Mridul Dhar

Premedication in an autistic, combative child: Challenges and nuances

Children with autistic spectrum disorders are often encountered in anesthesia practice mainly for outdoor procedural sedation or anesthesia in endoscopy and magnetic resonance imaging suites. We describe a case of a 7-year-old autistic boy who required management of dental caries. He had a phobia to intravenous cannulation, displayed increasing anxiety and became combative on the day of surgery. With parental involvement and distraction, we succeeded in giving oral midazolam by concealing it, with the intent of avoiding intramuscular injection or unnecessary restraint. Lack of knowledge about the medical condition of such a patient can lead to inadequate preoperative preparation and use of restraint on the patient, which might cause anxiety or panic attacks in the operative room. To effectively manage children with special needs one needs to have clear guidelines on the management of uncooperative children, involve parents perioperatively, plan ahead with an emphasis on perioperative analgesia and sometimes incorporate the ethical use of restraint.

Analysis of functioning and efficiency of a code blue system in a tertiary care hospital

Background: “Code blue” (CB) is a popular hospital emergency code, which is used by hospitals to alert their emergency response team of any cardiorespiratory arrest. The factors affecting the outcomes of emergencies are related to both the patient and the nature of the event. The primary objective was to analyze the survival rate and factors associated with survival and also practical problems related to functioning of a CB system (CBS). Materials and Methods: After the approval of hospital ethics committee, an analysis and audit was conducted of all patients on whom a CB had been called in our tertiary care hospital over 24 months. Data collected were demographic data, diagnosis, time of cardiac arrest and activation of CBS, time taken by CBS to reach the patient, presenting rhythm on arrival of CB team, details of cardiopulmonary resuscitation (CPR) such as duration and drugs given, and finally, events and outcomes. Chi-square test and logistic regression analysis were used to analyze the data. Results: A total of 720 CB calls were initiated during the period. After excluding 24 patients, 694 calls were studied and analyzed. Six hundred and twenty were true calls and 74 were falls calls. Of the 620, 422 were cardiac arrests and 198 were medical emergencies. Overall survival was 26%. Survival in patients with cardiac arrests was 11.13%. Factors such as age, presenting rhythm, and duration of CPR were found to have a significant effect on survival. Problems encountered were personnel and equipment related. Conclusion: A CBS is effective in improving the resuscitation efforts and survival rates after inhospital cardiac arrests. Age, presenting rhythm at the time of arrest, and duration of CPR have significant effect on survival of the patient after a cardiac arrest. Technical and staff-related problems need to be considered and improved upon.

A randomised comparative study on customised versus fixed sized pillow for tracheal intubation in the sniffing position by Macintosh laryngoscopy

Background and Aims: The sniffing position has been most commonly used for positioning of the head and neck to facilitate tracheal intubation. However, the optimum degree of head elevation for the optimal laryngeal view is not well studied, especially in non-Western countries. The present study was aimed to compare the use of a fixed height pillow versus a customised pillow (CP) height for head elevation, in terms of glottis visualisation and time required for tracheal intubation. Methods: With research and ethics committee approval from the institute, this randomised study was conducted among patients of both sexes aged 16 years or more and American Society of Anesthesiologists physical Status I to IV. A total of 134 patients were randomly allocated into routinely used fixed-sized pillow (FP) and CP group (to achieve horizontal alignment of external auditory meatus [EAM] and sternal notch). Primary and secondary outcomes were Cormack–Lehane (C–L) grade of glottic visualisation and time required for tracheal intubation, respectively. They were compared using unpaired t-test and Fishers exact test as applicable; P < 0.05 was considered statistically significant. Results: One hundred and nineteen patients completed the study. Both groups were similar in terms of demographic and external airway measurements. The mean ± standard deviation height of pillow required in Group CP was 6.26 ± 0.97 cm. Group FP had C–L Grade 3 view more often than Group CP (28.33% vs. 13.56%). In patients with modified Mallampati (MMP) Grade ≥3, the C–L grades and time required for intubation were both significantly lower in group CP. The time required for tracheal intubation was significantly lower in group CP (P = 0.04), even though the C–L grades were similar. Conclusion: Customising pillow for head elevation to horizontally align the EAM and the sternal notch gives better glottic visualisation and intubating conditions in patients with higher MMP grades.

Comparison of laryngeal tube suction II and proseal LMA™ in pediatric patients, undergoing elective surgery

Background: Supraglottic airway devices now have an established place in pediatric anesthesia practice. The laryngeal tube suction (LTS) II, a recent revision of the LTS, has very few studies evaluating its use in pediatric patients. The aim of this study was to compare insertion and ventilation profiles of the LTS-II size 2 and the ProSeal™ Laryngeal Mask Airway (PLMA) size 2 in pediatric patients undergoing elective surgeries. Materials and Methods: A randomized prospective study was conducted in 100 children aged 2–5 years between 12 and 25 kg weight, of the American Society of Anesthesiologists physical status I and II scheduled for routine elective surgeries of <90 min duration. They were randomly divided into two groups of 50 each, depending on the device inserted, and a standard protocol for anesthesia was followed. Outcome measures were studied in terms of ease and time of insertion, oxygen saturation (SpO2), oropharyngeal seal pressure (OSP), and ventilation failures. Results: Both groups were well matched in terms of age, weight, and type of surgery. The success rate for the first attempt was 90% for both the LTS-II group and PLMA group. Insertion was found to be easy in the majority of cases in both groups, and there was no statistical difference in blood pressure, heart rate, or SpO2on insertion. However, the OSP was significantly more in LTS-II and PLMA (P < 0.001). There were no clinically important complications in the postoperative period. Conclusions: Pediatric size 2 LTS-II is easy to insert and provides higher OSP compared with same size PLMA in anesthetized and paralyzed children undergoing elective surgery. It is a safe alternative to PLMA in short duration elective surgeries and may be a better device as it provides for higher OSPs.

Vaginal delivery in a case of mitral stenosis: Sevoflurane to the rescue

Rheumatic heart disease is the most common cardiac disease associated with pregnancy in developing countries. In India, rheumatic mitral stenosis (MS) comprises 88% of heart diseases complicating pregnancy. Despite advances and improved anesthetic techniques, the management of parturients with cardiac valvular pathology can be challenging. Therefore, the anesthesiologist has to be vigilant and meticulous in planning the technique of anesthesia to aid in safe confinement. In this article, we present the anesthetic management of a parturient who presented to our hospital with a medical record of moderate MS, in active labor. We combined a technique most feasible at that moment, with tactful and detailed knowledge of the pathophysiology to guide our anesthetic management and facilitate a normal vaginal delivery. We have tried to highlight how clinically individualized and personalized care with sound pathophysiological knowledge of the patients cardiac condition can achieve optimal outcomes, especially when conventional modes and techniques are not feasible.

Choice of sedative for deep brain stimulation in Parkinson’s disease: Our experience and comparison of two cases

Abstract Introduction Parkinson’s disease (PD) is a severe, debilitating disease of the extra pyramidal central nervous system, which has a significant effect on lifestyle and day to day living of the affected population. Statistically, more of the elderly are now going to present with this disease. Moving ahead from older procedures such as cingulotomy, pallidotomy and thalamotomy which had irreversible side effects, deep brain stimulation (DBS) has emerged as a new, safer and more attractive option for such patients. Anaesthetic concerns for such procedures mainly incorporate principles of awake craniotomy, for which the basic requirement is a cooperative patient. Although Propofol was somewhat of a gold standard for this purpose until a few years back, Dexmedetomidine has emerged as the new drug of choice. Case While conducting two surgeries for DBS over two days, we had an obverse experience with these drugs. We describe the pre-operative assessment and intra-operative management of the two cases and a discussion of the factors which might have contributed to this contradiction. Conclusion The choice of sedation for DBS in PD should take into consideration factors such as patient cooperation, ‘drug off’ state due to pre-op medication stoppage, GABA versus non-GABA mediated mechanism of drugs, amount of dependence on PD drugs, severity of disease and finally requirement of the testing team. No drug can be singled out to be better and must be chosen based on individual merits of the patient and disease.

Neonate with omphalocele and dextrocardia: Anaesthetic goals and challenges

Omphalocele and gastroschisis are the two common congenital malformations of the anterior abdominal wall. Omphalocele can be associated with other congenital anomalies such as cardiac anomalies. Association of omphalocele with dextrocardia has been reported in few literatures previously. We describe here such a rare association of omphalocele, dextrocardia with patent ductus arteriosus with a brief review on the anesthetic challenges in the perioperative period.

Triple A to triple S: From diagnosis, to anesthetic management of Allgrove syndrome

INTRODUCTION Allgrove syndrome (AS) is a rare autosomal recessive disorder characterized by achalasia cardia, alacrimia, and adrenocorticotropic hormone-resistant adrenal insufficiency which is sometimes associated with autonomic dysfunction. It has also been referred to as the triple A syndrome in view of the cardinal symptoms described above. First described by Allgrove et al in 1978, the disorder usually presents mostly during the first decade of life. These patients have the threat of adrenal crisis, shock, and hypoglycemia and are usually on steroid supplementation. CASE REPORT The anesthesiologists encounter with such patients, although rare, is mostly for repair of the achalasia cardia. We thus report a similar case of AS in a 2-year-old girl who was scheduled to undergo Heller myotomy along with the preoperative evaluation and intraoperative management of the same. CONCLUSION Being aware of the pathophysiology of AS gives useful insight about the disease and successful perioperative management in the form of the triple S strategy, that is, stress dose of steroids, slow induction and positioning, and finally maintenance of stable hemodynamics and euglycemia.

A low cost, customised anaesthesia information management system: An evolving process

Traditional techniques of record keeping in most hospitals include manual entry in case sheets and then adding to piles of paper files.[1] Although gradual transition towards automated and computerized record systems is in place, it is still a distant prospect in many peripheral institutes and low resource hospitals. An anaesthesia information management system (AIMS) is an electronic record system that allows collection, storage and presentation of patient data during the peri-operative course.[2] Our institute is a research oriented referral institute and we have designed a low cost model of an AIMS, which can be customized to local needs. We briefly describe the process and evolution of this recording system in our anaesthesiology department and operation theatre complex, its effect on the staff including the doctors, nurses and technicians and how it can be incorporated on a wide scale to other institutes and hospitals, where modern, automated and technology heavy systems[2,3] will take time to establish.

Peri-operative management of a neonate with tracheo-oesophageal fistula and anorectal malformation: Survival of the fittest

Oesophageal atresia (OA) with tracheo‐oesophageal fistula (TOF) is a rare congenital anomaly usually seen in association with the VACTERL spectrum of disorders in neonates.[1] Management of these groups of anomalies is generally an early surgical intervention in most cases. Majority of neonates are managed with a palliative procedure until fit for a definitive surgery.[2] Isolated case reports have been published about management of multiple defects.[3,4] We describe a case of a neonate with a high anorectal malformation (ARM) along with TOF who was managed surgically in a single setting for both defects. The pathophysiology of TOF gets further accentuated in a setting of ARM as there is absolutely no way to decompress the bowel, either from above or below. This calls for an urgent intervention in the form of a colostomy/gastrostomy or definitive repair, given further compromise of the already susceptible lungs.