Neeru Sahni

Comparison of different routes of administration of clonidine for analgesia following anterior cruciate ligament repair

Background and Aims: A high percentage of patients undergoing arthroscopic repairs on day care basis complain of inadequate postoperative pain relief. Clonidine was evaluated for the best route as an adjuvant in regional anesthesia in anterior cruciate ligament (ACL) repair to prolong analgesia. Material and Methods: A prospective randomized double-blinded study was planned in a tertiary care hospital in North India in which 85 American Society of Anesthesiologists I and II patients undergoing ACL repair were enrolled. All groups received 0.5% hyperbaric bupivacaine intrathecally as in control group C. Group IT received intrathecal 1 μg/kg of clonidine along with hyperbaric bupivacaine, group IA received 0.25% bupivacaine and 1 μg/kg clonidine intra-articularly, and group NB received 0.25% bupivacaine and 1 μg/kg clonidine in femoro-sciatic nerve block (FSNB). Postoperative pain free interval and block characteristics were the primary outcomes studied. Results: Pain-free duration was 546.90 (±93.66) min in group NB (P < 0.001) in comparison to 234.90 (±20.99), 367.80 (±47.40) and 172.20 (±54.82) min in groups IA, IT and C, respectively. Sensory block and motor blockade in NB were 474.90 (±43.80) and 267.40 (±34.59) min, respectively, and were significantly prolonged (P > 0.001) in comparison to other groups. The mean rescue analgesic requirement and cumulative frequency of rescue analgesia were least in group NB, followed by groups IT, IA and C. Conclusion: Clonidine is safe and effective adjuvant with bupivacaine in prolonging analgesia through various routes employed for post knee surgery pain. The maximum prolongation of analgesia is achieved through FSNB with a risk of prolonging postanesthesia care unit stay.

Intraoperative and Postoperative Administration of Dexmedetomidine Reduces Anesthetic and Postoperative Analgesic Requirements in Patients Undergoing Cervical Spine Surgeries.

Background: Early recovery from anesthesia and avoidance of analgesics with respiratory depressant properties are vital for maintenance of extubated airway in cervical spine surgeries. The current study investigated the role of dexmedetomidine as an anesthetic sparing agent and as a sole postoperative analgesic in these cases. Materials and Methods: Sixty adult patients undergoing cervical spine surgeries were randomized into 2 groups. Group D received intravenous dexmedetomidine infusion 0.5 &mgr;g/kg/h throughout the surgery after a loading dose of 1 &mgr;g/kg over 10 minutes. Postoperatively, dexmedetomidine infusion was continued at 0.2 &mgr;g/kg/h for 24 hours. Group C received a volume-matched bolus and infusion of 0.9% saline. Intraoperative anesthetic requirement, time to recovery, and discharge were recorded. Patients were observed for rescue analgesic requirements for 24 hours after surgery. Hemodynamic stability, sedation scores, and pain scores were assessed for 48 hours after surgery. Results: There was significant reduction in intraoperative anesthetic requirement in group D (P<0.001). Although sedation scores and recovery criteria were comparable, pain scores were significantly lower in group D compared with group C for first 24 hours postoperatively at all corresponding times. The mean pain-free period after surgery was significantly longer in group D (1460.67±517.16 min) with significantly less rescue analgesic requirement during 24-hour postoperative period (P=0.018) compared with group C (98.17±81.20 min). Hemodynamic parameters were maintained within clinically normal range during study period. Conclusions: Dexmedetomidine lowered the anesthetic requirement with clinically permissible hemodynamic variations without undue prolongation of recovery time. Postoperative dexmedetomidine infusion provided effective analgesia without excessive sedation in patients undergoing cervical spine surgeries.

Sepsis of unknown origin with multiorgan failure syndrome: Think of hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis is a clinic pathologic entity characterized by increased proliferation and activation of benign macrophages with hemophagocytosis throughout the reticuloendothelial system. It is a potentially lethal disorder due to an uncontrolled immune response to a triggering agent. HPS may be primary, or secondary to malignancy, infections, auto-immune diseases, and pharmacotherapy. HPS is a rare, but life-threatening complication. Herein, we described a female patient with HPS with secondary sepsis. Our objective was to raise the importance of early diagnosis of HFS by presenting a representative case.

Accidental intra-arterial injection of neostigmine with glycopyrrolate or atropine for reversal of residual neuromuscular blockade: a report of two cases.

bation was successfully conducted by using the introducer as a guide. Insertion of a flexible guide for retrograde intubation via a tracheostomy with a caudal orientation of the internal tracheal lumen results in advancement of the guide further into the trachea rather than cephalad through the larynx. In our case, because the Cook airway exchange catheter, initially used as a guide, was flexible and did not have an angled tip, it could not be advanced in the cephalad direction via the caudally directed tracheostomy tract, causing our initial attempt at retrograde intubation to fail (Fig. 1). However, the Frova intubating introducer is made of more rigid polyethylene and has a length of 65 cm, an outside diameter of 4.7 mm, a tip portion of approximately 2 cm with a flexible angle of 65°, and an internal stylet that can be inserted for rigidity up to the distal 5 cm. These features account for why we were able to advance the Frova intubating introducer in the cephalad direction via a caudally oriented tracheostomy tract (Fig. 2). Retrograde intubation using an intubating introducer via a tracheostomy is not a recommended technique and could result in creation of a false passage, vocal cord injury, retropharyngeal hematoma, and tissue damage. Because our patient had maintained a tracheostomy for over 8 years, the risk of a false passage was relatively low.

Anti‑N-Methyl-D-Aspartate-Receptor Encephalitis in Young Females

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an immune-mediated disease commonly associated with ovarian teratoma. Anti-NMDA-receptor autoantibodies disrupt NMDA function leading to the development of psychosis, seizures and autonomic dysfunction. The treatment includes underlying tumour resection and immunosuppression. Slow recovery and unpredictable clinical course makes intensive care management of these patients challenging. We report the management of two young female patients with anti-NMDA-receptor encephalitis associated with ovarian teratoma.

Effect of intensive education and training of nurses on ventilator-associated pneumonia and central line-associated bloodstream infection incidence in intensive care unit at a tertiary care center in North India

Objective: The aim was to analyze the impact of education and training of nurses on the incidence of ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI). Patients and Methods: A prospective observational study at a tertiary care hospital included adult patients with Intensive Care Unit stay >48 h. The study was done in three phases: in Phase 1, baseline VAP and CLABSI incidence was calculated; in Phase 2, education and training of nurses; and in Phase 3, data were recollected for the incidence of VAP and CLABSI. Results: The baseline incidence of VAP in Phase 1 was 28.86/1000 ventilator days and that of CLABSI was 7.89/1000 central-line days. In Phase 3, the incidence of VAP increased to 35.06 and that of CLABSI decreased significantly, 1.73. Conclusion: Intensive education and training sessions with feedback from nurses over a period of 6 months led to significant reduction in the incidence of CLABSI; however, the incidence of VAP increased.

Mechanical ventilation in neurological and neurosurgical patients

Approximately 20% of all patients requiring mechanical ventilation suffer from neurological dysfunction. It is imperative in the ventilatory management of such patients to have a thorough understanding of the disease pathology that may require institution of mechanical ventilation as well as in realizing its effects on the injured brain. These patients have unique challenges pertaining to the assessment and securing of the airway, maintenance of mechanical ventilation, as well as weaning and extubation readiness. This manuscript aims to present the current evidence in ventilatory management of the important subset of patients with neuronal injury. The indications for ventilatory management include both neurological and neurosurgical causes.

Anaesthetic challenges in a child with sickle-cell disease and congenital heart block.

Sir, We present a case report of anaesthetic management of a 12-year-old boy with sickle-cell disease (SCD) and congenital heart block (CHB) with pacemaker [Figure 1], undergoing laparoscopic splenectomy. Figure 1 12-lead electrocardiography of the patient The child had suffered sickle-cell crisis and pacemaker malfunction a month back. His preoperative investigations were normal and weight was 30 kg. He received intravenous (IV) fluids during fasting period, pneumococcal vaccine, antibiotic prophylaxis and cefotaxime 500 g IV. The cardiologist changed the mode of pacemaker to asynchronous (fixed rate). Standard American Society of Anesthesiologists monitoring, urine output and temperature monitoring were used. Morphine 4.5 mg IV, thiopentone 150 mg IV and atracurium 0.5 mg/kg IV were used for induction and intubation. Anaesthesia was maintained with isoflurane (MAC: 1.0), air and oxygen (FiO2: 0.5). Pneumoperitoneum was created with CO2 and intra-abdominal pressure was kept around 8–10 mmHg. The surgeon used bipolar cautery, blood loss was approximately 800 ml and 1 unit packed red cell was transfused. The patient was given fluid at 60 ml/h intra-operatively as he had been kept hydrated preoperatively. For post-operative analgesia, paracetamol 500 mg IV was given and skin incision was infiltrated with 12 ml 0.2% ropivacaine. Neuromuscular blockade was reversed and trachea was extubated. The patient remained haemodynamically stable, normothermic and had adequate urine output. Post-operative analgesia was maintained with paracetamol 500 mg IV 8th hourly and fentanyl boluses of 30 μg as rescue analgesic whenever visual analogue scale exceeded 3. The child was discharged on the 7th post-operative day after uneventful course. CHB (incidence 1 in 22,000 live births) with no structural abnormality and when diagnosis is established beyond neonatal period has better survival.[1] Intraoperatively, pacemaker mode is advised to be changed to asynchronous, and bipolar electrocautery is to be used. The availability of manual pacing should be ensured to manage pacemaker malfunction.[2] SCD is the disorder of beta-globin chain characterised by haemolytic anaemia, intermittent vascular occlusion, pulmonary compromise and multi-organ damage. Electrocardiogram changes are non-specific and first-degree heart block may be found.[3,4] Not usually associated with SCD, CHB in our patient is perhaps an additional finding. Splenectomy is recommended in children older than 2 years or after one major or two minor episodes of splenic sequestration crises.[3,4] When done laparoscopically, the duration of surgery increases, but hospital stay is decreased.[3] Any major surgery is associated with 7% mortality. Preoperatively, the history of episodes of painful crises must be sought.[4] Pre-operative examination should be thorough as SCD involves multiple organ systems. Neurological evaluation rules out the previous cerebrovascular accident as ischaemic infarcts are common in anaemic children.[3] Kidneys may get involved during advanced disease. Presence of rib infarcts can lead to hypoventilation. Perioperative cardiopulmonary manifestations such as acute chest syndrome usually remain undetected in young children.[3,4] As dehydration precipitates RBC sickling and occlusion of microvasculature at a level of precapillary sphincters, perioperative hydration must be ensured.[3,4] There is a controversy regarding blood transfusion, benefit being dilution of haemoglobin S and disadvantage being triggering of sickling.[3,4] Other factors leading to sickling crises are vascular stasis, hypoxia, metabolic acidosis, hypothermia and presence of infection.[3] Previous case reports have emphasised the importance of preventing sickling crisis perioperatively.[5] To conclude, perioperative anaesthetic management of children suffering from SCD and CHB needs meticulous pre-operative and intra-operative management and post-operative vigilance for preventing sickle-cell crisis and associated complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Anaesthetic management of a patient with Huntington's chorea undergoing robot-assisted nephron-sparing surgery

A 52-year-old, 50 kg female with history of abdominal pain for past 1 month was diagnosed to have multiple cystic lesions in the upper pole of the left kidney for which robot-assisted NSS was planned [Figure 1]. The patient was known case of HC for 5 years with choreiform movements, behavioural abnormalities and depression. She had a positive family history. Magnetic resonance imaging of the brain and genetic analysis confirmed diagnosis, and she was under neurology follow-up [Figure 2]. She was receiving tablet olanzapine 5 mg at bedtime and lorazepam 0.25 mg twice a day. Furthermore, she suffered from bronchial asthma for 2 years and was advised budesonide metered-dose inhaler for which she was non-compliant. Pre-anaesthetic evaluation revealed dysarthria and mild choreiform movements with no complaints of difficulty in swallowing. She refused nebulisation with bronchodilator in pre-operative period. She was advised to continue her medication, and tablet ranitidine 50 mg was given at night and morning of surgery.

A randomized clinical trial of prone position extubation to reduce the severity of coughing in patients undergoing dorsolumbar spine surgery

To the Editor, When patients undergoing spine surgery in the prone position are turned supine for extubation, coughing and bucking may occur. We conducted a prospective, randomized clinical trial (CTRI/2014/09/004982) with the primary aim to assess the incidence of coughing and a secondary aim to assess the severity of coughing in patients extubated prone compared to those extubated in the supine position. Sixty American Society of Anesthesiologists physical status I-II patients (18-60 yr) undergoing dorsolumbar spine surgery in the prone position were randomly allocated (1:1) prior to the induction of anesthesia to either prone (group P) or supine (group S) extubation. Patients with a history of cardiovascular disease, chronic obstructive pulmonary disease, morbid obesity, or obstructive sleep apnea were excluded. Morphine 0.1 mg kg, propofol 1-2 mg kg, and vecuronium 0.1 mg kg were given intravenously for induction. Desflurane (end tidal concentration 2-4%) with nitrous oxide in oxygen (60:40) was used for maintenance of anesthesia. After turning the patients prone, the head was positioned to one side on a gel-padded head ring. Intravenous diclofenac 2 mg kg body weight was given for postoperative analgesia at the time of skin closure. No additional opioids were given to any patient after induction. At the end of surgery, 20 mL of 0.25% bupivacaine was infiltrated along the incision line. In group P, anesthetics were discontinued after applying the dressing and extubation was completed in the prone position. In group S, anesthetics were switched off just before turning the patient supine, and subsequent extubation was performed in the supine position. In both groups, tracheal extubation was done after reversal of neuromuscular blockade (neostigmine 0.5 mg kg iv and glycopyrrolate, 0.01 mg kg iv), return of adequate spontaneous respiration and oxygen saturation, and when the patient followed commands. After extubation in group P, the patients were turned back to the supine position. The study’s observation period extended from the time of switching off the inhalational agent until 30 min after extubation. The primary outcome was to assess the incidence of coughing during extubation. Severity of coughing was assessed as none, mild (single cough), moderate (more than one cough but unsustained coughing), and severe (sustained C five seconds of coughing). Other secondary outcomes were the time to extubation, various hemodynamic parameters, and adverse events (respiratory insufficiency, loss of airway, significant desaturation). The sample size was calculated to be 30 in each group using data from a previously published study that reported the incidence of coughing during emergence at one minute after extubation as 9% in the prone group vs 40 % in the supine group (alpha = 0.05 and power = 0.8). Statistical analysis was conducted using SPSS for Windows (version 15.0; SPSS Inc., Chicago, IL, USA) and a two-sided P\ 0.05 was considered statistically significant. The two groups were comparable in terms of demographic variables, duration of surgery, and anesthetic exposure. Coughing occurred in all 30 (100%) patients in group S compared to four of 30 (13 %) patients S. Kumar, MD N. Sahni, MD H. Bhagat, MD (&) A. Jain, MD J. Wig, MD K. Gandhi, MD Department of Anaesthesia & Intensive Care, PGIMER, Chandigarh, India e-mail: hembhagat@rediffmail.com