Maitree Pandey

Efficacy of low-dose caudal clonidine in reduction of sevoflurane-induced agitation in children undergoing urogenital and lower limb surgery: a prospective randomised double-blind study.

Background Sevoflurane is commonly used as an inhalational induction agent in paediatric patients. Emergence agitation is a common post-operative problem in young children who have received sevoflurane. Clonidine has proven to be effective in reducing the incidence of post-operative agitation at a higher dose (3 and 2 μg kg−1). It has some dose-dependent disadvantages, prominently bradycardia, hypotension and respiratory impairment. Objective The authors conducted a study to evaluate the effectiveness of low-dose caudal clonidine (1 μg kg−1) in reducing the incidence of sevoflurane-induced agitation in preschool children undergoing urogenital and lower limb surgery. Methodology A double-blind study was conducted comparing 0.25% (0.75 ml kg−1) bupivacaine and clonidine 1 μg kg−1 (group 1), 0.25% bupivacaine (0.75 ml kg−1) and clonidine 0.75 μg kg−1 (group 2), with 0.25% bupivacaine (0.75 ml kg−1) alone (group 3). Ninety children of 1–5 years of American Society of Anesthesiologists I and II were randomly assigned into three groups. Post-operatively, patients were monitored for 1 h to observe emergence agitation, which was assessed with the help of Pain and Discomfort Scale. Result Post-anaesthetic agitation was observed in two patients (6.6%) in group 1, eight patients (26.6%) in group 2 as compared to 12 patients (40%) in group 3 after 15 min of post-operative observation. The mean scores in group 1 at 15 and 30 min were significantly lower than those in group 3 (P value <0.05). None of the groups had showed any haemodynamic and respiratory compromise, either clinically and statistically. Conclusion Caudal clonidine at a lower dose (1 μg kg−1) could be effective in reducing the incidence of sevoflurane-induced emergence agitation in children undergoing urogenital and lower limb surgery without any significant adverse effects.

Subdural haematoma in pregnancy-induced idiopathic thrombocytopenia: Conservative management.

Conservative management of subdural haematoma with antioedema measures in second gravida with idiopathic thrombocytopenic purpura (ITP) resulted in resolution of haematoma. We present a case of second gravida with ITP who developed subdural haematoma following normal vaginal delivery. She was put on mechanical ventilation and managed conservatively with platelet transfusion, Mannitol 1g/kg, Dexamethasone 1mg/kg and Glycerol 10ml TDS. She regained consciousness and was extubated after 48 hrs. Repeat CT after 10 days showed no mass effect with resolving haematoma which resolved completely after 15 days. Trial of conservative management is safe in pregnant patient with ITP who develops subdural haematoma.

Abnormal oculocardiac reflex in two patients with Marcus Gunn syndrome

Marcus Gunn phenomenon is seen in 4 to 6% of congenital ptosis patients. We report two cases of abnormal oculocardiac reflex during ptosis correction surgery. Marcus Gunn syndrome is an autosomal dominant condition with incomplete penetrance. It is believed to be a neural misdirection syndrome in which fibres of the motor division of the trigeminal nerve are congenitally misdirected into the superior pterygoid and the levator muscles. Anesthetic considerations include taking a detailed history about any previous anaesthetic exposure and any reaction to it as this syndrome has a high probability of being associated with malignant hyperthermia. It is also postulated that an atypical oculocardiac reflex might be initiated in these patients as seen in our patients, so precautions must be taken for its prevention and early detection.

Ludwig's angina in children anesthesiologist's nightmare: Case series and review of literature

Ludwigs angina is potentially lethal, rapidly spreading cellulitis of the floor of mouth and neck. The anticipated difficult airway becomes even more challenging when it occurs in children. In children, the larynx is positioned relatively higher in the neck, and one does not have the option for blind nasal intubation or awake fiberoptic, which otherwise is the technique of choice in adult patients. We present the clinical course of 16 children and highlight various problems encountered during the anesthetic management of six children who required emergency surgical drainage under general anesthesia.

Intrathecal levobupivacaine versus bupivacaine for inguinal hernia surgery: a randomized controlled trial

Background Levobupivacaine is an attractive alternative to racemic bupivacaine for spinal anesthesia due to the lower potential for cardio-toxicity and faster recovery profile. This study was designed to compare isobaric levobupivacaine with hyperbaric racemic bupivacaine with respect to intraoperative quality of anesthesia and the postoperative recovery profile in patients undergoing inguinal hernia surgery. Methods A total of 100 American Society of Anesthesiologists 1 and 2 patients, aged 18–60 years, undergoing elective daycare unilateral inguinal hernia surgery, were randomized into two groups. Group L received spinal anesthesia with 3 ml of 0.5% plain levobupivacaine. Group B received 3 ml of 0.5% hyperbaric racemic bupivacaine. Quality of anesthesia, sensory and motor block characteristics, duration of effective analgesia, time to mobilization, and incidence of side effects were compared. Results The quality of anesthesia was comparable between the two groups. No difference was observed in the block onset time or maximum block height. The duration of anesthesia was significantly shorter in group L compared with that in group B (206.2 ± 18.9 min vs. 224.1 ± 15.6 min, P < 0.001), as was duration of motor block (185.9 ± 20.3 min vs. 196.4 ± 21.2 min, P = 0.016) and time to walk unaided (321.9 ± 19.2 min vs. 356.7 ± 26.6 min, P < 0.001). The incidence of hypotension was less in group L (12%) compared to group B (32%) (P = 0.028). Conclusions Levobupivacaine is an effective alternative to bupivacaine for patients undergoing unilateral inguinal hernia surgery. It has a shorter duration of sensory and motor block, allowing earlier mobilization in daycare surgeries, and a lower incidence of intraoperative hypotension.

Anaesthestic management of sacrococcygeal teratoma in infants.

Sir, Sacrococcygeal teratomas (SCT), are the most common perinatal germ cell tumours which originate from primordial pluripotent cells.[1,2] The majority have a sporadic origin occurring with an incidence of 1 in 30,000–40,000 births[3] with female preponderance.[4] We address perioperative management of three patients (Cases I, II, III - aged 6, 4 and 3 months, respectively) for SCT excision. All presented with a progressively increasing swelling in sacral area (7 cm × 8 cm, 8 cm × 9 cm, 10 cm × 11 cm, respectively) since birth Figure 1. Cases I and III were of Altman type III (apparent externally but pre-dominantly a pelvic mass extending into the abdomen, Figure 2) and Case II was of type I (pre-dominantly external with minimal presacral component). Case I had polydactyly, Case II had hydronephrosis and Case III had epispadias as associated anomalies. Two large bore intravenous (i.v.) cannula were established. Standard anaesthesia technique was followed in all the cases. After pre-oxygenation and pre-medication with 1 μg/kg fentanyl, the trachea was intubated after induction with injection thiopentone 4-5 mg/kg i.v. and muscle relaxation with injection rocuronium 0.9 mg/kg i.v. Surgery duration exceeded 4 h in all. They were maintained on sevoflurane (0.2-2%) in N2 O:O2 at 60:40 and top ups of rocuronium. In all the cases, blood loss exceeded the maximum allowable blood loss (80, 40 and 60 ml, respectively) which was replaced by packed red blood cells (10-15 ml/kg). In Case I, we encountered bradycardia which was atropine-resistant but responded to the removal of traction. At the end of the surgery, trachea could be extubated in Cases I and II. In Case III, since the mass was larger than the other two, excessive blood loss (27% blood volume) manifested despite adequate volume replacement with fluid and blood followed by elective ventilation and extubation 3 h after the surgery. In all the three cases, post-operatively, we provided i.v. paracetamol for pain relief, as intraoperatively caudal block cannot be given due to mass in the sacral region itself. Figure 1 Lobulated mass in sacrococcygeal region adherent to overlying skin in Case I Figure 2 Type III sacrococcygeal teratoma; mass extending inferiorly up to the upper thigh and destroying lower sacral vertebra and coccyx The multiorgan involvement makes the anaesthetic management challenging. The associated anomalies in SCT include hydrocephalous, spina bifida, cleft lip and cleft palate, polydactyly, transposition of great vessels, neurogenic bladder, hypospadias, epispadias and ectopic kidney.[2] Pre-anaesthetic checkup mandates assessment to rule out coagulopathy, renal obstruction by the mass, high output cardiac failure and any neurological deficit. Patients are at respiratory disadvantage due to large abdominal mass pushing the diaphragm and prone position assumed during surgery. Large pelvic venous bed, intratumour arteriovenous fistula and associated coagulopathy accounts to major blood loss and hypovolemic shock in such patients. Smith et al.[4] found that the main blood supply to SCT arises from the median sacral vessels and recommend early ligation of these vessels to avoid excessive blood loss. Meticulous dissection in the avascular plane between the tumour and the normal tissue can prevent excessive blood loss, especially in benign tumours.[2] Disseminated intravascular coagulation, dilutional coagulopathy and thrombocytopaenia from massive transfusion may occur. Long duration of surgery demands close attention to fluid balance and temperature regulation which was taken care of.[5] Having two saphenous i.v. lines allowed us to give fluid boluses quickly during the periods of haemorrhage. Hypothermia itself worsens coagulopathy and can lead to fatal consequences. Measures adopted to prevent hypothermia in such patients include raising the ambient temperature of operation theatre to 27°C, wrapping the patient with warm blankets, use of radiant warmers, fluid warmers and humidified inspired gas. Another alarming complication is tumourlysis, which can lead to cardiac arrest due to extreme hyperkalaemia.[6] Surgical injuries include damage to the pelvic nerve, rectum, bladder can lead to bowel and bladder dysfunction in the later course of management. Thus, early diagnosis, management of intraoperative blood loss, hypothermia, early extubation and post-operative nursing in high dependency unit can bring out favourable outcome. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Oral midazolam versus oral triclofos for sedation of children for computed tomography scan - a randomized clinical trial

Background: Effective and safe pediatric procedural sedation is still a concern especially in areas outside operation theatres. The aim of the study was to compare the efficacy and safety of oral triclofos and oral midazolam in children undergoing computed tomography. Methods: A prospective randomized double blind study was conducted in 100 children aged one to five years. Group-I (n=50) received oral triclofos 100 mg/kg and Group-II (n=50) oral midazolam 0.75 mg/kg. Both groups were given oral atropine 0.03 mg/kg and supplemented with intravenous midazolam upto 0.1 mg/kg in case of inadequate effect. Onset and duration of sedation, success for completion of procedure and time to recovery were noted. Student’s t test and Z test of proportions were used for statistical analysis. Results Majority of children 36(72%) in Group-I achieved Ramsay Sedation Score >4 as compared to 25(50%) in Group-II. Computed tomography scan could be successfully completed at comparable rate (52% vs 56%). Success rate improved to 96% vs 80% after supplementing intravenous midazolam in Group I & II respectively (p< 0.05). Onset (37.91minutes ± 7.96 vs 26 ± 10), duration of sedation ( 117.91minutes ± 72.41 vs 66.2minutes ± 33) were significantly shorter and recovery (98.19minutes ± 72.58 vs 47.4minutes ± 31.42) in Group I & II respectively was faster in children who received oral midazolam (p< 0.05). Conclusion We conclude that both drugs were equally effective and safe for computed tomography scan in children. However better recovery profile of midazolam makes it more suitable for day care procedures. Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 41-45

Malfunctioning pilot balloon assembly

DOI: 10.4103/0970-9185.105828 the fluoroscopic technique for endobronchial intubation with a single lumen endotracheal tube quickly in infants. Fluoroscopic guidance allows manipulation of the DLT tip under direct visual control and observation of the DLT tip from various angles. Gentle handling should be used, while advancing the DLT, to prevent injury to the bronchial tree. Studies are recommended to determine the efficacy of the technique and evaluate the risks such as injury to the bronchus.

Anaesthetic challenges in a patient with Axenfeld Rieger Syndrome

The patient was a 3 year-old girl with no family history of ARS. She was first taken to ophthalmology clinic at 6 months of age when her parents noticed squinting of her eyes. Further workup confined the presence of glaucoma in both of her eyes. Slit lamp examination revealed a prominent Schwalbe’s line in all quadrants of both the eyes. There was no anomaly of the lens or fundus. A diagnosis of ARS was made.