Praveen Talawar

Perioperative management and post-operative course in preterm infants undergoing vitreo-retinal surgery for retinopathy of prematurity: A retrospective study

Background: Premature infants scheduled for surgery under general anesthesia are more prone to cardio-respiratory complications. Risk factors include post-conception age (PCA), cardiac and respiratory disease, anemia and opioid administration. This retrospective study evaluates the perioperative management and post-operative course (apnea and bradycardia) in premature infants undergoing surgery for retinopathy of prematurity (ROP). Materials and Methods: We analyzed the pre-operative data, anesthesia chart and post-operative course of 52 former premature infants for 56 general anesthesia exposures for ROP surgery. Results: At the time of procedure, median PCA was 51 (36-60) weeks. 71% of the infants were above 46 weeks of PCA. Five infants had cardiac disease and four had a history of convulsion. Four infants had a pre-operative history of apneic spells. The airway was secured with either endotracheal tube (46) or supraglottic device (10). Fentanyl (0.5-1 μg/kg), paracetamol, topical anesthetic drops and/or peribulbar block were administered for analgesia. Extubation was performed in the operating room for 54 cases. Three infants had apnea post-operatively. Seven infants were shifted to neonatal intensive care unit either for observation or due to delayed recovery, persistent apneic spells and pre-existing cardio-respiratory disease. Conclusion: In the present study, intravenous paracetamol and topical anesthetics reduced the total intra-operative opioid requirement, which resulted in low incidence of post-operative apnea. Regional anesthesia may be considered in infants with high risk of post-operative apnea. Infants with PCA > 42 weeks and without any co-morbidity can be managed in post-anesthesia care unit.

Entropy monitoring decreases isoflurane concentration and recovery time in pediatric day care surgery ‐a randomized controlled trial

Aim:  To assess if titrating anesthesia with entropy would result in faster awakening in children undergoing day care surgery.

Severe ovarian hyperstimulation syndrome: Intensive care management of two cases

Severe ovarian hyperstimulation syndrome (OHSS) is characterized by increased capillary permeability and fluid retention in the third space. It is generally a complication of assisted reproduction therapy (ART) with exogenous gonadotropins, but cases with natural onset of OHSS have been reported. The massive extravascular exudation can cause tense ascites, pleural and pericardial effusion, hypovolemic shock, oliguria, electrolyte imbalance (hyponatremia and hyperkalemia), and hemoconcentration, with a tendency for hypercoagulability and risk of life-threatening thromboembolic complications. The patient can rarely develop multi-organ failure (adult respiratory distress syndrome, renal failure) and death. With increasing use of ART, this syndrome may be seen more frequently in the intensive care unit (ICU), requiring multidisciplinary care. We report the management of two cases of severe OHSS, which required admission to the ICU in our hospital.

USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: A report of two cases

The postoperative pain management in open thoracotomy is very crucial as the effective analgesia can prevent respiratory and thrombotic complications and lead to early mobilization and discharge. The thoracic epidural analgesia is the gold standard in such surgeries; however, there are few adverse effects such as hypotension, dural puncture, and contralateral block that always warrants safer alternative. Recently, with the advent of ultrasound, the regional anesthetic techniques are getting more popular to avoid such complications. Erector spinae plane (ESP) block is one of the novel techniques that has been described as a safe thoracic paravertebral block. We are reporting here the continuous ESP block as a primary mode of postoperative analgesia which was continued for 48 h. The intraoperative opioid requirement was very less, and the maximum NRS score in postoperative period was 4 at 12 h, which was well managed with multimodal analgesic regimen along with rescue doses of opioid.

Sono-anatomical analysis of right internal jugular vein and carotid artery at different levels of positive end-expiratory pressure in anaesthetised paralysed patients

Background and Aims: Increasing the cross-sectional area (CSA) of the internal jugular vein (IJV) improves the success rate of cannulation and decreases complications. Application of positive end-expiratory pressure (PEEP) may increase the CSA of IJV beyond that achieved in Trendelenburg position. However, the optimum PEEP to achieve maximal increase in CSA of IJV and the effect of PEEP on IJV and CA relationship is not known. Methods: In this prospective, blinded, randomised controlled study, 120 anesthetised paralysed patients of the American Society of Anesthesiologists physical Status I–II were placed in 20° Trendelenburg position. Patients were randomised into four groups as follows: PEEP of 0, 5, 10 and 15 cmH2O. CSA, anteroposterior (AP) diameter and transverse diameter (Td) of IJV and overlapping of IJV with CA were assessed using two-dimensional ultrasound. Statistical analysis was performed in SPSS version 21.0 software using Chi-square/Fishers exact test (categorical data) and analysis of variance (continuous data) tests and P < 0.05 was considered statistically significant. Results: There was significant increase in AP diameter, CSA and Td with the application of PEEP 10–15 cmH2O. Increase in CSA up to 25% with PEEP 10 and 44% with PEEP 15 was noted. There was a significant decrease in the overlapping of the internal CA with an increase in PEEP. It ranged from 21% at P0 to 17% P15. Conclusion: Application of PEEP 10–15 cmH2O in Trendelenburg position significantly increased CSA and AP diameter of IJV and decreased CA overlap of IJV in anesthetised paralysed patients.

Erector Spinae Block a safe, simple and effective analgesic technique for major hepatobiliary surgery with thrombocytopenia

Abstract Hepatobiliary surgeries are associated with severe pain, and coagulopathy. Adequate pain control is vital and difficult to achieve for these patients. Epidural analgesia is considered the routine standard technique for the management of both somatic and visceral pain from major abdominal surgeries until now. However, it is invasive, blind and carries the risk of dural or vascular puncture. Coagulopathy found in patients posted for hepatobiliary surgery further increases the concerns. We found ultrasound guided erector spinae plane block as a safe, simple yet an effective alternative to epidural analgesia for postoperative pain management of hepatobiliary surgeries.

Early diagnosis of a nearly missed complication made by anatomical landmark guided internal jugular vein canulation

Internal jugular vein (IJV) canulation for central venous pressure monitoring or venous access is a routine procedure in the operation theatre. Among the all-anatomical site, right IJV is the most preferred and technically favorable site because of its straight course.1 However complications are not unusual even with expert hands. Various vascular injuries are possible with blind technique. We are reporting an unusual complication of anatomical landmark guided catheter placement. We did not find similar complication in literature review. A 45-year-old male patient (weight 60 kg height 168 cm) with peripheral vascular diseasewas scheduled for aorto-femoral bypass

Anesthesia in a child with Kinsbourne syndrome: Does anesthesia technique matters?

Kinsbourne syndrome is a rare neurological paraneoplastic syndrome associated with neuroblastic tumors. There are very few literatures on its anesthetic management and interaction with anesthetic agents. The epileptogenic potential of certain anesthetic agents such as ketamine, etomidate, and meperidine might trigger opsoclonus and myoclonus and have an impact on the long-term neurological outcome. The objective of this case report is to discuss the safety of anesthetic agents and their relationship in a patient with Kinsbourne syndrome. We discuss our experience in the anesthetic management of a child with Kinsbourne syndrome with ganglioneuroblastoma in the thoracic paravertebral space.

Perioperative concerns in pediatric patients u10/1/2013ndergoing different types of scoliosis correction surgery: A retrospective observational study.

Background: Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction. Objectives: To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery. Patients and Methods: After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution. Results: Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobbs angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care. Conclusions: Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients.