Verghese T. Cherian

Low-dose ketamine infusion for labor analgesia: A double-blind, randomized, placebo controlled clinical trial.

Background: Most primary and secondary level hospitals in developing countries provide inadequate labor analgesia due to various medical, technical and economic reasons. This clinical trial was an effort to study the efficacy, safety and feasibility of intravenous (IV) ketamine to provide labor analgesia. Materials and Methods: A total of 70 parturients were consented and randomly assigned to receive either IV ketamine or 0.9% saline. A loading dose of ketamine (0.2 mg/kg) was followed-by an infusion (0.2 mg/kg/h) until the delivery of the neonate. Similar volume of saline was infused in the placebo-group. Intramuscular meperidine was the rescue analgesic in both groups. The pain score, hemodynamic parameters of mother and fetus and the anticipated side-effects of ketamine were observed for. The newborn was assessed by the Neonatologist. Results: The pain score showed a decreasing trend in the ketamine group and after the 1st h more than 60% of women in the ketamine group had pain relief, which was statistically significant. There was no significant clinical change in the maternal hemodynamics and fetal heart rate. However, 17 (48.5%) of them had transient light headedness in the ketamine group. All the neonates were breast fed and the umbilical cord blood pH was between 7.1 and 7.2. The overall satisfaction was significantly high in the intervention group (P = 0.028). Conclusion: A low-dose ketamine infusion (loading dose of 0.2 mg/kg delivered over 30 min, followed-by an infusion at 0.2 mg/kg/h) could provide acceptable analgesia during labor and delivery.

Low-concentration, continuous brachial plexus block in the management of Purple Glove Syndrome: a case report

IntroductionPurple Glove Syndrome is a devastating complication of intravenous phenytoin administration. Adequate analgesia and preservation of limb movement for physiotherapy are the two essential components of management.Case presentationA 26-year-old Tamil woman from India developed Purple Glove Syndrome after intravenous administration of phenytoin. She was managed conservatively by limb elevation, physiotherapy and oral antibiotics. A 20G intravenous cannula was inserted into the sheath of her brachial plexus and a continuous infusion of bupivacaine at a low concentration (0.1%) with fentanyl (2 μg/ml) at a rate of 1 to 2 ml/hr was given. She had adequate analgesia with preserved motor function which helped in physiotherapy and functional recovery of the hand in a month.ConclusionA continuous blockade of the brachial plexus with a low concentration of bupivacaine and fentanyl helps to alleviate the vasospasm and the pain while preserving the motor function for the patient to perform active movements of the finger and hand.

Oral bisoprolol improves surgical field during functional endoscopic sinus surgery

Background: The success of functional endoscopic sinus surgery (FESS) depends on visual clarity of the surgical field, through the endoscope. The objective of this double-blind, randomized, controlled study was to determine if a pre-operative dose of bisoprolol (2.5 mg) would reduce the bleeding during FESS and improve the visualization of the operative field. Materials and Methods: Thirty American Society of Anesthesiologists I or II patients, scheduled for FESS were randomized to receive either a placebo (Group A) or 2.5 mg of bisoprolol (Group B) 90 min prior to the surgery. All the patients received standard anesthesia and monitoring. The aim was to maintain the mean arterial pressure (MAP) of 60-70 mmHg, by titrating dose of isoflurane and fentanyl. The concentration of isoflurane used was recorded every 15 min. At the end of the surgery, the volume of blood loss was measured and the surgeon was asked to grade the operative field as per the Fromme-Boezaart Scale. Result: The blood loss was significantly (P < 0.0001) more in the control group (398.67 ± 228.79 ml) as compared with that in the bisoprolol group (110.67 ± 45.35 ml). The surgical field was graded better in those who received bisoprolol as compared with those in the control group (P − 0.0001). The volume percent of isoflurane and the dose of fentanyl used was significantly lower in those who received bisoprolol. During the operative period, the MAPs were 70.0 ± 2.7 (Group A) and 62.6 ± 3.6 mmHg (Group B) and the heart rate was 99.8 ± 5.0/min (Group A) and 69.2 ± 4.4/min (Group B). These differences were statistically significant ( P − 0.001). Conclusion: This clinical trial has demonstrated that administration of a single pre-operative dose of bisoprolol (2.5 mg) can significantly reduce the blood loss during FESS and improve the visualization of the operating field.

Ancient schwannoma of the oesophagus presenting with stridor: case report.

OBJECTIVE We report a rare presentation of ancient schwannoma of the oesophagus, management of which required tracheal resection. CASE REPORT A 40-year-old woman was referred to our hospital with a six-year history of progressively worsening stridor. She had undergone laser excision of a tracheal tumour thrice in the past. Fibre-optic bronchoscopy showed a tumour arising from the posterior wall of the trachea. Computed tomography scanning showed evidence of extension along the retrotracheal plane. The patient required tracheal resection and anastomosis due to significant involvement of the posterior tracheal wall. The mass was seen to be arising from the oesophagus, and was able to be enucleated from the oesophageal wall. Histopathology was typical of an ancient schwannoma. CONCLUSION This case emphasises the need to consider oesophageal schwannomas in the differential diagnosis of posterior tracheal tumours; it also highlights the need for careful pre-operative assessment in the management of these tumours in order to avoid complications.

An Uncommon Complication with a Supraglottic Airway: The King LT.

General anesthesia was administered in an 18-year-old man for removal of hardware from his right knee using a King Laryngeal Tube supraglottic airway. An hour after extubation, he reported inability to swallow with no respiratory distress. Examination showed an edematous uvula, which took 3 days to subside with anti-inflammatory medication. During the positioning of the King Laryngeal Tube, it was pulled back to ensure adequate ventilation. The inflated cuff could have dragged the uvula and folded it on itself, leading to venous congestion and edema.

Neuraxial anesthesia in CADASIL syndrome.

To JNA Readers: We report a case of anesthetic management in a patient with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) syndrome. CADASIL syndrome is a form of ischemic arteriopathy associated with a NOTCH3 gene mutation on chromosome 19q12 and has perioperative implications. The disorder is rare in overall incidence, but is considered the most common genetic cause of ischemic strokes. A 51-year-old 90-kg woman presented to our hospital for elective hemorrhoidectomy. Her past medical history included CADASIL syndrome and severe internal hemorrhoids. Her medication list included warfarin, which was started 20 years prior for a deep venous thrombosis and hyperhomocysteinemia. Warfarin was stopped 5 days before surgery and bridged to enoxaparin postoperatively. On the day of surgery, her coagulation status was confirmed and she was premedicated with 2mg of midazolam. A subarachnoid block was performed in the sitting position at the L3-L4 level. Using a 25-G Whitacre needle, 12mg of hyperbaric bupivacaine with 20mcg of fentanyl was injected into the intrathecal space. Her blood pressure was monitored with the intention to treat with ephedrine and crystalloids if needed. The patient underwent hemorrhoidectomy with hemorrhoidopexy and required no vasoactive medication. Blood pressure remained within 10% of baseline throughout the case and normocapnia was maintained by the patient’s respiratory drive. Before discharge, we brought her antithrombotic therapy into question. After discussion with our patient’s primary care physician and neurologist, her warfarin therapy was discontinued and antiplatelet therapy with aspirin was started. Few cases describe the anesthesia management of the CADASIL syndrome. Despite the paucity of information on the perioperative management of this syndrome, it seems reasonable to focus on preventing cerebral ischemic events. Preoperatively, medical management should focus on reducing the risk factors for ischemic stroke.1 Hypertension and tobacco use are risk factors that should be treated aggressively.2 For patients at risk for ischemic stroke, the proper perioperative management of aspirin is uncertain. However, there is growing evidence that cessation of aspirin significantly increases stroke risk.3 Intraoperative anesthetic techniques should focus on preventing cerebral ischemia and vasospastic events. This is typically accomplished by maintaining mean arterial blood pressure within the range of cerebral autoregulation and by maintaining normocapnia. For patients chosen to undergo general anesthesia, mean arterial blood pressure should be kept >60mm Hg and endtidal carbon dioxide kept near 40mm Hg. Volatile anesthetics decrease cerebral metabolism and increase cerebral blood flow in the normal brain. As the reactivity of the vasculature to CO2 is reduced in CADASIL syndrome, cerebral vascular response may be unpredictable.4 In addition, intravenous anesthetics cause dose dependent decreases in cerebral metabolism and blood flow. If neuraxial anesthesia is chosen, consideration should be made for the patient’s thrombotic status, and efforts should be taken to maintain blood pressure so as to reduce the risk of cerebral ischemia. In our patient, neuraxial anesthesia was chosen with the understanding that perianal surgery is very stimulating. Deep anesthesia would be required necessitating high doses of anesthetics and analgesics, with the added harmful effects on cerebral circulation. Postoperatively, factors associated with intracranial hypertension should be mitigated. These include postoperative pain, respiratory depression, vomiting, shivering, and seizures. Antithrombotic therapy should be restarted as soon as possible after surgery and hyperglycemia should be avoided. There are no data to support the use of oral anticoagulants in CADASIL syndrome patients and their use may pose a high risk for complications. Perioperative management of CADASIL syndrome should center on preventing cerebral ischemia by maintaining blood pressure within the range of cerebral autoregulation and by maintaining normocapnia. Neuraxial anesthetic techniques may have advantages over general anesthesia in patients with CADASIL syndrome.

Physics of Instrumentation

It is important for the anesthesiologist to be familiar with the physics of instrumentation to be able to effectively use the information provided by various monitors in the operating room. The basic physical principles of some of the commonly used monitors and equipment are explained here.

The Postoperative Period

Emergence from anesthesia is a transition from a controlled to an uncontrolled state and is rife with possibilities of complications. The patient may be distressed by inadequate pain control, nausea, or shivering. However, complications involving the respiratory, the cardiovascular, the renal, or the neurological systems can be associated with significant morbidity and even mortality. A brief summary of the potential complications to be anticipated in the post-anesthesia care unit is described here.