Rajesh Singh Rautela

Intravenous Dexamethasone Causes Perineal Pain and Pruritus

Background: Dexamethasone has been used for postoperative nausea and vomiting (PONV). Single dose dexamethasone in premedication does not cause any side effect. During our previous published study conducted on effect of dexamethasone for PONV, an unusual side effect of excruciating pain and perineal itching immediately following administration of this drug was observed. The present prospective incidence study was conducted in tertiary hospital of East Delhi, India to find out incidence and management of severe perineal pain and perineal pruritus immediately post-administration of dexamethasone. Methods: 30 ASA 1 or 2 males (Group 1) and 30 ASA 1 or 2 females (Group 2) patients were selected to find incidence and intensity of pain after dexamethasone administration in both sexes posted for routine ophthalmologic, ENT and gastrointestinal surgeries. An intravenous canula (18 G) was inserted ringer lactate fluid was started. Dexamethasone in dose of 0.15 mg/kg was administered (after dilution with normal saline to 5 ml volume) along with i.v. fluid. Immediately patients were asked for any discomfort, pain/pruritus. Onset of pain & duration of pain was noted. Intensity of pain was assessed with 11 point Numeric pain scale and Simple descriptive pain intensity scale and Chi-Square test was applied with P value of <0.05 was considered as significant. Any other adverse effect was noted, if any. Results: Seventy percent male patients suffered no pain as compared to 43.3% female patients (p<0.05). Only 30% male patients had suffered pain as compared to 56% female patients with similar perineal pruritus incidence and similar mean pain/pruritus onset time. The mean duration of persistence of pain was 23 seconds and 29 seconds in group 1 and 2 respectively. Conclusion: Perineal itching or excruciating pain in patients receiving dexamethasone is more common in female patients with incidence more than 55%. The pain subsides on its own without any treatment.

Laryngeal Tube pilot balloon kinking in the presence of a bite block

To the Editor, Supraglottic airway devices are being developed with increasing frequency following the overwhelming success of the Laryngeal Mask Airway (LMA). The LMA, the ProSeal Laryngeal Mask Airway (PLMA), the Laryngeal Tube (LT), the Laryngeal Tube with integrated suctioning (LTS) and the Esophageal Tracheal Combitube (OTC) are currently the most evaluated and widespread supraglottic airway devices. The Laryngeal Tube (VBM Medizintechnik, Sulz, Germany) is a relatively new supraglottic device designed to secure a patent airway during either spontaneous breathing or controlled ventilation. The manufacturer’s standard LT has since been redesigned and modified to incorporate a suction port. The standard LT consists of an airway tube with a small distal cuff attached at the tip and a larger balloon proximal cuff located at the middle part of the tube (Fig. 1). The cuffs are inflated through a single pilot tube and balloon through which inflation pressure can be monitored. There are three black lines on the tube close to a standard 15 mm connector to indicate adequate depth of insertion when aligned with the teeth. The device is inserted while the patient’s head and neck are placed either in the sniffing position or in a neutral position. The tip of a well-lubricated LT is placed against the patient’s hard palate behind the upper incisors. The device is then advanced through the centre of the mouth until either resistance is felt or the device is almost fully inserted. The LT is inserted properly when the second bold black line on the tube has just passed between the upper and lower incisors. A bite block is inserted when ventilation is adequate, and the LT is secured in its wedge. Both are fixed in place with an elastic strap supplied with the device set. Once it is correctly placed with the bite block and the provided elastic strap, the LT will maintain its intended position after insertion. We have used the LT extensively for 3 years in at least 250 cases conducted under general anesthesia in all age groups. The device is used routinely to maintain the patient’s airway, either during spontaneous breathing or controlled ventilation. Although the cuff deflator is applied correctly, we have noted each time that the pilot balloon cuff is not deflated immediately before the LT is removed. We have observed that the pilot balloon tube continually slips and tightens in the groove between the LT shaft and the M. Singh, MD (&) Government Medical College Hospital, Chandigarh, India e-mail: manpreetdawar@hotmail.com

Anesthetic management for bronchoscopy and debulking of obstructing intratracheal tumor

Primary tracheal tumors comprise a rare group of benign and malignant tumors. Bronchoscopy is required for diagnosis and staging of tracheal neoplasms as well as debulking of the tumor. The management of anesthesia for rigid bronchoscopy in a patient with tracheal neoplasm presents with many challenges to the anesthetist. We present anesthetic management of an 18-year-old female who presented with orthopnea. Computed tomography scan of the thorax revealed a polypoidal lesion in the trachea proximal to carina and consolidation in the right middle lobe. The patient was scheduled for rigid bronchoscopy and debulking of the tumor. Case was successfully managed by providing positive pressure ventilation and oxygenation during rigid bronchoscopy using manual ventilation through the side port of the rigid bronchoscope. The procedure was uneventful, and patient improved symptomatically in the immediate postoperative period. The successful management of this case demonstrates the airway management in a patient with tracheal tumor for rigid bronchoscopy.

Is midazolam superior to triclofos and hydroxyzine as premedicant in children

Background: Search for an ideal premedicant drug for children is still on. A prospective, randomized trial was conducted to compare the efficacy of midazolam, triclofos and hydroxyzine as premedication in children undergoing lower abdominal surgeries. Materials and Methods: Sixty American Society of Anesthesiologists I or II patients 2-8 years of age, scheduled for elective lower abdominal surgery were included. The patients were randomly divided into three groups M, T and H of 20 children each who received midazolam 0.5 mg/kg, triclofos 75 mg/kg and hydroxyzine 0.5 mg/kg respectively, orally 60 min before surgery. The acceptability of drugs, level of sedation, anxiety during separation and on mask application was assessed. Results: The acceptability of midazolam and hydroxyzine was better than triclofos. Hydroxyzine was found to have lesser sedative effect as compared to both midazolam and triclofos. No major adverse effects were observed. Conclusion: Midazolam was found to be a better premedicant in terms of sedation, anxiolysis and safety.

Subcutaneous emphysema: Unique presentation of a foreign body in the airway

Foreign body airway (FBA) is a common problem among the children. Variable presentation makes it difficult to diagnose a case of FBA, particularly, when no definite history of aspiration is available. Subcutaneous emphysema (SCE) and pneumomediastinum are rare presentations. We report a case of FBA who presented with SCE without any history of aspiration. A 3-year-old female child was admitted with respiratory distress, fever and SCE over the right side of chest, neck and face. Initially, she was diagnosed as a case of pneumonitis with barotrauma. X-ray of the chest revealed SCE with pneumomediastinum without pneumothorax. Diagnostic bronchoscopy with rigid ventilating bronchoscope was done under general anesthesia. A plastic foreign body with sharp projections embedded in the mucosa was detected and retrieved from right main bronchus. Postoperatively SCE regressed gradually.

Femorosciatic nerve block for lower limb orthopedic surgeries

Abstract Femorosciatic block is an important peripheral nerve block that can be used in surgeries of lower limb. The present study was conducted to evaluate the efficacy of femorosciatic nerve block via posterior approach for lower limb orthopedic surgeries. A total of 40 ASA grade I or II patients were taken for this prospective double-blind study. Various orthopedic surgeries were selected and femoro-sciatic blocks were made. Adequate amount of drug was injected, and effect was evaluated via pin-prick method. The extent of sensory blockade of both nerves, success rate, and intensity of pain were measured. The success of block was observed in 90% patients, and only 4 patients required supplementation of analgesia or general anesthesia. Femorosciatic blockade is an effective and safe technique for lower limbs orthopedic surgeries.