Naveen Yadav

Radio Frequency Ablation in Drug Resistant Chemotherapy-induced Peripheral Neuropathy: A Case Report and Review of Literature

Chemotherapy-induced peripheral neuropathy (CIPN) is a frequently encountered complication. It can result from a host of agents. Various modalities of treatment have been advocated, of which a novel method is radio frequency ablation. A 63-year-old male, a case of carcinoma prostrate with bone metastases, presented with tingling and numbness in right upper limb. He was given morphine, gabapentin and later switched to pregabalin, but medications provided only minor relief. Initially he was given stellate ganglion block, then radiofrequency ablation of dorsal root ganglion was done, but it failed to provide complete relief. Pulsed radiofrequency ablation (PRF) was then done for 90 seconds; two cycles each in both ulnar and median nerve. After the procedure the patient showed improvement in symptoms within four to five hours and 80% relief in symptoms. We conclude that PRF can be used for the treatment of drug resistant CIPN.

Acute hemodynamic instability during alcohol ablation of symptomatic vertebral hemangioma: A prospective study

Symptomatic vertebral hemangiomas (SVH) are difficult to treat and many therapeutic options, including surgery, radiotherapy, arterial embolization, and injection of methyl-methacrylate into hemagiomatous vertebrae have been reported. Alcohol ablation of vertebral hemangiomas is an effective management option; however, a literature search did not reveal any reports of anesthetic complications or hemodynamic instability during and report a series of four males and seven females and report hemodynamic variations observed at the time of injection of absolute ethanol under general anesthetic, for the treatment of SVH. The median age of the patients was 20 years (range, 10-36 years), and median weight was 45 kg (range, 30-70 kg). All patients developed transient hypotension and bradycardia at the time of alcohol injection (8-10 mL of absolute alcohol). No patient required intervention with vagolytics or vasopressors. It is likely that the administration of alcohol in small aliquots prevented any major consequences. Moreover, patients under general anesthesia are at lower risk than those receiving monitored sedation, with better control over hemodynamics.

Upper lip bite test in a patient with McCune Albright syndrome with acromegaly.

We report a patient with McCune Albright syndrome with acromegaly and features predictive of difficult airway except a class I upper lip bite (ULB) test. Our patient, a 33-year-old woman, had a history of polyostotic fibrous dysplasia. Tracheal intubation was performed under general anaesthesia. Although we did not find any difficulty in visualizing the glottis by direct laryngoscopy; our patient had multiple poor predictive signs of airway assessment including a Mallampati grade III, restricted neck movement and macroglossia. Our report suggests that the ULB test in people with acromegaly may act as an indicator of easy intubation in spite of other poor predictive signs. However, this finding needs further corroboration by a large study to evaluate the role of the ULB test in people with acromegaly.

Unilateral bronchospasm during microcatheter manipulation in an interventional neuroradiology suite

To the Editor: Bronchospasm during general anesthesia has many etiologies, including the patient’s intrinsic disease and mechanical, chemical or neurogenic causes [1, 2]. Reactions to drugs used for embolization and contrast drugs are important causes of bronchospasm in patients undergoing interventional radiological procedures [3, 4]. Unilateral bronchospasm per se is a known but rare entity. We report a case where manipulations of intercostal artery by a microcatheter led to acute unilateral bronchospasm. A 2-year-old girl weighing 12 kg and 65 cm in height was electively scheduled for glue embolization of dorsal (D2) spinal arteriovenous malformation under general anesthesia. Her preoperative respiratory and cardiovascular examinations were normal. The child was premedicated with oral atropine 0.3 mg an hour before the procedure. General anesthesia was induced with propofol 2 mg kg and fentanyl 2 lg kg. A 4-mm ID uncuffed endotracheal tube was placed after complete muscle relaxation, which was achieved with the administration of rocuronium 1 mg kg. The tube was fixed at the 12 cm mark at the angle of the mouth. Anesthesia was maintained with isoflurane in a mixture of nitrous oxide and oxygen (2:1) and intermittent boluses of fentanyl 1 mcg kg and rocuronium 0.1 mg kg. The procedure was performed in the supine position. Forty-five minutes later, the patient had a sudden increase in airway pressure (from 10 to 22 cm H2O) followed by an increase in expired carbon dioxide partial pressure (from 34 to 48 mmHg) and a decrease in peripheral oxygen saturation. On auscultation of the chest, air entry was found to be diminished on the left side along with wheezing and ronchi all over the left lung field. Possible causes of intraoperative bronchospasm such as endobronchial displacement of the tracheal tube, oropharyngeal secretions and inadequate depth of anesthesia and analgesia were ruled out, and after proper oral and tracheal tube suctioning, a combination of theophylline and etophylline was administered along with hydrocortisone. By this time the radiologist had stopped the procedure, as the patient was being managed for bronchospasm. The radiographic image of the chest did not reveal any obvious abnormality and the lung fields appeared normal. On discussing with the radiologist, it was found that he was manipulating the microcatheter through intercostal artery on the side concerned when the problem was noted. Nearly 30–40 min later, following conservative management, the bronchospasm was relieved and the procedure was allowed to continue. The unilateral nature of bronchospasm rules out the possibility of contrast media as the etiology of intraoperative bronchospasm in our patient. The onset and presence of spasm exclusively on the side of catheter manipulation in the intercostal artery is highly suggestive of the possible etiology. It is likely that stimulation of the bronchial artery at its origin from the intercostal artery might have produced vessel spasm and triggered a series of events resulting in bronchospasm. Though it is difficult to speculate about the exact mechanism of bronchospasm, the possibility of some neural or chemical mediators can always be anticipated, as bronchial musculature is always under the influence of parasympathetic tone. Subsequent negotiation of the catheter through the vessel at a later stage did not produce K. Reddy H. Prabhakar (&) N. Yadav G. P. Singh Department of Neuroanaesthesiology, Neurosciences Center, 7th floor, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: prabhakarhemanshu@rediffmail.com

Airway management in a patient of ankylosing spondylitis with traumatic cervical spine injury

Traumatic cervical lesions compressing the spinal cord pose a significant risk of exacerbating the existing neurological condition during tracheal intubation and subsequent positioning. Preexisting ankylosing spondylitis with spinal column involvement renders the spinal column more rigid and introduces difficulty in airway management of the patient with traumatic cervical spinal cord. To improve ease and success, and reduce cervical spine movement, awake fibreoptic intubation (FOI) is considered the gold standard technique for airway management in such cases. Attaining appropriate position for intubation was challenge in this case due to rigid curvature of the ankylosed spinal column. To prevent neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and attaining appropriate position was of prime concern. Optimal sedation with self-positioning by the patient in a comfortable posture is quite imperative and assures both airway as well as neurological protection in such expected difficult situations. We report the use of dexmedetomidine for self-positioning and awake FOI in a patient with ankylosing spondylitis having traumatic cervical spine who was otherwise neither able to co-operative nor able to give appropriate position for FOI.

Permissive hypotension in traumatic brain injury with blunt aortic injury: How low can we go?

With an ever-increasing incidence of high impact collisions, polytrauma is becoming increasingly common. Patients with traumatic brain injury (TBI) may require urgent surgical intervention along with maintenance of an adequate mean arterial pressure (MAP) to maintain cerebral perfusion. On the other hand, patients who sustain blunt aortic injuries (BAI) have a high mortality rate, many of them succumbing to their injury at the site of trauma. Surgery has been the mainstay of the management strategy for the remaining survivors. However, in recent years, the paradigm has shifted from early operative management to conservative treatment with aggressive blood pressure and heart rate control, serial imaging, and close clinical monitoring. When TBI and BAI coexist in a patient, it becomes crucial to maintain the MAP within a narrow range to prevent secondary insult to the brain as well as to prevent aortic rupture. We present the management of a case of TBI with traumatic aortic pseudoaneurysm, which required stringent monitoring and maintenance of hemodynamics during decompressive craniectomy.

Thoracic epidural for post-thoracotomy pain: a comparison of three concentrations of sufentanil in bupivacaine

ABSTRACT Background: The aim of this prospective, double blind, randomised trial was to compare the analgesic and adverse effects of three concentrations of the thoracic epidural sufentanil with bupivacaine in patients undergoing thoracotomy. Methods: We studied 60 (randomised) patients who were to receive a 10 ml bolus dose of sufentanil, 1μg/ml, 2 μg/ml and 3 μg/ml, in bupivacaine 0.125%, via thoracic epidural. Postoperatively, pain at rest, on coughing and with ambulation was assessed using a visual analogue scale (VAS) and observer verbal ranking score (OVRS) at 2, 6, 12 and 24 hours. Adverse effects were simultaneously assessed. Results: There was no significant difference in the baseline characteristics between the three groups. The number of patients with episodes of unsatisfactory pain, i.e. a VAS scores ≥ 40 and OVRS ≥ 2, at each of the four assessments postoperatively, was significantly higher with sufentanil 1 g/ml than with sufentanil 2 μg/ml or μ3 g/ml (p < 0.05). In the 3 μg/ml sufentanil group, four patients (20%) had a sedation score ≥ 3 compared with one (5%) and no (0%) patients in the 2 μg/ml and 1 μg/ml sufentanil groups, respectively (p < 0.05). In addition, 30% patients experienced pruritus in the 3 μg/ml sufentanil group compared with 10% and 5%, respectively, in the 2 μg/ml and 1 μg/ml sufentanil groups. In the sufentanil 3 μg/ml, 2 μg/ml and 1 μg/ml groups, 30%, 20% and 5% patients, respectively, had emetics symptoms (p < 0.05). Conclusions: We conclude that a thoracic epidural bolus of 10 ml sufentanil 2 μg/ml with bupivacaine 0.125% provides the optimal balance between pain relief and side-effects following thoracotomy.

Airway Management of a Post Tracheostomy Stenosis Patient With Respiratory Difficulty: Make Sure You Have Fibre Optic Guidance Before Administering a Muscle Relaxant!

Dear Editor, Post-tracheostomy stenosis is a rare but serious complication that may be encountered in the emergency department (ED). The incidence of severe tracheal stenosis (TS) with symptoms is seen in 1-2% of patients (1-3). Patients with severe TS may present with respiratory difficulty, requiring emergency intubation in the ED. A 35-year-old male was a follow-up case of an exploratory laparotomy for a blunt injury to his abdomen. He had stayed 25 days in the ICU with a tracheostomy. His decannulation was done a week prior to his presentation to the ED. The patient had a respiratory rate of 24/minute; air entry was present bilaterally but decreased, and stridor was present. Computed tomography (CT) (Figure 1), revealed TS with a constriction band of 9 mm, 3 cm distal to the larynx and 6.9 cm proximal to the carina. The patient was shifted to the ICU and was posted for tracheal resection anastomosis the next day. In the operating theater, all routine monitoring was attached. Based on CT findings, it was decided to do a fiber optic bronchoscopy (FOB), 5.7 mm in size, both for identifying the stricture and for intubation. The patient was given a superior and transtracheal nerve block and awake FOB intubation was tried. On the first attempt, a fibrous web was seen (Figure 2) a short distance below the larynx and a small constriction was present. Despite several attempts, we were not able to negotiate the FOB through the constriction. Any patient with Post tracheostomy stenosis presenting with respiratory difficulty should be approached with caution in emergency department. No muscle relaxant and deep sedation should be given without adequate back up like fibre optic bronchoscope and preparation of emergency tracheostomy. Therefore, we decided to puncture the fibrous web Figure 1. Computed Tomography Image of Lateral Neck, Showing Tracheal Stenosis (White Arrow)

Anesthetic concerns in a huge congenital sublingual swelling obscuring airway access

Presence of intraoral pathology poses a great challenge during management of pediatric airway. We report management of big intraoral cystic swelling physically occupying the entire oral cavity restricting access to airway. Preintubation aspiration of swelling was done to decrease its size and make room for airway manipulation, followed by laryngoscopy and intubation in lateral position. Airway patency is at risk in postoperative period also, in this case, though the swelling decreased in size postoperatively but presence of significant edema required placement of tongue stitch and modified nasopharyngeal airway. Case report highlights simple maneuvers to manage a difficult case.

Effect of anaesthesia on the perioperative outcomes of pelvi-acetabular fracture surgeries in the apex trauma centre of a developing country-a retrospective analysis

BackgroundRegional anaesthesia has been proposed to reduce intraoperative blood loss, duration of hospital stay and in-hospital complications with improved postoperative pain control. General anaesthesia is advantageous for prolonged surgeries. We hypothesized that combined regional and general anaesthesia would offer advantages of both in pelvi-acetabular fracture surgeries.MethodsWe identified 71 patients who underwent open reduction and internal fixation of pelvi-acetabular fractures from May 2012 to 2013 in our trauma centre. We excluded patients with incomplete records (n = 4) and other injuries operated along (n = 8). Hence, 59 patients were divided into three groups: G group (general anaesthesia), R group (regional anaesthesia) and GR group (combined regional and general anaesthesia).Main outcome measurements studied were intraoperative blood loss, duration of hospital stay, duration of surgery and intraoperative and postoperative complications.ResultsNo differences were obtained in between the groups in terms of age, gender, Injury Severity Score, number of comorbidities, or duration from injury to surgery. No significant differences were found between the three groups for intraoperative blood loss, days of hospital stay and duration of surgery. Intraoperative and postoperative complications were also comparable between the groups (p > 0.05).ConclusionsThere is no specific significant advantage of the technique of anaesthesia on the observed perioperative complications in pelvi-acetabular fracture surgeries.