Swati Chhabra

Comparison of Effect of Epidural Bupivacaine, Epidural Bupivacaine Plus Fentanyl and Epidural Bupivacaine Plus Clonidine on Postoperative Analgesia after Hip Surgery

Background: Management of postoperative pain is one of the most challenging and gratifying domains of anaesthesia. Search for an ideal adjuvant for post operative epidural analgesia still continues. Methods: A total of 75 healthy patients of both sexes in age group 50-80 years belonging to ASA status I and II posted for elective hip surgeries were enrolled and randomly divided into three groups of 25 each - Group B, Group BF and Group BC All the patients in the three groups received 3.5 ml Bupivacaine heavy (0.5%) intrathecally before surgery, followed by epidural bolus postoperatively, at ‘two segment sensory regression’ in following manner: initial bolus made to 10 ml with each group given - 7 ml of 0.125% Bupivacaine and 3 ml distilled water with adjuvant as 50 μg Fentanyl in group BF and 100 μg Clonidine in group BC. Top up of 7 ml was given to each group with 5 ml of 0.125% Bupivacaine and 2 ml distilled water with adjuvant as 50 μg Fentanyl in group BF and 75 μg Clonidine in group BC. Results: There was no statistically significant difference between the demographic profile. VAS scores were found to be better in Group BF and BC at most of the times and these scores were significantly lower than Group B. Rescue analgesia was required in 12% patients in Group B while none of the patients in Group BF or Group BC required rescue analgesia. Nausea, vomiting and pruritus were observed in 52% of the patients in Group BF and in none of the patients in Group BC and Group B.Degree of sedation was significantly more in Group BC when compared with Group BF and Group B. Conclusion: Combination of Bupivacaine-Clonidine was found to be a better option than Bupivacaine-Fentanyl for postoperative epidural analgesia in hip surgery patients.

Sedation in a child with Klippel-Feil syndrome scheduled for magnetic resonance imaging

imaging (MRI) suites to perform imaging in children and uncooperative adults. The choice of anesthesia may range from moderate sedation to general anesthesia depending on the patient’s characteristics and/or institutional protocols. Due to challenges in accessing patients in the MRI suite, the anesthetic technique should be chosen carefully. This is even more important when the patient has an anticipated difficult airway. A four-year-old male child weighing 14 kg presented with delayed developmental milestones, diminished hearing, and no organized speech. The patient had a diagnosis of Klippel-Feil syndrome (KFS). Ultrasonography of the abdomen and echocardiography ruled out any associated systemic defects and the patient was scheduled for MRI of the brain and cervical spine for further evaluation. After a failed attempt at sedating the patient with oral chloral hydrate in the MRI suite, he was scheduled for MRI under general anesthesia. The pre-anesthetic evaluation showed that the patient had a short webbed neck with limited extension and a low posterior hairline (Fig. 1). Due to an anticipated difficult airway and the diagnostic nature of the procedure, we planned to provide sedation with dexmedetomidine via a backup laryngeal mask airway if required. Intravenous access was obtained with a 22-gauge cannula after application of a eutectic mixture of local anesthetics. Baseline vitals (electrocardiography [ECG], blood pressure, and pulse oxygen saturation [SpO2]) were recorded. A loading dose of 1 μg/kg dexmedetomidine was administered over 10 minutes followed by an infusion of 0.7 μg/kg/h dexmedetomidine. Monitoring of the depth of sedation was performed based on the Ramsay Sedation Score and the patient was moved onto the MRI table once a score of 5 was achieved; following this, ear plugs were applied. Oxygen supplementation was achieved with fraction of inspired oxygen of 0.28 with continuous monitoring of ECG, noninvasive blood pressure, SpO2, and end-tidal carbon dioxide throughout the diagnostic procedure, which lasted approximately 50 minutes. All of the above parameters were within normal limits and no additional intervention was required. At the end of the procedure, dexmedetomidine infusion was stopped and the patient was responsive to verbal stimuli after 7 minutes. The patient was discharged home once the discharge criteria were met. KFS is an inherited condition with the classic triad of a short webbed neck, limited neck movements, and a low posterior hairline [1,2]. KFS may be associated with conductive or sensorineural deafness, congenital heart disease (most commonly a ventricular septal defect), cleft palate, rib defects, and scoliosis. Anesthetic challenges include a difficult airway, cervical spine instability, and associated cardiovascular and genitourinary system abnormalities. There is an increased risk of spinal cord injury during maneuvers such as laryngoscopy, intubation, and placing the patient in an appropriate position for the procedure [3]. Patients with KFS may need to be anesthetized for diagnostic procedures, surgical correction of congenital defects, or any othLetter to the Editor

Air- Q intubating laryngeal airway guided intubation in Morquio syndrome

Mucopolysaccharidoses (MPS) are lysosomal storage disorders caused by the deficiency of enzymes required for the stepwise breakdown of glycosaminoglycans (GAGs), also known as mucopolysaccharides. Patients with MPS may develop complications during general anaesthesia (GA) due to the presence of airway obstruction, excessive secretions, a large tongue and an abnormal airway anatomy. Patients with MPS type IV, also known as Morquio syndrome, pose even greater challenge because of additional problems such as neck instability, restrictive pulmonary disease and end-organ damage.

The ketamine enigma

Ketamine, first introduced into clinical practice in the 1960s as a general anesthetic, is a noncompetitive antagonist at the glutamate N-methyl-d-aspartate receptor and binds to sites located in the cortex and limbic structures of the brain. This mechanism is believed to be responsible for most of its dissociative effects. It interacts with muscarinic, nicotinic, and cholinergic receptors and inhibits the neuronal uptake of norepinephrine, dopamine, and serotonin resulting in the sympathomimetic effects. At high doses, ketamine binds to mu and sigma opioid receptors, resulting in the loss of consciousness. Ketamine is redistributed from the central nervous system and undergoes hepatic transformation by the cytochrome P450 system into its active metabolite, norketamine. Norketamine has about one-third of the anesthetic potency of ketamine with a half-life of 2.5 h. Ketamine metabolites are mainly excreted in the urine.

Can ultrasound-guided subcostal transverse abdominis plane block be used as sole anesthetic technique?

Subcostal transverse abdominis plane (TAP) block anesthetizes area of the abdomen with cutaneous innervation of T6–T10 dermatomes. These abdominal field blocks become very advantageous when cardiac patient presents for noncardiac surgeries as sole anesthetic or as a part of multimodal anesthesia. A 58-year-male came for open surgical repair of subxiphoid incisional hernia developed post coronary artery bypass grafting (CABG). Echocardiography showed hypokinesia of left ventricle (LV) in the left anterior descending (LAD) artery territory, dilated LV, and ejection fraction of 30%, and coronary angiography after 6 months of CABG showed 70% stenosis of LAD. Surgery was successfully accomplished under ultrasound-guided bilateral subcostal TAP block except for a brief period of pain and discomfort when hernia was being reduced which required narcotic supplementation. The patient remained comfortable throughout the procedure as well as 24 h postoperatively without any analgesic supplementation. Thus, subcostal TAP block can be a safe alternative to neuraxial or general anesthesia for epigastric hernia repair in selected patients.

Can we ignore changing P wave polarity

Changing P wave polarity is a known entity, although there are very few reports on it involving patients with symptomatic cardiac disease. However, little has been reported on this entity during the perioperative period. Not long ago, we reported the case of a 61-year-old woman scheduled for an orthopedic procedure under spinal anesthesia. Spontaneous changes in P wave polarity were detected intraoperatively, although the patient was asymptomatic and the intra- and postoperative courses were uneventful [1]. Recently, we encountered a similar situation in an asymptomatic 65-year-old woman scheduled to undergo laparoscopic cholecystectomy. A cardiologists opinion was sought and no cardiac compromise was observed. She underwent the procedure under general anesthesia. The detection of two such cases within a short time span raises questions about the true incidence and causes of this entity and its relevance to anesthesiologists. It is likely that intraoperative changes in P wave polarity might go unnoticed despite continuous monitoring of the electrocardiogram if there are no changes in heart rate and rhythm. In a reported case involving an asymptomatic patient, spontaneous changes in P wave polarity were due to intermittent changes in internodal conduction, as diagnosed in an electrophysiological study [2]. However, conducting electrophysiological studies in all patients would be irrational. We hope to highlight this entity and bring it to the notice of anesthesia stalwarts so that we can frame preoperative protocols for such rare events.

Dexmedetomidine: A Saviour in a Child with Hand Schuller Christian Diseasefor MRI

Hand Schuller Christian disease (HSC) primarily affects infants and children. Its classical presentation includes triad of exophthalmos, diabetes insipid us, and calvariallytic lesions. Systemic involvement may include hepatomegaly, lymphadenopathy, dermatological, gastrointestinal tract, renal, pulmonary and CNS involvement. CNS involvement includes convulsions, increased intracranial pressure, focal neurological deficits, mental retardation, hearing disturbance, and tremors. We encountered a 4 year old female child with HSC disease who was posted for elective MRI scan under anaesthesia. Patient’s history, physical examination, and lab reports revealed multitude of problems enumerated in case report. Such patients when posted for anaesthesia pose a major challenge in view of multiple organ involvement. Polydipsia made difficult to keep the patient fasting and giving general anaesthesia as per standard protocol became risky. The loose teeth with bleeding gums and protruded mandible would have compounded the mask ventilation, LMA placement or laryngoscopy and intubation, manifolds. We managed this case successfully with intravenous sedation with inj. dexmedetomidine at 1 μg/kg/min over 10 min and then maintenance infusion at 0.1 μg/kg/min. Spontaneous ventilation was supplemented with oxygen (FiO2 0.60). MRI scanning was completed in 45 minutes comfortably. Hence, dexmeditomidine offers advantage in such patients if anaesthesia has to be given in remote locations like MRI suite.

Restoration of 'red plug' to rescue a ProSeal® laryngeal mask airway

Sir, Use of supraglottic airway devices has become an important part of anaesthesia practice since the introduction of classic laryngeal mask airway (cLMA®) by A. J. Brain in 1983. The induction of gastric channel into the basic design as in a ProSeal® laryngeal mask airway (PLMA®) proved to be a major advancement over cLMA® due to various reasons, the most important being the protection of lower airways from aspiration of gastric contents.[1] The reusable PLMA is made up of medical grade silicon that can be sterilized by autoclaving and manufacturers recommend it to be used not more than 40 times. However, there is supporting evidence that a PLMA can be used till it fails the pre-use check test rather than till it has been used a specific number of times.[2] During one such pretest of a PLMA, we found the occluder of the red plug of a size 4 PLMA to be broken. The cuff, shaft, inflation line, and valve were all intact. Since the reusable PLMA is expensive, options to repair the red plug were sought. The plug at the proximal end of a paediatric size nasogastric tube (12 Fr Gauge) was cut and checked whether it fitted the red plug. It fitted over the red plug snugly and was secured using a water proof commercial adhesive (‘Quickfix®’) over the red plug [Figure 1]. Since this part of the PLMA remains outside the patient at all times, the risk of the new plug to break off inside the patient was not there. Further, the device cleared the pre-test including the inflation and deflation and has been used in patients without any failure due to the new ‘red plug’. Figure 1 The ‘repaired’ ProSeal laryngeal mask airway. Arrow a shows the broken red plug without occluder and the cut end of nasogastric tube is encircled (inset showing the broken red plug repaired with cut end of a nasogastric tube) There have been reports of damaged LMA devices where the ones with damage to cuff and shaft were disposed but the damages to inflation line and valve were repaired using different methods.[3,4] And our ‘innovation’ to repair the red plug is a further step to save an otherwise reusable device when resources are limited. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pediatric fiberoptic intubation: Another challenge… another approach!!

• Combined NPA–FOB technique: Involves administration of oxygen and general anesthesia through an (intact) NPA in one nostril and the FOB can be introduced orally or from the opposite nasal passage. • Combined endoscopy mask–FOB: Endoscopy mask has a single port for administration of oxygen and anesthetic gases and another port with an insertion diaphragm wide enough to allow passage of ETT and FOB. • Intubation with FOB through the laryngeal mask airway, intubating laryngeal mask, and air-Q.

Comparison of ProSeal laryngeal mask airway placement techniques using digital, introducer tool and gum elastic bougie in anaesthetized paralyzed patients

Background: Conventionally laryngeal mask airway (LMA) is placed in the oral cavity using fingers without the need for laryngoscope. ProSeal laryngeal mask airway (PLMA) placement is relatively difficult owing to its bulky design and sometimes require alternative techniques. We compared three techniques (digital, introducer-tool, gum-elastic bougie) for its placement. Methods: One hundred fifty patients of ASA class I & II of either sex, undergoing surgery under general anaesthesia were randomly allocated to one of the three groups. Standard anaesthesia protocol comprising of glycopyrrolate, thiopentone, vecuronium and halothane in oxygen plus nitrous oxide was used. Insertion attempts, success rate and time taken were noted after confirmation of proper placement. Efficacy of airway seal, oropharyngeal leak pressure (OLP) , ease of gastric tube insertion, trauma to oropharyngeal structures, postoperative airway morbidity were noted. Haemodynamic monitoring was done throughout the procedure. Results: First attempt success rate as well as overall success rate was high in gum elastic bougie group. Although in this group insertion time was slightly longer. Airway seal was also better in this group as shown by high OLP. Airway trauma was comparable in all the three groups. Conclusions: Gum elastic bougie guided PLMA insertion is a good alternative if traditional methods of its placement fail.