V. Darlong

Sensorineural hearing loss after general anaesthesia: 52 cases reported until now!

We read with interest the recent description of unilateral sensorineural hearing loss (SSNHL) after general anaesthesia [1]. The authors highlighted a case of profound and persistent unilateral SSNHL after general anaesthesia. The authors state that the scarcity of reported cases and lack of detail in many of the reports to date make definite conclusions impossible and leave the apparent connection between anaesthesia and SSNHL conjectural. They further state that reporting of additional cases should be encouraged, promoting further understanding of this rare complication. Sudden sensorineural hypoacusis in non-otological surgery under general anesthesia is most frequently associated with cardiopulmonary bypass surgery [1]. Hearing loss following general anaesthesia for non-bypass surgery does not appear to have a uniform prognosis. If a specific aetiology can be identified, treatment maybe effective. Otherwise, any recovery appears to be independent of any type of treatment. Warltier et al. [2] reviewed the possible causes of SSNHL after general anaesthesia for non-bypass surgery. They analysed 35 cases reported in the English literature up 2003. However, in addition to these cases, our literature search revealed eight additional cases reported before 2003 of which five are in non-English literature (one report describes two cases) [3–9]. Since this review article, there are seven more reported cases [1, 10–14]. One case report describes two cases. Thus making the total number of cases reported 52 to date!

Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy?: A randomized control trial

STUDY OBJECTIVE To compare the incidence of postoperative nausea and vomiting (PONV) during perioperative administration of 5% dextrose and normal saline in laparoscopic cholecystectomy. DESIGN Prospective, randomized, double-blind trial. SETTING Operating rooms in a tertiary care hospital of Northern India. PATIENTS One hundred patients with American Society of Anesthesiologists status I to II undergoing laparoscopic cholecystectomy were enrolled in this study. INTERVENTIONS Patients were randomized into two groups [normal saline (NS) group and 5% dextrose (D) group]. Both the groups received Ringer acetate (Sterofundin ISO) intravenously as a maintenance fluid during intraoperative period. Besides this, patients of group NS received 250ml of 0.9% normal saline and patients of group D received 5% dextrose @ 100ml/h started at the time when gall bladder was taken out. It was continued in the postoperative period with the same rate till it gets finished. MEASUREMENTS Incidence of PONV, Apfel score, intraoperative opioids used and consumption of rescue antiemetics. MAIN RESULTS Demographic data was statistically similar. Out of total 100 patients, 47 patients (47%) had PONV. In group D, 14 patients (28%) had PONV while in group NS, 33 patients (66%) had PONV within 24h of surgery (p value 0.001). The incidence of PONV was reduced by 38% in group D which is significantly lower when compared with that of group NS (p value 0.001). The consumption of single dose of rescue antiemetics in group D was also reduced by 26% when compared to that of group NS (p value 0.002). CONCLUSIONS Perioperative administration of 5% dextrose in patients undergoing laparoscopic surgery can reduce PONV significantly and even if PONV occurs, the quantity of rescue antiemetics to combat PONV is also reduced significantly.

An atypical presentation of fentanyl rigidity following administration of low dose fentanyl in a child during intraoperative period

1 Ko YP, Huang CJ, Hung YC et al. Premedication with low-dose oral midazolam reduces the incidence and severity of emergence agitation in pediatric patients following sevoflurane anesthesia. Acta Anaesthesiol Sin 2001; 39: 169–177. 2 Abu-Shahwan I. Effect of propofol on emergence behavior in children after sevoflurane general anesthesia. Paediatr Anaesth 2008; 18: 55–59. 3 Abu-Shahwan I, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Paediatr Anaesth 2007; 17: 846–850.

Hemiparesis after robotic laparoscopic radical cystectomy and ileal conduit formation in steep Trendelenburg position

Robotic surgery is becoming popular for minimally invasive surgical procedures as robotic devices allow unprecedented control and precision. We report a case of robotic radical cystectomy with ileal conduit urinary diversion surgery having perioperative neurological complications related to prolonged surgery in the steep head-down position. There was a neurological deficit in the form of hemiparesis, which resolved with conservative management. We suggest that duration and positioning should be optimized for such prolonged surgery in the steep head-down position, and make some recommendations. Moreover, in such surgeries great vigilance must be observed in the perioperative period.

Pectoral nerve blocks to improve analgesia after breast cancer surgery: A prospective, randomized and controlled trial

STUDY OBJECTIVE To evaluate the analgesic efficacy of ultrasound guided combined pectoral nerve blocks I and II in patients scheduled for surgery for breast cancer. DESIGN Prospective, randomized, control trial. SETTING Operating rooms in a tertiary care hospital of Northern India. PATIENTS Sixty American Society of Anesthesiologists status I to II adult women, aged 18-70years were enrolled in this study. INTERVENTIONS Patients were randomized into two groups (30 patients in each group), PECS (P) group and control (C) group. In group P, patients received both general anesthesia and ultrasound guided combined pectoral nerve blocks (PECS I and II). In group C, patients received only general anesthesia. MEASUREMENTS We noted pain intensity at rest and during abduction of the ipsilateral upper limb, incidence of postoperative nausea and vomiting; patients satisfaction with postoperative analgesia and maximal painless abduction at different time intervals in both groups. MAIN RESULTS There was significant decrease in the total amount of fentanyl requirement in the in P group {(140.66±31.80μg) and (438±71.74μg)} in comparison to C group {(218.33±23.93μg) and (609±53.00μg)} during intraoperative and post-operative period upto 24h respectively. The time to first analgesic requirement was also more in P group (44.33±17.65min) in comparison to C group (10.36±4.97min) during post-operative period. There was less limitation of shoulder movement (pain free mobilization) on the operative site at 4h and 5h after surgery in P group in comparison to C group. However there was no difference in the incidence of post-operative nausea and vomiting (22 out of 30 patients in group P and 20 out of 30 patients in group C) but patients in group P had a better satisfaction score with postoperative analgesia than C group having a p value of <0.001(Score 1; 5 VS 20; Score 2; 12 VS 9; Score 3; 13 VS 1). CONCLUSIONS Ultrasound guided combined pectoral nerve blocks are an effective modality of analgesia for patients undergoing breast surgeries during perioperative period. CLINICAL TRIAL REGISTRATION CTRI/2015/12/006457.

Oral submucous fibrosis and restricted mouth opening.

We read with interest, Greenland’s article ‘A proposed model for direct laryngoscopy and tracheal intubation’ [1]. Greenland lists the causes of low compliance of the submandibular tissues that may lead to difficult laryngoscopy. We would like to highlight another common cause of restricted mouth movements, oral submucous fibrosis. Oral submucous fibrosis is a chronic disease characterized by subepithelial collagen deposition with formation of bands involving the oral cavity and adjacent structures. It is a premalignant condition of the oral cavity associated with fibrosis of involved structures that can be associated with malignancy of the aerodigestive tract. It is caused by chewing betel quid (Areca catechu, Piper betel, lime and tobacco) and ready-made products like pan masala and gutka which also contain areca nut [2–4]. These products are available all over Southern Asia. The hallmark of oral submucous fibrosis is extremely restricted mouth opening and distortion of the airway anatomy which may render intubation difficult. It can cause unanticipated difficulty in intubation [5]. An anesthetist in any part of the world may be involved in providing anesthesia to a patient from Southern Asia [6] and pre-operatively, a history of chewing betel quid should be sought. A positive history should alert the anaesthetist of the possibility of difficult intubation. Indirect laryngoscopy maybe useful in the preoperative evaluation.

Perioperative concerns in a beta-ketothiolase-deficient child

Presentation includes ketoacidosis, vomiting (hematemesis), bloody diarrhea, hyperpnea, hypotonus, cardiomyopathy, prolonged QT, lethargy, and coma [1–4]. Other symptoms are neutropenia, thrombocytopenia, and renal failure. Acute decompensation occurs with infection, starvation, and surgery [1–3]. A history of vomiting, rapid breathing, altered sensorium, and decreased urine output indicates impending ketosis. The anesthetic goal is to avoid factors and drugs that trigger ketosis: minimize preoperative fasting, administer glucose-based infusions, and avoid propofol and etomidate (inhibit mitochondrial enzymes) [4]. Thiopental, ketamine, volatile agents, and opioids appear safe. Adequate suction of surgical blood needs to be ensured because aspirated blood on digestion can be ketotic.

One should avoid central venous cannulation on the same side as a functioning forearm arteriovenous haemodialysis fistula

with focal medulla inflammation, resulting in several degrees of paresis, paresthesia and autonomic dysfunction (6). However, TM was discarded because the examinations did not reveal any sign of medulla inflammation. Therefore, somatosensory-evoked potentials are recommended, but we did not have it available. The treatment of this patient included placebo (corticotherapy) and suggestion (discharge from the hospital), which possibly have contributed for her improvement. Probably, this patient presented hysteria with paraplegia symptoms because she had already ‘learned’ them with her previous experience of TM. This article reported a case of hysterical paraplegia after general anesthesia in a patient with a previous history of TM, which made the accomplishment of the diagnosis more difficult.

In reply to the letter to the editor 'What to do if the endotracheal tube will not pass through the nasal passage during fiberoptic nasotracheal intubation'.

Sir, We read with interest the letter to the editor ‘What to do if the endotracheal tube (ET) will not pass through the nasal passage during fiberoptic nasotracheal intubation’ (doi 10.1111/j.1399-6576.2007.01318.x) and congratulate S. W. Na et al. for their excellent management. However, we would like to suggest that whenever we encounter difficulty when passing fiberoptic bronchoscope with an ET, we can try rotating the fiberscope-tube assembly 180 anticlockwise with the bevel facing down. Orientation of the leading edge bevel is the most important determinant of successful passage of ET. The bevel-down orientation appears to improve the success of fiberoptic endotracheal intubation by allowing the ET to slip past the potentially obstructing right arytenoid cartilage (1, 2).

Malignant hyperthermia--who should be tested?

Sir We read with interest the letter published in the January 2008 issue titled ‘Fulminant Malignant Hyperthermia’. The authors here investigated the extended family members of an individual who developed malignant hyperthermia (MH) and was subsequently treated successfully. The preoperative history revealed no myopathy in the family and the patient reported some uneventful anaesthesias in his father and siblings. The investigations revealed a positive in vitro contracture test (IVCT) in an agnate half brother of the patient, indicating that the father transmitted the MH. Because of old age, the father was waived off IVCT. The authors further state that another agnate half brother and another agnate half sister with the same father had several uneventful general anaesthesias and were therefore not tested. This confused us as we have always read that MH can occur in individuals who have undergone previous uneventful anaesthesias. On review of the literature, to the best of our knowledge, we did not come across any reference stating as to how many uneventful anaesthetics an MH-susceptible patient can undergo before MH manifests in them. Also, it was pointed out by Islander et al. that a fraction of the pathological outcome is 0.65 in the IVCT for male probands with MH susceptibility and 0.7 for male relatives in MH-susceptible families. Keeping these facts in mind, we feel that the half brother and half sister of the patient should also have been tested by IVCT, especially because they had the same father. Needless to say, this would go a long way in preventing the mishaps of MH and/or its related morbidities in these individuals.