Rahul Kumar Anand

Partial facial nerve paralysis after laparoscopic surgery under general anaesthesia.

1. Ray SB, Wadhwa S. The enigma of morphine tolerance: Recent insights. J Biosci 2001;26:555-9. 2. Corbett AD, Henderson G, Mcknight AT, Paterson SJ. 75 years of opioid research: the exciting but vain quest for the holy grail. Br J Pharmacol 2006;147(Suppl): S153-62. 3. Bell RF. Low-dose subcutaneous ketamine infusion and morphine tolerance. Pain 1999;83:101-3. 4. Ray SB, Mishra P, Verma D, Gupta A, Wadhwa S. Nimodipine is more effective than nifedipine in attenuating morphine tolerance on chronic co-administration in the rat tail-flick test. Indian J Exp Biol 2008;46:219-28. 5. Kim JH, Park IS, Park KB, Kang DH, Hwang SH. Intraarterial nimodipine infusion to treat symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2009;46:239-44. 6. Scroggs RS, Fox AP. Calcium current variation between acutely isolated adult rat dorsal root ganglion neurons of different size. J Physiol 1992;445:639-58. 7. Kumar R, Mehra RD, Ray SB. L-type calcium channel blockers, morphine and pain: Newer insights. Indian J Anaesth 2010;54:127-31. 8. Mogil JS, Wilson SG, Wan Y. Assessing nociception in murine subjects. In: Kruger L, editor. Methods in pain research. Ist Ed. Boca Raton USA: CRC Press; 2001. p. 11-39. 9. Nabhani T, Shah T, Garcia J. Skeletal muscle cells express different isoforms of the calcium channel alpha2/delta subunit. Cell Biochem Biophys 2005;42:13-20. 10. Karl T, Pabst R, von Horsten S. Behavioral phenotyping of mice in pharmacological and toxicological research. Exp Toxicol Pathol 2003;55:69-83. 11. Contreras E, Tamayo I, Amigo M. Calcium channel antagonists increase morphine-induced analgesia and antagonize morphine tolerance. Eur J Pharmacol 1988;148:463-6. 12. Antkiewicz-Michaluk L, Michaluk J, Romanska I, Vetulani J. Reduction of morphine dependence and potentiation of analgesia by chronic co-administration of nifedipine. Psychopharmacol (Berl)1993;111:457-64. 13. Michaluk J, Karolewicz B, Antkiewicz-Michaluk L, Vetulani J. Effect of various Ca2+ channel antagonists on morphine analgesia, tolerance and dependence, and on blood pressure in the rat. Eur J Pharmacol 1998;352:189-97. 14. Tomassoni D, Lanari A, Silvestrelli G, Traini E, Amenta F. Nimodipine and its use in cerebrovascular disease: Evidence from recent preclinical and controlled clinical studies. Clin Exp Hypertens 2008;30:744-66. 15. Messeter K, Brandt L, Ljunggren B, Svendgaard NA, Algotsson L, Romner B, et al. Prediction and prevention of delayed ischemic dysfunction after aneurysmal subarachnoid hemorrhage and early operation. Neurosurgery 1987;20:548-53. 16. Medhi B, Prakash A. Practical manual of experimental and clinical pharmacology. Ist ed. New Delhi: Jaypee Brothers Medical Publishers;2010. P. 23-5. 17. Mishra S, Bhatnagar S, Choudhary P, Rana SP. Breakthrough cancer pain: Review of prevalence, characteristics and management. Indian J Palliat Care 2009;15:14-8.

Anaesthesia management of caesarean section in a patient with severe factor XI deficiency

Factor XI deficiency is a rare coagulation disorder associated with bleeding tendency and prolonged APTT. Parturients can have increased bleeding during vaginal delivery or cesarean section. Patients with severe factor XI deficiency should receive prophylactic fresh frozen plasma or factor XI transfusion in the peripartum period to maintain a near normal APTT. Limited evidence based on case reports and series is inconclusive as to the choice of anesthesia technique for cesarean section. We describe the anesthesia management of a parturient with severe factor XI deficiency for cesarean section and discuss the relevant literature.

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.

Unfavourable outcome after uneventful anaesthesia and surgery in a child with Hurler syndrome

1. Blanco R. The ‘PECS block’: A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66:847-8. 2. Bouzinac A, Brenier G, Dao M, Delbos A. Bilateral association of pecs I block and serratus plane block for postoperative analgesia after double modified radical mastectomy. Minerva Anestesiol 2015;81:589-90. How to cite this article: Tewari S, Dhiraaj S, Sachan V, Bhargava T, Verma A. Ultrasound as a point-of-care tool for early detection of potential complications like pneumothorax associated with the pectoralis block. Indian J Anaesth 2017;61:852-3.

Inspired–expired oxygen gap: an alternative method for oxygen saturation monitoring in a patient with an undiagnosed hemoglobinopathy

up in the present case possibly due to massive hydrocephalus and prior brain damage at the time of presentation. Following VP shunt surgery, the neurological improvements in patients of hydrocephalus depends on number of factors; concomitant medical problems, structural anomalies, degree of neurological compromise, timing of shunt, etiology, duration, and severity of hydrocephalus (3). Jansen and Jørgensen (4) have described the risk of mortality in patients with hydrocephalus with persistent sunset sign, downward displacement of eyes, clinical signs and symptoms, and the associated risk of death in detail. However, the authors did not mention any grading regarding the severity of hydrocephalus and downward displacement of eye. The ‘sunsetting sign’ and ‘downward displacement of eye’ are well described in literature (3,4). The ‘drowning eye sign’ described in the present patient is different from the earlier two signs in two ways. Firstly, the eyeballs were lying in the inferior part of the orbital cavity with a virtually empty superior orbital cavity. Secondly, during the downward displacement of eye, the palpebral aperture is usually normal sized, but it was greatly reduced in the present case (rather it was same both during awake and sleep). This characteristic eye sign in a case of massive hydrocephalus seems as if the eyeballs have drowned below the orbital cavity into inferior margin of orbit and maxilla, and hence termed as the ‘drowning eye sign’. We believe this is the first literature report describing drowning eye sign in an advanced case of massive hydrocephalus. The presence of drowning eye sign in patients needs to be identified and evaluated for therapeutic prognosis in patients of hydrocephalus.

Blue rubber bleb nevus syndrome – Anaesthetic experience of prolonged bowel surgery in a twelve year old child and review

Abstract Blue rubber bleb nevus syndrome (BRBNS) is a rare hereditary disease manifested by multiple vascular malformations involving skin, mucosa and musculoskeletal system. Available literature consists of mainly airway management of such patients. We describe the perioperative anaesthetic management of a child of BBRNS with gastrointestinal bleeding disorder scheduled for resection of multiple nevi and discuss the relevant anaesthetic concerns.

Dental guards: An alternative solution for loose tooth

1. Liu D, Görges M, Jenkins SA. University of Queensland vital signs dataset: Development of an accessible repository of anesthesia patient monitoring data for research. Anesth Analg 2012;114:584-9. 2. Kennedy RR, French RA. The development of a system to guide volatile anaesthetic administration. Anaesth Intensive Care 2011;39:182-90. 3. van Schalkwyk JM, Lowes D, Frampton C, Merry AF. Does manual anaesthetic record capture remove clinically important data? Br J Anaesth 2011;107:546-52. 4. Peterfreund RA, Driscoll WD, Walsh JL, Subramanian A, Anupama S, Weaver M, et al. Evaluation of a mandatory quality assurance data capture in anesthesia: A secure electronic system to capture quality assurance information linked to an automated anesthesia record. Anesth Analg 2011;112:1218-25.