Rashid M Khan

Methylergonovine maleate (methergine) relieves postdural puncture headache in obstetric patients

Sir, Postdural puncture headache (PDPH) is usually related to persistence of the dural hole, with leakage of cerebrospinal fluid into the surrounding soft tissue. This leads to lowering of cerebrospinal fluid pressure. This in turn produces intracranial venous dilatation resulting in an increase in brain volume (Monro–Kellie doctrine) (1). This increase in brain volume results in brain sag, which exerts traction on the surrounding nerves, vessels and meninges resulting in headache. Methylergonovine maleate (methergine) is a semisynthetic derivative of the ergot alkaloid. Stimulation of vascular smooth muscles by ergot alkaloid through their agonist action at a-adrenergic receptors is the basis for their usefulness in the treatment of migraine headaches (2–4). We planned a pilot study to evaluate the usefulness of methergine in relieving PDPH in obstetric patients based on this observation. The study was conducted on 25 obstetric patients (ASA I and II, aged 18–30 years), undergoing cesarean section under spinal anesthesia, who developed PDPH that was not relieved by bedrest, analgesics and fluids for 24 h. Following approval by the Board of Studies, these patients were administered oral tablets of methergine, 0.25 mg three times a day for 24 h. If the intensity of headache reduced or disappeared within 24 h, the treatment was carried on for a further 48 h. Tablet metoclopramide 10 mg twice a day was also advised as a prophylactic antiemetic. At 8-h intervals, patients were asked to rate their intensity of headache on a Visual Analog Scale (VAS; 11⁄4 no headache, 101⁄4maximum headache). All of the patients except one (4%) showed improvement in the intensity of headache within 24 h. Of these 24 (96%) patients who responded, headache disappeared completely in four (16%) patients, and reduced to less than half in the remaining 20 (80%) (VAS< 5) in the first 24 h. By the third day all of these 24 patients were completely relieved of their headache. Only one (4%) patient who showed no improvement in her condition had to undergo the application of an epidural blood patch for relief of PDPH. The probable mechanism of action of methergine in PDPH is the vasoconstriction of cranial and extracranial vessels leading to decrease in brain volume and corresponding traction on vessels, nerves and meninges. In conclusion, this preliminary trial suggests that tablet methergine can be successfully used to relieve PDPH in postcesarean section patients.

Dexmedetomidine used to provide hypotensive anesthesia during middle ear surgery.

This study was carried out to assess the hypotensive effect of low dose dexmedetomidine (DEX) infusion during middle ear surgery. 42 ASA grades I and II patients of either sex aged 18–45 years undergoing elective middle ear surgery were randomly divided into two groups of 21 each. Group I received placebo bolus and infusion of saline at a rate similar to DEX in Group II. Group II received 10–15 min prior to induction of anesthesia 1 µg/kg IV bolus DEX diluted in 10 ml of normal saline over 10 min. Immediately thereafter an infusion of 0.4 µg/kg/hr of DEX commenced. Standard anesthetic technique was used. Halothane was titrated to achieve a mean arterial pressure 30% below the control value (value taken just after premedication). We observed that a statistically significant reduction in the percentage of halothane required to reduce MAP 30% below control value occurred in patients receiving DEX infusion (1.3 ± 0.4%) in comparison to those receiving placebo (3.1 ± 0.3%). Patients receiving DEX infusion had a better surgical field. The mean awakening time was significantly reduced in patients of Group II (9.1 ± 2.7 min) when compared to patients of Group I (12.8 ± 2.2 min).We conclude that DEX can be safely used to provide hypotensive anesthesia during middle ear surgery.

Successful airway management in patient with Goldenhar's syndrome using Truview PCD ® laryngoscope.

Unfortunately, studies have not looked at use of lignocaine in the difficult pediatric airway and therefore are unable to ensure absolute adequate placement for an MLB procedure in a child with a difficult airway. It should also be noted directly placed lignocaine is frequently required in addition to nebulized lignocaine to achieve satisfactory anesthesia. We have now used this technique with the Glidescope with no side effects from the lignocaine in over 25 children where previously it was completely impossible to view the larynx or ensure correct placement of topical anesthesia.

Continuous anesthetic insufflation and topical anesthesia of the airway using Trachlight in chronic facial burns.

In chronic burn patients undergoing reconstructive surgery, securing a patient airway quickly, atraumatically, and, preferably, on the first attempt is a challenge. We describe a patient of chronic severe burns in whom fiberoptic endotracheal intubation failed but in whom a modified Trachlight intubation enabled us to secure the airway uneventfully. An ASA physical status III 35-yr-old man with history of epileptic convulsions presented with severe burns of the head, neck, and chest sustained 7 mo previously (Fig. 1). The patient was scheduled for transfer of pedicle flap to the forehead. The patient had a mouth opening of 1.0 cm and neck extension was restricted because of two bands of anterior neck contracture. There was complete destruction of both the eyes and external nose. The turbinates and nasal passages had granulation tissue. All other relevant investigations were within normal limits. The patient refused an awake tracheal intubation. Anesthesia was induced with halothane in 100% oxygen. Fiberoptic intubation was attempted after topical nasal application of ephedrine 0.75% but failed as a result of bleeding. A size 5F infant feeding tube was attached beginning from the tip of the Trachlight to the wand. The Trachlight-endotracheal tube assembly was now configured into a “C-shape” against the patient’s lateral facial profile (Fig. 1). The tip of the wand was placed at the thyroid cartilage; the next bend was taken at the level of the posterior one third of the mandible such that the other end of the C portion of the wand was approximately at the level of the external nasal opening. The Trachlight with infant feeding tube in a 7.0 mm inner diameter endotracheal tube was now introduced and maneuvered so as to make the glow of light appear in the midline just below the scar. At this juncture 1 mL of 2% lidocaine was injected with moderate force via the infant feeding tube. After waiting for 60 s, the Trachlight glow was gradually moved into the larynx (Fig. 2). Minimal coughing and bucking were noted, and a second 1 mL of 2% lidocaine was injected through the infant feeding tube. The stylet was partially withdrawn and Trachlight-endotracheal tube assembly was taken until the light glow just disappeared under the suprasternal notch. The clamp was released, the Trachlight disengaged and removed, and correct endotracheal tube placemen was confirmed. During this period, the patient continued to receive 4 L of oxygen and 2% halothane via the infant feeding tube (Fig. 2) except for two brief periods when lidocaine was injected through the infant feeding tube. The entire procedure lasted 11 min. Oxygen saturation remained between 97% and 99%. Tracheostomy was avoided, as it would result in loss of speech in an illiterate and visually handicapped patient. We therefore opted for Trachlight-aided intubation with an attached size 5F infant feeding tube on the side of the wand. This gave us the flexibility of using this additional tubing for continuous insufflation of oxygen and halothane during a procedure tending to be prolonged. This also gave us the option of injecting lidocaine on the glottic and intratracheal structures to obtund coughing and bucking on the tracheal tube. In conclusion, using an infant feeding tube with Trachlightendotracheal tube assembly serves the triple function of assisting intubation, maintaining inhalational anesthesia, and administering topical local anesthetic.

Truview PCD™ eases laryngoscopy and tracheal intubation in patient with cleft lip, palate, and protruding premaxilla

eign body. We decided to maintain spontaneous breath instead of MJV during the procedure just in case there was a large foreign body in the main trachea. If the small tube managed to pass through the space around the foreign body, the boy would definitely develop into a life-threatening situation – pneumothorax because of barotraumas resulted from MJV. In this case, a half of peanut, almost totally obstructing the trachea, was removed from the narrow main trachea. Inhalation anesthesia with spontaneous respiration is traditionally used to facilitate airway bronchoscopy in children. The advantages are as follows: firstly, spontaneous respiration allows for continued ventilation during removal of the foreign body and rapid assessment of the adequacy of the airway after removal of the foreign body; it is safer than the apnoeic technique with complete neuromuscular paralysis (4). Secondly, a spontaneously breathing patient receives fresh gas through the lumen of the bronchoscope as well as by entrainment around the bronchoscope and can exhale the same way. Thirdly, if there is any doubt of foreign body, spontaneous ventilation should be preserved to make a diagnosis. Disadvantages of spontaneous breathing may relate to increase CO2 which may also occur with controlled ventilation, hard to guarantee no movement, and prolonged emergence. Sevoflurane alone may be hard to maintain a deeply anesthetized spontaneous breathing throughout bronchoscopy. Remifentanil, like all opioids, has antitussive properties, which makes it an ideal agent for airway bronchoscopy by reducing the incidence of coughing and gagging under anesthesia. Crawford et al. (5) found that remifentanil can obtund airway reflexes and facilitate endotracheal intubation in infants and children. In this case, we administered low dosage of remifentanil and provided adequate depth of anesthesia. In summary, in clinical experience, either spontaneous ventilation or control ventilation is used successfully or unsuccessfully for foreign body removal. In cases where the airway is shared, not only is communication between the surgeon and anesthesiologist during the case exquisitely important, but agreement beforehand on the details of management is critical.

Barotrauma: a life-threatening complication of fiberoptic endotracheal intubation in a neonate.

found. Hence, no major and no minor criteria are fulfilled, and we must conclude that this patient does not have SM based on WHO criteria. The question remains as to why this patient developed bronchospasm and hypotension under anesthesia. Interpretation of the ‘raised’ tryptase at the time of the incident is problematic because the tryptase level remains elevated 8 months later. Raised tryptase is a marker of anaphylaxis but its absence does not exclude anaphylaxis. In this instance, no elevation of tryptase from baseline is apparent leaving the etiology of the event unclear. However, on the basis of the evidence provided, we do not agree that this patient fulfills the diagnostic criteria for SM. N A R G I S A H M A D P H I L I P P A E V A N S Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK (email: ahmadn@gosh.nhs.uk)

Effect of peri-operative intravenous infusion of lignocaine on haemodynamic responses to intubation, extubation and post-operative analgesia

Background and Aims: Lignocaine in intravenous (IV) bolus dose has been used for minimising haemodynamic changes associated with intubation and extubation. Furthermore, IV infusion has been used for post-operative analgesia. We investigated whether IV peri-operative lignocaine (bolus and infusion) would be able to produce both the effects simultaneously in elective laparoscopic cholecystectomies. Methods: In this randomised prospective study, 60 patients undergoing elective laparoscopic cholecystectomy were randomly divided into two groups of 30 each. In Group A, patients received 6 ml normal saline as bolus over 10 min followed by 6 ml/h infusion whereas in Group B, patients received preservative free 2% lignocaine 1.5 mg/kg IV bolus (made to a volume of 6 ml with normal saline) administered over a period of 10 min and thereafter an infusion at a rate of 1.5 mg/kg/h (pre-diluted in normal saline made to a volume of 6 ml/h. P < 0.05 was considered as significant. Results: The rise in pulse rate (PR) and mean arterial pressure (MAP) were less in Group B as compared to the Group A (P < 0.05) during intubation as well as during extubation. Furthermore, the Group B had significant longer mean pain-free post-operative period of 5½ h as compared to 54.43 min in the Group A (P < 0.05). Conclusion: Administration of lignocaine infusion attenuates the rise in PR as well as MAP during the peri-intubation and peri-extubation period. Furthermore, infusion of lignocaine significantly increases the mean pain-free period post-operatively.

Assessment of Truflex™ articulating stylet versus conventional rigid Portex™ stylet as an intubation guide with the D-blade of C-Mac™ videolaryngoscope during elective tracheal intubation: study protocol for a randomized controlled trial

BackgroundA variety of videolaryngoscopes with angulated blade have been recently introduced into clinical practice. They provide an indirect view of the glottic structures in normal and challenging clinical settings. Despite the very good visualization of the laryngeal structures by these devices, the insertion and advancement of the endotracheal tube may be prolonged and occasionally fail as it does not conform to the enhanced angulation of the blade. To overcome this handicap, it is recommended to use a pre-shaped, styleted tracheal tube during intubation. Unfortunately, these malleable rigid stylets permit only a fixed shape to the advancing endotracheal tube. This may necessitate withdrawal of endotracheal tube-stylet assembly for reshaping, before undertaking a new attempt. This may cause soft tissue injury and hemodynamic disturbance.This single-blinded randomized clinical trial aims to overcome these handicaps using a novel method of dynamically changing the shape of the advancing endotracheal tube by Truflex™ articulating stylet as per need during D-blade C-Mac™ videolaryngoscopy.MethodsOne hundred and fifty four patients between 18 and 60 years of age belonging to either sex undergoing tracheal intubation under uniform general anesthetic technique will be randomly divided into Portex™ malleable stylet group and Truflex™ articulating stylet group. The primary efficacy variable of success/failure between the two groups will be analyzed using the chi square test. For comparison of intubation times and the Intubation Difficulty Score, ANOVA will be used. Primary efficacy endpoint results will be successful or failed tracheal intubation in the first attempt, total intubation time and the intubation difficulty score. Secondary efficacy endpoints will be overall user satisfaction graded from 1 to 10 (1 = very poor, 10 = excellent), Cormack and Lehane’s grading, glotticoscopy time and ETT negotiation time and total number of intubation attempts. Result of safety endpoints will include dental and airway trauma, hemodynamic disturbances, arrhythmias or cardiac arrest.Trial registrationCurrent Controlled Trials ISRCTN57679531; Date of registration 12/02/2013

Airway management in trauma

Trauma has assumed epidemic proportion. 10% of global road accident deaths occur in India. Hypoxia and airway mismanagement are known to contribute up to 34% of pre-hospital deaths in these patients. A high degree of suspicion for actual or impending airway obstruction should be assumed in all trauma patients. Objective signs of airway compromise include agitation, obtundation, cyanosis, abnormal breath sound and deviated trachea. If time permits, one should carry out a brief airway assessment prior to undertaking definitive airway management in these patients. Simple techniques for establishing and maintaining airway patency include jaw thrust maneuver and/or use of oro- and nas-opharyngeal airways. All attempts must be made to perform definitive airway management whenever airway is compromised that is not amenable to simple strategies. The selection of airway device and route- oral or -nasal, for tracheal intubation should be based on nature of patient injury, experience and skill level.

Anesthesia in a patient with arginase deficiency: implications and management

high in presence of structural heart disease or other malformations. Although the surgical management of ectopia cordis has been reported in the literature, to the best of our knowledge, the anesthetic management and problems of perioperative monitoring have not been highlighted before. As the heart was lying outside the thoracic cavity, the vector did not cross the ECG electrodes and ECG complexes displayed on monitor were very small inconclusive even after achieving maximum gain on cardioscope. Thus, heart rate and cardiac activity were monitored merely by direct visualization of the beating heart in the surgical field. Invasive arterial pressure monitoring was not possible as peripheral pulses were not palpable. For the same reason, pulse oximeter also did not show any tracing ⁄ reading even after adequate hydration and warming. Capnograph was the only intraoperative monitor which gave an idea of cardiac activity and perfusion status. As the protruding heart was lying on anterior chest wall, there was less space available for maneuvering the handle of the laryngoscope during laryngoscopy. The handle kept touching the heart with chances of direct potential injury to it and causing hemodynamic instability. Intraoperative handling of heart resulted in few episodes of bradycardia which resolved on relieving it. These patients are a great challenge for an anesthetist in view of their difficult airway, cardiac, and noncardiac anomalies and hemodynamic embarrassment during surgery and difficulty in perioperative monitoring. In conclusion, patient with ectopia cordis, must be evaluated carefully for all associated anomalies. Difficulty in securing airway and perioperative hemodynamic monitoring must also be anticipated. Ravindra Pandey Rakesh Garg Vanlal Darlong Jyotsna Punj Arvind Kumar Mahesh Kumar Arora Dilip Shende Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India (email: trips22003@yahoo.co.in)