Neha Baduni

Anaphylactic reaction to intravenous diclofenac.

Diclofenac sodium is a non-steroidal anti-inflammatory drug widely used as an opioid sparing agent for postoperative analgesia. Anaphylaxis due to intravenous diclofenac sodium is very rare. We report a case of anaphylactic reaction to IV diclofenac sodium, occurring postoperatively in a 25-year-old primigravida, the clinical features of which mimicked pulmonary embolism. The rarity, clinical importance and the diagnostic dilemma associated prompted us to report this case.

A comparative evaluation of magnesium sulphate and nitroglycerine as potential adjuncts to lidocaine in intravenous regional anaesthesia.

Introduction: This randomized control trial was carried out to evaluate and compare the efficacy of magnesium sulphate and nitroglycerine (NTG) as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). Materials and Methods: Seventy-five, ASA grade I and II patients, aged between 20-50 years, scheduled for hand and forearm surgery were selected and entered randomly into three study groups. Patients in group C received 3 mg/kg of preservative free lidocaine 2% diluted with saline to a total volume of 40 ml. Patients in group M received 3 mg/kg of preservative free lidocaine 2% mixed with 6 ml of 25% magnesium sulphate (1.5 g) diluted with saline to a total volume of 40 ml. Patients in group N received 3 mg/kg of preservative free lidocaine 2% mixed with 200 ΅g of nitroglycerine diluted with saline to a total volume of 40 ml. Sensory and motor block onset and recovery time, tourniquet pain onset time, intraoperative fentanyl requirement, the total number of patients requiring rescue analgesia and the time to first analgesia requirement, intra-operative and postoperative degree of analgesia were evaluated. Results: The sensory and motor block onset times were shorter in group M and N as compared to group C (P- = 0.004, 0.0036 for sensory block, 0.021, 0.038 for motor block. The mean time of onset of sensory block was earliest in group M and the mean time of onset of motor block was earliest in group N. Mean time of onset of tourniquet pain in the three groups was similar in groups M and N. The sensory and motor block recovery time were significantly prolonged in M and N group as compared to group C (P < 0.001). Intraoperative fentanyl requirement (P value- = 0.041), the total number of patients requiring rescue analgesia (P value = 0.009) and the time to first analgesia requirement (P value = 0.038) were lower in group M. Conclusion: The addition of both magnesium suphate and nitroglycerin (NTG) to lidocaine for intravenous regional anesthesia (IVRA) leads to early onset of sensory block and prolonged postoperative analgesia, with no side effects.

Abnormal oculocardiac reflex in two patients with Marcus Gunn syndrome

Marcus Gunn phenomenon is seen in 4 to 6% of congenital ptosis patients. We report two cases of abnormal oculocardiac reflex during ptosis correction surgery. Marcus Gunn syndrome is an autosomal dominant condition with incomplete penetrance. It is believed to be a neural misdirection syndrome in which fibres of the motor division of the trigeminal nerve are congenitally misdirected into the superior pterygoid and the levator muscles. Anesthetic considerations include taking a detailed history about any previous anaesthetic exposure and any reaction to it as this syndrome has a high probability of being associated with malignant hyperthermia. It is also postulated that an atypical oculocardiac reflex might be initiated in these patients as seen in our patients, so precautions must be taken for its prevention and early detection.

Comparison of palanosetron with ondansetron for postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy under general anesthesia

Background: Post-operative nausea and vomiting (PONV) is a ′big little′ problem especially after laparoscopic surgeries. Palanosetron is a new potent 5 hydroxy tryptamine 3 antagonists. In this randomized double blind clinical study we compared the effects of i.v. ondansetron and palanosetron administered at the end of surgery in preventing post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy under general anesthesia. Materials and Methods: A total of 100 subjects between 18-60 years with Apfel score ≥2, were randomly assigned into one of the two groups, containing 50 patients each. Group A received ondansetron 4 mg i.v. and Group B received palanosetron 0.07 5mg i.v. both as bolus before induction. The incidence of nausea, retching and vomiting, incidence of total PONV, requirement of rescue antiemetics and adverse effects were evaluated during the first 24 h following end of surgery. Results: The incidence of nausea was significantly lower in patients who had received palanosetron (16%) as compared to ondansetron (24%). Need of rescue antiemetics was significantly higher in patients receiving ondansetron (32%) as compared to palanosetron (16%). The incidence of total PONV was also significantly lower in group receiving palanosetron (20%) as compared to ondansetron (50%). Among the side effects, headache was noted significantly higher with ondansetron (20%) as compared to palanosetron (6%). Conclusion: Palanosetron has got better anti-nausea effect, less need of rescue antiemetics, favourable side effect profile and a decrease in the incidence of total PONV as compared to ondansetron in 24 h post operative period in patients undergoing laproscopic cholecystectomy under general anesthesia.

Acute pulmonary edema after intramyometrial prostodin

A 25 year old, 68 kg, primigravida, was taken up for emergency caesarean section for meconium stained liquor and fetal distress. She was a known case of pre eclampsia and her blood pressure was controlled on tab methyl dopa. she was administered general anaesthesia. after delivery of baby she went into postpartum hemorrhage which was controlled with intramyometrial prostodin. but immediately after its administration she went into acute pulmonary edema.

Awareness of basic life support among dental practitioners

Background: It is important that every member of our community should be trained in effective BLS technique to save lives. At least doctors including dental practitioners, and medical and paramedical staff should be trained in high quality CPR, as it is a basic medical skill which can save many lives if implemented timely. Aim: Our aim was to study the awareness of Basic Life Support (BLS) among dental students and practitioners in New Delhi. Materials and Methods: This cross sectional study was conducted by assessing responses to 20 selected questions pertaining to BLS among dental students, resident doctors/tutors, faculty members and private practitioners in New Delhi. All participants were given a printed questionnaire where they had to mention their qualifications and clinical experience, apart from answering 20 questions. Statistical Analysis: Data was collected and evaluated using commercially available statistical package for social sciences (SPSS version 12). Results: One hundred and four responders were included. Sadly, none of our responders had complete knowledge about BLS. The maximum mean score (9.19 ± 1.23) was obtained by dentists with clinical experience between 1-5 years. Conclusion: To ensure better and safer healthcare, it is essential for all dental practitioners to be well versed with BLS.

Caesarean section in a patient with Myasthenia Gravis: A bigger challenge for the anesthesiologist than the obstetrician

Myasthenia Gravis (MG) is an acquired, autoimmune disorder affecting neuromuscular junction presenting with easy fatigability, progressive weakness, diplopia, difficulty in speaking and swallowing and even ventilatory failure in severe cases. During pregnancy the disease may go into remission or may exacerbate at any time during first, second and third trimesters or postpartum period. We are reporting the case of a 28 year old primigravida, known case of MG, who underwent caesarean section and developed muscular weakness on third postoperative day. Her neonate also had tachypnoea and hypotonia, Both, the mother and the baby were managed aggressively and responded well to therapy.

Perioperative management of a patient with myxedema coma and septicemic shock

Myxedema coma is a life-threatening but uncommon complication of long-standing, neglected hypothyroidism. It was first reported by Ord in 1879. Till date only around 200 cases have been reported in literature. The incidence in European countries is 0.22 per million per year. No epidemiological data is available from the Indian subcontinent. We are reporting the case of an elderly lady who went into life-threatening myxedema coma along with septicemic shock, and was successfully treated with oral thyroxine.

Cesarean section under local anesthesia: A step forward or backward?

Sir, I read with pleasure the letter to the editor regarding our paper entitled “Caffeine for the prevention of postoperative nausea and vomiting (PONV),[1]” which was published in your journal. While our paper represents a first ever prospective, randomized, double-blind, placebo-controlled study examining the effects of intravenous caffeine on PONV rates and other side-effects of general anesthesia, more studies are needed to potentially uncover any positive effects of caffeine on postoperative recovery. In our study, we attempted to account for as many PONV risk factors as possible, and control for them appropriately. For example, we controlled for four major risk factors such as female gender, smoking status, prior history of PONV, and perioperative opioid use.[2] In addition, we controlled for baseline caffeine consumption, duration of anesthesia, and type of surgery all known to potentially influence study results.[3] In addition, we made every attempt to standardize induction and maintenance of anesthesia among different practitioners. All patients received intravenous induction with propofol, and anesthesia was maintained with an inhalational agent. Overall, this was a well-controlled study. In fact, the most recent PONV guidelines from the Society for Ambulatory Anesthesia published a list of overall positive risk factors, which were all acknowledged and controlled for in our study.[4] As far as intravenous fluid administration is concerned, we agree that there is some evidence that high amount of intravenous fluid administration can reduce postoperative emesis.[5,6] Our ambulatory anesthesia practitioners follow internally developed ambulatory anesthetic protocols that allow little room for variation. In our study, most patients would have received similar amounts of fluid as these cases were generally short and similar in duration; similarly, although we did not report the intraoperative dose of the inhalational agent(s), we believe it would have had a minor effect on the reported outcomes. In summary, our pilot study explores the possibility of using a different drug modality (intravenous caffeine) for the prevention of PONV and other anesthetic side-effects. Larger prospective studies are warranted to further explore this drug’s potential.

Malfunctioning pilot balloon assembly

DOI: 10.4103/0970-9185.105828 the fluoroscopic technique for endobronchial intubation with a single lumen endotracheal tube quickly in infants. Fluoroscopic guidance allows manipulation of the DLT tip under direct visual control and observation of the DLT tip from various angles. Gentle handling should be used, while advancing the DLT, to prevent injury to the bronchial tree. Studies are recommended to determine the efficacy of the technique and evaluate the risks such as injury to the bronchus.