Nanda Shetty

Posterior reversible encephalopathy syndrome at term pregnancy.

Posterior reversible encephalopathy syndrome (PRES) is a cliniconeuroradiological syndrome associated with various clinical conditions, presenting with headache, encephalopathy, seizures, cortical visual disturbances or blindness. Imaging predominantly shows parieto-occipital white matter changes, with vasogenic oedema being the most accepted pathophysiology. We report a 25-year-old primigravida who presented in term pregnancy with seizures and blindness, scheduled for emergency caesarean section. She was managed peroperatively under general anaesthesia and shifted to intensive care unit. Postoperative computed tomography brain revealed an intra-axial hypodensity involving predominantly white matter regions of bilateral parieto-occipital lobes, right caudate nucleus and right cerebellum, suggestive of PRES. Clinical improvement with complete resolution of visual disturbances was observed with supportive treatment. The importance of prompt suspicion and management in preventing short- and long-term neurological deficits in reversible condition like PRES is highlighted.

Low minimum alveolar concentration alarm: a standard for prevention of awareness during general anaesthesia maintained by inhalational anaesthetics.

Awareness during general anaesthesia is a rare but significant problem that can be frightening to the patients. We suggest that newer generation monitors should include this facility to provide a low alarm limit to MAC settings so as to improve the quality of patient care. Also we suggest that a “near empty” alarm be incorporated into vaporizers which can warn the anaesthesiologist prior to development of possible light plane of anaesthesia. We hope that adopting these two features can help enhance patient safety and can further aid in quality assurance.

A Comparison of Macintosh and Airtraq Laryngoscopes for Endotracheal Intubation in Adult Patients With Cervical Spine Immobilization Using Manual In Line Axial Stabilization: A Prospective Randomized Study.

Background: During cervical spine immobilization using Manual In Line Axial Stabilization (MILS), it is difficult to visualize the larynx by aligning the oropharyngeolaryngeal axes using Macintosh laryngoscope. Theoretically, Airtraq an anatomically shaped blade with endotracheal tube guide channel offers advantage over Macintosh. We hypothesized that intubation would be easier and faster with Airtraq compared with Macintosh laryngoscope. Materials and Methods: Ninety anesthetized adult patients with normal airways were intubated by experienced anesthesiologists after cervical immobilization with MILS either with Macintosh or Airtraq. Primary outcomes compared were successful intubation, and degree of difficulty of intubation as assessed by Intubation Difficulty Scale (IDS) score. Secondary outcomes compared were duration of laryngoscopy and intubation, degree of difficulty of intubation as assessed by Numerical Rating Scale score, soft tissue, and dental trauma. Results: All 90 patients were successfully intubated in the first attempt. Intubation as assessed by IDS score was easier in Airtraq (84.44%) in contrast to slight difficulty in the Macintosh (77.78%) group; Numerical Rating Scale score was easy in both the groups (Airtraq—91.12%; Macintosh—93.34%). The median (interquartile range [IQR]) time for laryngoscopy, (12 s [IQR, 8 to 17.5) vs. 8 s [IQR, 6 to 12]); total duration for intubation (25 s [IQR, 20-33] vs. 22 s [IQR, 18-27.5]) were prolonged in Airtraq group in comparison to Macintosh group. Conclusions: In anesthetized adult patients with MILS compared with Macintosh, Airtraq provides equal success rate of intubation, statistically significant (although clinically insignificant) longer duration for laryngoscopy and intubation. Intubation with Airtraq was significantly easier than Macintosh as assessed by the IDS score.

Patients with postpartum hemorrhage admitted in intensive care unit: Patient condition, interventions, and outcome

Background: We conducted this study to analyze the data of patients admitted to intensive care unit (ICU) following postpartum hemorrhage (PPH) during one-year period, the interventions they received, and the outcome. Materials and Methods: Case records of patients admitted to ICU with PPH were analyzed. Data retrieved were as follows: Primary admission or referred case, duration between onset of PPH and arrival, condition at admission, resuscitative measures, procedures to manage PPH, presence of disseminated intravascular coagulation (DIC) and its management, duration of ICU stay, and the outcome. Results: Of 21 patients with PPH, 15 were admitted in the ICU. All were referred from other hospitals. Duration between onset of PPH and arrival was 6 (15) hours (mean [standard deviation]). All were conscious on arrival. In 10 patients, blood pressure was not recordable. Tachycardia was a common feature. One patient had bradycardia (54 bpm/BP not recordable). Resuscitative measures included oxygen supplementation and fluid resuscitation. Eight patients underwent uterine artery embolization, 2 patients underwent embolization followed by surgery, and 11 patients underwent surgical intervention only. Twelve patients had DIC on admission which was managed with blood component therapy. Duration of stay in ICU was 12.6 (5.4) days (mean [standard deviation]). Two patients expired following intractable DIC and multiorgan dysfunction syndrome. Though these 2 patients had severe shock on presentation, they did not have DIC at the time of presentation. Conclusions: Despite early resuscitation and intensive care management, DIC is a major cause of mortality. Late onset DIC (onset after admission to ICU) was associated with poor outcome in this study.

Suxamethonium stands the test of time: it is too early to say goodbye

We read Lee’s article with great interest [1], in which the author suggests that in present day practice suxamethonium finds its utility in only a handful of situations. Under the subheading ‘a new challenge to suxamethonium’, the author further explains that with the availability of rocuronium and sugammadex, even in these situations there is no real role left for suxamethonium and concludes that suxamethonium has done its job! However the author has failed to mention the utility of suxamethonium in certain situations where it still plays a vital role. One of these is the management of laryngospasm where suxamethonium is still considered the gold standard [2, 3]. Intravenous suxamethonium 0.1–3 mg.kg together with atropine 0.02 mg.kg has been widely used for the management of laryngospasm [3]. Although intravenous propofol can be used in the management of laryngospasm, suxamethonium is the only effective drug that is available to treat laryngospasm in the absence of an intravenous access, as it can be administered by the sublingual, intramuscular or the intraosseous route [2]. No studies to date mention the utility of rocuronium and sugammadex in the management of laryngospasm. Suxamethonium may also have a role to play where the neuromuscular blockade of vecuronium or rocuronium has been effectively antagonised with sugammadex towards the end of the surgical procedure but the situation demands continuation of paralysis for a little longer period. As has been described in another article in the same issue, either a benzylisoquinolinium nondepolarising relaxant or suxamethonium can be used in this situation [4]. Here suxamethonium may score over the benzylisoquinolinium compounds as they take approximately 3 min to establish reliable neuromuscular blockade and have an intermediate duration of action which is undesirable in most situations. In contrast, since the neuromuscular blockade would have been antagonised by sugammadex, suxamethonium is an attractive option to provide immediate but brief reliable paralysis as its effect is unlikely to get prolonged unlike when it is administered after reversal of neuromuscular blockade with anticholinesterases. Sugammadex has been found to antagonise the effects of aminosteroids within minutes [4] which may encourage the clinicians to use higher doses of aminosteroids to ensure profound relaxation until the end of the procedure. One must be cautious as such actions may result in a greater risk of awareness as total absence of movement may mask inadequate anaesthesia or analgesia [5, 6]. One important adverse effect of suxamethonium that has not been mentioned in the article is its ability to undergo autodegradation over a period during its storage and its photosensitivity which may contribute to bradyarrhythimas [7]. We conclude that with the availability of sugammadex it is obvious that the sun of suxamethonium is beginning to set while aminosteroids will be in the ascendant in most situations. However, suxamethonium has stood the test of time and is here to stay for some more time until effective replacements are found to the above mentioned situations.

Does neck circumference help to predict difficult intubation in obstetric patients? A prospective observational study

Background: Failed intubation in obstetrics remains the most common cause of death directly related to anesthesia. Neck circumference has been shown to be a predictor for difficult intubation in morbidly obese patients. The aim of this study was to determine an optimal cutoff point of neck circumference for prediction of difficult intubation in obstetric patients. Methods: Ninety-four parturients scheduled for cesarean section under general anesthesia were included in the study. Preoperative airway assessment and neck circumference were measured. Difficult intubation was the primary outcome according to the intubation difficulty scale (IDS), intubation reported difficult if the IDS score was ≥5. Results: Univariate analysis showed that Mallampati score and neck circumference were positive predictors for difficult intubation (P = 0.005 and P = 0.011, respectively). Mouth opening, thyromental distance, sternomental distance, and the hyomental distance ratio were not useful predictors (P = 0.68, P = 0.87, P = 0.48, and P = 0.27, respectively). Logistic regression for the Mallampati score and neck circumference negative results as independent predictors of difficult intubation in obstetric (P = 0.53). Sensitivity analysis showed that neck circumference of 33.5 cm is the cutoff point to detect difficult intubation with 100% sensitivity (95% confidence interval [CI]: 69.2–100) and 50% specificity (95% CI: 38.9–61.1). The area under the curve for neck circumference was 0.746 (95% CI: 0.646–0.830) with a positive predictive value of 19.2 (95% CI: 9.6–32.5), a negative predicative value of 100 (95% CI: 91.6–100), and a P < 0.0001. Conclusions: In obstetric patients, a neck circumference ≥33.5 cm is a sensitive predictor for difficult intubation.

Child with bilateral pheochromocytoma and a surgically solitary kidney: Anesthetic challenges.

Pheochromocytoma is a rare neuroendocrine tumor of childhood. We present a 14-year-old boy with bilateral pheochromocytoma, post nephrectomy in view of a non-functioning kidney presenting with severe hypertension and end organ damage. Diagnosis was confirmed with 24-hour urinary VMA, catechol amines, and CT scan. Preoperative blood pressure (BP) was controlled with prazosin, propranolol, nicardipine, and HCT-spironolactone. Anesthesia was given with general endotracheal anesthesia with epidural analgesia. Intraoperative BP rise was managed with infusion of NTG, MgSO4, esmolol, and dexmedetomidine which was especially challenging on account of bilateral tumor.

Unrecognized blunt tracheal trauma with massive pneumomediastinum and tension pneumothorax.

Blunt neck trauma with an associated laryngotracheal injury is rare. We report a patient with blunt neck trauma who came to the emergency room and was sent to ward without realizing the seriousness of the situation. He presented later with respiratory distress and an anesthesiologist was called in for emergency airway management. Airway management in such a situation is described in this report.

Questioning succinylcholine usage in grade IV (difficult) mask ventilation.

ration will occur before return to an unparalyzed state following 1 mg/kg succinylcholine. ANESTHESIOLOGY 1997; 87: 979 – 82 8. Berthoud MC, Peacock JE, Reilly CS: Effectiveness of preoxygenation in morbidly obese patients. Br J Anaesth 1991; 67:464 – 6 9. Tanoubi I, Drolet P, Donati F: Optimizing preoxygenation in adults. Can J Anesth 2009; 56:449 – 66 10. Xue F, An G, Xu K, Deng X, Tong S, Li G: The summarization of clinical experience of difficult tracheal intubation (Chinese). Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2000; 22: 170 –3

Ultrasound guided brachial block in a case of brachial plexus hypertrophy.

Sir, A 38-year-old man with machine-related crush injury of the left hand was scheduled for emergent debridement of the injured limb. In view of his inadequate fasting and relative asymptomatic presentation, an ultrasound-guided brachial block was planned after discussion of the risks. A sonographic scout examination done at the supraclavicular level revealed hypertrophic brachial plexus bilaterally [Figure 1]. The individual trunks of the plexus were nearly equal in diameter to the size of the visualised subclavian artery in cross section, measured to be about 4.1 mm [Figure 1]. A colour Doppler interrogation did not reveal any colour flow over the area of apparent plexus hypertrophy. Due to the association of such plexus hypertrophy with demyelinating disease, the history was obtained again. The patient denied any history of weakness in the upper limbs, except for occasional tingling sensation after heavy work. He also denied any onset of muscle weakness after an episode of fever or any breathing difficulty in the past. He had no history of comorbid disease and laboratory tests were unremarkable. He had grade 5/5 power in his right upper limb with no sensory deficits or hyporeflexia in either limb. Supraclavicular brachial block was performed with 20 ml of 2% lignocaine with 1:200,000 adrenaline and 20 ml of 0.5% bupivacaine. Adequate surgical condition was achieved in approximately 30 min. Figure 1 Sonogram of the left (a) and right (c) brachial plexus at supraclavicular level showing hypertrophy of trunks lateral (L) to subclavian artery (SCA) in cross section. Colour Doppler of the left (b) and right (d) brachial plexus at supraclavicular level ... The rest of the anaesthetic management was uneventful. The regression of brachial block was assessed hourly. After approximately 8 h, the patient was able to lift the upper limb against gravity. He did not complain of any paraesthesias or pain. A neurology consult was obtained the following day, motor and sensory nerve conduction velocity (NCV) tests were performed in the right upper limb and both lower limbs. As the NCV test was reported normal, no further management was advised except follow-up. Myriad conditions such as Charcot-Marie-Tooth disease formerly called hereditary motor and sensory neuropathy, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), neoplasms and leprosy, have been reported causes for brachial plexus hypertrophy.[1] Its occurrence is rare and very few cases have been reported.[2] Repeated episodes of demyelination and remyelination produce a proliferation of multiple layers of Schwann cells around the axon, termed an onion bulb. Acquired demyelination (i.e., inflammatory demyelination) but not hereditary myelinopathies produce a conduction block, resulting in loss of the ability of the nerve action potential to reach the muscle, thereby producing weakness. Demyelination is present if motor and sensory NCVs are reduced to <70% of the lower limits of normal. In CIDP, patients typically present with proximal limb weakness for at least 2 months duration, significant hyporeflexia or areflexia, with reduced NCV and nerve biopsy features of demyelination. Biopsy of sural nerve tissue in our case was not done (due to patient reluctance) but could have shown the confirmatory microscopic features of demyelinating disease. Magnetic resonance imaging has been suggested to obtain detailed views and three-dimensional reconstruction.[3] Literature is unable to definitively support or refute the use of regional anaesthesia in patients with pre-existing peripheral neuropathy.[4,5] However, in our case, history and NCV testing seems to suggest this finding of hypertrophy to be either a hereditary variant or an early stage of the disease. Focal neoplasms of the plexus may produce a similar appearance, however, in our case it was seen bilaterally. There are reports of prolonged conduction blockade with the use of local anaesthetics in demyelinating disease, postoperative monitoring in our case, however, showed a normal duration of recovery.[6] Although caution is advised in performing nerve block on cases detected to have brachial plexus hypertrophy, we report a case that did not have prolonged conduction block. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.