Sachidanand Jee Bharti

Asystole during posterior fossa surgery: Report of two cases

Asystole during posterior fossa neurosurgical procedures is not uncommon. Various causes have been implicated, especially when surgical manipulation is carried out in the vicinity of the brain stem. The trigemino-cardiac reflex has been attributed as one of the causes. Here, we report two cases who suffered asystole during the resection of posterior fossa tumors. The vago-glossopharyngeal reflex and the direct stimulation of the brainstem were hypothesized as the causes of asytole. These episodes resolved spontaneously following withdrawal of the surgical stimulus emphasizing the importance of anticipation and vigilance during critical moments of tumor dissection during posterior fossa surgery.

Causes of tracheal re-intubation after craniotomy: A prospective study

Background: Re-intubation of neurosurgical patients after a successful tracheal extubation in the operating room is not uncommon. However, no prospective study has ever addressed this concern. This study was aimed at analyzing various risk factors of re-intubation and its effect on patient outcome. Methods: Patients aged between 18-60 yrs and of ASA physical status I and II undergoing elective craniotomies over a period of two yrs were included. A standard anesthetic technique using propofol, fentanyl, rocuronium, and isoflurane/sevoflurane was followed, in all these patients. ‘Re-intubation’ was defined as the necessity of tracheal intubation within 72 hrs of a planned extubation. Data were collected and analyzed employing standard statistical methods. Results: One thousand eight hundred and fifty patients underwent elective craniotomy, of which 920 were included in this study. A total of 45 (4.9%) patients required re-intubation. Mean anesthesia duration and time of re-intubation were 6.3±1.8 and 24.6±21.9 hrs, respectively. The causes of re-intubation were neurological deterioration (55.6%), respiratory distress (22.2%), unmanageable respiratory secretion (13.3%), and seizures (8.9%). The most common post-operative radiological (CT scan) finding was residual tumor and edema (68.9%). Seventy-three percent of the re-intubated patients had satisfactory post-operative cough-reflex. The ICU and hospital stay, and Glasgow outcome scale at discharge were not significantly affected by different causes of re-intubation. Conclusion: Neurological deterioration is the most common cause of re-intubation following elective craniotomies owing to residual tumor and surrounding edema. A satisfactory cough reflex may not prevent subsequent re-intubation in post-craniotomy patients.

Neurogenic pulmonary edema after rupture of intracranial aneurysm during endovascular coiling

Neurogenic pulmonary edema (NPE) is a well-known entity, occurs after acute severe insult to the central nervous system. It has been described in relation to different clinical scenario. However, NPE has rarely been mentioned after endovascular coiling of intracranial aneurysms. Here, we report the clinical course of a patient who developed NPE after aneurysmal rupture during endovascular surgery. There was significant cardiovascular instability possibly from stimulation of hypothalamus adjacent to the site of aneurysm. This case highlights the predisposition of minimally invasive procedures like endovascular coiling to life-threatening complications such as NPE.

Epidural Catheter Fixation and Care-A Novel Technique

A lot of emphasis is put on the technique of epidural insertion but however technique of catheter fixation is often neglected [2]. Ideally, the fixation method should be safe, non-invasive and cost-effective and maintain the sterility of the catheter. Correct catheter fixation goes a long way in preventing catheter migration and infection which ensures a safe epidural analgesia without complications [2].

Intrapleural migration of paravertebral catheter in spite of ultrasound guidance

The patient was positioned supine and the airway secured using a 35 Fr left-sided double lumen tube. An infusion of ropivacaine 0.25% was started via the PV catheter. The patient was positioned in left lateral decubitus position. The right lung was isolated and deflated, and thoracotomy was done. The epidural catheter was found lying in the thoracic cavity below the lung [Figure 1]. No further drug was given via the epidural catheter. Since the intercostal drain was already in place after thoracotomy, there was no need for any further radiological examinations to rule out pneumothorax. He was managed with intravenous morphine, paracetamol and diclofenac potassium in the postoperative (PO) period. The PO course was uneventful and was discharged on 7th PO day.

Embolisation of a large carotid body tumour: Anaesthetic implications

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