Ld Mishra

Spinal cord injury without radiographic abnormality

Spinal cord injury without radiological abnormality is rare in adults. Below we present a case report of 20 yrs old male with isolated cervical cord injury, without accompanying vertebral dislocation or fracture involving the spinal canal rim. He fell down on plain and smooth ground while carrying 40 kg weight overhead and developed quadriparesis with difficulty in respiration. Plain radiographs of the neck revealed no fractures or dislocations. MRI showed bulky spinal cord and an abnormal hyper intense signal on the T2W image from C2 vertebral body level to C3/4 intervertebral disc level predominantly in the anterior aspect of the cord The patient was managed conservatively with head halter traction and invasive ventilatory support for the initial 7 days period in the ICU. In our patient recovery was good and most of the neurological deficit improved over 4 weeks with conservative management.

Injectable midazolam as oral premedicant in pediatric neurosurgery.

In a randomized, double blind, placebo controlled study; the acceptability, efficacy and safety of injectable midazolam as oral premedicant in children was evaluated. One hundred children (ASA 1,2) aged 6 months to 6 years, undergoing elective neurosurgical operations, like meningomyelocele, meningo-encephalocele, ventriculo peritoneal and other shunts and craniotomies for tumour decompression etc., were included in the study. The patients were randomly assigned to one of four groups (A, B, C, D) receiving respectively saline or 0.50, 0.75 and 1.0 mg/kg midazolam in honey, 45 min before separation from parents. All received identical general anesthesia (GA). Age, sex, weight, heart rate, blood pressure, respiratory rate, saturation (SaO2), reaction to parents separation, sedation score and duration of anesthesia, recovery conditions and side effects were noted. We found no difference in age, sex, weight, patient acceptability vomiting after ingestion and duration of anesthesia between groups. Even though many children resisted the placement of premedicant in the mouth, only three children spat it out and none vomited after swallowing. The reaction to separation from parents was better after midazolam premedication. However, on reaching the operating room, 24% children (placebo-60%) were found anxious after 0.50 mg/kg, but 12% were deeply sedated after a dose of 1.0 mg/kg. Recovery was similar in groups A, B and C except that more (48%) patients were anxious in group A. Recovery, however was delayed in 16% patients of group D. Though, fewer complications were reported during recovery after midazolam than placebo premedication, they were minimal in the 0.75 mg/kg group. We concluded that giving injectable midazolam orally as premedication in pediatric age group scheduled for neurosurgical operations is acceptable, effective and safe in 0.75 mg/kg dose. While 0.50 mg/kg is less effective, 1.0 mg/kg does not offer any additional benefit over 0.75 mg/kg but does delay recovery and may compromise safety.

A prospective, randomized, double blind and placebo-control study comparing the additive effect of oral midazolam and clonidine for postoperative nausea and vomiting prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystecomy

Background: Reduction of postoperative nausea and vomiting (PONV) continues to be a major challenge in perioperative care in spite of introduction of newer antiemetics with better efficacy and safety profiles. Therefore, we evaluated the additive effect of oral midazolam and clonidine for PONV prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystectomy. Materials and Methods: In a prospective, randomized fashion, 120 selected cases were randomized into three groups: I, II or III to receive a tablet of midazolam (15 mg, n = 36), clonidine (150 mcg, n = 40), or glucose as placebo (5 g, n = 44) orally, 1 h before anesthesia. Occurrence of PONV along with need for rescue antiemetic during the first postoperative day was compared between groups as a primary outcome. Results: Episodes of PONV reduced significantly in Group II (15%) as compared to group I and III (22.2%, 59%) at various time points during the period of observation (P = 0.002). Need for rescue antiemetic was significantly lower in group I (13.88%) and II (5%) as compared to group III (52.27%, P < 0.001). Conclusion: Oral clonidine is better adjuvant for PONV prophylaxis, as compared to midazolam, in granisetron premedicated patients undergoing laparoscopic cholecystectomy.

Propofol Requirement during Propofol and Butorphanol Anesthesia with and without Nitrous Oxide in Short Duration Intracranial Surgeries: A Bispectral Index Guided Study

Introduction: Propofol is a preferred agent in neurosurgical anesthesia because of its favorable effects on cerebral hemodynamics and excellent recovery profile. Butorphanol is a synthetic opioid which is 5-8 times more potent than morphine and is known to provide stable hemodynamics during various surgical procedures. Owing to its unfavorable effects on cerebral metabolism and hemodynamics nitrous oxide has a debatable role in neurosurgical anesthesia. But studies on exact dose requirement during propofol induction and maintenance anesthesia along with butorphanol with and without the use of N2O during craniotomies are lacking. So we aimed at studying the requirement of propofol (used along with butorphanol) with and without the use of nitrous oxide in intracranial surgeries using bispectral index (BIS) monitoring.

Pain and emergence agitation in children

Sir, We read with great interest the article by Aouad et al. (1). On reading the title of the paper, ‘Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia’, readers will get the impression that the authors have attempted to investigate the effect of preoperative caudal block on emergence agitation (EA) associated with sevoflurane anaesthesia. At the outset, we wish to emphasize that EA in children is not only seen after sevoflurane anaesthesia, but after almost all inhalational anaesthetics, and sometimes even after continuous propofol anaesthesia. Although several factors, including hypoxaemia, hypercapnia and gastric or urinary bladder distension, may cause EA and patient non-cooperation, pain is the most common cause. Most causes of postoperative pain can be managed by giving small intravenous doses of a narcotic, yet pain associated with urinary retention, coughing and deep breathing cannot be completely eliminated with narcotics. However, following infra-umbilical operations, this pain can be eliminated by caudal anaesthesia. In relation to the study in question, the following facts should also be kept in mind when devising any comparative study between the analgesic effects of two or more regimens.

Non‐physician anaesthetists: should we still continue with the provision?

priority. Starting from this assumption, all people agree that day surgery not routinely performed should be discouraged. In our experience, a large teaching hospital is the ideal location, assuring facilities and the personnel and teaching staff able to deliver a continuous training process by skilled management of children. Maximizing patient and family satisfaction is of prime importance in today’s competitive outpatient surgery market. One-stop surgery (OSS) is one of the models that allows paediatric patients to undergo initial surgical evaluation, anaesthesia, surgery and discharge home, on the same day. In our clinical experience, this organization appears to be clear and safe, cost-effective and a valid alternative to the traditional process for patients and their families. Most opinion leaders stress the importance of involving families in the decision making regarding the health care of their child and make an effort to understand the needs of the family as well as the child. A winning process of day surgery in children is based on the family-centered model of care. Peri-operative care includes interdependent steps that need specific interventions to reduce pre-operative anxiety; to make anaesthetic preparation easier; to select patients to perform personalized anaesthesia procedures according to the patient’s needs; to monitor oxygen saturation and maintenance of intraoperative homeostasis; and post-operative pain management and prevention of nausea and vomiting are recognized as basic standards. Finally, control of bleeding represents the ABCD of care and ‘life-saving procedures’. The satisfaction of all these aspects is mandatory and represents an important measure of the outcome. Children make excellent candidates for day surgery; team work is all important, the surgeon and nurses’ opinion is vital and every child should be examined by the anaesthesiologist before discharge. the primary outcome measure is the total time spent in the PACU, i.e., oxygen saturation is a good predictor of prolonged LOS. However, young patients without episodes of desaturation require 50% less recovery time in the PACU. Children who undergo otoryngology procedures are 1.5 times more likely to develop adverse respiratory events compared with other surgical procedures, and this risk is inversely proportional to age. The mission to optimize standardization of procedures for day surgery in children represents a challenge for the health system and the community; this activity is based on multidisciplinary and multiprofessional cooperation, although the role of family members is very important. Day surgery for children could be implemented successfully in institutions that support good hospital/family/child communication, coordination and continuous improvement of the programmes for children and families. In other words, day surgery for children represents a dynamic process based on expressing the best standards of procedures and quality of care. We must reach a consensus to promote day surgery for children in a reassuring environment. This scenario would be recognized as part of evidence-based medicine. The challenge continues. The working team is ready.

Monitored anaesthesia care for colonoscopies

Sir, We would like to respond to the article ‘Can remifentanil be a better choice than propofol for colonoscopy during monitored anesthesia care?’ by Akcaboy et al. published in your journal [Acta Anaesthesiol Scand 2006; 50: 736–41]. The authors compared remifentanil with propofol for colonoscopy to provide effective analgesia, sedation, amnesia and patient comfort. In this context, we would like to point out that the study was done using two unequal drugs by their clinical effect. Whereas remifentanil, an opioid, is known to provide good analgesia and sedation to the patient; propofol, a non-opioid anaesthetic, provides hypnosis and amnesia but without any analgesia. As propofol does not provide any analgesia, it is recommended that it is given along with an analgesic such as ketamine (1), an opioid [alfentanil (2), fentanyl (3) or remifentanil (4)] or at least with nitrous oxide in oxygen. On the other hand, remifentanil alone does not provide optimal hypnosis and amnesia unless given in higher doses. Both the drugs possess similar quick onset and offset. Therefore, combining these two drugs will probably be a better choice (4), rather than using either of them as a sole agent in day-care procedures including colonoscopies. Colonoscopy is a sensitive procedure, often causing much discomfort to the patient and administering only remifentanil or propofol, even by continuous infusion, is not expected to provide optimal anaesthesia. The authors also used a low-dose infusion for both remifentanil and propofol. Studies have shown that when used as a sole agent, remifentanil should be used at an infusion rate of 0.1 mg/kg/min or higher (5), to provide optimal anaesthetic conditions. On the other hand, the authors used relatively lower infusion doses of remifentanil (0.05 mg/kg/min) in their patients. However, Moerman et al. (5), using an infusion of 0.2 mg/kg/min, reported a frequent occurrence of remifentanilinduced hypoventilation. Although remifentanil can be used as a sole agent for monitored anaesthesia care provided it is used in optimal doses; adding propofol, however, will produce better anaesthetic conditions and fewer complications for procedures such as colonoscopy.