Ramasamy Govindarajan

Epidural buprenorphine in management of pain in multiple rib fractures.

Background: Pain from multiple rib fractures may affect pulmonary function, morbidity, and length of stay in the intensive care units. This study describes some clinical characteristics of epidural buprenorphine, a lipophilic and partial opiate agonist with a higher µ receptor affinity than morphine, in combating the pain in multiple rib fractures.

Intraoperative wake‐up test in neonatal neurosurgery

Intraoperative wake‐up test (WPT) still remains the gold standard to monitor anterior spinal cord function during spinal surgery. However, the test requires patient cooperation and hence difficult to perform in very young children or mentally challenged. In this report, we describe a WPT in a newborn during surgical repair of a large myelomeningocele. We relied on mivacurium for intubation and the relaxant effect was allowed to wear‐off to permit the use of intraoperative nerve stimulator. We used desflurane and propofol infusion for rapid titration of the anesthetic depth and BIS monitor to ‘gauge’ the ‘wakefulness’ of the child during the WPT. We employed lidocaine infusion to improve tolerance to the tracheal tube and to bestow beneficial effect on intracranial pressure during surgery and the WPT. The results of the WPT were judged to be satisfactory after confirming flexion and extension of the lower extremities at the hip and knee level, correlating it with the BIS values, and comparing it with the preoperative status. Frequently associated prematurity, higher possibility of remaining intubated in the immediate postoperative period and any new onset neurologic deficit not becoming apparent until after extubation makes intraoperative neuromonitoring relevant in this age group. Our methodology of management has permitted us to perform a delicate test safely and will allow us to repeat the WPT if needed during neonatal neurosurgery.

Anesthetic management of bronchopleurocutaneous fistula - an alternate approach

To the Editor: A 48-yr-old man with a persistent left bronchopleurocutaneous fistula (BPCF) and empyema thoracis following pneumonectomy presented for bronchial stump closure and left thoracoplasty. The patient refused any attempts at awake intubation. He was placed in semi-recumbent position with the left side down after topicalization and mask induction. Right-sided double-lumen tube (DLT) placement was attempted while the patient was breathing spontaneously, but was unsuccessful in the absence of adequate muscle relaxation. Attempts to position a left bronchial blocker under fibreoptic guidance resulted in the balloon either slipping into the fistulous opening or backing up into the trachea. Advancing a single-lumen tube into the right main stem bronchus resulted in right upper lobe obstruction and attempted DLT insertion over a tube exchanger was also unsuccessful. When rescheduled, he was positioned and induced in the same manner as before and intubated with an 8.5 size endotracheal tube. Anesthesia was maintained with air, oxygen and sevoflurane using a Bain circuit, the patient breathing spontaneously. A triple-lumen central line and a transesopheal echocardiograph (TEE) were added to standard monitoring. The patient was positioned in the sitting position and stabilized in the appropriate frame, with his hands abducted and flexed forwards. The surgeon approached the BPCF through a left thoracotomy by transaxillary approach. Transtracheal jet-ventilation was delivered through the tip of a catheter placed above the level of fistula, to lessen the possibility of barotrauma. Anesthesia was maintained with an infusion of ketamine. During jet-ventilation PaO2 values were 80 to 90 mmHg while PaCO2 increased to 60 mmHg. The fistula was repaired and leak tested while purulent material from the left chest cavity was suctioned clean. Controlled ventilation restored blood gas levels towards normal. Left thoracoplasty was completed and the patient was extubated in the operating room. Postoperative pain control was achieved by a thoracic epidural catheter with continuous infusion of bupivacaine and fentanyl. While anesthetizing the patient with BPCF in the sitting position, oxygenation can be assured with jetventilation, and gravity aids in draining away purulent secretions from the trachea.1 CO2 accumulation can be managed by limiting the surgical time and establishing controlled ventilation at the earliest opportunity. Hypotension can be corrected with crystalloid infusion. The hazard of air embolism can be monitored with TEE and treated with a triple lumen central venous catheter.2 When conventional methods of pulmonary isolation fail, anesthesia and surgery pose unusual challenges during the operative management of BPCF.3,4 Careful planning and meticulous anesthetic management can transform a difficult case into a manageable one.