Maya Dehran

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery.

Methods: Fifty children (age 5–14 years, ASA I–II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique.

Analgesic Efficacy and Safety of Medical Therapy Alone vs Combined Medical Therapy and Extraoral Glossopharyngeal Nerve Block in Glossopharyngeal Neuralgia

OBJECTIVE The aim of this study is to compare medical therapy alone and medical therapy with add on extraoral glossopharyngeal nerve block in terms of analgesic efficacy and hemodynamic safety in patients with glossopharyngeal neuralgia (GPN). As GPN is a rare disease, our secondary targets were to review the demographic profile of the disease, clinical profile, and any associations with the disease. DESIGN This was a randomized, prospective, active-controlled, parallel group study conducted from 2007 to 2009 to determine the safety and efficacy of extraoral glossopharyngeal nerve block in GPN and compare it with pharmacological intervention. After institutional ethics committee approval and patients consent, GPN patients were randomly allocated into two groups. Group A (N = 15) received standard medical therapy (gabapentin 300 mg, tramadol 50 mg TDS, methylcobalamin 500 μgm PO) and group B (N = 15) patients received extraoral glossopharyngeal nerve block together with standard medical therapy. Patients were analyzed for analgesic outcome using numerical pain scale (NPS) and brief pain inventory (BPI) assessing both analgesic effect and degree of interference in quality of life (QOL) during 3-month follow-up. They were also evaluated for any significant hemodynamic alterations. RESULTS Over the follow-up of 90 days, the mean NPS in group A decreased from 6 ± 2 to 3 ± 2 and in group B from 5 ± 1 to 2 ± 2. From the mean NPS scores, it can be interpreted that both the modalities were effective clinically in treating GPN. However, NPS scores were statistically similar by the end of 90 days. Improvement from baseline in BPI measurement of QOL (mood, interpersonal relationship, and emotion) was earlier in group B (1, 2, and 1 months, respectively) compared with group A (2, 3, and 2 months, respectively). However, there were no significant hemodynamic adverse outcomes after administration of the block. CONCLUSION This study found that patients in both the groups had significantly lower pain intensities, improved pain relief, and reduced pain interference with QOL, which was especially evident on fourth visit (2 months) after the initiation of treatment regimen. Both were safe and well tolerated. The study advocates rational polypharmacy approach (oral and block) in difficult to treat painful conditions. Further controlled trials are warranted to further define the impact of such a combination therapy.

Advancement of epidural catheter from lumbar to thoracic space in children: Comparison between 18G and 23G catheters

Backgrounds and Objectives: Lumbar-to-thoracic advancement of epidural catheter is a safe alternative to direct thoracic placement in children. In this prospective randomized study, success rate of advancement of two different types and gauges of catheter from lumbar-to-thoracic space were studied. Materials and Methods: Forty ASA I and II children (up to 6 years) undergoing thoracic or upper-abdominal surgery were allocated to either Group I (18G catheter) or Group II (23G catheter). After induction of general anesthesia a pre-determined length of catheter was inserted. Successful catheter placement was defined as the catheter tip within two segment of surgical incision in radio-contrast study. Intra-operative analgesia was provided by epidural bupivacaine and intravenous morphine. Post-operative analgesia was provided with epidural infusion of 0.1% bupivacaine+1mcg/ml fentanyl. Observations and Results: Catheter advancement was successful in 3 cases in Group I and 2 cases in Group II. Five different types of catheter positions were found on X-ray. Negative correlation was found between age and catheter advancement [significance (2-tailed) =0.03]. However, satisfactory post-operative analgesia was obtained in 35 cases. Positive correlation was found between infusion rate, the number of segment of gap between desired level and the level reached [significance (2-tailed) =0.00]. 23G catheter use was associated with more technical complications. Conclusion: Advancement of epidural catheter from lumbar to thoracic level was successful in only 10-15% cases but satisfactory analgesia could be provided by increasing the infusion rates.

Gestational trophoblastic disease with hyperthyroidism: Anesthetic management

The coexistence of hyperthyroidism with gestational trophoblastic disease is a known albeit rare clinical condition. We herein report the successful anesthetic management of such a case in our institute. There are only few case reports in literature of this association. Often, the diagnosis of hyperthyroid state is retrospective one, as it can be missed in the emergency scenario of patient requiring molar evacuation. This case report highlights the perioperative management and optimization of hyperthyroid state prior to surgical evacuation of the invasive hydatidiform mole.

Unanticipated subglottic stenosis complicating airway management of a child with Langer–Giedion syndrome

1 Murphy E, Willis S. Awareness and hypoxia risk with Dragger Cato and Fabius anaesthesia machine. Anaesth Intensive Care 2004; 32: 721–722. 2 Robinson BJ, Caldwell C, Mark M. Design of new anaesthesia machines. Anaesth Intensive Care 2005; 33: 413. 3 Medical devices – application of usability engineering to medical devices IEC 62366:2007. Available at: http://www.iso.org/iso/home/ store/catalogue_tc/catalogue_detail. htm?csnumber=38594. Accessed 29 July, 2013. 4 Dalley P, Robinson B, Weller J et al. The use of high fidelity human patient simulation and the introduction of new anaesthesia delivery systems. Anesth Analg 2004; 58: 1737–1741.

Safety and analgesic efficacy of intravenous dexmedetomidine in arthroscopic knee surgery

Context: Dexmedetomidine, a highly selective alpha-2 agonist has been used as an adjuvant analgesic in vascular, bariatric, and thoracic surgery. We assessed the efficacy of intravenous dexmedetomidine as an analgesic adjunct to local anesthetic infiltration for control of postoperative pain in arthroscopic knee surgery. Settings and Design: This was a randomized control study performed in a Tertiary Care Hospital. Materials and Methods: Forty-five adult patients scheduled for anterior/posterior cruciate ligament reconstruction were randomized into three groups. Group B (bupivacaine group) received bupivacaine intraarticularly and normal saline by the intravenous route. Group D (dexmedetomidine group) received Intravenous dexmedetomidine and normal saline intraarticularly. Group BD (bupivacaine + dexmedetomidine group) received a combination of intravenous dexmedetomidine and intraarticular bupivacaine. Patients cardiorespiratory parameters, time to first rescue, total rescue analgesic consumption in first 24 h, visual analog scale for pain were assessed. Statistical Analysis: The data were analyzed using analysis of variance and Chi-square test. Results: The time to first request for rescue analgesia was significantly prolonged in Group D and Group BD patients (P < 0.05) compared to Group B. Total rescue analgesic consumption was least in Group BD. Group D and Group BD patients had lower heart rate and systolic and diastolic blood pressure values. Conclusion: Intravenous dexmedetomidine in combination with intraarticular bupivacaine decreased perioperative analgesic requirement in patients undergoing arthroscopic knee surgery. However, monitoring and vigilance are essential if dexmedetomidine is used as part of a multimodal analgesic regimen in view of its hemodynamic side effects.

Central neuraxial anesthesia for caesarean section in parturients with uncorrected tetralogy of fallot: Two cases

Tetralogy of fallot (TOF) is the most commonly encountered congenital cyanotic heart disease in pregnant females and maternal mortality approaches 10% in unrepaired TOF. General anesthesia is classically considered the technique of choice for incidental surgery in TOF and neuraxial anesthesia is considered relatively contraindicated. However, general anesthesia for caesarean section can increase maternal morbidity. We report two cases of caesarean section performed under combined spinal epidural (CSE) anesthesia and epidural anesthesia respectively in patients with uncorrected TOF. Adequate preloading to maintain hydration, continuous invasive monitoring, gradual extension of neuraxial blockade by epidural/CSE technique, and judicious use of phenylephrine infusion enabled us to successfully manage both the cases without any complication.

Intraoperative anaphylaxis with a complicated pulmonary hydatid cyst.

complications. Spinal anesthesia has been recommended as an alternative to general anesthesia for high-risk infants who undergo herniotomy and has been associated with minimal respiratory and hemodynamic changes during this procedure (6,7). Dohi et al. (8) studied hemodynamic stability during spinal anesthesia in young children and premature infants and found little or no change in BP or HR in response to sympathectomy. It was postulated that the lack of hemodynamic changes was due to the immaturity of the sympathetic nervous system in young children. The lesser relative blood volume of the lower extremities compared with adult proportions may account for less lower extremity venous pooling during sympathectomy and thus fewer cardiovascular changes (6,9). Spinal anesthesia was carried out with administering 4.25 mg of 0.5% bupivacaine. The choice of hyperbaric bupivacaine was suggested by the study of Kokki et al. (10). The dose of 0.8 mgÆkg administered to our patient is in the range suggested by Frawley et al. (11). Our practice is in agreement with other authors, particularly for high-risk neonates. So, we consider the choice of spinal anesthesia for a high-risk child affected by Williams syndrome as good practice to minimize the risk of sudden perioperative death. Marinella Astuto M D* , Danila Sapienza M D* , Vincenzo Di Benedetto M D†, Nicola Disma M D* Departments of *Anesthesia and †Pediatric Surgery, University of Catania, Catania, Italy (email: nicoladisma@tin.it)