Suman Arora

Comparison of posterior and subcostal approaches to ultrasound-guided transverse abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy

STUDY OBJECTIVE To evaluate the effectiveness of subcostal TAP block and to compare its efficacy with that of posterior TAP block in decreasing postoperative pain in patients undergoing laparoscopic cholecystectomy during general anesthesia. DESIGN Prospective, randomized, double-blind study. SETTING Academic medical center. PATIENTS 60 adult, ASA physical status 1 and 2 patients of both genders, aged 18-60 years, scheduled for elective laparoscopic cholecystectomy. INTERVENTIONS Patients were randomized to three groups of 20 patients each. Group 1 patients received standard general anesthesia (control group); Group 2 patients received an ultrasound-guided posterior TAP block using 15 mL of 0.375% ropivacaine on each side; and Group 3 patients underwent a subcostal TAP block with 15 mL of 0.375% ropivacaine on each side. MEASUREMENTS The presence and severity of pain during rest and movement, as well as nausea or vomiting and sedation, were assessed in all patients postoperatively on PACU admission, then at 2, 4, 6, 8, 12, and 24-hour intervals. Patients with a visual analog score (VAS) greater than 4, or those requesting analgesic were given intravenous tramadol 2 mg/kg as an initial dose; subsequent 1 mg/kg doses of tramadol, if needed, were given. RESULTS Patients who received a subcostal TAP block had significantly lower pain scores at rest and on movement than the control group at all times postoperatively. Although, in the initial postoperative measurement times, the subcostal and posterior TAP groups had comparable pain scores, after 4 hours these scores were significantly lower in patients who had received the subcostal TAP block. CONCLUSION For incisions mainly involving the supra-umbilical region, subcostal TAP block may be a better alternative than the posterior approach for providing postoperative analgesia.

A comparison of three vasopressors for tight control of maternal blood pressure during cesarean section under spinal anesthesia: Effect on maternal and fetal outcome

Purpose: Maintaining systolic blood pressure (SBP) at 100% of baseline is best for fetal and maternal outcome. We hypothesized that irrespective of the vasopressor used, maintaining SBP at 100% of baseline with phenylephrine (P), metaraminol (M), or ephedrine (E) will produce the best fetal pH after cesarean section (LSCS) under subarachnoid block (SAB). Materials and Methods: Ninety ASA 1 women scheduled for elective LSCS were randomly allocated to receive P, M, or E. SAB was established with patient in left lateral position using 2.5 cc of 0.5% hyperbaric bupivacaine. Immediately following SAB, patients received a bolus of the study drug (E = 5 mg, M = 0.5 mg, P = 30 mcg) followed by infusion (E = 2.5 mg/min, M = 0.25 mg/min, P = 15 mcg/min) to maintain SBP at 100% baseline. Umbilical blood gases, maternal hemodynamic parameters, and complications were recorded. Results: The umbilical pH was comparable in all the three groups (P > 0.05). The mean SBP from spinal block until delivery was similar over time for all the three groups. The incidence of reactive hypertension was more in group M (P < 0.05) than in group E and group P. Total drug consumption to meet target blood pressure till delivery was 39.3 ± 14.6 mg in group E, 1.7 ± 0.9 mg in group M, and 283.6 ± 99.8 mcg in group P. The incidence of nausea and vomiting was comparable in the three groups. Conclusion: All the three vasopressors were equally effective in maintaining maternal blood pressure as well as umbilical pH during spinal anesthesia for cesarean section without any detrimental effects on fetal and maternal outcome.

An evaluation of the retromolar space for oral tracheal tube placement for maxillofacial surgery in children.

BACKGROUND: The eruption of the first and second permanent molar teeth may influence the size of the retromolar space. In this study we evaluated the adequacy of the retromolar space for retromolar intubation and any effect of eruption of the first and second permanent molar teeth on this space in children. METHODS: Children 3–15 yr of age, undergoing surgery other than facial surgery were included for evaluation of the retromolar space. After standard oral tracheal intubation, the endotracheal tube was shifted to the retromolar space and the mandible was slowly closed to achieve centric occlusion. At the same time, any increase in airway resistance or decrease in oxygen saturation was noted. In the second part of the study, the feasibility of retromolar intubation in pediatric patients undergoing maxillofacial surgery with intraoperative maxillomandibular fixation was assessed. RESULTS: There was enough space for endotracheal tube placement in the retromolar region. The eruption of the first and second permanent molar teeth did not affect intubation. It was possible to achieve centric occlusion in 79 of 80 children with the endotracheal tube positioned in the retromolar space. Retromolar intubation was successfully accomplished in six pediatric patients undergoing maxillomandibular fixation and maxillofacial surgery. CONCLUSION: The retromolar space can be safely used for intubation in children when intraoperative maxillomandibular fixation, and simultaneous access to the nose and oral cavity are needed.

A comparison of McCoy, TruView, and Macintosh laryngoscopes for tracheal intubation in patients with immobilized cervical spine

Background: Cervical spine immobilization results in a poor laryngeal view on direct laryngoscopy leading to difficulty in intubation. This randomized prospective study was designed to compare the laryngeal view and ease of intubation with the Macintosh, McCoy, and TruView laryngoscopes in patients with immobilized cervical spine. Materials and Methods: 60 adult patients of ASA grade I-II with immobilized cervical spine undergoing elective cervical spine surgery were enrolled. Anesthesia was induced with propofol, fentanyl, and vecuronium and maintained with isoflurane and nitrous oxide in oxygen. The patients were randomly allocated into three groups to achieve tracheal intubation with Macintosh, McCoy, or TruView laryngoscopes. When the best possible view of the glottis was obtained, the Cormack-Lehane laryngoscopy grade and the percentage of glottic opening (POGO) score were assessed. Other measurements included the intubation time, the intubation difficulty score, and the intubation success rate. Hemodynamic parameters and any airway complications were also recorded. Results: TruView reduced the intubation difficulty score, improved the Cormack and Lehane glottic view, and the POGO score compared with the McCoy and Macintosh laryngoscopes. The first attempt intubation success rate was also high in the TruView laryngoscope group. However, there were no differences in the time required for successful intubation and the overall success rates between the devices tested. No dental injury or hypoxia occurred with either device. Conclusion: The use of a TruView laryngoscope resulted in better glottis visualization, easier tracheal intubation, and higher first attempt success rate as compared to Macintosh and McCoy laryngoscopes in immobilized cervical spine patients.

A comparison of Truview EVO2 laryngoscope with Macintosh laryngoscope in routine airway management: A randomized crossover clinical trial.

Background: The Truview EVO2 blade facilitates the view of vocal cords by indirect laryngoscopy and does not require the proper alignment of the oral, pharyngeal and tracheal axes as with the Macintosh blade. Methods: In a crossover fashion, we prospectively compared the view obtained at laryngoscopy with Truview EVO2 and the Macintosh blade in 110 adult patients of either sex between the age of 18 and 60 years, who were scheduled to undergo general anesthesia with endotracheal intubation. The patients were intubated with the second laryngoscope. The preoperative airway variables, laryngoscopic view, difficulty of intubation scale (IDS) score, duration of intubation, and degree of difficulty percentage of glottic opening (POGO score) of use with each laryngoscope were compared. Results: The IDS score was low and comparable between the two laryngoscopes. The laryngeal view was easy; Modified Cormack Lehane (MCL) grade 2a or less in 98.14% of the cases with the Truview laryngoscope compared to 78.7% of the cases with the Macintosh laryngoscope. Nineteen patients of MCL grade 3, one patient of grade 2b, and seven patients of grade 2a view with the Macintosh laryngoscope had MCL grade 1 view with the Truview laryngoscope. The duration of intubation was comparable between Truview and Macintosh laryngoscopes (12.1±3.8 s vs. 10.9±2.1 s). Conclusion: Truview laryngoscope performed comparably to Macintosh laryngoscope in patients with normal airway; however, the Truview laryngoscope may be a better option in difficult airway situations when the Macintosh blade fails to show the glottic opening.

Intraoperative cardiac arrest because of oculocardiac reflex and subsequent pulmonary edema in a patient with extraocular cysticercosis.

SIR—Oculocardiac reflex (OCR) results from traction on extraocular muscles, ocular manipulation or eye trauma. A number of cardiac arrests from OCR have been reported in the literature (1–3). However, to date pulmonary edema subsequent to cardiac arrest from OCR has not been reported. We report a case of intraoperative cardiac arrest because of OCR and subsequent pulmonary edema during excision of extraocular cysticercosis in a 13 year boy, which was successfully managed without sequelae. 13-year-old boy (50 kg, 165 cm) with a diagnosis of cysticercosis of the superior rectus and levator palpabrae superioris, was scheduled for surgical excision. Preoperatively the patient’s physical examination, blood and biochemistry were normal. General anesthesia was administered using morphine, thiopentone, O2, N2O, halothane and vecuronium with tracheal intubation. He remained hemodynamically stable throughout the surgery [SpO2 99%, systolic blood pressure 120–130 mmHg, diastolic blood pressure 70–80 mmHg, heart rate 80–90 bÆmin, endtidal CO2 4.3–4.6 kPa (33–35 mmHg), endtidal halothane concentration of 1.2%] and had received 0.81 of fluid over 1 h. After removal of the cyst, traction was exerted by the surgeon on the superior rectus muscle. The heart rate dropped to 30 bÆmin followed by asystole. Surgery was stopped and 0.6 mg i.v. atropine was administered. Ventilation with 100% O2 and closed cardiac massage was instituted. Normal sinus rhythm with heart rate of 110 bÆmin appeared after approximately 45 s. Copious pink frothy secretions were noted in the tracheal tube. Blood pressure was recorded as 70/40 mmHg. Dopamine infusion was started at 10 lgÆkgÆmin and an arterial cannula inserted. Arterial blood gas analysis revealed pH of 7.38, PaO2 38 kPa (296 mmHg), PaCO2 4.7 kPa (36 mmHg), HCO3 26 mmlolÆl , base excess )2 and oxygen saturation 99%. Blood pressure increased to 130/ 70 mmHg in 10 min. Morphine 6 mg and furosemide 40 mg were administered i.v. to treat pulmonary edema. Central venous cannulation and urinary catheterization were performed. Central venous pressure was 12 mmHg and urine output was 600 ml. Surgery was completed and patient was transferred to the intensive care unit and mechanically ventilated. Postoperative chest X-ray showed diffuse infiltrates suggestive of pulmonary edema. Plasma protein concentration and serum osmolarity were 6.6 gÆdl and 290 mOsmÆl. Echocardiography performed 4 h postarrest was normal. Pulmonary edema resolved after 12 h. The trachea was extubated after 16 h. He recovered without any sequelae and was discharged home on 3rd postoperative day. Fatal cardiac arrest because of OCR is uncommon and only two cases of death have been reported to date (2,3). In a death reported by Mallinson and Coombes, cerebral ischemia following repeated episodes of ventricular fibrillation from OCR was given as a cause (2). In another death, occult Epstein–Barr virus myocarditis was detected postoperatively (3). However, pulmonary edema, following cardiac arrest because of OCR, has never been previously reported. We believe that there was a period of acute left ventricular failure because of myocardial stunning after the arrest leading to hypotension and pulmonary edema. Myocardial stunning is the mechanical dysfunction that persists after reperfusion despite the absence of irreversible damage and restoration of normal or near normal coronary flow (4). Dysfunction is related to impaired contraction in the setting of calcium overload and oxidative stress occurring during reperfusion (5). As the stunned myocardium retains considerable inotropic reserve, it rapidly responds to inotropic support (4), as happened in our case following dopamine infusion. Recovery of systolic function after short ischemic periods lasting for 1–2 min is very rapid and any deficit, if present, is too small to be detected by a clinically applicable method (6). It is perhaps because of this that no impairment of myocardial systolic/diastolic performance was found on echocardiography after 4 h. Halothane causes depression of heart rate and contractile function in the normal myocardium and is the most arrhythmogenic of all the available anesthetic agents (7) Morphine has a central vagal effect on the heart (8). It can be speculated that the halothane/opioid technique we used made the patient more prone to bradycardia produced by OCR. Other factors leading to pulmonary edema secondary to CPR have been attributed to hypoxia, acidosis, overhydration, administration and release of catecholamine and external cardiac massage (9) Arterial blood gas analysis and central venous pressure monitoring performed immediately after resuscitation showed normal values. During sternal compression the pressures are almost identical in the four chambers of the heart as well as great vessels in the thorax. Hence if the pulmonary circulation is loaded, with elevated pulmonary capillary hydrostatic pressure, interruption of pulmonary capillary integrity can result (10). Although we did not insert a pulmonary artery catheter in our patient so pulmonary artery wedge pressure could not be recorded, cardiac massage lasted for a very short duration (approximately 30 s) ruling out sternal compression as a cause of pulmonary edema. We conclude that usually following transient cardiac arrests after OCR, patients are resuscitated and extubated uneventfully in the operating room. However, occasion-

Adult fiberoptic bronchoscope‐assisted intubation in children with temporomandibular joint ankylosis

logic modalities to manage hypertensive and tachycardic changes. We do agree with the general recommendation, however, that RFA of metastases from catecholamine-producing tumors requires antihypertensive pretreatment if the patient has symptomatic or laboratory-proven catecholamine production or secretion, or if the lesion is a biopsyproven catecholamine-producing tumor, or if the patient has demonstrated catecholamine synthesis by MIBG or FDA uptake. RFA of lesions of or near the adrenal gland may result in catecholamine release from thermal damage to the adrenals and should be covered by pretreatment. L I S B E T H P A P P A S C H R I S T I A N S E E F E L D E R Department of Anesthesiology Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, MA, USA (email: christian.seefelder@childrens.harvard.edu)

Ultrasound-guided single- vs double-level thoracic paravertebral block for postoperative analgesia in total mastectomy with axillary clearance☆☆☆

OBJECTIVES Thoracic paravertebral block (TPVB) for breast surgery reduces acute and chronic postoperative pain. Using ultrasound for administering the block makes it easier, with its administration at multiple levels decreasing the number of unblocked segments. We conducted this study to evaluate the efficacy and safety of single- vs double-level ultrasound-guided TPVB in patients undergoing total mastectomy with axillary clearance under general anesthesia. DESIGN This is a prospective, randomized study. SETTING Recovery room and operation theater. PATIENTS Sixty ASA I and II patients, aged 18 to 60 years, who were scheduled to undergo total mastectomy with axillary clearance under general anesthesia were enrolled in the study. INTERVENTIONS Patients received either single- (group S) or double-level (group D) ultrasound-guided TPVB at T4 or at T2 and T5 levels, respectively, using 0.3 mL/kg of 0.5% ropivacaine. MEASUREMENTS Primary outcome measure was 24-hour analgesic consumption, and secondary outcomes included number of segments blocked, postoperative pain scores, time to first request for rescue analgesic, and any side effects. RESULTS The mean total amount of rescue analgesic given in group S was 175.3 ± 70 mg and in group D was 115.7 ± 48 mg (P = .002). Median number of segments showing less sensation to pinprick was 3 in group S and 4 in group D (P < .001). The mean time to first request for rescue analgesic was 533 ± 124 minutes in group S and was 611 ± 214 minutes in group D (P = .118). CONCLUSION Patients receiving double-level TPVB had significantly less 24-hour analgesic consumption in the postoperative period than those in the single-level TPVB group. This could be due to decreased pain sensation to pinprick in significantly greater number of segments in the double-level TPVB group.

Benign swelling of submandibular glands under general anesthesia “anesthesia mumps”

Benign, noninfectious, acute, and transient swelling of salivary glands under general anesthesia is referred to as anesthesia mumps [1]. Although a rare clinical entity, it usually develops intraoperatively or during first few postoperative hours. Literature search shows its association with varied types of surgeries such as endoscopy, rigid bronchoscopy, and spine surgeries in prone position. It usually resolves spontaneously without many complications within 72 hours. A 5-year-old, 15-kg child was posted for esophagoscopy and endoscopic dilatation for esophageal stricture which developed following a tracheoesophageal fistula repair at day 1 of birth. Preoperative investigations were unremarkable. Child was induced with sevoflurane 6% to 8% in 50% oxygen and nitrous oxide, succinylcholine was used for muscle relaxation, and airway was secured using 5.0-mm ID uncuffed endotracheal tube. Fentanyl 1.5 μg kg−1 was given for analgesia. When the head was extended for esophageal dilatation with Eder-Pueston dilators, we observed swelling in the submandibular region bilaterally (Fig. 1). Swelling had no crepitations on palpation and no induration, and temperature appeared normal. The procedure went uneventful. There was no associated cord or laryngeal edema, and swallowing and cough reflexes were intact so the child was extubated. The child was kept under observation in the postanesthesia care unit, where parents of the child were reassured. One hour later, we found that there was complete resolution of the swelling (Fig. 2). This entity affects parotid glands more than submandibular glands. Etiology remains unclear but a number of mechanisms have been implicated including obstruction of salivary ducts due to head position (prone, sitting, neck rotation, or head extension), leading to retention of secretions by glandular ischemia by squeezing arterial or venous vessels and retrograde passage of air into glands. Another hypothesis is that inadequate plane of anesthesia during intubation leads to straining and coughing and hence causing increased intraoral pressures and overactive pharyngeal reflexes which stimulate copious

Laparoscopic nephrectomy in children for benign conditions: indications and outcome

Aim: To analyze the indications and outcome of laparoscopic nephrectomy for benign non-functioning kidneys in children. Materials and Methods: The data of all patients operated over a 10 year period was retrospectively analyzed. Results: There were 56 children, aged 4 months to 12 years with a male: female ratio of 2.3:1. The most common presentation in boys and girls was urinary tract infection (UTI) (61.5% and 47.05% respectively). Incontinence due to ectopic ureter was a close second in girls (41.17%). The most common underlying conditions were vesico-ureteric reflux (42.85%) and multicystic dysplastic kidney (23.2%). There were 6 nephrectomies, 4 heminephroureterectomies and the remaining nephroureterectomies. All children tolerated the surgery well. One patient underwent a concomitant cholecystectomy. The post-operative problems encountered were UTI (1), urine retention (1), pyonephrosis in the opposite kidney and development of contra-lateral reflux (1). All others had resolution of pre-operative symptoms with good cosmesis. Conclusions: As per available literature, this appears to be the largest Indian series of pediatric laparoscopic nephrectomies for benign non-functioning kidneys. Laparoscopic approach gives excellent results provided pre-operative investigations rule out other causes for the symptoms with which the patient presents. Often it is not the kidney but the dilated dysplastic ureter which is the seat of stasis and infection or pain and therefore should be completely removed.