Ravindra R Bhat

Obstetric hemorrhage in a case of hypertrophic obstructive cardiomyopathy with automatic implantable cardioverter defibrillator: Anaesthesia and intensive care management

The physiological changes occurring during pregnancy and labor may reveal or exacerbate the symptoms of hypertrophic obstructive cardiomyopathy (HOCM). The addition of obstetric hemorrhage to this presents a unique challenge to the anesthesiologists and intensivists managing these patients in the operation theatres and the Intensive Care Units. Here we present a case of HOCM with automatic implantable cardioverter defibrillator in situ and postpartum hemorrhagic shock.

Vincristine-induced acute life-threatening hyponatremia resulting in seizure and coma.

We report a case of a four-year-old boy with stage 1 Wilms tumour, who developed Vincristine-induced acute life-threatening hyponatremia, which presented as generalized tonic clonic seizures and coma. He was intubated and mechanically ventilated. There were no localizing neurological signs. CSF study showed no cells and CSF proteins were 20 mg%. Electrocardiography, chest X-ray, echocardiography, CT scan and liver function tests were normal. Evaluation of electrolytes and arterial blood gas showed serum sodium of 113 mEq/L with mild metabolic acidosis. Serum osmolality was 260 mOsm/L (normal value 285-295 mOsm/L) and urine osmolality was 625 mOsm/L (normal range 300-900 mOsm/L), urine sodium 280 mEq/d (normal range 100-260 mEq/d), serum potassium, blood urea, blood sugars were normal. Serial blood cultures showed no bacterial growth. Patient was treated with fluid restriction, hypertonic saline (3%) and other supportive care. Patient improved clinically over three days and was extubated on the third day and shifted to the ward on the fifth day.

Effect of pneumoperitoneum and Trendelenberg position on oropharyngeal sealing pressure of I-gel™ and ProSeal LMA™ in laparoscopic gynecological surgery: A randomized controlled trial.

Background : A sustained and effective oropharyngeal sealing with supraglottic airway (SGA) is required to maintain the ventilation during laparoscopic gynecological surgery in the Trendelenburg position. This study was conducted with I-gel™ and ProSeal LMA™, two prototype SGA devices with a gastric access. Materials and Methods: We enrolled 60 American Society of Anesthesiologists physical status I and II patients and randomized to either I-gel or ProSeal LMA (PLMA) group. After induction of anesthesia using a standardized protocol, one of the SGA devices was inserted. The primary objective of this study was to compare the oropharyngeal leak (sealing) pressure of I-gel™ and ProSeal LMA™ after pneumoperitoneum and Trendelenberg position. The secondary objectives were to compare ease of insertion, cuff position as assessed by the fiberoptic view of the glottis, adequacy of ventilation and incidence of complication. Results : The baseline (before pneumoperitoneum) oropharyngeal leak pressure of I-gel was less than the PLMA (mean (standard deviation [SD]) 24 (4) vs. 29 (4) cmH2 O, respectively; P < 0.001). After pneumoperitoneum, the leak airway pressure in I-gel group was significantly less than that of PLMA group (mean [SD] 27 (3) vs. 34.0 (4) cmH2 O, respectively; P < 0.001). Peak airway pressure was increased after pneumoperitoneum compared to baseline in both the groups. However, end-tidal carbon dioxide was maintained within normal limits. The insertion parameters, fiberoptic view of the glottis, fiberoptic view of the drain tube, and complications were comparable between the groups. Conclusion : Both I-gel and PLMA are effective for ventilation in gynecological laparoscopic surgeries. However, PLMA provides better sealing as compared to I-gel.

Anesthesia for noncardiac surgery in infant with undiagnosed single ventricle.

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Role of Intermittent Noninvasive Ventilation in Anticholinesterase Dose Adjustment for Myasthenic Crisis

A 27-year-old female was admitted with a history of speech and swallowing difficulties associated with ptosis for 6 months. There was progressive worsening of the symptoms with weakness that involved the facial and respiratory muscles. The patient had no significant concurrent illness. A provisional diagnosis of myasthenia gravis in crisis was made and confirmed by appropriate investigations. Computed tomography showed thymic enlargement. Trans-sternal thymectomy was done because prior plasmapheresis treatment with pyridostigmine, azathioprine and prednisolone was unsuccessful. The use of neuromuscular blockers with anesthesia was avoided to facilitate extubation at the end of the surgery in the absence of residual paralysis associated with muscle relaxants under neuromuscular transmission (NMT) monitoring. On postoperative day 3, the patient developed ptosis, breathing difficulties and respiratory arrest because the primary care physician had attempted to decrease the pyridostigmine dose, resulting in emergency intubation and mechanical ventilation. The pyridostigmine dose was gradually increased to 120 mg every 6 hours over 2 days. The patient’s condition steadily improved, allowing the withdrawal of ventilatory support and the patient was returned to a ward, with strict instructions regarding dosage and timing of the medications. The patient was readmitted the following week with respiratory difficulty, mild ptosis, and swallowing difficulties. It was found that the patient irregularly took her medications. The pyridostigmine dose was adjusted to 120 mg every 6 hours. Intermittent noninvasive ventilation (NIV) was also performed. It was observed that the patient regularly experienced intermittent breathing difficulties approximately 4 hours after each pyridostigmine dose. Thus, we provided intermittent NIV to maintain adequate and satisfactory ventilation and oxygenation during this transitional period (Figure 1), and thus avoid intubation. The pyridostigmine dose was further adjusted to 120 mg every 4 hours. Over the following 3 days the patient’s Role of Intermittent Noninvasive Ventilation in Anticholinesterase Dose Adjustment for Myasthenic Crisis