Ramesh Chandra Rathod

Anesthesia for awake craniotomy: A retrospective study

CONTEXT Awake craniotomy is increasingly performed the world over. We share our experience of performing craniotomy awake with our anesthetic protocol. AIMS To evaluate and analyze the anesthesia records of the patients who underwent awake craniotomy at our institution. SETTINGS AND DESIGN University teaching hospital, Retrospective study. MATERIALS AND METHODS We reviewed records of the 42 consecutive patients who underwent awake craniotomy under conscious sedation using Fentanyl and Propofol infusion until December 2005. The drugs were titrated (Bispectral monitoring was used in 16 patients) to facilitate intermittent intraoperative neurological testing. All patients received scalp blocks with a mixture of bupivacaine and lignocaine with adrenaline. Haloperidol and ondansetron were administered in all patients at induction of anesthesia. RESULTS All patients completed the procedure. One patient each needed endotracheal intubation and LMA for airway control during closure, while another required CPAP perioperatively because of desaturation to <80%. There was significantly decreased use of anesthetics (P<0.001) and a trend towards reduction in complications (e.g. respiratory depression and deep sedation) (P>0.05) with the use of BIS as compared to without BIS. Intraoperative complications were hypertension (19%), tight brain (14.2%), focal seizure (9.5%) respiratory depression (7.1%), deep sedation (7.1%), tachycardia (7.1%) and bradycardia. Two patients desaturated to <95%. 23.8% patients developed transient neurological deficits. The most frequent postoperative complications were PONV (19%) and seizures (16.6%). CONCLUSIONS With the use of advanced monitoring and newer anesthetics, awake craniotomy is a relatively safe procedure with an accepted rate of complications.

Severe seizures during propofol induction in a patient with syringomyelia receiving baclofen.

We report the occurrence of recurrent severe generalized seizures during induction of anesthesia with propofol in a patient with syringomyelia receiving baclofen for flexor spasms undergoing neurosurgery. We discuss the possible epileptogenic interaction between baclofen and propofol in our patient.

Superior vena cava syndrome after pulsatile bidirectional Glenn shunt procedure: Perioperative implications

Bidirectional superior cavopulmonary shunt (bidirectional Glenn shunt) is generally performed in many congenital cardiac anomalies where complete two ventricle circulations cannot be easily achieved. The advantages of BDG shunt are achieved by partially separating the pulmonary and systemic venous circuits, and include reduced ventricular preload and long-term preservation of myocardium. The benefits of additional pulsatile pulmonary blood flow include the potential growth of pulmonary arteries, possible improvement in arterial oxygen saturation, and possible prevention of development of pulmonary arteriovenous malformations. However, increase in the systemic venous pressure after BDG with additional pulsatile blood flow is known. We describe the peri-operative implications of severe flow reversal in the superior vena cava after pulsatile BDG shunt construction in a child who presented for surgical interruption of the main pulmonary artery.

Sinus venosus atrial septal defect closure in an achondroplastic dwarf: anesthetic and cardiopulmonary bypass management issues.

1 Nunnelee JD. Superior vena cava syndrome. J Vasc Nurs 2007; 25: 2–5. 2 Economopoulos G, Kimitrakakis G, Brountzos E et al. Superior vena cava stenosis: a delayed BioGlue complication. J Thorac Cardiovasc Surg 2004; 127: 1819–1821. 3 Garcia-Delgado M, Navarrete-Sanchez I, Colmenero M et al. Superior vena cava syndrome after cardiac surgery: early treatment by percutaneous stenting. J Cardiothora Vasc Anesth 2007; 21: 417–419. 4 Ro PS, Hill SL, Cheatham JP. Congenital superior vena cava obstruction causing anasarca and respiratory failure in a newborn: successful transcatheter therapy. Catheter Cardiovasc Interv 2005; 65: 60–65. 5 Mert M, Saltik L, Gunay I. Remodelling of the superior caval vein after angioplasty in an infant with superior caval vein syndrome. Cardiovasc Intervent Radiol 2004; 27: 402–404. Sinus venosus atrial septal defect closure in an achondroplastic dwarf: anesthetic and cardiopulmonary bypass management issues

Mainstream Time-Capnography: An Aid to Select an Appropriate Uncuffed Endotracheal Tube in Small Children

Uncuffed endotracheal tubes are commonly used in children in an attempt to decrease the potential for pressure induced tracheal injury. However, uncuffed endotracheal tube may increase the risk of aspiration and lead to erratic delivery of preset tidal volume during mechanical ventilation. Therefore, it is desirable to intubate trachea with an appropriate but not an oversized endotracheal tube. In children, for selecting an endotracheal tube, a variety of formulas and techniques are used to find the endotracheal tube size that minimizes both pressure induced tracheal injury and aspiration potential or variable ventilation. Air-leak following tracheal intubation can be recognized by the presence of audible leak, by auscultation over the trachea, by palpation over the trachea and by observing effects of positive end-expiratory pressure on inspiratory expiratory tidal volume difference during mechanical ventilation. We describe mainstream time-capnograph as an aid to recognize leak around the endotracheal tube and its utility to determine appropriate endotracheal tube size in small children.

Airway problems caused by hypogonadism in male patients undergoing neurosurgery.

Unanticipated difficult endotracheal intubations can pose challenges for the anesthesiologist. Risks include airway injury, hypoxemia, and death. There is intubation difficulty in various conditions including Downs syndrome, achondroplasia, acromegaly, and dwarfism. We describe difficulty in intubating the trachea with an appropriate sized endotracheal tube in two young male patients with hypogonadism presenting for neurosurgical procedures under general anesthesia. We discuss the role of hypogonadism and the effects of gonadotropin hormones on pubertal laryngeal growth in male patients.

Combined monitored anesthesia care and femoral nerve block for muscle biopsy in children with myopathies.

1 Wheeler M. Proseal laryngeal mask airway in 20 paediatric surgical patients: a prospective evaluation of characteristics and performance. Paediatr Anaesth 2006; 16: 297–301. 2 Marttinez-Pons V, Madrid V. Ease of placement of LMA Proseal with a gastric tube insert. Anesth Analg 2004; 98: 1816–1817. 3 Lopez Gil M, Brimacombe J. The Proseal laryngeal mask airway in children. Paediatr Anaesth 2005; 15: 229–234. 4 LMA. LMA ProsealTM Instruction Manual, Ist edn. San Diego: LMA North America Inc 2000. 5 Lopez Gil M, Brimacombe J, Barragan L et al. Bougie guided insertion of Proseal laryngeal mask airway has higher first attempt success rate than the digital technique in children. Br J Anaesth 2006; 96: 238–241. 6 Howath A, Brimacombe J, Keller C. Gum elastic bougie guided insertion of PLMA: a new technique. Anaesth Intensive Care 2002; 30: 818.

Resolution of Airway Compression Induced by Transesophageal Echocardiography Probe Insertion in a Pediatric Patient After Repair of an Atrial Septal Defect and Partial Anomalous Pulmonary Venous Connection

S d RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is routinely used in the operating room to assess surgical epairs in children with congenital heart disease (CHD). In a tudy of TEE examinations involving 1,650 children, Stevenon1 described airway obstruction in 14 patients (1%), right ainstem advancement of the endotracheal tube (ETT) in 3 atients (0.2%), inadvertent tracheal extubation in 8 patients 0.5%), vascular compression in 10 patients (0.6%), and addiional complications in 4 patients (0.2%). In another intraopertive TEE study of 200 pediatric cardiac patients undergoing urgical repair of CHD, complications associated with probe nsertion occurred in 11 patients (5.5%) and included airway bstruction in 6, inability to pass the probe in 4, and vascular ompression in 1 patient.2 The authors now report resolution of airway compression rom a TEE probe after surgical closure of an atrial septal efect (ASD) and rerouting of partial anomalous pulmonary enous connection (PAPVC) in a child. The patient had shown igns of airway compression after TEE probe insertion that ecessitated its removal shortly after initial endotracheal intuation. The mechanisms and the risk factors associated with irway compression by TEE probe insertion are discussed.

The depth markings on Portex blue-line pediatric tracheal tubes need to be re-organized for enhanced safety.

1 Luthy CL, Collart L, Dayer P. The rate of administration influences the analgesic effects of paracetamol. Clin Pharm Ther 1993; 2: 171. 2 Anderson BJ, Holford NH, Woollard GA et al. Perioperative pharmacodynamics of acetaminophen analgesia in children. Anesthesiology 1999; 90: 411–421. 3 Ameer B, Divoll M, Abernethy DR et al. Absolute and relative bioavailability of oral acetaminophen preparations. J Pharm Sci 1983; 72: 955–958. 4 Anderson BJ, Woolard GA, Holford NH. Pharmacokinetics of rectal paracetamol after major surgery in children. Paediatr Anaesth 1995; 5: 237–242. 5 Montgomery CJ, McCormack JP, Reichert CC et al. Plasma concentrations after high-dose (45 mgÆkg) rectal acetaminophen in children. Can J Anaesth 1995; 42: 982–986. 6 Holmer Pettersson P, Jakobsson J, Owall A. Plasma concentrations following repeated rectal or intravenous administration of paracetamol after heart surgery. Acta Anaesthesiol Scand 2006; 50: 673–677.

Activated clotting time during cardiopulmonary bypass: is repetition necessary during open heart surgery?

We evaluated the need of activated clotting time monitoring and efficacy of heparinization protocol in 100 patients undergoing open heart surgery. Patients were anticoagulated with 300 or 400 units·kg−1 heparin, based on their heparin sensitivity assessed at 5 min by activated clotting time. One-third of the initial dose was repeated at 90 min and thereafter hourly until completion of cardiopulmonary bypass. Patients who attained an activated clotting time of > 350 seconds at 5 min were included. Activated clotting time was repeated every 30 min. A time of < 350 seconds or presence of clot in the surgical field/extracorporeal circuit was considered failure of the protocol. Cardiopulmonary bypass was performed using a membrane oxygenator, non-pulsatile flow, hypothermia and crystalloid/blood priming solution. At 5 min, 94 patients had activated clotting time of > 350 seconds, 6 were < 350 seconds. At predetermined time intervals of 30 min, up to 210 min, 406 activated clotting time measurements were above 400 seconds and 40 were between 350 and 400 seconds. No clot was observed in the surgical field or extracorporeal circuit. This anticoagulation protocol ensures adequate anticoagulation during hypothermic cardiopulmonary bypass. With this protocol, only one activated clotting time at 5 min after heparin administration is required and essential; subsequent monitoring is not necessary.