Rudrashish Haldar

Pain management following spinal surgeries: An appraisal of the available options.

Spinal procedures are generally associated with intense pain in the postoperative period, especially for the initial few days. Adequate pain management in this period has been seen to correlate well with improved functional outcome, early ambulation, early discharge, and preventing the development of chronic pain. A diverse array of pharmacological options exists for the effective amelioration of post spinal surgery pain. Each of these drugs possesses inherent advantages and disadvantages which restricts their universal applicability. Therefore, combination therapy or multimodal analgesia for proper control of pain appears as the best approach in this regard. The current manuscript discussed the pathophysiology of postsurgical pain including its nature, the various tools for assessment, and the various pharmacological agents (both conventional and upcoming) available at our disposal to respond to post spinal surgery pain.

Pain following Craniotomy: Reassessment of the Available Options

Pain following craniotomy has frequently been neglected because of the notion that postcraniotomy patients do not experience severe pain. However a gradual change in this outlook is observed because of increased sensitivity of neuroanaesthesiologists and neurosurgeons toward acute postcraniotomy pain. Multiple modalities exist for treating this variety of pain each with its own share of advantages and disadvantages. However, individually none of these modalities has been proclaimed as the best and applicable universally. A considerable amount of dispute remains to ascertain the appropriate therapeutic regimen for treating postcraniotomy pain in spite of numerous trials using different drugs and their combinations. This review aims to highlight the genesis, characteristics, and different strategies that are undertaken for management of acute postcraniotomy pain. Chronic postcraniotomy pain which can be debilitating sequelae is also discussed concisely.

Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation

Background and Aim: Induced hypotension limits intra-operative blood loss to provide better visibility of the surgical field and diminishes the incidence of major complications during functional endoscopic sinus surgery (FESS). We aimed at comparing nitroglycerine, esmolol and dexmedetomidine for inducing controlled hypotension in patients undergoing FESS. Material and Methods: One hundred and fifty American Society of Anesthesiologists physical status I or II adult patients undergoing FESS under general anesthesia were randomly allocated to three groups of 50 patients each. Group E received esmolol in a loading and maintenance dose of 1 mg/kg over 1 min and 0.5-1.0 mg/kg/h, respectively. Group D received a loading dose of dexmedetomidine 1 μg/kg over 10 min followed by an infusion 0.5-1.0 μg/kg/h, and group N received nitroglycerine infusion at a dose of 0.5-2 μg/kg/min so as to maintain mean arterial pressure (MAP) between 60 and 70 mmHg in all the groups. The visibility of the surgical field was assessed by surgeon using Fromme and Boezaart scoring system. Hemodynamic variables, total intra-operative fentanyl consumption, emergence time and time to first analgesic request were recorded. Any side-effects were noted. The postoperative sedation was assessed using Ramsay Sedation Score. Result: The desired MAP (60-70 mmHg) could be achieved in all the three study groups albeit with titration of study drugs during intra-operative period. No significant intergroup difference was observed in Frommes score during the intra-operative period. The mean total dose of fentanyl (μg/kg) used was found to be significantly lower in group D compared to groups E and N (1.2 ± 0.75 vs. 3.6 ± 1.3 and 2.9 ± 1.1 respectively). The mean heart rate was significantly lower in group D compared to groups E and N at all times of measurement (P < 0.05). The MAP was found to be significantly lower in group D compared to groups E and N after infusion of study drugs, after induction, just after intubation and 5 min after intubation (P < 0.05). The Ramsay Sedation Scores were significantly higher in group D (score 3 in 46%) when compared to group E (score 2 in 50%) and group N (score 2 in 54%) (P < 0.001). The emergence time was significantly lower in group E and group N compared to group D. Time to first analgesic request was significantly longer in group D. Conclusion: Dexmedetomidine and esmolol provided better hemodynamic stability and operative field visibility compared to nitroglycerin during FESS. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.

Endocrinological disorders affecting neurosurgical patients: An intensivists perspective

Management of critically ill neurosurgical patients is often complicated by the presence or development of endocrinological ailments which complicate the clinical scenario and adversely affect the prognosis of these patients. The anatomical proximity to the vital centers regulating the endocrinological physiology and alteration in the neurotransmitter release causes disturbances in the hormonal homeostasis. This paves the way for development of diverse disorders where single or multiple hormones may be involved which can have deleterious effect on the different organ system. Understanding and awareness of these disorders is important for the treating intensivist to recognize these changes early in their course, so that appropriate and timely therapeutic measures can be initiated along with the treatment of the primary malady.

Emergency caesarean delivery in a patient with cerebral malaria-leptospira co infection: Anaesthetic and critical care considerations

Malaria-leptospira co-infection is rarely detected. Emergency surgery in such patients has not been reported. We describe such a case of a 24-year-old primigravida at term pregnancy posted for emergency caesarean delivery who developed pulmonary haemorrhage, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Here, we discuss the perioperative management, pain management (with transverse abdominis plane block), intensive care management (special reference to management of pulmonary haemorrhage with intra pulmonary factor VIIa) and the role of plasmapheresis in leptospira related jaundice with renal failure.

Anesthesia for an achondroplastic individual with coexisting atlantoaxial dislocation.

Achondroplasia is a congenital, disfiguring condition which is the most common form of short-limbed dwarfism. Defective cartilage formation is the hallmark of this condition, which results in a wide spectrum of skeletal abnormalities including spinal defects. Various other systems such as cardiac, pulmonary, and neurological can be simultaneously affected adversely including airway defects. Anesthetic management of such individuals is complicated because of their multisystem affliction. Concomitant atlantoaxial dislocation can further amplify the difficulty during the administration of anesthesia in such patients. We report the successful anesthetic conduct of such a patient with the positive outcome.

A unique anesthesia approach for carotid endarterectomy: Combination of general and regional anesthesia.

Carotid endarterectomy (CEA), a preventable surgery, reduces the future risks of cerebrovascular stroWke in patients with marked carotid stenosis. Peri-operative management of such patients is challenging due to associated major co-morbidities and high incidence of peri-operative stroke and myocardial infarction. Both general anesthesia (GA) and local regional anesthesia (LRA) can be used with their pros and cons. Most developing countries as well as some developed countries usually perform CEA under GA because of technical easiness. LRA usually comprises superficial, intermediate, deep cervical plexus block or a combination of these techniques. Deep block, particularly, is technically difficult and more complicated, whereas intermediate plexus block is technically easy and equally effective. We did CEA under a combination of GA and LRA using ropivacaine 0.375% with 1 mcg/kg dexmedetomidine (DEX) infiltration. In LRA, we gave combined superficial and intermediate cervical plexus block with infiltration at the incision site and along the lower border of mandible. We observed better hemodynamics in intraoperative as well as postoperative periods and an improved postoperative outcome of the patient. So, we concluded that combination of GA and LRA is a good anesthetic technique for CEA. Larger randomized prospective trials are needed to support our conclusion.

Isolated bradycardia due to skull pin fixation: an unusual occurrence.

To JNA Readers: Skull pin fixation before most craniotomies involves manually driving sharp metallic pins through the skin, muscle, and periosteum up to outer table of the skull. This produces an intense nociceptive stimulus even when the patient is under deep anesthesia,1 resulting in a precipitous rise in heart rate, blood pressure, and intracranial pressure (ICP).2,3 Tachycardia and hypertension are the dominant manifestations of this noxious stimulus, but we observed an incident where skull pin fixation leads to bradycardia. After obtaining written informed consent from the patient, we wish to report and attempt to explain the possible mechanism of this event. A 21-year-old male patient with the diagnosis of interventricular ependymoma with hydrocephalus was scheduled for tumor resection using anterior hemispheric approach. History of recurrent vomiting and bilateral papilledema indicated raised ICP. Otherwise the preanesthetic evaluation was unremarkable. Contrast enhanced computerised tomography revealed a 7 5 cm hyperdense left ventricular lesion blocking the foramen of Monroe with resultant ventriculomegaly. Induction was carried out with 150mcg fentanyl and 110mg propofol and intubation with 8mg vecuronium. Anesthesia was maintained with air, oxygen (1:1), and isoflurane (1% to 1.5%). Five minutes before skull pin fixation, 50mcg of fentanyl was administered intravenously and concentration of isoflurane increased to decrease the hemodynamic surges. In addition, 2mL of 2% lignocaine was infiltrated at the scalp pinning sites. The patient’s head was then fixed in the Sugita frame and the pin fixation progressed. During pin tightening, we observed that the heart rate decreased suddenly from 80 to 44 beats/min (Fig. 1). Witholding pin application normalized the heart rate. Another attempt to fasten the pins caused the heart rate to drop to 45 beats/min. Further interventions were ceased. The patient’s head was elevated and he was hyperventilated for 5 minutes. Additional 50mg of propofol was administered. Pin fixation was again attempted and safely accomplished. This time the drop in heart rate was not so marked (78 beats/min) and rest of the procedure proceeded uneventfully. Propofol, fentanyl, and raised ICP are known factors causing bradycardia. Bradycardia may be caused by increased ICP because of direct mechanical distortion of the vagus nerve. Furthermore, raised ICP increases vagotonicity.4 In our case, in the presence of a clear cause-effect relationship, we hypothesize that pin fixation increased ICP transiently, thereby mechanically stimulating the vagus nerve and evoking a parasympathetic response (bradycardia). The swift and intense elevation of ICP in a closed cranium whose fluid dynamics were already delicately balanced overshot its limits of compensation and led to an exponential rise. Mechanical distortion of the vagus nerve compounded by high vagotonicity resulted in this response. Head elevation, hyperventilation, and augmenting the depth of anesthesia decreased ICP and subsequently the response was ablated. Various adverse effects of skull pin fixation like hypertension, tachycardia, skull perforation, hematoma, and venous air embolism have been described. Bradycardia in the presence of raised ICP is another potential addition to the list, and hence, extreme caution and vigilance during pin fixation is advocated.

Unexpected tracheal tube blockage from a semi-dissolved misoprostol tablet

Fig. 1 Distal end of the tracheal tube blocked by a misoprostol tablet through the PLMA. Anaesthesia was maintained with nitrous oxide and isoflurane in 50% oxygen and surgery commenced. The baby was delivered within 5 min, after which intravenous fentanyl and atracurium were given. Umbilical cord blood gases and Apgar scores were satisfactory. A paediatric 3.5 mm fibreoptic bronchoscope was passed through the PLMA and showed the airway was clear of foreign bodies. Maternal perioperative blood gases were satisfactory. After completion of surgery, residual neuromuscular block was reversed and the PLMA was removed after awakening the patient. She was monitored closely for signs of aspiration for the next 24 h and was discharged uneventfully on the fourth postoperative day. Subsequent review of the patient’s treatment chart showed that she had received a sublingual tablet of misoprostol 30 min before anaesthesia induction. The patient in her distressed state had not disclosed its presence. Two previous reports have implicated oral medications in tracheal tube obstruction. Misoprostol is a synthetic prostaglandin E1 analogue used for cervical ripening. Although it can be administered vaginally and orally, the sublingual route avoids vaginal examination, the need for fluid intake and results in higher bioavailability by avoiding hepatic first pass metabolism. Being water soluble, it usually dissolves under the tongue in about 15–20 min. In our patient, we believe that the stress of labour resulted in a dry oral cavity, preventing the tablet from dissolving and then sticking to the underside of the tongue. It was therefore missed during airway examination. We postulate that tongue deflection during laryngoscopy led to its displacement into the pharynx and during attempts at intubation it lodged inside the lumen of the tracheal tube, obstructing ventilation. We recommend specific enquiry about intake of oral or sublingual drugs and their presence in the oral cavity before induction of anaesthesia and would emphasize the importance of meticulous examination of the airway. In obstetric patients, difficulty with tracheal intubation has an incidence of approximately 1 in 30. We report a case where a sublingual misoprostol tablet inadvertently blocked the lumen of a tracheal tube during intubation in a pregnant patient with an unexpected difficult airway. A 29-year-old, 65 kg, nulliparous woman at term presented for an urgent caesarean section for fetal distress following non-progressive labour. The patient was extremely distressed and airway assessment by the anaesthesia resident revealed adequate mouth opening and a Mallampati class III airway. The patient refused neuraxial anaesthesia, so general anaesthesia with a rapidsequence induction was performed using thiopental, succinylcholine and cricoid pressure. The first attempt at intubation failed because of an anteriorly-placed larynx (Cormack and Lehane grade 3). After another attempt using a stylet, the trachea was successfully intubated with a 7.0 mm internal diameter tracheal tube (Portex, Smiths Medical, Hythe, UK) with moderate difficulty. With cricoid pressure maintained, there was unusual resistance to bag ventilation associated with high peak airway pressures of 45–50 cmH2O. Breath sounds and capnographic trace were absent. A check of the breathing circuit revealed no malfunction. A 12 French suction catheter was passed through the lumen of the tube and resistance was encountered at around 30 cm. The tube was removed immediately with cricoid pressure maintained. When the tube was examined, a semi-dissolved tablet was occluding the lumen above the Murphy eye (Fig. 1). The patient started to desaturate (SpO2 <90%), so a size 4 ProSeal laryngeal mask airway (PLMA) was inserted with transient release of cricoid pressure. After optimizing ventilation and oxygenation, gastric drainage was performed using a suction catheter

Intense Intraoperative Thirst: A Neglected Concern during Awake Craniotomy Surgeries.

Cyrill Meuwly, MMed* Tumul Chowdhury, MD, DM, FRCPCw Ricardo Gelpi, MD, PhDz Paul Erne, MD* Bernhard Schaller, MD, PhD, DSCy *Department of Research, University Hospital Basel, Basel, Switzerland wDepartment of Anaesthesiology and Perioperative Medicine, University of Manitoba, Winnipeg, Canada zDepartment of Pathology, University of Buenos Aires, Buenos Aires, Argentina yDepartment of Research, University of Southampton, Southampton, UK