General Anesthesia In Supine Position Research Articles

Acute-onset paraplegia as an unexpected complication under general anesthesia in supine position during abdominal endovascular aneurysm repair: a case report

BackgroundAcute onset paraplegia after endovascular aneurysm repair (EVAR) is a rare but well-known complication. We here show a 79-year-old woman with paraplegia caused by static and dynamic spinal cord insult not by ischemia after EVAR.Case presentationThe patient underwent EVAR for abdominal aortic aneurism under general anesthesia in the supine position. She had a medical history of lumbar canal stenosis. After the surgery, we recognized severe paraplegia and sensory disorder of lower limbs. Although the possibility of spinal cord ischemia was considered at that time, postoperative magnetic resonance imaging (MRI) revealed burst fracture of vertebra and compressed spinal cord.ConclusionsPatients with spinal canal stenosis can cause extrinsic spinal cord injury even with weak external forces. Thus, even after EVAR, it is important to consider extrinsic factors as the cause of paraplegia.

Ease of ProSeal laryngeal mask airway insertion in children (after placement) using suction catheter: A comparison with conventional techniques

Objectives: The ProSeal Laryngeal Mask Airway (PLMA) mostly inserted by finger technique and by an introducer tool method. Recently a newer Suction Catheter Guided (SC) insertion technique has been successfully used in children. We performed a study in children with aims and objective to compare the ease of PLMA insertion using SC and conventional techniques. Methods: 126 American Society of Anaesthesiologist’s class I and II children in age group of 1-12 years weighing 10-50 kg, admitted in our hospital, undergoing an elective surgery in under general anaesthesia in supine position were included in our study. An appropriate size PLMA was inserted using Suction Catheter, introducer tool or digital technique in Groups SC, I and D respectively (n=42) after induction of general anaesthesia. Correct placement of the PLMA was confirmed by using appropriate clinical tests. Ease of PLMA insertion with hemodynamic response was done by time to insertion, number of insertion attempts to achieve effective ventilation and number of cases which required lateral approach of insertion. Results: In Group SC, PLMA device was inserted after a single attempt in 41 (97.6%) patients, but PLMA insertion was failed in 5 patients in Group I (11.9%) and 6 patients in Group D (14.3%) even after two attempts, and the difference was statistically significant (p=0.044). Time taken for successful placement was statistically shorter in the SC-guided group (SC 22.5±4.021 seconds, I 31.4± 17.57 seconds, D 27.10±12.9 seconds, p value Conclusion: Suction Catheter guided ProSeal LMA insertion was an easier, faster, more successful and a relatively atraumatic technique which also ensures correct placement of the PLMA in the hypopharynx as compared to the routine conventional PLMA insertion techniques with no hemodynamic pressor response to PLMA insertion using any of the three techniques. Keywords: ProSeal LMA, Suction Catheter insertion.

The effect of prolonged steep head-down laparoscopy on the optical nerve sheath diameter.

Both the steep head-down position and pneumoperitoneum increase the intracranial pressure (ICP), and their combination for a prolonged period during laparoscopic radical prostatectomy (LRP) might influence the central nervous system homeostasis. Changes in optic nerve sheath diameter (ONSD) may reflect those in ICP. This study aims to quantify the change in ONSD in response to peritoneal CO2 insufflation and steep Trendelenburg position during LRP. ONSD was measured by ultrasound in 20 patients undergoing LRP and ten awake healthy volunteers. In patients, ONSD was assessed at baseline immediately after induction of general anesthesia in supine position, 10 and 60min from baseline in a 25° head-down position during pneumoperitoneum, and after deflation of pneumoperitoneum with the patient supine at 0° angle. ONSD in controls was assessed at baseline with the patient lying supine, after 10 and 60min of 25° head-down position, and 10min after repositioning at 0° angle. ONSD increased significantly in both patients and controls (p < 0.0001) without between-group differences. The mean increase was 10.3% (95% CI 7.7-12.9%) in patients versus 7.5% (95% CI 2.5-12.6%) in controls (p = 0.28), and didn't affect the time to recovery from anesthesia. In the studied patients, with a limited increase of end-tidal CO2 and airway pressure, and low volume fluid infusion, the maximal ONSD was always below the cut-off value suspect for increased ICP. ONSD reflects the changes in hydrostatic pressure in response to steep Trendelenburg position, and its increase might be minimized by careful handling of general anesthesia.

Laparoscopy: a tool for undiagnosed pain abdomen

Background: Diagnostic laparoscopy has been in the armamentarium of the surgeon and gynaecologist for many years as a useful technique for evaluating pelvic pathology and it is now one of the most frequently performed laparoscopic procedures. The purpose of this study is to evaluate the role of diagnostic laparoscopy in undiagnosed pain abdomen. The Objectives of this study is to evaluate laparoscopy as a diagnostic tool in cases of undiagnosed abdominal pain where clinical symptoms and investigations are not conclusive and to evaluate benefits and complications of diagnostic laparoscopy.Methods: The study was done in 60 patients, presenting with chronic undiagnosed pain abdomen to a tertiary care hospital. All the patients were operated under general anesthesia in supine position. Diagnostic laparoscopy was done using 3 ports, one umbilical 10 mm, other two depending upon possible pathology. After the study, the data was analyzed to evaluate the role of laparoscopy in undiagnosed abdominal pain.Results: Out of 60 patients, 44 were female and 16 males. On diagnostic laparoscopy, findings were- chronic appendicitis - 31, chronic appendicitis with left ovarian cyst - 1, endometriosis with adhesions - 3, PID - 5, PID with adhesions - 3, suspected TB (GI/Genital) - 4, adhesions - 12, negative diagnostic lap - 1. So it may be concluded that diagnostic laparoscopy is a very useful tool to establish diagnosis in patients with undiagnosed abdominal pain with the following benefits are, superior diagnostic ability, better visualization of the abdominal cavity including the paracolic gutters and the pelvis, able to pin point the sites of adhesions with adhesiolysis during the same procedure, retrieval of specimen for histopathological examination, management of the pathology during the same procedure, avoiding unnecessary laparotomy, low complication rate.Conclusions: Laparoscopy is an efficient tool in the armamentarium of the surgeon to diagnose the patients of undiagnosed pain abdomen with numerous benefits and minimal complications.

The effect of spinal versus general anesthesia on intraocular pressure in lumbar disc surgery in the prone position: A randomized, controlled clinical trial

ObjectiveTo compare IOP changes between spinal anesthesia (SA) and general anesthesia (GA) in patients who underwent lumbar disc surgery in the prone position. DesignProspective, randomized, controlled trial. SettingOperating room. PatientsForty ASA I–II patients scheduled for lumbar disc surgery in prone position. InterventionPatients were randomly allocated to the SA or GA groups. MeasurementsIOP was measured before anesthesia (IOP1), 10 min after spinal or general anesthesia in supine position (IOP2), 10 min after being placed in the prone position (IOP3), and at the end of the operation in the prone position (IOP4). Main resultsThere was no significant difference between baseline IOP1 (group GA = 19.4 ± 3.2 mmHg; group SA = 18.6 ± 2.4 mmHg) and IOP2 values (group GA = 19.7 ± 4.1 mmHg; group SA = 18.4 ± 1.9 mmHg) between and within the groups. IOP values after prone positioning and group GA measurements (IOP3 = 21.6 ± 3.1 mmHg; IOP4 = 33.9 ± 3.1 mmHg) were significantly higher when compared with the SA group (IOP3 = 19.3 ± 2.7 mmHg, IOP4 = 26.9 ± 2.4 mmHg) (p = 0.018 and p < 0.001, respectively). Furthermore, IOP3 was significantly increased when compared with IOP2 in the GA group but not in the SA group (p = 0.019 and p = 0.525, respectively). In both groups, IOP4 values were significantly higher than the other three measurements (p < 0.001). ConclusionThe results indicated that IOP increase is significantly less in patients who undergo lumbar disc surgery in the prone position under SA compared with GA.

Effect of modified herringbone-Trendelenburg position during gynecological laparoscopic operation of the elderly

Objective To explore the effects of modified herringbone-Trendelenburg position during gynecological laparoscopic operation of the elderly. Methods A total of 60 elderly patients undergoing gynecological laparoscopic operation under general anesthesia were recruited and assigned to the observation group (30 cases) and control group (30 cases) by random digits table method with 30 cases each according to admitting time; Patients in the control group were placed in conventional Trendelenburg position, while the patients in the observation group were positioned in modified herringbone-Trendelenburg position .Intraocular pressure (IOP) were measured in the patients at anesthesia induction (T1), 5 minutes after general anesthesia in supine position (T2), and 5 minutes after pneumoperitoneum while in the operation position (T3), every 30 minutes (times 4 to 11), while supine at the end of pneumoperitoneum (time 12) and before awakening (time 13); Patients were followed up at 24 h and 48 h after surgery, researcher investigate and record the scores of the Operation Position Comfort Questionnaire, the situation of the pain in the shoulder and postoperative complications of the lower limbs. Results There was no statistically significant difference (t=-1.098, -0.772, -0.656, P>0.05) of the IOP at T1, T2, T13. The IOP in the observation group had statistically significant difference compared with the control group at T3 to T12 (t=6.523-19.866, P < 0.01). The incidence rate of the postoperative complications of the lower limbs in the observation group was 6.7% (2/30) lower than 26.7% (8/30) of the control group (χ2=4.320, P<0.05) and the VAS scores of the patients in the two groups was statistically significant (t=2.471, P<0.05). The incidence rate of the postoperative shoulder pain in the observation group was 10.0% (3/30) lower than 43.3% (13/30) of the control group (χ2=8.523, P<0.01), and the Visual Analogue Scale scores of the patients in the two groups was statistically significant (t=3.575, P<0.05).The scores of the Operation Position Comfort Questionnaire in the observation group was higher than the control group (t=-2.319, P<0.05). Conclusions Modified herringbone-Trendelenburg position can reduce the elevation of intraocular pressure in elderly patients without affecting the operation ,and effectively improve the comfort of the operation position of the patients, reduce the incidence rate of the shoulder pain and postoperative complications of the lower limbs, is conducive to the operation safety of elderly patients. Key words: Gynecological laparoscopic operation; Elderly patients; Operation position; Intraocular pressure; Comfort

Monitorización intraoperatoria del bloqueo neuromuscular y la presión arterial con un solo dispositivo (TOF-Cuff): estudio comparativo con la mecanomiografía y la presión arterial invasiva

ObjectiveThe overall objective of the study is to determine the ability of TOF-Cuff device (blood-pressure modified cuff, including stimulation electrodes) to monitor with the same device the non-invasive blood pressure (NIBP) and the depth of a neuromuscular blockade (NMB) induced pharmacologically, by stimulation of the brachial plexus at the humeral level and recording evoked changes in arterial pressure. Material and methodClinical, single-centre, open-controlled study with 32 adult patients ASA I-III for scheduled elective surgery under general anaesthesia in supine position, for the validation of neuromuscular monitoring, comparing the values obtained from neuromuscular relaxation TOF-Cuff with those obtained by mechanomyography (MMG) (control method) during the recovery phase of NMB, when a TOF ratio>0.7 and>0.9 (primary endpoint) were reached respectively. And an additional consecutive study of 17 patients for validation of NIBP monitoring with TOF-Cuff device vs invasive blood pressure measured by an intra-arterial catheter. All data were analyzed using the Bland-Altman method. ResultsRecovery from NMB measured with the TOF-Cuff was earlier compared to MMG. Comparing TOF-ratio>0.9 measured with TOF-Cuff vs TOF-ratio>0.7 with MMG, a specificity of 91% and a positive predictive value of 84% were obtained.In NIBP measurement, the mean error and standard deviation of both systolic blood pressure (1.6±7mmHg) and diastolic blood pressure (−3.4±6.3) were within the European accuracy requirements for medical devices. ConclusionsThe TOF-Cuff device has been shown to be valid and safe in the monitoring of NMB and in the measurement of NIBP, with no patient presenting any adverse events, skin-level lesions or residual pain. It is not interchangeable with MMG, having a TOF-ratio>0.9 quantified by the TOF-Cuff device, a good correlation with a TOF-ratio>0.7 on MMG.

A comparative study between i-gel and classical laryngeal mask airway in elective surgery under general anaesthesia

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Supraglottic airway devices have been widely used as an alternative to tracheal intubation during general anesthesia both in adults and children. This study was carried out to compare classical laryngeal mask airway (LMA) and i-gel, regarding ease of insertion, adequate placement of device, ability to maintain ETCO&lt;sub&gt;2&lt;/sub&gt; and SPO&lt;sub&gt;2&lt;/sub&gt;, perioperative hemodynamic parameters and intra operative and postoperative complication.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective, randomized clinical study was done on 100 patients of either sex, age between 5 to 60 years, ASA grade I-III who underwent different surgical procedures under general anesthesia in supine position. After giving premedication, induction of anesthesia was done with inj. Propofol 2-3 mg/kg and inj. Succnylcoline 1.5-2 mg/kg. In “sniffing air” position, airway was secured with either LMA or i-gel. An effective placement of device was checked by a square wave capnography, normal chest expansion, SPO&lt;sub&gt;2&lt;/sub&gt; &amp;gt;95%, and absence of audible leak. Patients were observed for time and ease of insertion, number of attempts, perioperative hemodynamic changes and complications.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; No statistically significant difference was reported between both the groups, regarding heart rate, BP, SPO&lt;sub&gt;2&lt;/sub&gt; and ETCO&lt;sub&gt;2&lt;/sub&gt;. Duration of insertion was more in group LMA. Insertion was easy and was possible in first attempt in 88% of patients without much manipulation in group i-gel.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; I-gel is a better alternative supraglottic airway device than LMA in view of ease of insertion with minimal manipulations and minimal complications. Hemodynamic parameters, SPO&lt;sub&gt;2&lt;/sub&gt; and ETCO&lt;sub&gt;2 &lt;/sub&gt;were maintained in both the groups. &lt;/p&gt;

Comparative Study of body pressure in beagles under general anaesthesia in supine position

Comparative Study of body pressure in beagles under general anaesthesia in supine position

Modified prone position using lateral brace attachments for cervico-dorsal spine surgeries

The purpose of the study was to propose a method of prone positioning for posterior cervico-dorsal spine surgeries that is easy to achieve without additional equipment and may reduce complications associated with prone positioning in patients. 41 patients underwent posterior spine surgeries using our method of prone positioning on a fluoroscopy compatible conventional operation table, and the technical difficulties and complications associated were noted. After induction under general anaesthesia in supine position, cervical tongs were applied. An assembly of two adequately padded cylindrical bolsters and two lateral brace attachments was set on a conventional operating table. The patient was then positioned prone so that the tongs as well as insertion pins of the tongs rest on the lateral brace attachments, with the face and head suspended freely in between. A neutralisation weight was then applied suspended from the tongs to stabilize the head. The time required for patient positioning was noted and was found to be nearly the same as that required for traditional prone positioning. No problems were noted during patient positioning and with anaesthesia tubing management. All surgeries went well without position related complications except for one patient who developed post-operative macroglossia. All cervical tong pin sites healed without any complications. The fluoroscope easily gained access to the operative areas. Our modification appears simple, versatile and reproducible for posterior approach procedures of the cervical and upper dorsal spine in prone position. Also, the method can be easily implemented in most conventional operating room facilities with minimal surgeon effort and without the need for any additional inventory.

Comparison between Supine and Lateral Positions In Relation To Ease of Mask Ventilation and Laryngoscopic Views With or Without Burp Maneuver in General Anaesthesia

In patients undergoing surgeries, airway is most often secured with the endotracheal tube under general anaesthesia in supine position. Then position of the patient is changed according to the surgical requirement. Many surgical procedures are done in lateral position under regional anaesthesia. Because of various reasons we may have to supplement with general anaesthesia using endotracheal tube. In many situations turning the patient to supine may be difficult because of the ongoing surgery and endotracheal intubation has to be done in the lateral position. LMA and ILMA are considered safe and first choice for securing the airway in lateral position but it requires more expertise and positive pressure ventilation may be difficult. Direct laryngoscopy is still the fastest and easiest method of securing airway as it is an instrument familiar to all anaesthesiologists and readily available at every anaesthetizing location. In this study we compare the efficacy of BURP (backward, upward, rightward pressure) maneuver in improving the visualization of vocal cords in both supine and lateral positions. We also compared the ease of mask ventilation in supine and lateral positions.

Fracture shaft of humerus with anterior dislocation of shoulder treated with closed locked nailing

Correspondence: Dr. Hitesh Lal, A-1/207, Janakpuri, New Delhi – 110058. E-mail: drhiteshlall@gmail.com decided to take the patient to the operating room. The patient was taken up for surgery under general anesthesia in supine position with a sandbag below the ipsilateral shoulder. Close reduction of the dislocation was done under anesthesia with an assistant pushing manually on the head under the coracoid and another one applying traction along the axis of arm. The dislocation was surprisingly seen to reduce under radiographic control. It was decided to choose a closed interlocking nail over a plate for fixing the humerus as it is minimally invasive. But while making the entry point for the nail the head slipped again into a dislocated position even when the assistant resisted it manually with a fist pressure. A percutaneous 4 mm Steinmann pin was passed after reducing the head in an anteroposterior direction. Then 1 assistant held the head in reduced position with the help of the aforesaid pin loaded on a T handle. The operating surgeon was thus able to make an entry point with a thick Kirchner wire and the position was checked on anteroposterior and lateral views. A cannulated awl was passed over it to enlarge it and the shaft was then reamed with flexible reamer to appropriate size. A standard technique was then used to put an interlocking nail; proximal interlocking was done with the help of a targeting device and distal locking by a free hand technique. The nail of adequate length was appropriately buried in the head so as not to cause any impingement during range of motion. The rotator cuff incision at the entry site was sutured. The shoulder was then immobilized in an arm chest strapping after rechecking the position of head of humerus under C arm. Postoperative period was uneventful (Figure 2). Sutures were removed at 10 days and patient was mobilized at 15 days postoperatively. Initially pendulum exercises were started followed by shoulder range of motion and overhead abduction exercises within 10 days.

Hybrid Approach for Treatment of Behind the Knee Popliteal Artery Aneurysms

We describe herein a combined approach to the treatment of popliteal artery aneurysms (PAA) that averts extensive dissections and potential blood loss particularly in cases of behind-the-knee aneurysms. Over the last 4 years, 13 patients (12 males) with mean age of 75 +/- 8 years were treated for PAAs at our institution with a combined surgical and endovascular approach. The mean size of popliteal aneurysms was 2.9 cm +/- 1.7 cm. One of the 13 cases (8%) was performed for acute ischemia and an additional 5 (38%) for claudication. All operations were performed under general anesthesia in supine position. Vein conduits (eight ipsilateral great saphenous veins, two contralateral great saphenous veins and one arm vein) were utilized for 11 bypasses. Of these, eight were from superficial femoral artery (SFA) to below the knee popliteal artery, two popliteal to popliteal and one SFA to posterior tibial artery. In addition, two expanded polytetrafluoroethylene femoral popliteal bypasses were performed. The distal anastomosis was performed after the popliteal artery was ligated distal to the aneurysm. Next, coil embolization of the aneurysmal sac was performed under fluoroscopic or ultrasound guidance. Coils were embolized through a 5F sheath. Lastly, the popliteal artery was ligated distal to the proximal anastomosis. Completion studies were obtained with duplex in six cases and arteriography in the remaining five cases. Mean follow-up was 11.6 months +/- 9.6. One bypass occluded in 2 months after surgery. One patient demonstrated continued growth of his aneurysm despite coil embolization twice and underwent an open ligation of the branches perfusing the aneurysm from within the sac through a posterior approach. This approach may be particularly useful for PAAs located behind the knee where optimal surgical exposure is often difficult and the collateral circulation is abundant. The proposed technique is simple, effective and averts extensive dissections required to minimize blood loss.

7041 Is ercp under general anesthesia more complicated compared to ercp under conscious sedation?

ERCP is usally performed under intravenous analgosedation (AS). In particular cases examinations or planned interventions have to be terminated prematurely due to inadequate sedation. In cases of difficult anatomy supine position is useful. Supine position requires intubation for airway protection. Methods: In the present study we compared the extent and efficacy of examinations performed under general anesthesia (GA)and AS. 20 ERPCs under AS and GA (10m, 10f) were analyzed. ERCPs under AS were carried out in left position, ERCPs under GA in supine position. Results: Patients who received GA were younger compared to patients who received AS (40 vs. 51 years mean). The underlying diseases were distributed similary. In the GA group interventions were more extensive. Indications for GA were: prematurely terminated ERCP under AS due to inadequate sedation (n=10), intubation for airway protection and achievment of ideal examination conditions (n=10). To identify risk factors, the ASA-(American Society of Anesthesiologists) classification was used. Both groups showed the mean ASA-grade 2. All patients were recovered from GA without incidents with postoperative extubation at a mean time of 8.7 min after termination of ERCP. The recovery time until PARS (post anesthesia recovery score) >9 achieved did not differ between the groups examined (AS vs. GA: 12.1 vs. 13.0 min, p=0.20). In comparison to AS, more interventions were performed under GA (2.4 vs. 1.7). The duration of ERCP under GA was 25 min prolonged (GA vs. AS: 59 vs. 34 min). All ERCP performed under GA were successful, whereas 2 examinations under AS had to be terminated prematuraly due to inadequate sedation. The endoscopic procedure was not impaired by monitoring, oral intubation, mechanical ventilation and supine position. Discussion: Although more extensive ERCP interventions were performed, and the duration of ERCP under GA requieres more time compared to AS, recovery time did not differ. There were no complications due to the anesthetic procedure. GA allows a successful and safe completion of difficult ERCPs.

Incidence of Low Back Pain after General Anesthesia in Supine Position

Incidence of Low Back Pain after General Anesthesia in Supine Position