Shaji Mathew

Evaluation of effect of entropy monitoring on isoflurane consumption and recovery from anesthesia

Background and Aims: Entropy monitoring entails measurement of the effect of anesthetic on its target organ rather than merely the concentration of anesthetic in the brain (indicated by alveolar concentration based on which minimum alveolar concentration [MAC] is displayed). We proposed this prospective randomised study to evaluate the effect of entropy monitoring on isoflurane consumption and anesthesia recovery period. Material and Methods: Sixty patients undergoing total abdominal hysterectomy under general anesthesia using an endotracheal tube were enrolled in either clinical practice (CP) or entropy (E) group. In group CP, isoflurane was titrated as per clinical parameters and MAC values, while in Group E, it was titrated to entropy values between 40 and 60. Data including demographics, vital parameters, alveolar isoflurane concentration, MAC values, entropy values, and recovery profile were recorded in both groups. Results: Demographic data and duration of surgery were comparable. Time to eye opening on command and time to extubation (mean ± standard deviation) were significantly shorter, in Group E (6.6 ± 3.66 and 7.27 ± 4.059 min) as compared to Group CP (9.77 ± 5.88 and 11.63 ± 6.90 min), respectively. Mean isoflurane consumption (ml/h) was 10.81 ± 2.08 in Group E and 11.45 ± 2.24 in Group CP and was not significantly different between the groups. Time to readiness to recovery room discharge and postanesthesia recovery scores were also same in both groups. Conclusion: Use of entropy monitoring does not change the amount of isoflurane consumed during maintenance of anesthesia or result in clinically significant faster recovery.

Radiographic mislead: apparent arterial placement of subclavian central venous catheter due to mediastinal shift

Optimal placement of central venous catheters (CVC) is essential for accurate monitoring of central venous pressure (CVP) in major surgeries and ensuring long-term use of the catheter for managing the critically ill patient. Accidental subclavian artery catheterization is one of the most serious complications of the procedure. Radiography is commonly used to ensure optimal placement of CVC tip and rule out subclavian artery catheterization in the absence of Doppler ultrasound and a pressure transducer. We present a case of a haemodynamically unstable and hypoxaemic patient with mediastinal shift, in which the anaesthesiologist was in a dilemma about the arterial placement of the right subclavian CVC. The CVC crossing the midline due to mediastinal shift gave the false impression of it being placed in subclavian artery rather than the vein. Subsequently, it was proved to be correctly placed in the subclavian vein.

Airway management in Escobar syndrome: A formidable challenge

Escobar syndrome is a rare autosomal recessive disorder characterized by flexion joint and digit contractures, skin webbing, cleft palate, deformity of spine and cervical spine fusion. Associated difficult airway is mainly due to micrognathia, retrognathia, webbing of neck and limitation of the mouth opening and neck extension. We report a case of a 1 year old child with Escobar syndrome posted for bilateral hamstrings to quadriceps transfer. The child had adequate mouth opening with no evidence of cervical spine fusion, yet we faced difficulty in intubation which was ultimately overcome by securing a proseal laryngeal mask airway (PLMA) and then by intubating with an endotracheal tube railroaded over a paediatric fibreoptic bronchoscope passed through the lumen of a PLMA.

A prospective observational study of the outcome of central venous catheterization in 100 patients

Context: To Study the outcome following central vein catheterization in patients receiving chemotherapy. Aims: To Study the outcome of central venous catheterization in terms of difficulty during insertion, duration, incidence of infections and other complications and reasons for removal. Settings and Designs: Prospective observational study conducted in 100 patients attending to Gujarat Cancer and Research Institute. Materials and Methods: Both onco-medical and onco-surgical patients who required insertion of central venous catheters were enrolled after ethical approval from June 2008 to November 2010. The study comprised 100 patients. Statistical Analysis Used: Mean and percentage. Results: Mean duration of the indwelling catheter was 109 days for Hickman catheter, 39 days for cavafix and 59 days for certofix. Difficulty in insertion and arrhythmias were common complications. There were no incidences of major life threatening complications. Catheter related infection was 30%. The commonest reason for catheter removal was treatment completion 72%. The next frequent cause was catheter infection 14% and patient death 6%. Conclusions: Even though central venous catheterization is associated with acceptable complications, they serve a useful aid in management of patients on chemotherapy.

Prospective comparative randomized controlled study to determine the optimal priming dose of atracurium

Introduction: The advantages of the use of muscle relaxants in the current practice of balanced anesthesia are well documented. Most often, nondepolarizing muscle relaxants (NDMR) with minimal side effects are used to serve the purpose. Atracurium is a commonly used NDMR in day-to-day anesthetic practice, although it is not desirable for rapid sequence induction and intubation due to its late onset of action. To overcome this problem priming principle was introduced. Aim: This study aims to determine optimal priming dose of atracurium to speed up the onset of action. Patients and Methods: In this prospective randomized controlled study, 90 patients were allocated into one of the three groups by a computer-generated table of random numbers, i.e., Group A, B, and C. Total dose of atracurium used in all patients was 0.5 mg/kg body weight, including the priming dose. Each group received different priming doses of atracurium as follows: Group A received 0.05 mg/kg body weight, Group B received 0.025 mg/kg body weight, whereas Group C (control) received saline as priming dose. Results: Patients were comparable with respect to demographic data. The mean duration in seconds for train-of-four (TOF) count to reach zero were 147 s, 193, and 218 s in Group A, B, and C, respectively, with statistically significant P values. Of 60 patients who were administered atracurium as priming drug, two patient had ptosis at the end of 3 min after priming with 0.05 mg/kg body weight, with no other side effects. Conclusions: Priming principle employing atracurium reduces the time required for TOF count to reach zero by approximately 71 s while using 0.05 mg/kg body weight and by around 25 s while employing 0.025 mg/kg body weight, with clinically insignificant incidence of adverse effects.

Comparison of polyvinyl chloride, curved reinforced, and straight reinforced endotracheal tubes for tracheal intubation through Airtraq™ laryngoscope in anesthetized patients

Background and Aims: The Airtraq™ video laryngoscope facilitates tracheal intubations in patients with difficult airway or cervical spine immobilization. However, curved reinforced tracheal tube and straight reinforced tracheal tubes are useful where neck of the patient is likely to be moved or flexed or if patient is in prone position, wherein nonreinforced endotracheal tube (ETT) might get kinked and/or compressed. We compared intubation success rate of curved and straight reinforced tracheal tubes with polyvinyl chloride (PVC) tracheal tube using Airtaq™ laryngoscope in paralyzed and anesthetized patients. Material and Methods: Totally, 120 patients underwent random allocation to one of the three groups using computer-generated randomization table. Patients were intubated with appropriate size and type of ETT using Airtraq™ after obtaining optimal glottis view. Experienced anesthesiologist performed endotracheal intubation and unblinded observer noted down success and ease of intubation. Results: Patients intubated with PVC tube (100%) had higher rates of successful intubation and shorter intubation time (4 s), in comparison to intubation with curved reinforced (92.5%) and straight reinforced tubes (SRTs) (85%) using Airtraq™ laryngoscope (AL). However, there was no statistical difference in the incidence of airway trauma among all the three groups. Conclusions: PVC tracheal tube is significantly superior to both curved and SRTs for intubation using AL.

Anesthetic management of a child with corrected transposition of great vessels undergoing non-cardiac surgery.

We describe the successful anesthetic management of a 14-year-old child, a corrected case of transposition of great vessels in childhood and presently with residual atrial septal defect, peripheral cyanosis, and neurological deficit of lower limb presented for tendoachillis lengthening.

Safe intubation in Morquio-Brailsford syndrome: A challenge for the anesthesiologist.

Morquio-Brailsford syndrome is a type of mucopolysaccharidoses. It is a rare disease with features of short stature, atlantoaxial instability with risk of cord damage, odontoid hypoplasia, pectus carinatum, spine deformities, hepatomegaly, and restrictive lung disease. Neck movements during intubation are associated with the risk of quadriparesis due to cervical instability. This, along with the distortion of the airway anatomy due to deposition of mucopolysaccharides makes airway management arduous. We present our experience in management of difficult airway in a 3-year-old girl with Morquio-Brailsford syndrome posted for magnetic resonance imaging and computerized tomography scan of a suspected unstable cervical spine. As utmost sagacity during intubation is required, the child was intubated inside operation theatre in the presence of experienced anesthesiologists and then shifted to the peripheral location. Intubation was done with an endotracheal tube railroaded over a pediatric fibreoptic bronchoscope passed through the lumen of a classic laryngeal mask airway, keeping head in neutral position.

Intraoperative management of atrial fibrillation in a patient with restrictive cardiomyopathy

A 65-year-old patient with renal amyloidosis presented for Trans Urethral Resection of Prostate (TURP). There were no symptoms pertaining to the cardiorespiratory system. Preoperative investigations showed only secondary cardiomyopathy. Intraoperatively the patient developed atrial fibrillation with hypotension which was successfully managed by cardioversion.

Mean versus median in tables and figures.

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