranial pressure or worsening neurological symptoms. We used rocuronium considering that it avoids rising in cerebrospinal fluid pressure and hyperkalemia that can be seen with succinylcholine. CONCLUSIONS General anesthesia can be safely used in patients with syringomyelia. Care should be taken to prevent increase in intracranial pressure and neuromuscular blockade should be monitored.

ProSeal laryngeal mask airway improves oxygenation when used as a conduit prior to laryngoscope guided intubation in bariatric patients

Background: The primary objective of this study was to compare the effect of ventilation using the ProSeal™ laryngeal mask airway (PLMA) with facemask and oropharyngeal airway (FM), prior to laryngoscopy, on arterial oxygenation in morbidly obese patients undergoing bariatric surgery. Methods: Forty morbidly obese patients were randomly recruited to either PLMA or FM. After pre-oxygenation (FiO2 1.0) in the ramp position with continuous positive airway pressure of 10 cm H2O for 5 min, anaesthesia was induced. Following loss of jaw thrust oropharyngeal airway, the FM and PLMA were inserted. On achieving paralysis, volume control ventilation with PEEP (5 cm H2O) was initiated. The difficulty in mask ventilation (DMV) in FM, number of attempts at PLMA and laryngoscopy were graded (Cormack and Lehane) in all patients. Time from onset of laryngoscopy to endotracheal tube confirmation was recorded. Hypoxia was defined as mild (SpO2 ≤95%), moderate (SpO2 ≤90%) and severe (SpO2 ≤85%). Results: Significant rise in pO2 was observed within both groups (P=0.001), and this was significantly higher in the PLMA (P=0.0001) when compared between the groups. SpO2 ≥ 90% (P=0.018) was seen in 19/20 (95%) patients in PLMA and 13/20 (65%) in FM at confirmation of tracheal tube. A strong association was found between DMV and Cormack Lehane in the FM group and with number of attempts in the PLMA group. No adverse events were observed. Conclusion: ProSeal™ laryngeal mask airway as conduit prior to laryngoscopy in morbidly obese patients seems effective in increasing oxygen reserves, and can be suggested as a routine airway management technique when managing the airway in the morbidly obese.

Anestesia para cesariana em paciente com siringomielia lombar

JUSTIFICATIVA Y OBJETIVOS: La Siringomielia es una condicion neurologica poco frecuente y caracterizada por la presencia de una cavidad cistica expansiva en la medula espinal, resultando en varias manifestaciones neurologicas. El objetivo de este articulo es destacar la seguridad de la anestesia general en ese grupo de pacientes. RELATO DEL CASO: Primipara de 28 anos, con diagnostico de siringomielia lumbar, que fue programada para la cirugia de cesarea (CC). La cirugia fue realizada bajo anestesia general, sin complicaciones. La anestesia general fue elegida, en el caso de esa paciente, para evitar cualquier manipulacion del espacio subaracnoide durante el bloqueo del neuro eje central, lo que podria conllevar a alteraciones de la presion intracraneana o al empeoramiento de los sintomas neurologicos. Se uso el rocuronio, al considerar que evita el aumento de la presion en el liquido cefalorraquideo y la hipercalemia, que puede ser vista con la succinilcolina. CONCLUSIONES: La anestesia general puede ser usada con seguridad en pacientes portadores de siringomielia. Debemos tomar precauciones para evitar el aumento de la presion intracraneana y el bloqueo neuromuscular debe ser monitorizado.

A novel method of intubation in two children with Pierre Robin Syndrome

performed with 10–12 mmHg intraabdominal pressures and after insufflation the peak airway pressure increased over 30 cmH2O. After insufflation the airleak increased because of increased intra-abdominal pressure and when the PECO2 levels were >5.8 kPa (45 mmHg) manual ventilation was started. Thirty minutes after insufflation, arterial blood gases analysis showed metabolic acidosis; pH 7.25, pCO2 5 kPa (39 mmHg) (PECO2 (35 mmHg)), pO2 25 kPa (191 mmHg), HCO3 17.3 mmolÆl , BE )9.9 mmolÆl, lactate 0.6 mmolÆl and 5 ml 8.4% NaHCO3 were given (preoperative arterial blood gases had not been evaluated). Maximal PECO2 was 7.5 kPa (58 mmHg) during laparoscopy but she never desaturated. The surgery lasted 255 min. The patient’s trachea was extubated 5 min after remifentanil infusion and sevoflurane were discontinued without the need for assisted mask ventilation. The postoperative period was uneventful and she was discharged home 5 days later. Deletion 9p syndrome is a rare condition from partial deletion of the short arm of chromosome 9 (1). There are no case reports in the literature describing anesthesia management of patients with deletion 9p syndrome. We encountered difficulty with tracheal intubation and the trachea was intubated with a smaller tube than expected for her age. Other respiratory problems were seen because of recurrent pulmonary infection related to gastroesophageal reflux. We used remifentanil, expected to allow rapid return of protective airway reflexes and minimize the risk of respiratory problems in this patient. In summary, we report the anesthesia management of a child with deletion 9p syndrome, with difficulty in tracheal intubation. Multiple anomalies and clinical features can be challenging for anesthesiologists in patients with deletion 9p syndrome. Ozlem Serpil Cakmakkaya , Mefkur Bakan , Fatis Altintas , Guner Kaya Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey (email: sercakmakkaya@hotmail.com; serpilcakmakkaya@yahoo.com)

Transversus abdominis plane block for pain relief in patients undergoing in endoscopic repair of abdominal wall hernia: A comparative, randomised double-blind prospective study

Introduction: Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia. Methods: Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events. Results: The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P< 0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P< 0.001 in hours. No adverse events were observed in any group. Conclusion: This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.