Navdeep Sokhal

Anaesthesia for awake craniotomy: A retrospective study of 54 cases.

Background and Aims: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Methods: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Results: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1-14 days) and mean hospital stay was 7.0 ± 5.0 day (3-30 days). Conclusions: ′Conscious sedation′ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.

Comparison of 20% mannitol and 3% hypertonic saline on intracranial pressure and systemic hemodynamics

Mannitol and hypertonic saline (HS) are most commonly used hyperosmotic agents for intraoperative brain relaxation. We compared the changes in ICP and systemic hemodynamics after infusion of equiosmolar solutions of both agents in patients undergoing craniotomy for supratentorial tumors. Forty enrolled adults underwent a standard anesthetic induction. Apart from routine monitoring parameters, subdural ICP with Codmann catheter and cardiac indices by Vigileo monitor, were recorded. The patients were randomized to receive equiosmolar solutions of either 20% mannitol (5ml/kg) or 3% HS (5.35ml/kg) for brain relaxation. The time of placement of ICP catheter was marked as T0 and baseline ICP and systemic hemodynamic variables were noted; it was followed by recording of the same parameters every 5min till 45min (Study Period). After the completion of study period, brain relaxation score as assessed by the neurosurgeon was recorded. Arterial blood gas (ABG) was analysed every 30min starting from T0 upto one and half hours (T90), and values of various parameters were recorded. Data was analysed using appropriate statistical methods. Both mannitol and HS significantly reduced the ICP; the values were comparable in between the two groups at most of the times. The brain relaxation score was comparable in both the groups. Urine output was significantly higher with mannitol. The perioperative complications, overall hospital stay, and Glasgow outcome score at discharge were comparable in between the two groups. To conclude, both mannitol and hypertonic saline in equiosmolar concentrations produced comparable effects on ICP reduction, brain relaxation, and systemic hemodynamics.

Hypopharyngeal injury leading to subcutaneous emphysema after anterior cervical discectomy and artificial cervical disc placement

Anterior cervical discectomy and fusion (ACDF) may lead to complications such as dysphagia, hoarseness, recurrent laryngeal nerve palsy, vocal cord palsy, dural tears with leakage of cerebrospinal fluid, haematoma, and oesophageal and vascular injuries. Hypopharyngeal injury in the early postoperative period is a rare, but life-threatening, problem. We present a patient with dyspnoea who developed subcutaneous emphysema in the early postoperative period after an iatrogenic hypopharyngeal injury following ACDF. These complications prolonged the postoperative course of the patient. The role of careful surgical intervention, and anticipation of potential complications, has been emphasized, especially when surgical exposure of the anterior spinal canal above C(4) is required.

Intraoperative dislodgement of an internal jugular central line with an undisturbed skin fixation.

SIR—Central venous catheter (CVC) dislodgements have been reported in children in the ICU where the CVC may be kept in situ for prolonged periods (1). Misplacements of these cannulae continue despite various methods of securing them to the skin (2). We report a case where displacement of an internal jugular venous (IJV) cannula occurred intraoperatively even when the fixation of the triple lumen catheter to the skin was not disturbed. A 16-month-female child presented with lymphangioma left parapharyngeal space extending into the thorax. On computed tomography, the tumor was found to be encasing the left subclavian vein and pulmonary artery necessitating a midline sternotomy to provide adequate surgical exposure. After inhalational induction of anesthesia, a 22-G peripheral intravenous cannula was secured on the right hand. A 5 FG (B. Braun, Melsungen, Germany) pediatric triple lumen catheter, 8 cm long, was inserted into the right IJV under ultrasound guidance (9 Hz probe; Site Rite, Bard Access Systems, Pittsburgh, PA, USA). The line was secured to the skin at the 5 cm mark by sutures taken through the eyelets of the adjustable Statlock fixation device. The catheter was looped in a semi-circle on the neck and proximally additional sutures were taken through the eyelets on the integrated fixation wings of the catheter. Dressing of the insertion site was done using a 6 cm · 7 cm ‘Tegaderm’ (3M Healthcare, St. Paul, MN, USA) transparent dressing with adhesive on the underside and a label to hold the cannula in place. Blood was freely aspirated through all three ports of the triple lumen. On connecting to the pressure transducer a typical CVP trace (showing ‘a, c, v waves, x and y descent’) was observed. Skin incision was made on the left side of the neck. After the neck dissection, the incision was extended to the front of neck to facilitate sternotomy. While the tumor was being dissected away from the left brachiocephalic vein, the CVP showed a value of 65, and the trace disappeared. Blood could not be aspirated through the triple lumen ports. A kink or displacement of the CVP line was diagnosed and infusion was stopped. After thoracic dissection the surgeons noticed bleeding from the tissue planes on the right side of the neck and a hematoma was seen in the muscles (Figure 1). External application of pressure stopped the bleeding. On inspection the skin suture was intact at the 5 cm mark of the cannula. The catheter was diagnosed to have slipped out of the internal jugular vein and come to lie in the extravascular tissue. The catheter was removed at the end of surgery in its entirety ruling out fragmentation. The skin incision extending from the left side of the neck to the midline and down to the thorax let the skin of the right side of the neck retract laterally. This lateral retraction of skin fold might have increased the distance between the cannula puncture site at skin and the IJV which probably got aggravated by retraction of the right half of sternum and dissection over the contralateral brachiocephalic vessels. These tissue pull and push factors could have let the cannula slip out of the IJV. To prevent such dislodgement IJV cannulation should be avoided and femoral route preferred in case of surgery involving extensive neck dissection even if it is on the contralateral side. In case a neck line is inserted care should be taken to prevent lateral retraction of skin from midline. Constant vigilance and the awareness that such a complication can occur can help to prevent accumulation of fluid and blood in the neck and thorax. Anjolie Chhabra Dilip Kumar Pawar Puneet Khanna Navdeep Sokhal Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India (email: anjolie5@hotmail.com) Figure 1 A photograph showing the incision extending from left side of neck to the upper chest over the sternum, the skin retracting towards the right (SR), hematoma (H) and bleeding in the tissue planes (B). 1130 CORRESPONDENCE

Epidemiological Investigation and Successful Management of Burkholderia cepacia Outbreak in Neuro-Trauma Intensive Care Unit

OBJECTIVE The detailed epidemiological and molecular characterization of an outbreak of Burkholderia cepacia at a neurotrauma intensive care unit of a level 1 trauma centre is described. The stringent infection control interventions taken to successfully curb this outbreak are emphasized. METHODS The clinical and microbiological data for those patients who had more than one blood culture that grew B. cepacia were reviewed. Bacterial identification and antimicrobial susceptibility testing was done using automated Vitek 2 systems. Prospective surveillance, environmental sampling, and multilocus sequence typing (MLST) were performed for extensive source tracking. Intensive infection control measures were taken to further control the hospital spread. RESULTS Out of a total 48 patients with B. cepacia bacteraemia, 15 (31%) had central line-associated blood stream infections. Two hundred and thirty-one environmental samples were collected and screened, and only two water samples grew B. cepacia with similar phenotypic characteristics. The clinical strains characterized by MLST typing were clonal. However, isolates from the water represented a novel strain type (ST-1289). Intensive terminal cleaning, disinfection of the water supply, and the augmentation of infection control activities were done to curb the outbreak. A subsequent reduction in bacteraemia cases was observed. CONCLUSION Early diagnosis and appropriate therapy, along with the rigorous implementation of essential hospital infection control practices is required for successful containment of this pathogen and to curb such an outbreak.

Non- neurological complications after traumatic brain injury: A prospective observational study

Introduction and Aims: Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. Materials and Methods: This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. Results: We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS <6 (4.2 times, P < 0.006) of TBI was independently associated with significantly increased risk of ICU mortality. Conclusion: TBI patients tend to have poor outcome due to concomitant nonneurological complications. These have significant bearing on ICU stay, disability, and mortality.

Tissue necrosis of hand caused by phenytoin extravasation: An unusual occurrence

Saudi Journal of Anesthesia Vol. 8, Issue 2, April-June 2014 between these drugs. In this situation, in case of severe hypotension, it is recommended to use vasopressors with direct action.[6] Anesthesia in patients using amphetamines requires a careful administration of drugs that interfere in the synthesis, release and reuptake of catecholamines, as unpredictable and severe interactions may occur.

See-saw pattern in ventilator graphic: Is there any story behind?

The importance of ventilator graphics cannot be over emphasized that provide the useful information about airway, ventilation, compliance and lung mechanics. Some bizarre forms of graphics are usually overlooked in view of artifacts, but sometimes these tracings may in fact predict some relevant information.

Propofol may be useful in patients with congenital dystonia syndrome undergoing magnetic resonance imaging

apparently beneficial role of propofol in a pediatric patient. The dystonia are clinically and genetically different group of disorders with a variety of causes. The major concerns in these patients are difficult positioning, difficult airway, intubation, and postoperative care. Propofol use seems logical in this patient as it has shorter half-life, better recovery profile and in addition, this drug also provides good environment for LMA insertion (blunting of airway reflexes).[3] More so, the use of propofol infusion eliminates the concurrent administration of muscle relaxant, which is beneficial for better recovery, especially in neurologic patients. The mechanism how it produced the abolishment of dystonic features even in the postoperative period needs further research. However in our opinion, we should use propofol–LMA technique as a first method of choice in pediatric patients with congenital dystonia syndrome undergoing MRI procedure.

Unusual difficulty during central venous catheterization

Subclavian vein cannulation is associated with multiple complications, including arterial puncture, pneumothorax, hemothorax, and hematoma, which are mostly related to introducer needle. Guidewire-related problems include kinking, knotting, looping, and entrapment of wire in filters, sternocleidomastoid muscle, or even subcutaneous tissue.[3,4] In our case we were not able to introduce guidewire beyond side port of introducer needle as it was impinging on side wall of the side port. On checking we found that due to some minor manufacturing defect, the distal ridge of guidewire-holding assembly was preventing it from fitting properly inside the side port. The improper fit was creating space for guidewire to follow its natural curve (J tip) and that’s why instead of going straight into the needle, the guidewire was abutting against the wall of the side port. Shaving distal ridge made it to fit properly and we catheterized the vein successfully.