Sachidanand Jee Bharati

Comparison of propofol versus sevoflurane on thermoregulation in patients undergoing transsphenoidal pituitary surgery: A preliminary study

Purpose: General anesthesia causes inhibition of thermoregulatory mechanisms. Propofol has been reported to cause more temperature fall, but in case of deliberate mild hypothermia, both sevoflurane and propofol were comparable. Thermoregulation is found to be disturbed in cases of pituitary tumors. We aimed to investigate which of the two agents, sevoflurane or propofol, results in better preservation of thermoregulation in patients undergoing transsphenoidal excision of pituitary tumors. Methods: Twenty-six patients scheduled to undergo transsphenoidal removal of pituitary adenomas were randomly allocated to receive propofol or sevoflurane anesthesia. Baseline esophageal temperature was noted. Times for temperature to fall by 1°C or 35°C and to return to baseline were also comparable (P>0.05). After that warmer was started at 43°C and time to rise to baseline was noted. Duration of surgery, total blood loss, and total fluid intake were also noted. If any, side effects such as delayed arousal and recovery from muscle relaxant were noted. Results: The demographics of the patients were comparable. Duration of surgery and total blood loss were comparable in the two groups. The time for temperature to fall by 1°C or 35°C and time to return to baseline was also comparable (P>0.05). No side effects related to body temperature were noted. Conclusion: Both propofol and sevoflurane show similar effects in maintaining thermal homeostasis in patients undergoing transsphenoidal pituitary surgery.

Anaesthesia in underdeveloped world: Present scenario and future challenges

The overall mortality and morbidity in underdeveloped countries are still unchanged and preventable risks factors constitute the main burden. Among these, anaesthesia-related mortality is largely preventable. Various contributory factors related to human resources, technical resources, education/teaching system and other utilities needs further attention in poor income group countries. Therefore, we have made an attempt to address all these issues in this educational article and have given special reference to those factors that might gain importance in (near) future. Proper understanding of anaesthesia-related resources, their overall impact on health care system and their improvisation methods should be thoroughly evaluated for providing safer anaesthesia care in these countries which would certainly direct better outcome and consequently influence mortality.

Anesthetics impact on cancer recurrence: What do we know?

Surgery is an important component of treatment in cancer patients. However, surgical stress, anesthesia, and perioperative analgesia interfere with the host immune defense mechanisms and may contribute to metastatic dissemination of malignant tumors and cancer progression. Little is known about the effects of anesthesia on tumor recurrence. In vivo studies and clinical data show some evidence that regional anesthesia is beneficial for cancer patients as it may decrease the risk of metastasis. This short review summarizes the clinical data on the possible association between anesthesia, perioperative analgesia, and the risk of cancer recurrence. Most of the clinical reports are based on retrospective studies, and properly designed prospective trials including a sufficient number of patients is required to reveal the interaction of various anesthetic drugs and methods and cancer progression.

Perioperative problems in patients with brainstem tumors and their influence on patient outcome

Background and Aims: Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome. Material and Methods: Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated. Results: Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome. Conclusion: Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.

Bronchoscopic Debulking Followed by Bronchoplastic Procedure Helps in Limiting Lung Resection in a Bronchial Carcinoid: A Case Report

Bronchoplasty is a conservative procedure in lung surgeries used in the past for patients with poor functional status but recently these procedures have been performed in low grade malignant tumors of lung avoiding extensive morbid procedure like pneumonectomy without compromising the oncologic outcome. We describe a case of bronchial carcinoid treated by bronchoscopic intervention followed by wedge bronchoplasty. The importance of bronchoscopic debulking of the tumor for accurate assessment of its extent has been highlighted. A parenchyma preserving pulmonary resection can then be performed with bronchoplastic technique, thus avoiding pneumonectomy.

Airway management for oral surgery in a patient with repaired cleft palate.

1. Solan KJ. Nasal intubation and previous cleft palate repair. anaesthesia 2004;59:923-4. 2. Hee HI, Conskunfirat ND, Wong SY, Chen C. Airway management in a patient with a cleft palate after pharyngoplasty: a case report. Can J anaesth 2003;50:721-4. 3. Schliephake H, donnerstag F, Berten Jl, lönquist N. Palate morphology after unilateral and bilateral cleft lip and palate closure. int J oral Maxillofac Surg 2006;35:25-30. Sir,

Paediatric Endobronchial Ultrasound-guided transbronchial needle aspiration: Anaesthetic and procedural considerations

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. How to cite this article: Singh S, Chowdhary NK. Erector spinae plane block an effective block for post‐operative analgesia in modified radical mastectomy. Indian J Anaesth 2018;62:148-50.

Bite Block for Interventional Pulmonology: Novelty at No Cost

To the Editor: Rigid bronchoscope is an age-old indispensable device being used for diagnosis and management of pulmonary diseases.1 Rigid bronchoscopy has been used for a variety of indications, including central airway obstruction due to neoplastic or non-neoplastic diseases, management of massive hemoptysis, clot removal, mucus plug removal and foreign body extraction. The common procedure-related complications include trauma to the oral cavity including lips, gums, teeth, tongue and pharynx.2 Apart from the procedural complications, the most neglected part is the discomfort and fatigue imparted to the pulmonologist hand during insertion and maintenance of the rigid bronchoscope. The standard technique includes introduction of the rigid bronchoscope after opening the angle of the mouth with the help of thumb and index finger of the nondominant hand. After insertion of the rigid scope in trachea, there will be a constant need to keep open the mouth of the patient to avoid trauma to his teeth and lips.3 This maneuvering with the thumb and index finger causes fatigue of the hand with prolongation of the procedure and hence increases the chances of injury. In addition, the nondominant hand is never free and the interventional pulmonologist needs assistance from other team members.2 Both the purposes can be easily achieved with the use of bite block without adding to total cost of the procedure. Hence, we are reporting our innovative method of using gauze piece bite block. The bite block is made by folding gauze pieces of size “4 4” as a roll placed at the angle of the mouth after insertion of rigid scope (Fig. 1). The width of the bite block can be modified as per the size of the rigid scope. The soft bite block will prevent dental trauma by minimizing the levering force to the teeth with metallic rigid bronchoscope. After placing the soft bite block at the angle of the mouth, there is no need of the thumb and index finger to open up the mouth during the procedure. This will prevent hand fatigue and the hand can be used for other purposes as it is free. The advantages of the soft bite block technique include easy preparation, comes at no cost to the patient, nontraumatic, and can be customized as per the patient and the size of the rigid scope. The precaution to be taken while using the bite block is to select proper size to prevent complications such as dislodgement from undersized bite block and edema of the tongue from oversized one.4 In conclusion, one can use the soft bite block for the cases in which prolonged use of the rigid bronchoscope is required, while increasing the patient safety, enhancing the pulmonologist performance and maintaining cost-effectiveness. In addition, if the hands of the pulmonologist are free, other ablative devices can be used comfortably obviating the need for an assistant.

Difficult airway leading to carbon dioxide narcosis in a case of fixed cervical spine

Inability to secure the airway of a patient after induction of anaesthesia may lead to serious consequences including permanent brain damage and even death. Hypoxia is quite common in difficult intubations especially when it is difficult to ventilate the patient. However, carbon dioxide retention severe enough to cause carbon dioxide narcosis and delayed recovery is a rare occurrence. Here, we report a case of a craniovertebral junction anomaly where inadequate ventilation after induction of anaesthesia resulted in carbon dioxide narcosis and delayed awakening. A 54-year-old, American Society of Anesthesiologists II female patient weighing 70 kg with a diagnosis of craniovertebral junction was scheduled for implant removal for dislodged occipital screw. Fibreoptic intubation was attempted after induction of anaesthesia and muscle paralysis. Even after multiple attempts, intubation could not be done and ventilation by face mask became difficult. Though oxygen saturation could be maintained with the insertion of a laryngeal mask airway (LMA), ventilation was not adequate. The patient remained unresponsive long after discontinuation of anaesthetic agent and reversal of muscle paralysis. Subsequent blood gas analysis showed severe carbon dioxide retention and respiratory acidosis. Patient was given assist control mechanical ventilation through LMA. LMA was removed after improvement in sensorium and the blood gas picture.

Cautious use and optimal dose of morphine for relieving malignant pain in a complex patient with multiple comorbidities.

Oral morphine remains the drug of choice for the management of severe pain due to cancer as per WHO ladder of analgesia. Providing adequate pain relief in palliative care settings for pain due to cancer is challenging. Options become limited in cases of associated systemic comorbidities such as renal dysfunction, hypoproteinaemia, anaemia. Patients with renal dysfunction and other comorbidities may develop drug overdose due to abnormal pharmacokinetics. Renal dysfunction affects the pharmacokinetics of morphine by altering its absorption, metabolism and clearance. Plasma albumin also influences drug availability, its plasma distribution and thus available free morphine for its clinical effect. Morphine should be used cautiously for the treatment of pain in patients with renal failure, hypoproteinaemia, hyperbilirubinaemia and anaemia. In such patients, alternate opiates like fentanyl, hydromorphone, or oxycodone may be used as these drugs are not significantly excreted by the kidneys.