Tim Thomas Joseph

Posterior reversible encephalopathy syndrome at term pregnancy.

Posterior reversible encephalopathy syndrome (PRES) is a cliniconeuroradiological syndrome associated with various clinical conditions, presenting with headache, encephalopathy, seizures, cortical visual disturbances or blindness. Imaging predominantly shows parieto-occipital white matter changes, with vasogenic oedema being the most accepted pathophysiology. We report a 25-year-old primigravida who presented in term pregnancy with seizures and blindness, scheduled for emergency caesarean section. She was managed peroperatively under general anaesthesia and shifted to intensive care unit. Postoperative computed tomography brain revealed an intra-axial hypodensity involving predominantly white matter regions of bilateral parieto-occipital lobes, right caudate nucleus and right cerebellum, suggestive of PRES. Clinical improvement with complete resolution of visual disturbances was observed with supportive treatment. The importance of prompt suspicion and management in preventing short- and long-term neurological deficits in reversible condition like PRES is highlighted.

Premedication with gabapentin, alprazolam or a placebo for abdominal hysterectomy: Effect on pre-operative anxiety, post-operative pain and morphine consumption

Background and Aims : Utility of gabapentin for pre-operative anxiolysis as compared to commonly administered alprazolam is not evident. The aim of the present study was to compare the effects of pre-operative oral gabapentin 600 mg, alprazolam 0.5 mg or a placebo on pre-operative anxiety along with post-operative pain and morphine consumption. Methods: Seventy five patients scheduled for abdominal hysterectomy under general anaesthesia were included. Groups gabapentin, alprazolam and placebo, received oral gabapentin 600 mg, alprazolam 0.5 mg and one capsule of oral B-complex forte with Vitamin C respectively, on the night prior to surgery and 2 h prior to surgery. Visual analogue scale (VAS) was used to measure the anxiety and post-operative pain. All patients received patient-controlled analgesia. Statistical tests used were Kruskal-Wallis test, Wilcoxon signed rank test and one-way ANOVA. Results: Alprazolam provided significant anxiolysis (median [interquartile range] baseline VAS score 35 [15.5, 52] to 20 [6.5, 34.5] after drug administration; P = 0.007). Gabapentin did not provide significant decrease in anxiety (median [interquartile range] VAS score 21 [7.5, 41] to 20 [6.5, 34.5]; P = 0.782). First analgesic request time (median [interquartile range in minutes]) was longer in group gabapentin (17.5 [10, 41.25]) compared to group placebo (10 [5, 15]) (P = 0.019) but comparable to that in group alprazolam (15 [10, 30]). Cumulative morphine consumption at different time periods and total morphine consumption (mean [standard deviation]) at the end of study period (38.65 [18.04], 39.91 [15.73], 44.29 [16.02] mg in group gabapentin, alprazolam and placebo respectively) were comparable. Conclusion: Gabapentin 600 mg does not have significant anxiolytic effect compared to alprazolam 0.5 mg. Alprazolam 0.5 mg was found to be an effective anxiolytic in the pre-operative period. Neither alprazolam nor gabapentin, when compared to placebo showed any opioid sparing effects post-operatively.

Peculiar breathing in Rett syndrome: Anesthesiologist's nightmare

1. Deja M, Menk M, Heidenhain C, Spies CD, Heymann A, Weidemann H, et al. Strategies for diagnosis and treatment of iatrogenic tracheal ruptures. Minerva Anestesiol 2011;77:1155‐66. 2. Goo JM, Im JG, Ahn JM, Moon WK, Chung JW, Park JH, et al. Right paratracheal air cysts in the thoracic inlet: Clinical and radiologic significance. AJR Am J Roentgenol 1999;173:65‐70. 3. Tanaka H, Mori Y, Kurokawa K, Abe S. Paratracheal air cysts communicating with the trachea: CT findings. J Thorac Imaging 1997;12:38‐40. 4. Buterbaugh JE, Erly WK. Paratracheal air cysts: A common finding on routine CT examinations of the cervical spine and neck that may mimic pneumomediastinum in patients with traumatic injuries. AJNR Am J Neuroradiol 2008;29:1218‐21.

Child with bilateral pheochromocytoma and a surgically solitary kidney: Anesthetic challenges.

Pheochromocytoma is a rare neuroendocrine tumor of childhood. We present a 14-year-old boy with bilateral pheochromocytoma, post nephrectomy in view of a non-functioning kidney presenting with severe hypertension and end organ damage. Diagnosis was confirmed with 24-hour urinary VMA, catechol amines, and CT scan. Preoperative blood pressure (BP) was controlled with prazosin, propranolol, nicardipine, and HCT-spironolactone. Anesthesia was given with general endotracheal anesthesia with epidural analgesia. Intraoperative BP rise was managed with infusion of NTG, MgSO4, esmolol, and dexmedetomidine which was especially challenging on account of bilateral tumor.

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.

Severed cuff inflation tubing of endotracheal tube: A novel way to prevent cuff deflation.

A well-secured endotracheal tube (ETT) is essential for safe anesthesia. The ETT has to be fixed with the adhesive plasters or with tie along with adhesive plasters appropriately. It is specially required in patients having beard, in intensive care unit (ICU) patients or in oral surgeries. If re-adjustment of the ETT is necessary, we should be cautious while removal of the plasters and tie, as there may be damage to the cuff inflation system. This can be a rare cause of ETT cuff leak, thus making maintenance of adequate ventilation difficult and requiring re-intubation. In a difficult airway scenario, it can be extremely challenging to re-intubate again. We report an incidence where the ETT cuff tubing was severed while attempting to re-adjust and re-fix the ETT and the patient required re-intubation. Retrospectively, we thought of and describe a safe, reliable and novel technique to prevent cuff deflation of the severed inflation tube. The technique can also be used to monitor cuff pressure in such scenarios.

Utility of intra-operative ultrasound in choosing the appropriate site for blood pressure monitoring in Takayasu's arteritis

Takayasus arteritis (TA) is rare, chronic progressive, pan-endarteritis involving the aorta and its main branches, with a specific predilection for young Asian women. Anaesthesia for TA patients is complicated by their severe uncontrolled hypertension, extreme arterial blood pressure differentials, aortic regurgitation (AR), end-organ dysfunction, stenosis/aneurysms of major blood vessels and difficulties encountered in monitoring arterial blood pressure. We present the usefulness of ultrasound during anaesthetic management of a 35-year-old woman posted for emergency caesarean section due to intra-uterine growth retardation, foetal tachycardia in active labour, who was already diagnosed to have TA along with moderate AR and uncontrolled hypertension, using epidural technique. The use of intra-operative doppler helped resolve the initial dilemma about the diagnosis and treatment of the differential blood pressure between the affected and the normal upper limb in the absence of prior arteriogram.

Mean versus median in tables and figures.

1390 www.anesthesia-analgesia.org aNESTHESIa & aNaLgESIa REFERENCES 1. Orkin FK. Possible leading indicator for decreased demand for anesthesiologists. Anesth Analg 2013;116:1389–90 2. Schubert A, Eckout GV, Ngo AL, Tremper KK, Peterson MD. Special article: Status of the anesthesia workforce in 2011, evolution during the last decade, and future outlook. Anesth Analg 2012;115:407 REFERENCES 1. Schubert A, Eckhout GV, Ngo AL, Tremper KK, Peterson MD. Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook. Anesth Analg 2012;115:407–27 2. Abt Associates. Estimation of Physician Work Force Requirements in Anesthesiology. Bethesda, MD: Abt Associates, Inc., 1994:1–53 3. Anders G. Once hot specialty, anesthesiology cools as insurers scale back. Wall St J March 17, 1995:1 4. Turner JA, Cole DJ. Baby boom or bust ... is 64 the new 57? Anesthesiology 2012;117:931–3 5. Schubert A. 2009 Anesthesiology resident class sizes and graduates. ASA Newsletter 2010;74:34 (Table 1) 6. Grogono AW. Resident numbers and graduation rates from residencies 2006. ASA Newsletter 2006;70:10 (Table 1) 7. Orkin FK, McGinnis SL, Forte GJ, Peterson MD, Schubert A, Katz JD, Berry AJ, Cohen NA, Holzman RS, Jackson SH, Martin DE, Garfield JM. United States anesthesiologists over 50: retirement decision making and workforce implications. Anesthesiology 2012;117:953–63

Selection of appropriate size endotracheal tube in cases of large goiters causing tracheal compression.

Tracheal compression due to any cause can lead to difficulty in either ventilating or intubating the patient. Most often, it is due to a large thyroid swelling. Often the anesthetist is completely guided by the radiological findings to plan the airway management, giving much less importance to the patients clinical picture. We report two cases of large multinodular goiter that caused tracheal compression without any symptoms of breathing difficulty in the patients. In both the cases we were able to pass larger size endotracheal tubes beyond the site of compression without any resistance. The external diameter of the endotracheal tubes were much larger than the diameter at the narrowest part of the airway measured by computerized tomography. We conclude that along with the extent of tracheal compression, its cause and site is of paramount importance in anesthetic planning and management of airway. A thorough history on the severity of patient symptoms due to the swelling is also important.

Congenital lobar emphysema: Challenges in diagnosis and ventilation

Congenital lobar emphysema (CLE) is a rare congenital anomaly of lung causing over aeration of one or more lobes of a histologically normal lung. It presents in infancy with respiratory distress due to compression atelectasis and often associated with mediastinal shift and hypotension. CLE poses a challenge in diagnosis and positive pressure ventilation due to air trapping. We report a case of 8-week-old infant with CLE posted for right lobectomy. Strategies to prevent misdiagnosis, over aeration and use of IPPV have been reviewed.