Nishant Kumar

Midazolam as a sole sedative for computed tomography imaging in pediatric patients

Objective:  To evaluate the efficacy and adverse effects of i.v. midazolam as a sole agent for sedation in children for computed tomography (CT) imaging.

Mandibular nerve block for peri-operative pain relief using a peripheral nerve stimulator.

with its synergistic effect with tramadol, may have also contributed to our case. Tramadol can cause mydriasis through stimulation of adrenergic receptors, or miosis through stimulation of opioid receptors, and previous reports concerning the net effect on pupillary size are conflicting [6]. Miosis is more likely to occur in extensive tramadol metabolisers, while mydriasis might develop in intermediate and poor metabolisers because of a delay in conversion of tramadol (which causes pupillary dilatation) to the active metabolite, O-desmethyltramadol (which causes pupillary constriction). Our patient may have been an intermediate metaboliser. One other possible diagnosis would be central anticholinergic syndrome. Athough tramadol is a relatively safe opioid, we believe it should be administered cautiously in the immediate postoperative period.

Intraoperative mandibular nerve block with peripheral nerve stimulator for temporomandibular joint ankylosis

We describe the use of peripheral nerve stimulator for mandibular nerve block intraoperatively in a 4.5year old child with complete temporomandibular joint ankyloses. The block was not possible preoperatively, therefore, it was administered after release of ankyloses. The use of peripheral nerve stimulator increased the chances of a successful block. No intraoperative analgesics and muscle relaxants were required. Postoperative pain relief was excellent. Peripheral nerve stimulator is an easy way of for accurate needle tip placement for mandibular nerve block in patients with distorted anatomy.

Addition of clonidine to bupivacaine in transversus abdominis plane block prolongs postoperative analgesia after cesarean section.

Background and Aims: The aim was to compare duration of postoperative analgesia with addition of clonidine to bupivacaine in bilateral transversus abdominis plane (TAP) block after lower segment cesarean section (LSCS). Material and Methods: One hundred American Society of Anesthesiologists (ASA) grade I and II pregnant patients undergoing LSCS under spinal anesthesia were randomly divided to receive either 20 ml bupivacaine 0.25% (Group B; n = 50) or 20 ml bupivacaine+1ug/kg clonidine bilaterally (Group BC; n = 50) in TAP block in a double-blind fashion. The total duration of analgesia, patient satisfaction score, total requirement of analgesics in the first 24 h, and the side effects of clonidine such as sedation, dryness of mouth, hypotension, and bradycardia were observed. P < 0.05 was taken as significant. Results: In 99 patients analyzed, TAP block failed in five patients. Duration of analgesia was significantly longer in Group BC (17.8 ± 3.7 h) compared to Group B (7.3 ± 1.2 h; P < 0.01). Mean consumption of diclofenac was 150 mg and 65.4 mg in Groups B and BC (P < 0.01), respectively. All patients in Group BC were extremely satisfied (P < 0.01) while those in Group B were satisfied. Thirteen patients (28%) in Group BC were sedated but arousable (P = 0.01) compared to none in Group B. In Group BC, 19 patients complained of dry mouth compared to 13 in Group B (P = 0.121). None of the patients experienced hypotension or bradycardia. Conclusion: Addition of clonidine 1 μg/kg to 20 ml bupivacaine 0.25% in TAP block bilaterally for cesarean section significantly increases the duration of postoperative analgesia, decreases postoperative analgesic requirement, and increases maternal comfort compared to 20 ml of bupivacaine 0.25% alone.

Conversion reaction mimicking a high spinal anesthesia

To the Editor: High spinal block is a known complication of spinal anesthesia [1]. Here we describe our experience in a clinical situation that initially prompted us to suspect a high spinal block but which was likely caused by a hysterical episode. A 40-year-old woman (ASA physical status I; 160 cm in height, weight 58 kg) with uterovaginal prolapse presented for elective vaginal hysterectomy. Although she was apprehensive about her surgery at preoperative clinic, she reassured and consented to receive spinal anesthesia. The night before the surgery, she was given 0.25 mg oral alprazolam. Her baseline vital parameters were stable. In the operating room, an intravenous access was established, and 1 mg midazolam was administered. A 25-G Quinke spinal needle with bevel facing upward was inserted in left lateral position at the L3–L4 level. Hyperbaric bupivacaine 0.5% 12.5 mg (2.5 ml) was injected intrathecally over a period of 15 s. The onset of the block occurred within a minute. She was placed in lithotomy position, and the surgery was started 20 min later with a sensory level of T8. Oxygen was administered at 3 l/min using a face mask. Verbal contact was made with her every few minutes. At 30 min after the start of surgery she suddenly became unresponsive to verbal commands, was not responding to skin pinch on arm, and her respiration was found to be very jerky and shallow. There was a transient fall in oxygen saturation to 92%. The anesthesiologist requested the surgeons to stop the surgery and provided 100% oxygen using a Bain’s circuit. Her jaw tone was maintained; her heart rate was 75 beats/min, and blood pressure was 126/70 mmHg. Her blood sugar was found to be 6.5 mmol/l. After 3 min she became responsive to verbal commands, her respiration became normal, and oxygen saturation improved to 99%. Her vital signs remained stable and she did not complain of anything. She perceived a sensory loss up to her shoulder tip. We checked for sensations over her face, and she mentioned sensory loss even on her face. Her pupils were normal in size and reacted normally to light. She was reassured, and after 2 min the level of block was rechecked. The level was up to the T8 dermatome level. Her husband was interviewed, and no history of any psychiatric illness was noted. The surgery was allowed to proceed and was completed uneventfully during the next 50 min. Postoperative evaluation was performed by a psychiatrist and a neurologist. Her electroencephalogram and a computed tomography (CT) scan of the brain were found to be normal. The episode was diagnosed to have been caused by hysteria. The subsequent postoperative period was uneventful. The spinal anesthesia lasted for 3 h, and there was no focal deficit. Conversion reaction is a condition characterized by sensory and motor derangement along with emotional disturbance. It is a psychological disorder in which severe physical symptoms such as blindness or paralysis appear with no apparent physical cause [2]. Conversion reactions have previously been reported after spinal anesthesia [3], but ours is perhaps the first case in which some of the features mimicked high spinal block. Clinical features in our patient initially resembled high spinal block, but her vital signs were stable. Her normal blood sugar level ruled R. Sharma (&) A. Jain R. Singh N. Kumar Department of Anesthesiology, Lady Hardinge Medical College and Associated Shrimati Sucheta Kriplani and Kalawati Saran Hospitals, New Delhi 110002, India e-mail: rajeevkrsharmaji@gmail.com

How green is my operation theater

Objective: To ascertain the awareness regarding global warming and the anesthesia practices contributing to it in the city of Delhi. Materials and Methods: A questionnaire was circulated amongst the qualified anesthesiologists (consultants and senior residents) in the city of Delhi. The initial contact was made through e-mail and the questionnaire was required to be filled and returned electronically. The questionnaire was also made available online at http://sites.google.com/site/surveydelhi. After 1 month, the forms were distributed physically. Assuming that at least 50% of the approximately 1200 practising anesthesiologists would be able to recognize the greenhouse gases correctly, the target number of responses was 150 with 99% confidence limit. Results: Of the 831 anesthesiologists contacted, only 184 responded. Ninety-eight percent were aware of the greenhouse effect, but only 15.8% (29) could correctly identify all the greenhouse gases. However, 47.28% (87) could identify nitrous oxide and inhalational agents as a cause of greenhouse effect. Ninety percent of the respondents use circle system and 87% use low flows frequently. Ninety-three percent (171) of respondents routinely use nitrous oxide, and 32.1% (59) would, however, not use air even if made available. Seventy-nine percent (145) advocated total intravenous anesthesia as an alternative to reduce the menace. Conclusion: Only 22% were motivated enough to respond to the survey. More than half of these anesthesiologists were not aware about the anesthetic agents contributing to the greenhouse effect. However, their clinical practices inadvertently do not add to the environmental pollution.