Rajesh Mahajan

Collet-Sicard syndrome after closed head injury

A case is reported of basilar fracture of the occipital bone passing through the left occipital condyle, ascending the clivus anteriorly, with marked medial displacement of the bony fragment. The injury produced ipsilateral palsies of nerves IX through XII (Collet-Sicard syndrome). A CT scan accurately delineated the extent of the fracture. Partial neurological recovery ensued following surgery.

Dose response study of caudal neostigmine for postoperative analgesia in paediatric patients undergoing genitourinary surgery

Background: Neostigmine given through the neuraxial route has been found to have analgesic properties. In this clinical trial, we evaluated for the first time the efficacy of a varying dose of caudal neostigmine for postoperative analgesia in children undergoing genitourinary surgery.

Bupivacaine/ketamine is superior to intra-articular ketamine analgesia following arthroscopic knee surgery

PurposeCentroneuraxial and parenteral administration of ketamine has been shown to produce analgesia. However, this analgesia is limited by adverse effects. The purpose of this study was to determine whether ketamine alone or in combination with bupivacaine provides superior pain relief after surgery in patients undergoing knee arthroscopy.MethodsSixty patients (classified as ASA status I or II) undergoing arthroscopic meniscus repair during general anesthesia were randomized to receive 1.0 mg·kg-1 ketamine (Group K), 0.25% bupivacaine (Group B) or a combination of 1.0 mg·kg-1 ketamine and 0.25% bupivacaine (Group BK) to a total volume of 20 mL by intra-articular route following surgery. Visual analogue score in the postanesthesia care unit at 0.5, 1, 2, 4, 6, 8, 12 and 24 hr after surgery, duration of analgesia and subsequent 24 hr consumption of rescue analgesic (dextroproxyphene/ acetaminophen) were evaluated.ResultsThe results showed significantly higher pain scores in Group K as compared to Group B and Group BK. The duration of analgesia was significantly shorter in Group K as compared to the other two groups (Group B = 5.7 ± 0.8; Group BK = 5.1 ± 1.1 vs Group K = 1.7 ± 0.9 hr; P < 0.05). However, 24 hr consumption of analgesic was similar in the three groups.ConclusionWe conclude that intra-articular bupivacaine-ket-amine combination provides better pain relief than intra-articu-lar ketamine after day care arthroscopic knee surgery.RésuméObjectifĽadministration centro-neuraxiale et parentérale de kétamine peut produire une analgésie, limitée toutefois par des effets indésirables. Nous avons voulu vérifier la qualité de ľanalgésie selon ľutilisation de kétamine seule ou en combinaison avec de la bupivacaïne à la suite ďune arthroscopie du genou.MéthodeSoixante patients, ďétat physique ASA I ou II, devant subir la réparation arthroscopique ďun ménisque sous anesthésie générale, ont été répartis au hasard pour recevoir 1,0 mg·kg-1 de kétamine (Groupe K), de la bupivacaïne à 0,25 % (Groupe B) ou une combinaison de 1,0 mg·kg-1 de kétamine et de bupivacaïne à 0,25 % (Groupe BK) dans un volume total de 20 mL administré par voie intra-articulaire après ľopération. Les scores de ľéchelle visuelle analogique 0,5, 1, 2, 4, 6, 8, 12 et 24 h après ľopération, la durée de ľanalgésie et les analgésiques supplémentaires pendant 24 h de plus (dextroproxyphène/acétaminophène) ont été enregistrés.RésultatsLes scores de douleur ont été significativement plus élevés chez les patients du Groupe K, comparé aux Groupes B et BK. La durée de ľanalgésie a été plus courte aussi dans le Groupe K (Groupe B = 5,7 ± 0,8 ; Groupe BK = 5,1 ± 1,1 vs GroupeK = 1,7 ± 0,9 h ; P < 0,05).La consommation ďanalgésique supplémentaire a toutefois été similaire dans les trois groupes.ConclusionĽadministration intra-articulaire ďune combinaison de bupivacaïne et de kétamine fournit une meilleure analgésie que la kétamine seule après une arthroscopie du genou en chirurgie ďun jour.Objectif Ľadministration centro-neuraxiale et parenterale de ketamine peut produire une analgesie, limitee toutefois par des effets indesirables. Nous avons voulu verifier la qualite de ľanalgesie selon ľutilisation de ketamine seule ou en combinaison avec de la bupivacaine a la suite ďune arthroscopie du genou.

Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children

PurposeTo evaluate the analgesic efficacy and duration of varying doses of caudal neostigmine with plain bupivacaine and its side effects in children undergoing genito-urinary surgery.MethodsIn a randomized double-blind prospective study 80 boys aged two to eight years scheduled for surgical repair of hypospadias were allocated randomly to one of four groups (n = 20 each) and received either only caudal 0.25% plain bupivacaine 0.5 mL · kg−1 (Group 1) or 0.25% plain bupivacaine 0.5 mL · kg−1 with neostigmine (Groups II-IV) in doses of 2, 3 and 4βg · kg−1 respectively. Postoperative pain was assessed for 24 hr using an objective pain score. Blood pressure, heart rate, oxygen saturation, total amount of analgesic consumed and adverse effects were also recorded.ResultsThe duration of postoperative analgesia in Group I (5.1 ± 2.3 hr) was significantly shorter than in the other three groups (II–16.6 ± 4.9 hr; III — 17.2 ± 5.5 hr; IV-17.0 ± 5.8 hr; P < 0.05). Total analgesic (paracetamol) consumption was significantly more in Group 1 (697.6 ± 240.7 mg) than in the groups receiving caudal neostigmine (II — 248.0 ± 178.4; III — 270.2 ± 180.8 and IV − 230.6 ± 166.9 mg; P < 0.05). Groups II, III and IV were comparable with regards to duration of postoperative analgesia and total analgesic consumption (P > 0.05). Incidence of nausea and vomiting were comparable in all four groups. No significant alteration in vital signs or any other adverse effects were observed.ConclusionsCaudal neostigmine (2, 3 and 4μg · kg−1) with bupivacaine produces a dose-independent analgesic effect (≈ 16–17 hr) in children as compared to those receiving caudal bupivacaine alone (approximately five hours) and a reduction in postoperative rescue analgesic consumption without increasing the incidence of adverse effects.RésuméObjectifÉvaluer l’efficacité analgésique et la durée de différentes doses de néostigmine caudale avec bupivacaïne simple et ses effets secondaires chez des enfants qui subissent une intervention génito-urinaire.MéthodeDans une étude randomisée, prospective et à double insu, 80 garçons de deux à huit ans devant subir la réparation chirurgicale d’un hypospadias ont été répartis au hasard en quatre groupes (n = 20 chacun) et ont reçu: seulement de la bupivacaïne caudale simple à 0,25 % (0,5 mL · kg−1 Groupe I) ou de la bupivacaïne simple à 0,25 % avec néostigmine (0,5 mL · kg−1, Groupes II-IV) en doses respectives de 2, 3 et 4 μg · kg−1. La douleur postopératoire a été évaluée pendant 24 h selon des scores de douleur objectifs. La tension artérielle, la fréquence cardiaque, la saturation du sang en oxygène, la quantité totale d’analgésiques consommés et les effets secondaires ont été aussi enregistrés.RésultatsLa durée de l’analgésie postopératoire a été significativement plus courte dans le Groupe I (5,1 ± 2,3 h) que dans les autres groupes (II — 16,6 ± 4,9 h; III — 17,2 ± 5,5 h; IV-17,0 ± 5,8 h; P < 0,05). La consommation totale d’analgésique (paracétamol) a été significativement plus élevée dans le Groupe I (697,6 ± 240,7 mg) que dans les groupes avec néostigmine caudale (II — 248,0 ± 178,4; III-270,2 ± 180,8 et IV — 230,6 ± 166,9 mg; P < 0,05). La durée de l’analgésie postopératoire et la consommation totale d’analgésique (P > 0,05) étaient comparables dans les groupes II, III et IV. Lincidence de nausées et de vomissements a été similaire dans les quatre groupes. Aucune modification significative des signes vitaux ou tout autre effet indésirable n’ont été observés.ConclusionChez des enfants, la néostigmine caudale (2, 3 et 4 μg · kg−1) avec bupivacaïne, comparées à la bupivacaïne caudale seule (≈ 5 h), produit une analgésie non reliée à la dose (≈ 16–17 h) et une réduction de la consommation postopératoire d’analgésique de secours sans augmenter l’incidence d’effets indésirables.

Un mélange de bupivacaïne et de kétamine est supérieur à la kétamine seule pour ľanalgésie intra-articulaire à la suite ďune arthroscopie du genou

PurposeCentroneuraxial and parenteral administration of ketamine has been shown to produce analgesia. However, this analgesia is limited by adverse effects. The purpose of this study was to determine whether ketamine alone or in combination with bupivacaine provides superior pain relief after surgery in patients undergoing knee arthroscopy.MethodsSixty patients (classified as ASA status I or II) undergoing arthroscopic meniscus repair during general anesthesia were randomized to receive 1.0 mg·kg-1 ketamine (Group K), 0.25% bupivacaine (Group B) or a combination of 1.0 mg·kg-1 ketamine and 0.25% bupivacaine (Group BK) to a total volume of 20 mL by intra-articular route following surgery. Visual analogue score in the postanesthesia care unit at 0.5, 1, 2, 4, 6, 8, 12 and 24 hr after surgery, duration of analgesia and subsequent 24 hr consumption of rescue analgesic (dextroproxyphene/ acetaminophen) were evaluated.ResultsThe results showed significantly higher pain scores in Group K as compared to Group B and Group BK. The duration of analgesia was significantly shorter in Group K as compared to the other two groups (Group B = 5.7 ± 0.8; Group BK = 5.1 ± 1.1 vs Group K = 1.7 ± 0.9 hr; P < 0.05). However, 24 hr consumption of analgesic was similar in the three groups.ConclusionWe conclude that intra-articular bupivacaine-ket-amine combination provides better pain relief than intra-articu-lar ketamine after day care arthroscopic knee surgery.RésuméObjectifĽadministration centro-neuraxiale et parentérale de kétamine peut produire une analgésie, limitée toutefois par des effets indésirables. Nous avons voulu vérifier la qualité de ľanalgésie selon ľutilisation de kétamine seule ou en combinaison avec de la bupivacaïne à la suite ďune arthroscopie du genou.MéthodeSoixante patients, ďétat physique ASA I ou II, devant subir la réparation arthroscopique ďun ménisque sous anesthésie générale, ont été répartis au hasard pour recevoir 1,0 mg·kg-1 de kétamine (Groupe K), de la bupivacaïne à 0,25 % (Groupe B) ou une combinaison de 1,0 mg·kg-1 de kétamine et de bupivacaïne à 0,25 % (Groupe BK) dans un volume total de 20 mL administré par voie intra-articulaire après ľopération. Les scores de ľéchelle visuelle analogique 0,5, 1, 2, 4, 6, 8, 12 et 24 h après ľopération, la durée de ľanalgésie et les analgésiques supplémentaires pendant 24 h de plus (dextroproxyphène/acétaminophène) ont été enregistrés.RésultatsLes scores de douleur ont été significativement plus élevés chez les patients du Groupe K, comparé aux Groupes B et BK. La durée de ľanalgésie a été plus courte aussi dans le Groupe K (Groupe B = 5,7 ± 0,8 ; Groupe BK = 5,1 ± 1,1 vs GroupeK = 1,7 ± 0,9 h ; P < 0,05).La consommation ďanalgésique supplémentaire a toutefois été similaire dans les trois groupes.ConclusionĽadministration intra-articulaire ďune combinaison de bupivacaïne et de kétamine fournit une meilleure analgésie que la kétamine seule après une arthroscopie du genou en chirurgie ďun jour.Objectif Ľadministration centro-neuraxiale et parenterale de ketamine peut produire une analgesie, limitee toutefois par des effets indesirables. Nous avons voulu verifier la qualite de ľanalgesie selon ľutilisation de ketamine seule ou en combinaison avec de la bupivacaine a la suite ďune arthroscopie du genou.

Value of precraniotomy shunts in children with posterior fossa tumours

Seventy children with posterior fossa tumours treated over a period of 6 1/2 years were studied. Most patients presented in the late stage of disease. Sixty-four required insertion of a precraniotomy shunt for one or more of the following: persistent vomiting, severe headache, dehydration, poor general condition, failing vision, altered sensorium, marked periventricular lucency, and brain stem involvement deferring total removal of the tumour. Insertion of precraniotomy shunt improved the general condition and signs and symptoms of increased intracranial pressure. It also provided a lax brain during definitive surgery and a smooth postoperative course. Shunt-related complications, consisting of block and/or infection, were observed in 21 patients. It was concluded that precraniotomy shunt is important in the management of children with posterior fossa tumours in developing countries where these patients present in the late stage of disease.

A dose-ranging study of intraarticular midazolam for pain relief after knee arthroscopy.

BACKGROUND: A variety of analgesic techniques have been used to manage postoperative pain after arthroscopic knee surgery. Intraarticular midazolam may have an analgesic effect similar to that seen when midazolam is used in a centroneuraxial fashion. METHODS: Sixty ASA status I or II patients undergoing knee arthroscopy with general anesthesia were randomized to receive intraarticular midazolam 50 &mgr;g/kg, 75 &mgr;g/kg, or isotonic saline. We assessed the efficacy of the analgesic technique with visual analog scale pain scores, time until first request for analgesics, and cumulative analgesic consumption. Patients were observed for 48 h. RESULTS: The addition of intraarticular midazolam significantly reduced visual analog pain scores in the early postoperative period compared with saline. Both doses similarly prolonged duration until first request for analgesic compared with saline (4.7 and 4.6 vs 0.7 h). There was no statistically significant difference between the two doses of midazolam or cumulative 48 h analgesic consumption. CONCLUSIONS: We conclude that when intraarticular midazolam was compared with placebo there was a reduction in pain after day-case arthroscopic knee surgery; however, this pain relief was of relatively short duration.

Supratentorial tumours in infants

Three hundred and ninetysix paediatric (below 15 years of age) patients with brain tumours were treated at our institute in the last 4 years. Eighty-two of the tumours were located supratentorially. These 82 patients included 14 infants (below 1 year of age), who made up 3.5% of all paediatric patients with brain tumours and 17% of those with brain tumours in a supratentorial location. There was a male preponderance, and two-thirds of the 14 patients were within their first 6 months of life. Increasing head size, vomiting and failure to thrive were the common presenting features. One infant presented with asymmetric skull growth. The tumours tended to be large, occupying almost the entire affected cerebral hemisphere; histological types included astrocytomas, malignant astrocytomas, glioblastoma multiforme, primitive neuroectodermal tumours, malignant choroid plexus papillomas and malignant teratomas. Two children had congenital tumours and another two tumours, in children with associated lobar agenesis, were thought to be congenital in origin. Associated hydrocephalus was present in seven patients, but precraniotomy shunt was required in only two patients. The perioperative (within 1 month) mortality was 57%. Only 30% of the patients survived for more than 1 year after surgery and chemotherapy. The longest survival was 20 months. Delay in diagnosis, poor general condition prior to surgery, and the high vascularity and malignant nature of these tumours accounted for the poor results.

Submucous fibrosis secondary to chewing of quids: another cause of unanticipated difficult intubation

PurposeTo report a case of unusual difficult intubation secondary to oral submucosal fibrosis (SMF) associated with malignancy of the hypopharynx.Clinical featuresA 57-yr-old male, ASA-I physical status presented for percutaneous nephrolithotripsy. The patient was a known alcoholic and smoker with a habit of chewing quids for the past 36 years. Airway assessment revealed oral SMF and slight difficulty in opening the mouth fully. Mentohyoid and mentothyroid distances were normal. However, during intubation, unanticipated difficulty was encountered. On direct laryngoscopy, the tip of the epiglottis could barely be visualized. Intubation was possible after passing a gum elastic bougie blindly under the epiglottis and negotiating a 7.0 internal diameter tracheal tube over it. Postoperatively, indirect laryngoscopy (IDL) showed severe SMF involving the oral cavity, epiglottis and pyriform fossae and an ulcerative malignancy of the hypopharynx with fixation of the left hemilarynx.ConclusionSMF is a premalignant condition of the oral cavity associated with fibrosis of involved structures that can be associated with malignancy of the aerodigestive tract. Distortion of the airway anatomy may render intubation difficult. IDL maybe useful in the preoperative evaluation of these patients.RésuméObjectifCiter un cas d’intubation difficile inhabituel secondaire à une fibrose sous-muqueuse buccale (FSM) associée à une condition maligne de l’hypopharynx.Eléments cliniquesUn homme de 57 ans, d’état physique ASA I, a consulté pour une néphrolithotripsie percutanée. Connu pour alcoolisme et tabagisme, il chiquait du tabac depuis 36 ans. L’évaluation des voies respiratoires a révélé une FSM et une légère réduction de l’ouverture buccale. Les distances mento-hyoïde et mento-thyroïde étaient normales, mais l’intubation a présenté une difficulté imprévue. Sous laryngoscopie directe, la pointe de l’épiglotte était à peine visible. L’intubation a été possible en passant à l’aveugle une bougie fiexible sous l’épiglotte et en glissant par-dessus un tube endotrachéal de diamètre interne 7,0. La laryngoscopie indirecte (LID) postopératoire a montré une FSM sévère de la cavité buccale, l’épiglotte et les fosses piriformes, et une ulcération maligne de l’hypopharynx avec fixation de l’hémilarynx gauche.ConclusionLa FSM est une condition maligne de la cavité buccale accompagnée de fibrose des structures concernées qui peut être associée à la malignité de la voie aéro-digestive. Une déformation anatomique des voies aériennes peut compliquer l’intubation. La LID peut faciliter l’évaluation préopératoire dans ces circonstances.

Digital assistance of nasotracheal intubation - another way to prevent trauma during nasotracheal intubation.

SIR—We read with great interest the case report by Dr Ghaffari regarding the piercing of posterior nasopharyngeal mucosa in a 7-year-old girl undergoing tonsillectomy with nasotracheal intubation (1). Authors have rightly pointed out that forceful insertion of the nasal tube is forbidden. This can be catastrophic and lead not only to submucosal dissection but a major posterior pharyngeal wall laceration can ensue (2–4). We would like to discuss the use of digital assistance to avoid this problem. Once resistance is felt to the passage of a nasal tube, it should never be forced. The tube can be rotated and again tried for smooth passage. Alternatively, the tube can be inserted for a short distance and the gloved index finger of the right hand introduced into the oral cavity. The finger is negotiated behind the soft palate into the nasopharynx and tube can be hooked with the gloved finger and manipulated. Once the tip is free, the assistant is asked to simultaneously push the tube gently from the nasal end; thereby facilitating its atraumatic entry into the oropharynx. Thereafter the tube can be further guided by Magill’s forceps or any other suitable maneuver into the larynx. We have successfully used this technique in more than 60 pediatric patients including those undergoing tonsillectomy and found it atraumatic and effective in all cases. Rajesh Mahajan Susheel Kumar Yatindra Kumar Batra Department of Anaesthesia, PGIMER (Post Graduate Institute of Medical Education and Research), Chandigarh, India (email: drmahajanr@yahoo.com; drmahajanr@rediffmail.com)