Anaesthetic Problems Research Articles

A Comparative Study between Intrathecal Clonidine and Neostigmine with Intrathecal Bupivacaine for Lower Abdominal Surgeries

Lower abdominal surgeries like hernioplasty, abdominal hysterectomy are commonly performed surgeries. Providing good analgesia with adequate muscle relaxation during intra operative period and managing pain in the post operative period is a good practice of anaesthesia. As pain influences the morbidity and mortality of the patients, it’s important to ease pain due to surgery for better outcome of the patients. Commonly, lower abdominal surgeries are performed under spinal anaesthesia, as it is easy to perform, single shot technique when compared to epidural anaesthesia and general anaesthesia. But the main problem of spinal anaesthesia is that postoperative analgesia lasts only for considerable period. This study is conducted to analyse the effect of adding additives 50 μ of neostigmine and 50 μ of clonidine to 0.5% hyperbaric bupivacaine and evaluating the duration of postoperative analgesia with each drug and the intraoperative haemodynamic stability in patients undergoing lower abdominal surgeries.

Perioperative adverse respiratory events in overweight and obese children

Overweight and obesity are increasing problems in pediatric anesthesia. This observational study was designed to examine how airway-related complications occur in overweight children and adolescents during general anesthesia and if this is arelevant problem in Germany. From October 2008 until August 2009, at the university clinic in Leipzig, 504 in- and outpatients, aged 2-18years, ASAI-III, undergoing elective procedures (ENT and pediatric surgery), were observed. With the aid of special data sheets, the following parameters were determined: Mallampati Score, difficult mask ventilation and intubation, use of a Guedel/Wendl tube, Cormack-Lehane Score, number of intubation attempts, airway obstructions (broncho- and laryngospasms), coughing as a sign of airway irritation, and decreases in oxygen saturation >10 %. Overweight and obese children had asignificantly higher Mallampati Score and asignificantly higher prevalence of coughing (p< 0.05). None of the other parameters showed any significant differences between the groups. However, the incidence of desaturation was 9.5 % in overweight children and 6.3 % in children of normal weight, and that of airway obstructions was 4.1 vs 2.7 %. This study demonstrated avery low incidence of respiratory problems, which may be caused by the low proportion of morbidly obese children and the older age of overweight children in comparison with other studies.

Developmental problems in patients with oesophageal atresia: a longitudinal follow-up study

ObjectiveTo longitudinally evaluate motor development and predictive factors in school-age children with oesophageal atresia.DesignCohort study with prospective longitudinal follow-up.SettingOutpatient clinic of a tertiary university paediatric hospital.PatientsChildren with oesophageal atresia born...

Single-Stage Posterolateral Transpedicular Approach With 360-Degree Stabilization and Vertebrectomy in Primary and Metastatic Tumors of the Spine

Currently, anterior, posterior, or combined approaches are used in various spinal disorders; however, a single-stage posterolateral transpedicular approach with 360° stabilization and vertebrectomy provides better results for spinal tumors. We evaluated the age, sex distribution, presenting symptoms, neurologic examination findings according to the pre- and postoperative Frankel classification, pre- and postoperative VAS pain scores, preoperatively administered medical therapies, pre- and postoperative corset use, level of the lesion, levels of previous surgical interventions, root ligation (if performed), results of the primary disease, hospitalization duration (after the operation), postoperative complications (if any), postoperative follow-up duration, and postoperative survival duration of 22 patients. We observed that primary bone tumors were localized in the lumbar (75%) and thoracic regions (25%) and that metastatic tumors were localized in the thoracic (77.78%) and lumbar regions (22.22%). The VAS and Frankel scores of the 22 patients who were included in the study revealed that this surgical treatment modality was associated with statistically significant improvements in test scores (P < 0.001). No ribcage dislocation was observed. In 1 patient (4.54%), a neurologic deficit developed. Two patients (9.09%) required revision because of screw malposition. In spinal tumors, 360° fusion performed via a posterolateral approach is a less risky, relatively safe, and less invasive method. This method, which reduces the risks of anesthesia and internal problems and decreases cost, is an essential technique for decreasing hospitalization duration, improving pain levels, and achieving faster mobilization and faster initiation of radiotherapy and chemotherapy.

Comparison of the landmark and ultrasound methods in cesarean sections performed under spinal anesthesia on obese pregnants

Difficulties in the palpation of anatomical landmarks in pregnancy due to obesity may create problems in the regional anaesthesia. Objective of this study was to compare ultrasound examination carried out before the procedure with conventional spinal anaesthesia method with papation of bony landmarks in caesarean sections performed under spinal anaesthesia in obese pregnants. Ninety-seven obese pregnants having pre- and post-pregnancy body mass index > 30 kg/m2 were prospectively examined. Patients were randomised to two groups as landmark group (n = 49) and ultrasound group (n = 48). The needle insertion point was determined at L4–L5 level before the procedure through palpation in the landmark group and with the examination in the ultrasound. The numbers of skin punctures and needle passes, total procedure time (TPT) and spinal block occurrence time (SBOT) were recorded. TPT was significantly longer in the ultrasound than in the landmark group (p < 0.001) (8 ± 2 and 5 ± 1; respectively). Whereas SBOT values were similar (p = 0.063). The numbers of skin punctures and needle passes were significantly fewer in the ultrasound than in the landmark group (p < 0.001). We believe that, accurate determination of the needle introducing site before the procedure by viewing the vertebral structures through ultrasound examination in obese pregnants could increase the success rate.

Feasibility of day case surgery in ENT

A variety of surgical procedures in otolaryngology are treated as day case surgery. The patients are screened and selected before giving an appointment for certain surgical procedures. There are well-established criterions for suitability of day case surgery. In this study 500 patients were interviewed to see the suitability for day case surgery. A Combination of domestic problems, anesthesia problems, and inability to co-op with day case surgery criterion are discussed. Design: It is s prospective study. Place and duration of study: This study was conducted at ENT Department of Lahore General Hospital Lahore. From January 2000 to June 2002. Subjects &amp; Methods: A Performs was filled after interviewing the patients to see the suitability for day case surgery. The problems of patients, who were unable to fulfill the criteria, are discussed in detail. Results: This study proves that more than 85% of patients are not suitable for day case surgery in our setup. Conclusion: Day case surgery is not feasible in patients coming from rural areas.

Successful Anaesthetic Management of Elderly Patients with Leprosy.

Leprosy is a chronic granulomatous infection that is caused by Mycobacterium leprae (1), wherein autonomic function is affected to varying degrees, and the important manifestations of such a dysfunction include orthostatic hypotension, baroreflex dysfunction and postprandial hypotension (2). Patients with leprosy have impaired respiratory function, breath holding time and response to cough (3). Hence, anaesthesiologists should be aware of complications, including difficult intubation and perioperative anaesthetic problems, in the management of patients with leprosy. Herein we present a case of a patient with leprosy having a transtrochanteric femur fracture who was successfully operated under spinal anaesthesia. A 70-year-old male patient with lepromatous leprosy, Parkinson’s disease and coronary artery disease was scheduled for a surgical repair of a transtrochanteric fracture of the femur. The patient was a known case of lepromatous leprosy for at least 2 years and received 100 mg dapsone per day po. The patient was symptomatic for cardiovascular disease. Preoperative electrocardiogram (ECG) revealed sinus rhythm, complete left bundle branch block and inferior wall ischaemia. Echocardiography revealed an ejection fraction of 50% with left ventricular diastolic dysfunction. After explaining the procedure and the risks involved to the patient, written informed consent was obtained. In the operating room, ECG, non-invasive blood pressure (NIBP) and pulse oximetry were attached and baseline parameters were noted. An 18-G intravenous cannula was secured. Preoperative heart rate was 90/min, blood pressure was 170/100 mm Hg, respiratory rate was 22/min and SpO2 (on room air) was 90%. An 18-G epidural catheter was inserted via the L3-L4 space with the patient in the left lateral position using midline approach and fixed at 11 cm. At the same level, 15 mg of 0.5% heavy bupivacaine was administered in the subarachnoid space using a 25-G Quincke’s spinal needle. Supplemented oxygen was administered via a venturi facemask (FiO2 0.5). A sensory loss up to T7 level was achieved with adequate motor paralysis after 9 min, and surgery was then initiated. ECG, NIBP and SpO2 were monitored. No complication was developed during operation. Leprosy is an uncommon disease in developed countries. A literature review suggests that there is limited information regarding the surgical management of patients with leprosy. During the course of leprosy, cell-mediated immunity reduces because of a decline in T-cell responses (4). In addition, patients with leprosy may have cardiac and respiratory dysautonomia and autonomic involvement. Therefore, proper pre-anaesthetic assessment and optimization with intraoperative period, adequate monitoring and preparation are essential while managing patients with leprosy. In our patient with leprosy, the other risk factor was advanced age. However, no adverse events were observed in the intra- and postoperative period. In conclusion, anaesthesiologists can use both spinal and epidural anaesthesia in elderly patients with leprosy.

A comparative study of intrathecal 0.5% hyperbaric bupivacaine with dexmedetomidine and 0.5% hyperbaric bupivacaine with fentanyl for lower abdominal surgeries

Background Adjuvants are added to improve the quality, to accelerate the onset of action and to overcome the problems of spinal anaesthesia. Depending on the purpose various adjuvants like morphine, fentanyl, clonidine, midazolam and dexmedetomidine are added. Adjuvants are administered by various routes like epidural, intrathecal and intravenous. Materials and methods Following detailed pre-anesthetic check-up, patients were randomised into 2 groups in a sealed envelope, Group D received 2.5ml of 0.5% hyperbaric bupivacaine with 5µg dexmedetomidine and Group F received 2.5ml of 0.5% hyperbaric bupivacaine with 25µg fentanyl. Subarachnoid block was given between L3-L4 space with 25G Quincke spinal needle under aseptic precautions after free and clear flow of CSF in sitting posture. Onset of action, level of blockade, sedation score, duration of analgesia, adverse effects and hemodynamics were monitored. The first rescue analgesia was given when Visual Analogue Scale (VAS) was >4. Results In our study dexmedetomidine provided better sensory block, motor block and longer duration of analgesia. The highest sensory level achievedby group D 6(4 – 8) and in group F was 8(6-10)(p 0.05). Conclusion We conclude that dexmedetomidine may be used as an alternate to fentanyl for intrathecal use and it may find a place forregular use in clinical practice.

Invariant based control of induction and maintenance phases for anesthesia

Abstract: Set theory and invariant sets are the key ingredients used in this paper to address the control problem of general anesthesia. Both the induction phase, corresponding to the administration of an open-loop bolus dose, and the maintenance phase of the depth of hypnosis during the surgical operation are considered. The obtained control results to emulate the multi-phase control law used in practice.

ACUTE APPENDICITIS

Objectives: The objective of this study was to compare the efficacy of ClinicalEvaluation and modified Alvarado scoring system in diagnosing acute appendicitis. StudyDesign: Cross sectional study. Place and Duration of Study: This study was conducted atSurgical Unit III of Civil Hospital Karachi from May 2010 to October 2010. Methodology: Thisstudy consisted of eighty patients. Patients were divided in two groups. Group A for completeclinical evaluation comprising of 40 patients and Group B for modified Alvarado scoring systemcomprising of 40 patients. Inclusion criteria were all patients presenting with RIF pain, nausea,vomiting, fever and/or anorexia, diagnosed as having acute appendicitis preoperatively andundergoing emergency appendectomy during this period, age &gt;12 years and both gender.Exclusion criteria included not willing for surgery, General anesthesia problem, pregnant femalepatients and those who did not give written consent. Results: A total of 80 patients were includedin the study, placed alternatively into two groups of 40 patients each with majority being male(n = 61, 76.3%). The mean age was 22.46 years. The positive predictive value for patients ofGroup A was 92.5% while for Group B was 77.5%. When diagnostic accuracy was compared onthe basis of Gender for the two groups, the positive predictive value for male patients of GroupA and B was 90.09% and 89.28% respectively, but for females the positive predictive valueof Group A and B was 100% and 50% respectively. Conclusion: We conclude that modifiedAlvarado score can be used safely and effectively in diagnosing acute appendicitis in adultmales especially as the score increases from seven to nine.

Prevention of sevoflurane agitation in children undergoing congenital hernia repair, impact of adding dexmedetomidine to caudal analgesia

BackgroundPostoperative agitation is a common problem in pediatric sevoflurane-based anesthesia. Dexmedetomidine has been described as a safe, long acting and effective additive in many anesthetic and analgesic techniques. The aim of present study was to evaluate the effect of adding dexmedetomidine to caudal lidocaine in sevoflurane-based anesthesia on the incidence and severity of emergency agitation (EA) in children after surgical repair of congenital hernia.Patients and methodsA total of 48 pediatric patients aged 18–38 months ASA I, II scheduled for congenital hernia surgery were randomly enrolled into 2 groups: Group L patients (n = 24) received 1% lidocaine 0.7 ml kg, while Group D patients (n = 24) received 1% lidocaine 0.7 ml kg + dexmedetomidine 2 μg/kg. Postoperatively, emergency agitation and modified Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) scores were observed and recorded.ResultsThe current study showed that the incidence and severity of agitation and modified CHEOPS scores were significantly lower in group D compared to group L. Also occurrence of EA in patients in group D was significantly lower.ConclusionThe present study suggested that use of dexmedetomidine in addition to lidocaine was effective to control emergency agitation after sevoflurane anesthesia.

Sugammadex Use in a Patient with Wolff-Parkinson-White (WPW) Syndrome.

Wolff-Parkinson-White (WPW) syndrome is a disease associated with episodes of supraventricular tachycardia and ventricular pre-excitation or atrial fibrillation. WPW is characterized by an aberrant electrical conduction pathway between atria and ventricles. The major anesthetic problem connected with WPW syndrome is the risk of tachyarrhythmias due to accessory pathway. Therefore, it has been proposed that the aim of anesthetic management should be the avoidance of tachyarrhythmia and sympathetic stimulation. Sugammadex was administered as a neuromuscular reversal agent in this case. To our knowledge, this is the first case report of sugammadex use in a patient with WPW. This report presents a case of general anesthesia management in a patient with WPW syndrome. We think that it is appropriate to use sugammadex to reverse rocuronium for the prevention of sudden hemodynamic changes in patients with WPW who underwent general anesthesia.

Neonatal surgical care: a review of the burden, progress and challenges in sub-Saharan Africa

The outcome of neonatal surgery has significantly improved over the decades in high-income countries. In sub-Saharan Africa (SSA), however, it has lagged behind. This is a review of the current state of neonatal surgery in SSA. The conditions requiring surgery in the newborn are largely congenital but the rate of emergency surgery is high, reaching 40% of all neonatal surgery in some settings. Most operations are for intestinal obstruction, commonly owing to anorectal malformations and intestinal atresia, as well as abdominal wall defects. Many of the patients are delivered outside a hospital facility and often present or are referred late and are very ill at time of presentation. The morbidity following surgery is high, particularly from surgical site infections and respiratory problems. Mortality is high, sometimes reaching 45%, but has decreased in recent times. Because of a lack of trained paediatric anaesthetists, anaesthesia is often problematic and surgery is sometimes undertaken using a local anaesthetic. Further care, including bowel management and orthopaedic and neurological rehabilitation, are sub-optimal owing to a lack of appropriately trained personnel and financial constraints. While the number of paediatric surgeons has increased, there are still few anaesthetists. In order to significantly improve the outcome for neonates with surgical problems in SSA, paediatric surgery, anaesthesia, neonatology and neonatal nursing capacity need to be scaled up and fast-tracked. To make neonatal surgery safer in these settings, neonatal intensive care facilities need to be provided and improved.

An urgent call to the labour ward

Obstetric anaesthetists’ primary role in the maternity unit is the provision of anaesthesia and analgesia to women in labour and who require Caesarean delivery. In addition, they are essential members of the multidisciplinary team who will assist with the management of the various types of emergency that can arise in the maternity unit. Emergencies in the maternity unit may arise as a result of obstetric, anaesthetic, or general medical problems and there is no widely recognized classification or definition for these situations. Emergency problems in obstetric patients pose a unique set of challenges: these situations are generally rare, so even experienced clinicians may only have limited experience; obstetric units are frequently geographically remote, so clinicians may be working in unfamiliar surroundings and lastly obstetric patients are generally fit and healthy, so, faced with a physiological insult, will initially compensate, before deteriorating precipitously, prompting an urgent call for help. The emergencies that may lead to an urgent call to labour ward are summarized in Figure 1. Maternal collapse is the generic term that may be used to describe the endpoint of a variety of clinical problems. It is defined as ‘an acute event involving the cardiorespiratory systems and/or brain resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to 6 weeks postdelivery’. Maternal collapse may arise as a result of pregnancy-related conditions, pre-existing disease, or co-incidentally during pregnancy. As with all patients, the aide memoire four Hs and four Ts (Hypoxia, Hypovolaemia, Hypothermia, Hypoor hyper-kalaemia/-magnesaemia/-calcaemia, Thromboembolism, Toxins, Tamponade, Tensionpneumothorax) can be used to classify common causes of collapse in pregnancy, with the addition of eclampsia and intracranial haemorrhage (Fig. 2).

Rapid dissolution of propofol emulsions under sink conditions

PurposePain accompanying intravenous injections of propofol is a major problem in anesthesia. Pain is ascribed to the interaction of propofol with the local vasculature and could be impacted by rapid dissolution of the emulsion formulation to release the drug. In this paper, we measure the dissolution of propofol emulsions including the commercial formulation Diprivan®. MethodsWe image the turbidity of blood protein sink solutions after emulsions are injected. The images are digitized, and the drug release times are estimated from the pixel intensity data for a range of starting emulsion droplet size. Drug release times are compared to a mechanistic model. ResultsAfter injection, pixel intensity or turbidity decreases due to reductions in emulsion droplet size. Drug release times can still be measured even if the emulsion does not completely dissolve such as with Diprivan®. Both pure propofol emulsions and Diprivan® release drug very rapidly (under five seconds). Reducing emulsion droplet size significantly increases the drug release rate. Drug release times observed are slightly longer than the model prediction likely due to imperfect mixing. ConclusionsDrug release from emulsions occurs very rapidly after injection. This could be a contributing factor to pain on injection of propofol emulsions.

Validation of the Apfel scoring system for identification of High-risk patients for PONV

Background and Aims: Postoperative nausea and vomiting (PONV) still present an important problem in anesthesia. In order to identify surgical patients who may benefit from prophylactic antiemetic medication, it is of interest to evaluate the risk factors for PONV using a simple scoring system. The simplified Apfel score includes four factors: female gender, nonsmoking status, postoperative use of opioids, and previous history of PONV or motion sickness. Each of these risk factors is supposed to elevate the incidence of PONV by about 20%. The aim of this study was to validate Apfel's clinical risk assessment score for identification of patients with high risk for PONV in our hospital. Materials and Methods: In a prospective study, 150 patients posted for various elective surgeries under general anesthesia with endotracheal intubation were analyzed and grouped into five groups, based on the Apfel risk scoring system. Each risk was given a score of 1, the total score being 4. PONV was monitored for 24 h and classified as grades 0, 1, and 2. Grades 1 and 2 were considered as PONV. The results obtained were analyzed for total incidence of PONV in each group of Apfel's scores and they were compared with the predicted incidence of PONV as per the documented Apfel's risk assessment. Collected data were analyzed by the Chi-square test, and the scoring system was assessed for sensitivity and specificity. Results: Of the 150 patients assessed, a total of 42% had PONV. Patients grouped under Apfel Score I had PONV incidence of 25.5%, the group with Score II had an incidence of 37.8%, the group with Score III had 64.6%, and the group with Score IV had 83.3%. This incidence of PONV corresponded to the predicted approximate values of 20% for Apfel Score I, 40% for Apfel II, 60% for Apfel III, and 80% for Apfel IV. Conclusions: The Apfel scoring system is simple and useful for identifying patients with high risk for PONV.

Twenty Weeks Pregnancy with Giant Cyst: Anesthesia Problem and Perioperative Preparation

Twenty Weeks Pregnancy with Giant Cyst: Anesthesia Problem and Perioperative Preparation

Addition of magnesium sulfate to caudal block for preventing emergence agitation in sevoflurane-based anesthesia in children

Background Postoperative emergence agitation (EA) is still a problem in sevoflurane-based anesthesia in children. Among the solutions of this problem is giving caudal anesthesia during operations in the lower half of the body. The aim of this study was to evaluate the addition of magnesium sulfate to bupivacaine in caudal block for the prevention of EA. Materials and methods In this prospective, randomized, double-blind study, 80 children aged 1-6 years, ASA I, undergoing unilateral hernia repair/orchiopexy with sevoflurane-based anesthesia were allocated into one of two groups: either bupivacaine 1 ml/kg 0.25% plus magnesium 50 mg (BM group) or bupivacaine 1 ml/kg 0.25% (B group) received in caudal block. EA was evaluated in both groups using the Pediatric Anesthesia Emergence Delirium scale and Aono's scale. The sedation score, the recovery time, and the occurrence of complications were assessed during the stay in the postanesthesia care unit. Results Only 72 children completed the study (36 in each group). There was a statistically significant difference in the Pediatric Anesthesia Emergence Delirium scale, the value being lower in the BM group than in the B group at 5 min [6 (5-17) compared with 8 (5-18)] ( P P P = 0.003). The sedation score was significantly higher in the BM group than in the B group at 15 min ( P = 0.001). In contrast, the duration of motor block after operation was similar in both groups. Conclusion The use of caudal magnesium sulfate (50 mg) combined with bupivacaine 0.25% was effective in reducing postoperative EA in preschool children undergoing hernia repair/orchiopexy procedures.

Anesthetic management in a newborn infant with Larsen syndrome undergoing closure of patent ductus arteriosus: Case Report

Larsen syndrome is a rare inherited embryonic connective tissue disorder characterized by facial dysmorphisms, congenital joint dislocations of the hips, knees and elbows, and deformities of the hands and feet and multi-system involvement includes musculoskeletal, respiratory, cardiovascular, and neurological systems. There are a wide variety of congenital and acquired cardiac abnormalities that are found similar to those seen in Marfan’s syndrome due to these abnormalities and functional limitations; there are potential anesthetic problems. We report the anesthetic management of a newborn infant with Larsen syndrome undergoing closure of patent ductus arteriosus.

Appropriate anesthesia regimen to control sevoflurane-induced emergence agitation in children; propofol-lidocaine and thiopental sodium-lidocaine: a randomized controlled trial.

Background:Emergence Agitation (EA) is a common problem in pediatric anesthesia. The current study evaluated the effect of intravenous lidocaine combined with propofol or thiopental sodium to control EA by sevoflurane in children.Objectives:The current study aimed to compare the effectiveness of two anesthesia regimen propofol–lidocaine and thiopental sodium lidocaine to control sevoflurane-induced emergence agitation in children.Patients and Methods:The study enrolled 120 children aged 12 to 36 months with retinoblastoma who underwent induction of anesthesia with sevoflurane for Eye Examination Under Anesthesia (EUA). Sampling was done at Rasoul-Akram Hospital in Tehran, Iran. The subjects were randomly assigned into four groups including: group one (thiopental sodium-lidocaine [TL]), group two (thiopental sodium-saline [TS]), group three (propofol-lidocaine [PL]), and group four (propofol-saline [PS]). Emergence agitation was assessed by using a five-point scoring scale, every 10 minutes during the first 30 minutes after admission to the recovery room.Results:EA occurred in 24 cases (20%) of children. Incidence of EA in the TS, TL, PS, and PL groups were 21 (70%), 2 (6.7%), 1 (3.3%), and 0 (0%), respectively (P < 0.001). Nausea and vomiting after anesthesia did not occur in any of the patients. After removal of the endotracheal tube, laryngospasm complication occurrence in the TS group (10 cases) was higher than the other groups and no statistically significant difference was observed (P = 0.1).Conclusions:Propofol–lidocaine anesthesia regimen was more effective to control the pediatric emergence agitation than the other combinations.