Samarjit Dey

Straight versus flex back: Does it matter in spinal anaesthesia?

Purpose: It is sometimes difficult for our patients to acquire recommended flexion of their back to perform subarachnoid block upon them. The aim of this study was to find out the degree of procedural success and patient preference when subarachnoid blocks were performed on patients with suboptimal flexion of the back. Methods: Subarachnoid blocks were performed on 160 adult patients from both sexes without any spinal deformity. Procedures were performed with patients in the lateral or seated position with the back either straight or flexed. This approach divided the study population into 4 equal groups: Lateral with back straight (LS) or flexed (LF) and seated with back straight (SS) or flexed (SF). The primary endpoint was correct needle placement. Numbers of attempts, needle redirections and patients’ preferred posture were determined to compare the outcome in different groups. Results: For both positions, the overall success rates were 95% and 100% in patients who had straight or flexed back, respectively (P=0.81). In the lateral position, significantly more patients of the LF group (40) than those of the LS group (32) had successful placement of spinal needle at first attempt (P=0.03). Altogether, 34 and 21 patients in the SS and SF groups, respectively, required cephalad redirections of the needle (P=0.003). Most patients preferred the straight back position (69.7–88%). Conclusion: With a higher preference by patients for the straight back posture, the overall success rate of correct spinal needle placement was comparable among the groups who had their back placed in a straight or in a flexed posture for subarachnoid block.

Water-cooled radiofrequency neuroablation for sacroiliac joint dysfunctional pain

Sacroiliac (SI) joint dysfunction is a common source of chronic low-back pain. Recent evidences from different parts of the world suggest that cooled radiofrequency (RF) neuroablation of sacral nerves supplying SI joints has superior pain alleviating properties than available existing treatment options for SI joint dysfunctional pain. A 35-year-old male had intractable bilateral SI joint pain (numeric rating scale [NRS] – 9/10) with poor treatment response to intra-articular steroid therapy. Bilateral water cooled = RF was applied for neuroablation of nerves supplying both SI joints. Postprocedure pain intensity was 5/10 and after 7 days it was 2/10. On 18th-month follow-up, he is pain free except for mild pain (NRS 2/10) on occasional extreme twisting of the back. This case attempts to highlight that sacral neuroablation based on cooled RF technique can be a long lasting remedial option for chronic SI joint pain unresponsive to conventional treatment.

Diagnostic accuracy of delirium assessment methods in critical care patients

Purpose: Delirium is a disorder of decreased ability to focus, sustain or shift attention, change in cognition and or perception. The main objective was to evaluate the diagnostic accuracy of Confusion Assessment Method for the ICU (CAM‐ICU) and Intensive Care Delirium Screening Checklist (ICDSC) among the nursing and medical staff in a multidisciplinary ICU. Methods and material: Three hundred ten verbally communicating and non‐communicating patients (mean age in years 47.9, standard deviation [SD] 14.5, mean Acute Physiology and Chronic Health Evaluation II score 13.8, SD 6.4) were assessed by a psychiatrist, nurse and intensivist for delirium. Inter‐rater agreement was measured by Cohens kappa coefficient. Sensitivity, specificity, predictive values, likelihood ratios and diagnostic odds ratio (DOR) were calculated. Results: CAM‐ICU showed higher sensitivity and DOR (84%, 86.1) compared to ICDSC (78%, 36.9). ICDSC had specificity and positive predictive value (94.5%, 92%) equal to that of CAM‐ICU. For both the assessment methods (CAM‐ICU and ICDSC), DORs for intensivists (120.5, 53.0) were relatively higher than nurses (67.0, 27.0). Conclusions: In our mixed ICU population, CAM‐ICU remained more sensitive than ICDSC. Though sensitivity and DOR were higher for medical staff, other diagnostic parameters were similar for both medical and nursing staff. HighlightsCAM‐ICU was found to be a better delirium assessment tool than the ICDSC.The results of the assessment tools whether performed by the intensivists or the nurses were comparable.Sepsis, benzodiazepines, mechanical ventilation, and APACHE II >16 were the risk factors to develop delirium.

Adjustable Horseshoe Headrest as a Positioning Adjunct in Airway Management for a Giant Occipital Encephalocele

CASE REPORT Adjustable Horseshoe Headrest as a Positioning Adjunct in Airway Management for a Giant Occipital Encephalocele Habib Muhammad Reazaul Karim, Muhammad Yunus, Angkita Barman, Sonai Datta Kakati and Samarjit Dey Andaman and Nicobar Islands Institute of Medical Sciences & GB Pant Hospital, Port Blair and NEIGRIHMS, Shillong, India North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, India

Rami Communicans Block Prior to Transforaminal Endoscopic Discectomy relieves Procedure Pain Significantly and adds Safety: A Case–control Study

Background: The ability to isolate and visualize the “pain” generators in the foramen and treat persistent pain by visualizing inflammation and compression of nerves serves as the basis for transforaminal endoscopic (TFE) surgery.It provides a least invasive basic access to the disc. One of the important steps is the insertion of dilator and working sleeve followed by introduction of endoscope. Often this step is carried out with the help of a hammer, which is agonizing for the patients undergoing surgery. This study aims at analyzing the efficacy of the rami communicans nerve block in reducing the intraoperative pain in patients undergoing TFE discectomy. Materials and methods: A total of 48 patients undergoing TFE discectomy were assigned into two groups. Group I (case, n = 27) received rami communicans block prior to endoscopic discectomy and for group II (control, n = 21), no rami communicans block was given. Under all aseptic precautions, the rami communicans block was given to group I patients after identification of corresponding level. After proper placement of block, lumbar TFE discectomy was performed using the “insideout” approach. Pain was assessed using numerical rating scale (NRS) at different time intervals. Statistical analysis was carried out using independent Student’s t-test, chi-squared test, and Mann–Whitney U test. Results: While comparing NRS, group I showed significantly lower NRS when compared with group II and it was highly significant (p-value < 0.0001). The need for rescue analgesia was also compared and this difference was also found to be highly significant (p-value < 0.0001). Conclusion: The rami communicans block is highly effective in reducing the intraoperative pain in patients undergoing TFE discectomy and thus, reduces the total dose of anesthetics and analgesics intraoperatively.

How useful is extravascular lung water measurement in managing lung injury in intensive care unit

Context: The primary goal of septic shock management is optimization of organ perfusion, often at the risk of overloading the interstitium and causing pulmonary edema. The conventionally used end points of resuscitation do not generally include volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). Aims: This study aimed to assess the prognostic value of EVLWI and PVPI by calculating their correlation with the severity of lung injury. Settings and Design: This prospective observational study included twenty mechanically ventilated critically ill patients with Acute Physiology and Chronic Health Evaluation score (APACHE II) >20. Subjects and Methods: EVLWI and PVPI were measured using transpulmonary thermodilution, and simultaneously, PaO2:FiO2 ratio, alveolar-arterial gradient of oxygen (AaDO2), and chest radiograph scores from two radiologists were obtained. Statistical Analysis: The correlation of EVLWI and PVPI with chest radiograph scores, PaO2:FiO2 ratio, and AaDO2 were calculated. The inter-observer agreement between the two radiologists was tested using kappa test. Results: EVLWI and PVPI correlated modestly with PaO2:FiO2 (r = −0.32, P = 0.0004; r = −0.39, P = 0.0001). There was a better correlation of EVLWI and PVPI with PaO2:FiO2 ratio (r = −0.71, P < 0.0001; r = −0.58, P = 0.0001) in the acute respiratory distress syndrome (ARDS) subgroup. The EVLWI values correlated significantly with corresponding chest radiograph scores (r = 0.71, P < 0.0001 for observer 1 and r = 0.68, P < 0.0001 for observer 2). Conclusions: EVLWI and PVPI may have a prognostic significance in the assessment of lung injury in septic shock patients with ARDS. Further research is required to reveal the usefulness of EVLWI as an end point of fluid resuscitation in the management of septic shock with ARDS.

Continuous axillary brachial plexus block for remission of sub-acute herpetic neuralgia

foreign bodies from airway is traditionally done with rigid bronchoscope.However, this was not feasible in our case due to the maxillofacial injury. Use of fibreoptic bronchoscope for the purpose is challenging, as the extraction beyond endotracheal tube may be limited due to size of the foreign body.[2] Kim et al. suggested tracheostomy as an alternative to facilitate secured airway and shorter distance for extracting foreign body associated with maxillofacial trauma.[3]

Successful tracheal stent placement for central airway obstruction using dexmedetomidine and regional airway anesthesia

1. Calabria M, Zamboli P, D’Amelio A, Granata A, Di Lullo L, Floccari F, et al. Gruppo di Studio di Ecografia Renale della Societa’ Italiana di Nefrologia (SIN-GSER). Use of ECG-EC in the positioning of central venous catheters. G Ital Nefrol 2012;29:49-57. 2. Peres PW. Positioning central venous catheters — A prospective survey. Anaesth Intensive Care 1990;18:536-9. 3. Jain M, Rastogi B, Singh VP, Gupta K. Central venous catheter placement: An alternative of Certodyn® (Universal Adapter). Anesthesia: Essays and Researches 2011;5:242-3. 4. Tibtech innovations, 2011. Available from: http://www.tibtech. com/conductivity.php [Last acces on 2013 Jun 01].

Intra-operative change of gastric pH during laparotomic cholecystectomy under general anaesthesia: A prospective case-control study.

Background: Gastric decompression by suctioning often shows greenish/greenish-yellow-coloured gastric aspirates following cholecystectomy under general anaesthesia (GA). Possible intraoperative regurgitation of duodenal contents into stomach because of surgical manipulation may be the reason for such alteration in colour of the gastric secretions. Aim: We conducted this study to determine whether there were any pH changes of gastric secretions during laparotomic cholecystectomy operation to confirm our hypothesis of regurgitation of duodenal contents into the stomach. Settings and Designs: Prospective observational controlled study in the Department of Anaesthesiology and Critical Care in a tertiary care university teaching hospital. Methods: Fifty adult ASA I and II patients scheduled for open cholecystectomy operation under GA were included in the study group and another 50 non-abdominal surgical patients without any gall bladder disease were taken as controls. Three to five milliliters of gastric secretions were aspirated just after intubation and also before reversal of residual neuromuscular blockade for analysis of pH. Statistical Analysis: Analysis of variance test and Chi-square test with Fishers exact correction were used for statistical analysis. Differences were significant when the P value was <0.05. Results: Post-operative values of pH in the study group were significantly higher than their pre-operative values (2.40±1.10 vs. 4.04±1.6, P≤0.001). Forty-nine patients (98%) in the study group had altered coloured post-operative gastric aspirations, while no patient in the control group had such changes (P<0.001). Conclusions: A significant change in gastric pH takes place during laparotomic cholecystectomy due to reflux of duodenal content into the stomach.