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PREVIOUS QUERIES AND RESPONSES Archive- Page1 Click for: Recent Q&A Page, Archive Q&A: Page- 4, 3, 2 |
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Query (Asked by Dr Merin Thomas from Kottayam, Kerala) Will a single dose of tramadol at a dose of 1 mg/kg given at the end of caesarian section produce any problem to the baby due to drug transfer via breast milk? |
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Response by Dr. Mary Korula One dose tramadol I/V or I/M at the end of Caesarian section should cause no problem with lactation as the concentration in the colostrum will be very little. Many centres give morphine and pethidine infusions for immediate post-op pain relief and even PCA morphine. Epidural pethidine infusions without local anaesthetics are commonly used post-operatively to avoid feeding problems in the baby as also intrathecal morphine. So I don't think it is a contraindication but it is well worth letting the neonatologist know its been given in case there happens to be a problem later. |
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Query (Asked by Dr Rajendra from Delhi) what is the best ventilatory strategy in ARDS open lung concept/low tidal volume, high respiratory rate. Do you want to maintain critical PEEP till you plan to wean or reduce it if your target in reducing FiO2 is reached |
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Response by Dr. Manimala Rao The low TV with high rate and optimal PEEP is the most commonly used strategy. The alveoli have to be recruited in a matter of an hour or two. Adequate preload and mean arterial pressure is very essential for applying peep. If recruitment is not possible or lung injury score is more than 3 then trying pressure controlled ventilation is better early than late. Use of fluid challenges, dopamine to keep up the MAP using the pressure volume loops are ideal to recruit lung at the earliest. Once the goals of recruitment are reached namely PaO2 > 70 SpO2 >90 and we are able to bring down the FiO2 to 60% then one has to stabilize the patient and keep the recruitment . The weaning protocols are different in the sense that we shift to SIMV or asst control at the earliest. As the lung parenchyma show improvement then I wean the SIMV rate keeping the PEEP at the same level. As the patients chest x-ray as well as the blood gasses improve, we reduce the peep and the pressure support and finally extubate after they meet the extubation criterion. |
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Query (Asked by Dr Abdelkader Hijazi from Riyadh, Saudi Arabia) Is ketamine useful in contracting floppy uterus? |
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Response by Dr. Anjan Trikha Ketamine has no role to play for treatment of floppy uterus after LSCS or otherwise. Ketamine can increase the tone of a pregnant uterus early in pregnancy but at term this effect is not seen. |
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Query (Asked by Dr Anlol Saikia from Guwahati) What are your personal views on the use of intrathecal clonidine? Do you think it is worth the combination with bupivacaine for prolonging post operative analgesia and improving the quality of analgesia? Where can this drug be procured from in India? |
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Response by Dr. Anjan Trikha I / T clonidine is used and can be used for prolonging analgesia. I have used it for labour analgesia intrathecally along with bupivacaine followed by continuous epidural with bupivacaine and fentanyl, CSE - Walking Epidurals. You can not get it in India. |
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Query (Asked by Dr Yashwant Verma from Shimla) What is the ideal concentration and volume for thoracic epidural anaesthesia in thoracic surgery |
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Response by Dr. Anjan Trikha For thoracic epidural with GA for intra op and post op analgesia I would use bupivacaine along with fentanyl. Intraoperatively 0.125% to 0.25 % mixed with fentanyl 2 micro gram per ml and the total volume would depend upon the segments that need to be blocked. For post op analgesia I would use 0.125% with 2 microgram per ml of fentanyl, the volume would vary but usually 8 - 15 ml per hour. |
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Query (Asked by Dr Shamik Nandi from Kolkata ) What is 'neostigmine resistant curarisation'? |
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Response by Dr. Manimala Rao The term neostigmine resistant curarisation was used in the early sixties when patients did not recover from curare. There was less understanding of the various factors which affected the neuromuscular block. It commonly used to be seen in patients with intestinal obstruction. later it was realized it was due to acidosis, hypokalemia hypomagnesemia hypothermia are few factors to name. When the causes were analyzed why there is resistance to reversal with neostigmine the above two causes stood out prominently. With advent of train of four and understanding of various factors which prolong the non depolarizing block the term no longer has much significance. the main thing one should understand when a block is prolonged is to identify various factors which could be responsible. |
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Query (Asked by Dr. Satish from Bangalore) How common is right ventricular infarction? Can we have some guidelines for the management of this problem? |
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Response by Dr. Yatin Mehta Right ventricular infarction is not uncommon. We are more concerned about RV dysfunction or failure during the perioperative period which is more difficult to manage. This is obviously more common with right coronary art. disease maybe with pulmonary hypertension [RV afterload] and poor RV myocardial preservation. As such anatomically and hence functionally right ventricle is less suited to handle sudden increases in afterload. With retrograde cardioplegia right ventricular preservation is poor. Principles of management are reduction of rt. vent. afterload and maintenance of cardiac output. Tradionally increasing the preload is recommended but excessive increase in that would further compromise RV subendocardial perfusion and worsen failure. Also septal shift would affect left vent. performance. Following steps may help in reducing RV aferload: 1.Pulmonary vasodilators like NTG, SNP, NO, Phenoxybenzamine, or sildenafil in chronic situations. 2.Hyperoxia or at least avoidance of hypoxia. 3. avoid hypercapnia or preferably maintain hypocapnia. 4. Correct or avoid acidosis. 5.Avoid high airway pressures. 6 Diuretics. 7.Inodilators like Amrinone, Milrinone or Dobutamine. In worst case scenario IABP or RVAD may buy some time. |
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Query (Asked by Dr Abhay Patwari from kuwait ) A 2 yr old unpremedicated child, ASA I, underwent elective circumcision under O2+N2O+ sevoflurane-LMA, spontaneous respiration + penile block with bupivacaine+ 250 mg paracetamol suppository. He inhaled 8% sevoflurane for 1-2 minutes followed by 1.5-2% sevo until the end of surgery. The whole procedure lasted for 10 minutes and was uneventful. child was monitored using standard monitors. the child did not regain consciousness for nearly 90 minutes after which the child awakened and cried. Have you encountered any case of such delayed recovery after a short exposure to sevoflurane (10 minutes)? Do you have any explanation for this case? |
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Response by Dr. Manimala Rao I have gone through literature and asked quite a few anaesthesiologists regarding delayed recovery after sevoflurane anaesthesia. I did not get any wiser,as this particular anaesthetic is known for its brevity of action. May be the child must have some enzyme dysfunction or highly sensitive to anesthetic which is rather rare for inhalation anaesthetics. If by mistake any other medication was administered as a suppository or does he have a defect of g6pd enzyme where all anesthetics can be prolonged. I am unable to enlighten you further on this. |
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Query (Asked by R Swaan from Amritsar) What complications do you anticipate in a patient of traumatic diaphragmatic hernia preop, intrap and postop.? How should we stabilize the patient preoperatively and what is the anaesthetic management of such patients? Please send some references also. |
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Response by Dr. Mary Korula Rupture of the diaphragm occurs in about 5% of patients sustaining severe blunt trauma to the trunk. It can be difficult to diagnose initially. Approximately 75% of ruptures occur on the left side. The stomach or colon commonly herniates into the chest & may strangulate. Sometimes even the spleen, liver & the whole of the gut herniates into the chest causing severe ventilatory embarrassment. Severe hemorrhage hemothorax, pneumothorax, leading to tension pneumothorax due to lung injury or bowel rupture can occur. In penetrating injuries, both the left and right sides can be affected. Elevation of the hemi-diaphragm should raise suspicion. A chest drain tube is inserted on the side of chest affected making sure it does not penetrate the bowel while doing so. Death is usually due to other injuries- neurological, lung, cardiac or abdominal. Signs and symptoms detected during the secondary survey may include: Diminished breath sounds on the ipsilateral side, Pain in the chest and abdomen, Respiratory distress, Bowel sounds in the chest, Injuries to chest, ribs & other organs. Investigations required: X-ray, CT scan & barium meals. Diagnostic peritoneal lavages are routinely done and if the lavage fluid escapes through the chest drain then a diagnosis of diaphragmatic rupture is made. Diagnosis can be made on a plain radiograph (elevated hemidiaphragm, gas bubbles above the diaphragm, shift of mediastinum to the opposite side, nasogastric tube in the chest) the definitive diagnosis is made by instilling contrast media through the nasogastric tube & repeating the radiograph. Once the patient is stabilized, investigated as in any other trauma, optimized & fluid & electrolyte balance achieved, the diaphragm will need surgical repair usually through an emergency laparotomy. The most important concern is an obstructed & strangulated bowel if herniation occurs, immediate surgery to bring the contents back to the abdomen and to expand the lungs which may be compressed. The smaller the tear the bigger the chances of obstruction. If this happens treat it as any intestinal obstruction case. Aspiration pneumonitis can occur. All patients are considered to be full stomachs & anti-aspiration measures are mandatory. Some people even employ inhalational & spontaneous ventilation techniques to prevent bowel distension & further respiratory embarrassment. Gentle assisted ventilation should be fine. Nitrous oxide is best avoided and air substituted. Chronic cases would need time for lung expansion and adequate ventilation. Sometimes a thoracotomy may be required in incarcerated bowels, one lung ventilation & problems with this should be anticipated. Post –op complications: wound infection, abscess & pneumonia. Post-op ICU care & ventilatory support may be needed. References: Any Std Critical care book 1.Miller L. Benett EV et al. Management of penetrating and blunt diaphragmatic injury. J trauma 1984;24;403, 2.Brown GL.Richardson JD. Traumatic diaphragmatic hernia- a continuing challenge. Ann Thoracic Surg 1985:39:170, 3.Anaesth Intens Care 2001 :29:292, 4. Injury 2001:32;153, 5.J thoracic Cardiovasc surg 1986:92:989. |
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Query (Asked by Pat Childress from Kansas, USA) Husband given bupivacaine injection prior to shoulder surgery, had cardiac arrest. He did survive was on respirator etc until overdose out of system. Now has sixth nerve palsy since three weeks after incident continuing now for three months. Is this due to the overdose? Is it permanent? MRI shows no damage. It was resident giving the block, misplaced the needle please help we are scared to death like waiting for something to happen to him. |
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Response by Dr. Anjan Trikha The information is incomplete. Is the 6th nerve palsy subsequent to the cardiac arrest or after 3 weeks of the arrest? If the 6th nerve palsy is subsequent to the cardiac arrest and the subsequent CPR and after three months of the incidence it has shown no signs of improvement it is very unlikely that it is going to improve. However if the nerve palsy has occurred later on, then the etiology for the same needs to be found out. The patient needs to be re assured that nothing catastrophic is likely to follow after three months of a successful management of Cardiac arrest. Isolated neurological deficits are not uncommon after such scenarios. |
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Query (Asked by Dr S. K. Laxman from Calicut ) Any opinion or experience regarding use of intrathecal neostigmine as an adjuvant in caesarian sections for postoperstive analgesia. |
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Response by Dr. Anjan Trikha I personally think it is of no use specially when one takes into consideration the side effects - nausea , vomiting, bradycardia and restlessness. The advantage gained is minimal as far as analgesia is concerned and the same can be taken care of with safer medications as paracetamol and volteron suppositories. Post operative Cesar pain is not very tough to treat. I am sure intrathecal neostigmine would never come into routine practice. |
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Query (Asked by Dr Vasudha from Chennai) I want to know about open heart surgery under thoracic epidural. What happens to negative thoracic pressure? How the patient will breath after thoracotomy? |
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Response by Dr. Yatin Mehta It is a problem! But is it LIMA can be taken down without opening the left pleura. If accidentally the pleura opens then the left lung collapses and the diaphragmatic movement become excessive and hamper the surgeon's work. We have used BIPAP / CPAP i.e NIPPV to circumvent this problem. If the pleural hole is small, surgeon can put in a chest tube (pleural tube) and close the hole. Overall it is not a very comfortable situation for anyone. |
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Query (Asked by Dr Saroj pattnaik from Chennai) How to calculate lean body mass? (eg. a 25 yr old pt. wt 110 kg, height 1.6 meter) |
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Response by Dr. Manimala Rao The lean body mass is calculated by dividing the body weight in pounds by height in inches. 25 year old 110kg=242 lbs, 1.6metrs=5feet 3inches; 242/5.3=45.0 the BMI for this person is 42.5 which is categorized obese. The lean body mass calculator is available on the web. |
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Query (Asked by Dr Swati from Bangalore) Can we give spinal anaesthesia in a cerebral palsy patient (adult patient for hip prostheses)? |
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Response by Dr. Mary Korula Spinal Anaesthesia and other regional techniques are not contraindicated in Cerebral Palsy (CP) patients even in children. In fact they are highly recommended especially in lower limb surgery or dorsal rhizotomy where patients are susceptible to severe muscle spasms post-operatively. A recent study however showed CP patients may have abnormalities of coagulation factor levels. So probably a coagulation workup may be required if doubtful. Also there are different varieties of CP-Spastic, Dyskinetic, Ataxic and Mixed. Though its a non-progressive central disorder of motion and posture, they have additional disabilities too- cognitive impairment, seizure disorders, communication and behavioral disturbances. These may make regional anaesthesia alone difficult, some sort of heavy sedation would also be required. Spasticity and rigidity becomes severe with age, contractures may make positioning for GA and intravenous access difficult. Dystonia, chorea, athetosis, head tremor, difficulty in balancing may make preoperative preparation difficult. Poor communication can increase post-op muscle spasms and pain. GI Reflux, Respiratory disorders, control of epilepsy should all be taken into consideration before rendering the regional anesthetic which remains a good option in these patients. |
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Query (Asked by Dr Anand Tiwari from Pune) After how many days osmotic diuretic be tapered in head injury patient? Should we perform serum osmolarity before tapering and omitting mannitol in each head injury patient? |
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Response by Dr. H. H. Dash Tapering of antiedema measures are carried out following clinical as well as CT scan examination. Once the pts condition improves antiedema measures are discontinued. In ideal situation during antiedema treatment one must monitor the electrolytes along with osmolality of blood. |
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Query (Asked by Rajesh Shah from Surendranagar) I use 2.5ml inj Bupivacaine 0.5%+ 7.5cc distill water for labour analgesia in first stage of labour in supine position and in second stage of labour I give it in sitting position. I introduce catheter for 3-4 cm cephalic through 18 g needle at L3-4 space. Am I correct in my technique? For how long should I keep the pt sitting up? I have to repeat the dose frequently. |
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Response by Dr. Anjan Trikha I personally will use 13-17 ml of 0.125% bupivacaine with 2 mg/ml of fentanyl for the first stage of labour and if inadequate would repeat another 10-15 ml in the subsequent 15-30 minutes in graded doses and while monitoring the vitals and fetal heart. The concentration used by Dr Shah is 0.125 but the volume is less. I personally never make the patient sit up. Subsequent doses too are 5-10 ml on sos basis in case I am not using an infusion pump. For the second stage I increase the volume to about 15 - 20 ml and if this inadequate I increase the concentration to 0.25%, 5 ml. In an event of instrumentation delivery one needs to give 0.5% of the bupivacine solution 5-10 ml preceded by about 1 liter of Normal saline intravenously. His technique is fine provided he is satisfied with the results. I can imagine the difficulty he may face in getting fentanyl but it would be worth the trouble and he can charge more if he in practice. I would advise him to go for CSE technique To cut on cost he could use a sequential injections. |
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Query (Asked by Saroj Pattnaik from Chennai) What will be the size of the reservoir bag for a patient, 500ml,1lit or 2lit for example a child of 20kg in closed circuit manual ventilation how to determine ? |
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Response by Dr. Anjan Trikha This is slightly tricky as there in no literature available on this and I myself am not aware of any details on this. The thumb rule is that the reservoir bag must have a capacity of two to three times the tidal volume which needs to be given for pediatric patients. Ventilation with the bag should monitor the airway pressure/etco2/chest expansion. There are no studies where the capacity of the reservoir bag has been correlated with the body weight of the patient. One has to maintain normocarbia, O2 saturation and most important keep a watch on the airway pressure. |
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Query (Asked by Jerry Joseph from Doha, Qatar ) A 45 yr old male patient,wt:94 kg, with history of surgery for gastric banding (done 8 months ago, when the patient was 146kgs) was posted for para-umbilical hernia repair. All the vital signs recorded were stable. On the previous day of surgery, a pre-anesthesia evaluation was done and overnight fasting (10hours)was recommended. Premedication was with Ranitidine 300 mg and Diazepam 10mgs at night and Metoclopramide 10mgs on the morning of surg. When in OR, immediately after induction with Propofol and Fentanyl, patient regurgitated food. It was well formed food. Immediate bronchoscopy was done, procedure postponed and patient shifted for ICU care. Can you let me know the current fasting guidelines for patients who had surgical gastric banding. |
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Response by Dr. Manimala Rao The patient referred here is 45 year old 96 kg had banding surgery and posted for umbilical hernia repair. He has fasted for 10 hours but still regurgitated formed food. The usual guidelines for such individuals who are obese as well as having some obstruction with umbilical hernia is 12 hours. With obesity still a problem, banding surgery already performed and the moderate obstruction associated with presence of umbilical hernia one should consider this patient as full stomach. All precautions have been taken. However it may be prudent to fast him at least 12 hours and give soft semi solid diet to avoid ketosis. The other thing one can think of is passing a ryles tube and aspirate before induction and take it out, Then a rapid sequence induction can be planned provided the airway assessment does not require any other interventions. I could not get any definite fasting guidelines for such patient. |
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Query (Asked by J John from Oswestry, UK ) Do any of the authors have experience with ketamine in the inrathecal space as an adjuvant to bupivacaine for spinals. How long does the analgesia last and what side effects may be expected. Do you need to use a preservative free preparation? |
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Response by Dr. Anjan Trikha Yes I have used intrathecal and epidural ketamine as adjuvants with bupivacaine for neuraxial blocks. Personally I had found no advantage to do so and an added disadvantage was high incidence of strange, uncomfortable feelings that the patients complained of. I had used preservative free ketamine and the dose used was 20 - 25 mg of normal ketamine. S - isomer of ketamine is not available in India till date. Ideally preservative free ketamine is to be used. The duration of the sensory block too does not show any change. Side effects that may be seen are - sedation, dizziness, nystagmus, and nausea and vomiting. The total dose of bupivacaine can be reduced if intrathecal ketamine is being used - local anesthetic sparing effect - but no advantage was seen as far as post operative analgesia was concerned. Lately I have used ketamine intrathecal in two cases of CRPS for chronic pain as boluses but the results were not very encouraging as far as pain alleviation is concerned. |
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Query (Asked by Dr Derek Rosen from Launceston, Australia ) In managing a patient with an acute intracerebral haemorrhage (and evidence of increased ICP on CT, midline shift) what SBP or Mean arterial pressure range do you aim for? Particularly if you are unable to monitor the ICP and thus CPP? |
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Response by Dr. H. H. Dash In presence of an intracerebral haematoma with midline shift and raised ICP - First line of treatment is to evacuate the haematoma. The SBP has to be maintained above 90 mm of Hg so as to maintain adequate perfusion. This will also help in minimizing ischaemia. Once the cause of intracerebral haematoma has been identified and effectively treated then one can go for hypertensive therapy. In this one should try to achieve a SBP and MBP of 20 to 30 percent higher than the basal recording so as to achieve good neurological recovery. |
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Query (Asked by Dr Shamik Nandi from Kolkata ) We don't have any device to measure depth of anaesthesia in our institution. But we want to carry out studies on anaesthetic awareness. Is it possible? If so what will be the most ideal method of determining awareness? |
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Response by Dr. Mary Korula None of the monitors available nor clinical scoring scales are completely reliable in assessing the depth of anaesthesia. Care should be exercised when interpreting results especially when multiple agents are used for hypnosis. Opioids can also modify response. We have used the Isolated forearm technique to determine awareness in LSCS patients long ago. Before giving muscle relaxants, isolate one arm by a BP cuff raised well over the patients systolic pressure, so that the arm is not paralysed and the patient can indicate she is awake and aware when you ask her to respond during anaesthesia. It is assumed that loss of response to voice corresponds to lack of awareness which may not always be the case. Lower Esophageal contractions are thought to increase and correlate to depth of anaesthesia, so also heart rate variability which is decreased with increasing depth, in fact there is a special monitor for this. The PRST score –Patient Response to Surgical Stimulus is based on autonomic changes and used as an index of depth of anaesthesia.0 indicates no awareness and 8 –light anaesthesia. (Ref: PG issue on Monitoring by Kaul et al in IJA 2003, & Asian Archives of Anaesthesiology & Resuscitation- April 2005 by Pramod Kumar.) OCULOMICROTREMOR MONITORING (OMT): Oculomicrotremor or high frequency eye tremor is a physiological tremor of the eye present in all subjects and is related to the tonic activity in brainstem oculomotor neurons. It has been shown OMT correlates with level of consciousness. OMT is suppressed by thiopentone, propofol and sevoflurane. It is measured by a piezo-electric strain gauge technique. The probe was earlier placed on the anaesthetised sclera, now-a-days it can be placed on the closed eyelid too. End-tidal sevoflurane from 1-2% did not decrease OMT nor decrease BIS though it showed a falling trend. When compared to BIS, OMT may exclude an aware patient more accurately than BIS, though the graded measure of emergence was seen to be better with BIS. The hysteresis effect was also seen with OMT as with BIS. OMT tended to remain depressed until just before the first response to verbal command hence it may be more useful as an awareness monitor than a depth monitor. (BJA 2002:89:551-5) To prevent awareness: -Check machine, delivery of volatile agents, -Consider Premedication with amnesics, -Administer adequate induction agents, -Avoid muscle paralysis unless required or partial paralysis if necessary, -At least 0.6MAC with N2O anaesthesia/ 0.8-1 MAC with volatile agents alone, -Develop awarensss monitors & use them wherever possible. Always remember, "Awareness with analgesia is regrettable, but Awareness with pain is unforgivable” Once awareness occurs, don’t try to evade the issue- the best options are to Verify the event > Sympathise > Explain > Reassure > Apologise and offer psychological support if necessary. It has been shown that supportive measures at the time of awareness will help minimize and cope with the stressful situation later on, like providing feedback and reassurance during the period of intra-anaesthetic awareness. |
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Query (Asked by Dr Shobha Pareek from Jodhpur ) A 25yr female presented in ER 37wks pregnancy APH BP70mm systolic, pulse 48/min. C/O severe chest pain and numbness& inability to lift rt leg. Chest X ray& ECG were found to be normal. Pt was given 1litre of crystalloid & her BP now was 120/80mm pulse96/min. Now there was no chest pain &she could move her leg also nearly 1hr after admission. All blood reports were WNL (Hb10g%&PCV28%).Pt was taken for LSCS at 11am. Induction with pento+scoline+intubation with COETT NO7 maintenance with O2+isoflurane+fentanyl+inj atracurium. Pt remained stable intra op &was extubated at spontaneous respiration. Fully conscious well oriented. Shifted to ward with stable vitals at 12pm.U/O was also adequate. There was frantic call from the resident in the ward, pt crashed while feeding the baby with help of nurse who called resident when she saw pt gasping suddenly at 6pm.her BP at5.30pm was 130/80mm. she was intubated after the cardiac arrest at 6pm CPR was done for 1hr but no response. Do the pre op conditions correlate with post op sequence? how do we explain the mortality? |
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Response by Dr. Anjan Trikha Very atypical presentation. But still indicates some kind of thromboembolic phenomenon. No details have been mentioned regarding any other medical history / medications, was the patient a booked case with ANC clinic or not. Did she have any history of DVT in the past / cardiac valvular disease or any S/S of TIA. Was she on beta blockers? Her neuorological symptoms too are atypical and can be only explained by a vasospastic neurological disease. Her improvement after 1 liter of fluid to normal BP is also strange as, if the cause of the hypotension was active bleed it should not have responded so dramatically to just 1 liter of fluid. Strange to have APH and 10 g% of HB and HCt of 28 after 1 liter of fluid. It seems that she developed respiratory distress followed by collapse after six hours of LSCS. these findings can only be explained by a thromboembolic event. Therefore any valvular disease or peripheral vascular disease could have caused such symptoms. Strangely enough if the patient had no past history then she should have been revived if help was immediately available. massive pulmonary embolism may be responsible for the inability to be revived. In conclusion I think that such symptoms and chain of events can partially be explained by an embolic etiology. However the presentation is atypical. It would have been worthwhile to do a autopsy but I can well imagine that such things are impossible in India. Such a report is worth reporting in an international journal. |
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Query (Asked by Dr Jaisree Gopinath from Thrissur ) Have you ever come across bilateral parotitis after general anaesthesia? If, so what could be the probable course of infection? |
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Response by Dr.
Manimala Rao Parotitis after G.A is reported infrequently. Post
anaesthesia parotitis occurs rarely, is a self limiting entity. Usually
seen in 24 hours. Could be due to multifactorial aetiology. Occurs
frequently after endoscopic procedures. It could be bacterial in origin
when the oral hygiene is improper. Increase in serum amylase levels are
noted in the post anaesthesia parotitis. It could be due to oedema and
saliva retention. It is also considered as acute post operative parotitis
induced during anesthesia induction by luxation of TM joint. |
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Query (Asked by Dr Shamik Nandi from Kolkata) What is narcotrend? Is it different from BIS? What is new in measuring depth of anaesthesia? |
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Response by Dr. Mary Korula NARCOTREND MONITOR : This is another EEG derived monitor which performs automated analysis of the EEG during anaesthesia (Hannover, Germany). Kugler et al in 1981 first described a 6 letter classification with 14 substages which was modified by Schultz et al for the Narcotrend system. So you have A-F components where A represents an awake patient and F denotes burst suppression. • A=awake, • B0-2=sedated, • C0-2=light anaesthesia, • D0-2=General Anaesthesia, • E0,1=GA with deep hypnosis, • F0,1-GA with burst suppression. With this system, stages D and E were aimed at during steady state anaesthesia, B and C should be avoided, F unnecessarily deep . This is different from the BIS monitor, here 2 easily available ECG electrodes are placed on the patients forehead and a third as the reference electrode. BIS when compared to NARCOTREND approximates: • BIS ~ 100-85=A & B levels of the Narcotrend system, • BIS ~ 65-40=D & E levels, • BIS ~ 50-60=C1 & D0 levels. Studies involving BIS and Narcotrend have both shown a reduction in recovery times by about 60% and reduction in drug consumption by 26% using these. PATIENT STATE ANALYSER (PSA 4000) is another depth or awareness monitor, which is also EEG derived colour coded Patient Safety Index recorded on a scale of 0-100.Green colour indicates the hypnotic state and comes in the 25-50 PSI range. Yellow indicates deep hypnosis and involves an index below 25.Blue indicates burst suppression and white indicates artifacts which PSA 4000 has identified and discarded. The main advantages claimed with this system is there is little interference with cautery, electromagnetic operating systems and noise pollution. • Green (25-50)=hypnotic state, • Yellow (<25)=deep hypnosis, • Blue (low)=burst suppression, • White (artifacts)=discarded Among the evoked potential monitors, AUDITORY EVOKED POTENTIALS (AEP) are used for monitoring depth of anaesthesia. The AEP monitor is claimed to be faster and simpler than BIS monitoring. We also have the latest ENTROPY MONITOR for monitoring depth of anaesthesia. The modules are available from Datex Ohmeda. Last years IJA July issue gives a review article on Awareness and depth monitors by me. Please look it up! There are other monitors also available but clinically they may not be useful in the OR. References: (1).Anaesthesiology 2002; 18 (supple 24) ;24, (2).Anaesthesiology 2003:99;34-41. (3). Anaesthesiology 2002;97:82-9, (4).BJA 1997;78:180-4 |
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Query (Asked
by Dr M. Aich from kolkata) As in India we do not have scavenging
system in OT and we cannot measure the amount of |
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Response by Dr. Anjan Trikha This is a big issue that has never been addressed in developing / third world countries. All the data and figures regarding chronic exposure of anesthetic agents and gasses are from the west where there are scavenging system and air circulations and exhaust of OT air is ensured. I am not aware of any Indian study that has addressed this. Personally speaking I am sure that chronic exposure among pregnant women anesthesiologist gives rise to a higher incidence of abortions. I have no study to support this. |
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Query (Asked by Dr Vandana Tak from Delhi) Systemic Lupus Erythromatosis and Anaesthesia |
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Response by Dr. Manimala Rao SLE is a multisystem inflammatory disease of unknown etiology. It is an auto immune disease without specific mechanism. Number of drugs have been implicated namely hydralazine, carbamazepine, phenytoin, and methyldopa in its development. Clinical features are varied and diverse. Arthritis, cutaneous manifestations and renal involvement are a few to name. The last one is the cause of significant morbidity and mortality. Anemia, leukopenia ,and thrombocytopenia are common. When CNS is involved it can manifest as seizures, neuropathies paralysis and cerebro vascular accidents. The cardio vascular system manifests with cardiomegaly secondary to hypertension, anemia, uremia or CAD. Or it can be due to cardiomyopathy secondary to direct involvement of the cardiac muscle. Mitral regurgitation can be present due to non infectious endocarditis. Pulmonary function usually gives a picture of restrictive defect A thorough pre op assessment is mandatory The necessary investigations pertaining to system involvement have to be ordered and evaluated .The drugs taken by the patient have to be thoroughly evaluated in the matter of both their effects on the anesthetic as well as on the organ dysfunction. Most of the patients are on corticosteroids. It is necessary to start the correct dosage and continue. The heart and kidney function has to be assessed and anesthetic technique chosen according to the need of the individual patient and type of surgical procedure .Post operative oxygen therapy invasive or non invasive ventilation in the post operative period must be kept in mind. There are no specific contraindications to type of anaesthesia, it should be tailored to the needs of the individual patient to the degree of organ involvement and their dysfunction . |
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Query (Asked by Dr Nitya Nand Kumar from Patna) Comparison of epidural tramadol & buprenorphine for postop pain. |
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Response by Dr. Mary Korula Buprenorphine is a partial agonist opioid with analgesic potency 33 times as morphine. Its affinity for mu receptors is 50 times greater than morphine causing prolonged action and resistance to reversal with naloxone. Placed in the epidural space, the high lipid solubility (5 times that of morphine) limits cephalic spread and likelihood of delayed depression of ventilation. Its advantage is the long duration of action, even upto 24 hours along with bupivacaine. The disadvantage is the ceiling effect & other adverse effects including urinary retention. All the adverse effects of opioids are as severe as morphine and may be prolonged and resistant to naloxone. It has been safely used in children via caudal routes but monitoring for 24 hrs is required. In a study done in our institution, comparing bupivacaine & bupivicaine with 3 mgms/kg of buprenorphine via caudals in children, upto 24 hrs analgesia was achieved without any major complications. Tramadol is a centrally acting synthetic opioid which causes weak activation of both central pain inhibitory mechanisms - the opioid as well as descending monoaminergic system, resulting in potentiation of anaesthesia with mild systemic effects. Given epidurally it is found to be 1:30 as potent as morphine. The usual single shot epidural dose is 50mg .The duration of action with bupivacaine is not consistent and varies from 2 - 8hrs. The side effects like nausea and vomiting are higher. Anti-emetics are frequently required. In a study comparing pethidine and tramadol done in our institution, the incidence of this was nearly double than with pethidine 20%vs40% so also urinary retention which was the same as pethidine. Sedation and respiratory depression is not a problem usually. CVS stability is maintained. Substance abuse has not been a problem with tramadol. Continuous infusions have not become popular due to the vomiting potential inspite of the lack of respiratory complications which would have made it suitable in a ward setup. With the availability of better, more potent shorter acting opioids like fentanyl, sufentanil & remifentanyl for continuous infusions which afford greater controllability, the popularity of tramadol & buprenorphine have decreased. But in developing countries, where infusion pumps & PCA pumps are still not available in many centres, single shot epidurals with these are still good cost effective alternatives. |
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Query (Asked by B. Kala from Chennai ) An 80 year male with trochantric fracture for DHS surgery. Problems-IHD (sorbitrate qid), Diabetic (metformin40-od), Hypertensive (ramipril 2.5od, asprin, altzor) Parkinson (syndopa110-tds).Surgery under spinal. Sensorcain 2.5ml.Now developed multiple focal cerebral infarct, post operative psychosis. Pl discuss management & comments regarding anaesthesia |
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Response by Dr. Mary Korula I would also have opted for a spinal or epidural anaesthesia ,most probably a combined- CSE to decrease any severe hypotension if the patient is only on low dose aspirin and for post-op analgesia. I presume the drug used was plain sensorcaine in the spinal. Adjuvant like ketamine can cause post-op delirium especially in the above 60 yr old group. Post op psychosis may be a part of his borderline brain disease process combined with a little ischemia due to lack of autoregulation or either hypotension or embolus during the surgery. Remember being a diabetic, his Autonomic Nervous System may not be intact to adapt quickly to changes in pressure which may be manifested as decreased cerebral blood flow. Defined Cerebral infarcts without respiratory system manifestations are uncommon with fat embolus which is the first complication we should consider in these cases. If this is so, V/Q studies and lung scans can give you a clue. Pulmonary embolism should be treated with thrombolytics but here in this case its tricky to start if there is any evidence of intra cerebral bleed. So a brain CT scan and MRI would have to be done to rule out this and also for any evidence of infarct and edema. Usually this is started only after 48hrs.If there is evidence of edema of brain, then anti edema measures will have to be instituted. Supportive measures as ensuring adequate airway and ventilation, hydration and ensuring adequate cerebral perfusion pressures are essential. Generalised poorly localised infarcts can occur with severe ischemia due to spinal hypotension or systemic embolisation from any of the vessels considering his age. Triple H therapy, Hypervolemic, hypertensive, hemodilution instituted for cerebral aneurysms or SAH may be useful to maintain cerebral blood flow and perfusion pressures, taking into consideration his urinary status. Transient episodes of psychosis and small infarcts resolve with adequate support in ICU, electrolyte management and small doses of antipsychotics. Major cerebral infarcts may need intervention if serial Scans don't show any improvement with supportive therapy. |
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Query (Asked by Abdelmoneim Ibrahim from Sudan) What is the anaesthetic management of patients with portal hypertension due to periportal fibrosis (2ry to bilharziasis) presented for elective splenectomy and gastric devascularization. |
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Response by Dr. Mary Korula Patients undergoing procedures for liver diseases are extremely ill, morbidity and mortality after surgery being very high. The effects of surgery & anaesthesia on splanchnic & hepatic circulation & hepatic function determine the final outcome. The main considerations should be the portal hypertension, variceal bleeding & the effects of ascitis. 60-80% of portal blood may be systemically shunted away from the liver. A high percentage of patients have increased blood volume & cardiac index with low SVR, decreased response to catecholamines, decreased renal blood flow, decreased albumin & oncotic pressure which can all compound the complications associated with the procedure. Splenomegaly with hypersplenism is frequently associated but does not correlate with the degree of portal hypertension. Thrombocytopenia, coagulopathy & excessive bleeding, cholestasis & associated hyperbilirubinemia, decreased hepatic blood flow causing decreased drug elimination and decreased albumin leading to increased free levels of potent anesthetic drugs causing more side-effects and toxicity should be considered. Renal hypoperfusion, causing hepato-renal syndrome is a major post-op complication. Meticulous volume and fluid management & invasive monitoring like CVP and PAP estimations may be warranted. These patients can have pre-op hypoglycemia persisting intra-operatively needing continuous replacements. Serial prothrombin estimations and liver function tests are required. Adequate plasma and platelet concentrates should be given preop and arranged pre-operatively for surgery. Vitamin K is also frequently used. Exaggerated fibrinolysis may occur- thrombo-elastographic study and aminocaproic acid in extreme cases may be arranged. Hepatopulmonary syndrome, a high diaphragm and pleural effusion associated with ascitis leads to atelectasis and V/Q mismatches. Thoracic pressures will increase leading to decreased venous return and added ventilation problems. Pre-operatively, investigations including ECGs, X rays, full blood picture and Liver and renal function tests are mandatory. Pre-op transfusion and replacement of coagulation factors are essential. Premedication should be with drugs not very affected by liver dysfunction and may be given in smaller doses if required. Intra-op, all general anaesthetics cause a dose related reduction in hepatic blood flow, halothane more than isoflurane. Regional anaesthesia can decrease liver blood flow if arterial pressures are allowed to fall drastically. Excessive sedation and triggering of hepatic encephalopathy can occur in borderline patients, hence drugs have to be carefully titrated intra-op. Post-op ICU & ventilatory care is usually required for a few days. Some sort of elective shunting may be required in some of these patients at a later stage. |
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Query (Asked by Usha Gopinath from Thrissur) Description about arterial transducers; zeroing; how many days can be kept; how to interpret. |
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Response by Dr. Manimala Rao Measurement of pressure waves in arteries require their transmission to a device which converts the mechanical energy into electrical signals. Components consists of intravascular catheter, fluid filled tubing, electromechanical transducer, an electronic analyzer storage and display system. The dynamic response of a pressure measurement system is characterised by its natural frequency and its damping. This can be demonstrated by snapping the end of the tubing with a finger which results in oscillations above and below the base line (natural frequency) and quickly decays to a straight line and this is due to friction developed in the system and is referred as damping. Longer the transducer tubing lower the natural frequency and cause of the errors. The optimal degree of damping is that which counterbalances the effects of transducer tubing systems with the lower natural frequencies. In an inadequately damped system the base line will be reached after one oscillation and in an over damped system the base line will be reached after a delay with out oscillation. The function of transducer is to convert the mechanical forces into electrical currant or voltage. Most transducers are of resistance type. Pairs of resistances are incorporated into the arms of Wheatstone bridge. Most modern disposable transducers have a silicon diaphragm into which the resistance elements have been etched. Modern transducers have eliminated many of the difficulties caused by frequent recalibration and drifting of the zero point. The major practical problem with transducing system remains is the improper zeroing relative to the patient. One has to zero at the staring to a reference point. It is usually the mid axillary line corresponding to left atrium. The system may have to be zeroed again when necessary. Most modern equipment is designed to analyse and display pressure information. It consists of a computerised system that handles several tasks such as acquisition and display of pressure signals, numerical values for SBP, DBP, MAP, alarm functions data signals etc. The wave forms and numbers are displayed. Flush systems- The arterial catheter should be kept patent all the time with continuous infusion of heparinised solution 1-3 ml /hr . It minimizes the risk of thrombus formation and prolongs the usefulness of the catheter. Intermittent flush can be carried out when ever a sample is withdrawn. The arterial wave form provides a lot of information. The slope of the upstroke correlates with dp/dt gives information regarding myocardial contractility. Increase in SVR will increase the slope . The acute changes in BP associated with arrhythmias give visual estimates of hemodynamic consequences like the premature ventricular contractions. Hypovolemia shows large respiratory variations and narrowed pulse pressure. The more experience one gains with invasive tracing the more information one gets. |
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Query (Asked by Dr K T George from Cochin) We are doing lots of laparoscopic surgeries but surgeon does not want us to use nitrous oxide during GA we are using only O2 and opioids. Will it produce awareness? Advantage of O2 and air ? |
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Response by Dr. Manimala Rao Use of medical air and oxygen has become mandatory for the laparoscopic surgery. Any anaesthesia machine capable of delivering air and oxygen mixture is ideally suited. The use of only opioid and oxygen could lead to awareness. Addition of inhalation agent like iso or sevoflurane or in the non availability even halothane is recommended. Nitrous oxide is more soluble gas and it is not preferred when one distends the cavities. |
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Query (Asked by Rajesh Shah from Surendranagar) I am using pentothal 3-5mg/kg for sedation for CT Scan in pediatric patients. What is ideal sedation technique? I have heard of intranasal midazolam. |
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Response by Dr. Anjan Trikha Well there is nothing known as ideal sedation technique. One can use what is available and with what one is comfortable. Midazolam can be used intra nasally & has also been used orally. The doses are intra nasally 0.3 mg/kg & orally 0.5 mg/kg. I have personally used intra nasal route for radiotherapy in children. It is effective. However ketamine too is not bad. For radiotherapy I prefer it by IM route though after repeated doses the requirement may go up or the patient may need a bolus iv dose. For short procedures one could use any of the oral preparations of sedatives, though the effect may vary & I would personally use IV midazolam if the IV line is in. In children the main problem is an IV access & with EMLA not popular single shot IM ketamine may be better if ICP, and IOP are not an issue. I have used rectal thiopentone too - 35 - 45 mg / KG. I think for children the major concern should be IV access. |
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Query (Asked by Debsanjay from Jamshedpur) After premedicating the patient with midazolam, I have been regularly using Propofol (2 mg/kg) as a sole agent (combined with opioids to suppress the stress response) for intubation. In over 100 cases till date, I have faced no difficulties ever. Is such a practice of intubation without neuromuscular blockers advisable? I have been using it mostly in Tonsillectomies because it gives me more time for nasal intubation. Then I maintain the patients on a continuous infusion of propofol, nitrous and oxygen, and opioids. I would like to know if this combination is unscientific? |
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Response by Dr. Manimala Rao Propofol is used as induction agent and as sole anaesthetic. Combining it with opioids makes it very useful for intubation too. The dose used is fairly sufficient for the same. As you have done it in 100 cases shows that in your hands it is safe. It is no more unscientific to use propofol and opioids for intubating using the correct dosage. Propofol was not recommended in children but now it is being used in children above three years in a dosage of 4mg per kilo. Children require higher does ranges. It is FDA approved now. Propofol inhibits the laryngeal reflexes better than other induction agents. One has to be cautious regarding hypotension, bradycardia and respiratory depression. It may be better to monitor both Spo2 and Etco2 in these children undergoing tonsillectomy. It may be better to assist ventilation rather than to leave it totally spontaneous. It is not at all unscientific to use it in the proper dosage to avoid any untoward effects and keep a watch for the complications. Using 10% lignocaine spray for the nose after induction could be quite beneficial. |
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Query (Asked by Terence Kanfoush from USA) During hemiarthoplasty of shoulder, what IV drugs would normally be administered during the pre & intraoperative period. I am a nursing student & have observed this procedure, & now attempting to recount the experience. |
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Response by Dr. Mary Korula The question isn't quite clear. You probably want the sequence of I/v drugs we give perioperatively for induction & maintenance of anaesthesia. The 3 basic components of balanced anaesthesia are analgesia, unconsciousness & reflex suppression. Preoperatilvely, we can give analgesics like opioids & NSAIDs I/v for analgesia & sedation with midazolam to allay anxiety. Antiemetics & anticholinergics like atropine/glycopyrrolate may be given if necessary. Sleep is induced with drugs like thiopenthol sodium or propofol, followed by muscle relaxation for intubation with scholine or rocuronium & the airway secured with an endotracheal tube for ventilating the patient & preventing aspiration of gastric contents. Maintenance of relaxation can be with drugs like vecuronium or atracurium, analgesia is mainly by I/V opioids like morphine, fentanyl, remifentanyl or sufentanyl. IV NSAIDs like ketorolac & COX2 inhibitors are administered to decrease the dose of opioids and their side effects. At the end, muscle relaxant action is reversed by neostigmine with anticholinergics. Antiemetics are given to decrease incidence of PONV. In TIVA, sleep is maintained by agents like propofol infusions with opioid. Remember IV fluids like NS, RL, starches, gelatins, blood & blood products may all be required. |
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Query (Asked by George Joseph from Cochi) What are the possible complications of general anaesthesia in a 5yr old child with cerebral palsy and epilepsy, management & choice of drugs? |
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Response by Dr. Mary Korula Cerebral palsy (CP) is a nonprogressive central disorder of motion and posture due to some insult to the CNS perinatally. They can present with various symptoms according to the type of CP-Spastic, Dyskinetic, Ataxic or Mixed. Most of them have rigidity, epilepsy, cognitive impairment, communication problems & complications due to the disorder. Additionally, pseudobulbar palsy, dystonia, balance & speech impairment makes history taking difficult. They come for various surgeries like Nissen fundoplication, gastrostomy, oesophageal stricture dilatations, bronchiectasis, scoliosis, dorsal rhizotomy etc. Preoperative evaluation should include complete history (including H/O epilepsy & drugs) & physical examination. GI reflux is common leading to chronic respiratory problems like recurrent pneumonias and pulmonary aspiration aggravated by their inability to cough & reactive airway. Anticholinergics are recommended, with physiotherapy, steam inhalations & bronchodilators. Medical therapy includes Baclofen orally or intrathecally to reduce the spasm & pain. It has been implicated with delayed awakening, bradycardia & hypotension during anaesthesia. Overdose may be treated with flumazenil & respiratory support. Botox is indicated if spasticity interferes with routine functions. Potentiation of muscle relaxants is a possibility with this drug. Latex allergy is suspected especially if they are coming for multiple procedures. Latex free environment is indicated. Premedication with sedatives should be done cautiously due to poor pharyngeal coordination. Antacids, antiemetic, EMLA cream preop may all be useful. Induction & maintenance: Contractures and deformities makes positioning, iv access & preoxygenation difficult. Modified rapid sequence induction is a good option if GI reflux is present. They may be more sensitive to Succinyl Choline & resistant to nondepolarisers due to immobility and increased acetyl choline receptors. Combined RA & GA have been recommended wherever possible. MAC of inhalational agents is less. Hypothermia may be a problem; these kids should be actively warmed intra & postop. Surgeries are more extensive, blood losses are also more & a recent report says coagulation abnormalities are also higher in this group. Postoperative considerations: Irritability on emergence from anaesthesia is common. They also have severe pain; lack of communication worsens the issue. Postop muscle spasm pain can be relieved by epidural opioids. Clonidine might also help to decrease spasticity. Urinary retention is another problem. Delayed emergence can be due to hypothermia. Extubation & oral intake: only after full recovery of pharyngeal and laryngeal reflexes. References: 1. Linda J Mason. Anaesthetising the Pediatric patient with coexisting Disease. 2. ASA Refresher course lectures 2004:233;5. |
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Query (Asked by Soumya S V from Bangalore) What is the maximum dose of lignocaine 2% that can be given iv in 1hr. please mention in mg/kg body wt. |
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Response by Dr. Mary Korula Is this been given for pain relief or for ventricular arrhythmias?? Lignocaine I/V has been tried out for conditions like fibromyalgia and in neuropathy of cancer. In these cases normally they are not given as 2% solutions, but diluted in RL/NS. We know the recommended maximum doses for lignocaine are 3-4mg/kg weight, lignocaine with adrenaline 7mg/kg. There are 2 articles you can refer for this IJA 2000:46(5)360-64 BMC musculoskeletal disorders 2002:3:21 The max recommended dose here is 500mg/hr or max of 550mg in 500ml RL over 6hrs. There are other studies where this is given as infusions at the rate of 5-7mg/kg given over days at 1ml/hr claiming to give better pain relief by maintaining adequate blood levels. All this is done with full monitoring. The infusion should be stopped or rate decreased with any sign of lignocaine toxicity, bradycardia, hypotension etc. For Biers block you have to dilute it according to bodyweight and volume required. You generally give a 0.5%-1% concentration with volumes of 30-40ml one shot. According to Cote, in "A Practice of Anaesthesia for Pediatrics and Children" 1mg/kg/min for children is the dose quoted and in adults,50-100mg/min, not exceeding 5mg/kg or 2mg/kg followed by 15-50Ug/kg/min. Usually its given as 1% solution. Without an initial bolus dose, it takes 5 and 1/2 half lives to approach plateau concentration of lignocaine, so for lignocaine it would take 7and 1/2 hr infusion to achieve this. |
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Query (Asked by Dr. Haq Dad Durrani from DGKhan, Pakistan) For prolonged procedures, combined spinal epidural is recommended. But I think that epidural catheter in Subarachnoid space will be much more useful especially in elderly where chances of post dural puncture headache are minimal because 1)minimal doses, so no chance of toxicity due to accumulation of drugs. 2)no chance of inadvertent intravascular injection. 3) no chance of higher (epidural doses) doses of drug being given to subarachnoid space inadvertently. So minimal chances of high or total spinal. 4) almost immediate onset, if any complaint of inadequate block or regression of block. 5) no chance of patchy or inadvertent unilateral block. 6)useful in procedures where patient is on his side. 7) if catheter is placed for 2-3 days, fibrosis around the catheter causes narrowing of dural hole and subsequent closure. I need expert opinion regarding my suggestion. |
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Response by Dr. Anjan Trikha Well the points put forward are fine, but Dr Durrani ignores the fact that he is advocating puncturing the dura when it is really not required. No matter how rare may be the incidence of intrathecal infection, it is something that should be avoided at all cost. There is always a potential of infection with an intraspinal catheter. Also of concern is the duration one can keep the catheter in place for post operative pain relief. I personally even with spinal catheters shift my patients to the PACU and ensure that the catheter is taken out before the patient is shifted to the ward. THE PRIMARY CONCERN IS INFECTION The incidence of post spinal headache in older age group may be less with all this but HOW LESS IS LESS? The administration of medication intraspinally is always done by anesthesiologists and not nurses so this can be an issue where anesthesiologists have already been over stretched. Lastly when a device is available for intraspinal route - Macro Spinal Catheters - there is no reason for using the epidural catheter routinely for intraspinal placement. |
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Query (Asked by Jyothi Rao from Lodhivali, Raigad) A 27 year old male was involved in a two-wheeler traffic accident in the evening hours, sustained fracture shaft femur with a large wound on the medial aspect of the thigh, with both skin and muscle tissue loss which was oozing blood significantly despite pressure bandaging. During the night the patient had two episodes of hypoxia ( SP02 < 70 ) but recovered spontaneously within a few minutes of increasing the flow of oxygen (by face mask) from 4 to 6 liters per minute. There was no alteration of mental state, the patient was coherent and oriented at all times, there were no skin manifestations. The patient was deemed to be at risk of FES if not operated upon immediately. The blood loss was sufficient to bring his Hb fro a pre-injury 13.8 to 7.0 g/dl. One pint of blood was given pre-operatively. The patient was operated, on the second day of admission, under GA Induced with a sleep dose of IVP, Scoline 100 mg, IPPR with 100% oxygen, intubated with 8.5 OTCT, cuff inflated, maintained on N2O & O2 & halothane 0.8 brought down to 0.6 after 15 to 20 minutes, Pancuronium and Fenatnyl iv boluses as required, (total doses did not exceed 8 mg and 60 micrograms resply). The vital parameters were extremely stable throughout, no incidents of hypotension or tachycardia, SPO2 was 99 or 100,EtCO2 remained between 29 and 32. Patient was ventilated with Datex Ohmeda ventilator 15 breaths per minute and 500ml tidal volume. one pint of blood was given intraoperatively. Operative blood loss was about 200 ml. Patient was not extubated but kept on a Servo ventilator with similar settings but with addition of 5 cm PEEP. Postoperatively the patient suddenly developed DIC & almost immediately suffered a cardio-respiratory arrest on the 3rd day. What else could or should have been done? |
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Response by Dr. Manimala Rao You have done all that is possible in the setting of trauma. The patients of trauma are well known to develop ARDS and sepsis. The later is the late cause of mortality. Here the mortality happened on the third day and that to due to sudden cardiac arrest. The patient was on the ventilator. Did you rule out pneumothorax?. DIC is the natural course of either sepsis or trauma. One should look for it with investigations. I have not got any idea regarding the platelets or PT, APTT and FDP values. These give early warnings and can be treated with respective blood products viz platelet concentrates and FFP. These patients require invasive monitoring which I am sure that was done. The immune response is different in different persons. The balance is maintained with SIRS and compensatory anti inflammatory mechanisms. When this balance is tilted, it leads to immune suppression. You have done all that is essential for management. If you had watched for DIC and given the necessary blood products it would have helped to an extent. Though rare, We have seen mortality in this subset of patients despite all efforts. |
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Query (Asked by Sanjivini from Delhi) Is the same vial of midazolam which we use for intravenous, may be used for intra nasal and sublingual route? |
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Response by Dr. Mary Korula we have used the I/v preparation for premedication via nasal route as well as sublingual route. Nasal midaz is to be used in dose 0.5 mg/kg. The higher the conc the better, so we use the 5mg/ml preparation. Action comes on in 3-4 mins, peak action in 10mins and wears off by 20 mins. So induction should be done within this time. Parental separation seems to be better with this method. Rectal administration can also be done with the same preparation with a higher volume . Midazolam syrups can be made mixing this with paracetemol syrup to make it palatable. It is water soluble, so this is not difficult. |
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Query (Asked by Joseph Polinski from Sussex) I am trying to find a cleaner that is used to clean the transesophageal [TEE] probe. Can you provide any information regarding a suitable cleaner. |
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Response by Dr. Yatin Mehta We are cleaning the TEE probe with Cidex solution manufactured by Johnson & Johnson. |
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Query (Asked by Rajeev Kumar from Dehradun) Please tell me how can we warm irrigation fluids used during TURP with minimum expenditure |
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Response by Dr. Manimala Rao The best way to warm these fluids is to have a regular fluid warmer and keep them at body temperature. This will be a one time investment and may cost around 2-3 lakhs. The cheapest and alternative is to keep the plastic irrigating two liter packs in the steriliser used for the instruments and keep the water lukewarm that is around 34 to 35 degrees. This is being used in many places and is found to be economical and simple. |
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Query (Asked by S.P.Maharajan from Madurai) In a patient of hemophilia to be taken for dental extraction a) does extraction can be done under general anaesthesia and skilled anaesthetic care or is it contraindicated b) dose of lignocaine required for anaesthesia. Is it same as that for normal individual or varies? |
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Response by Dr.
Mary Korula No surgery or GA is contra-indicated in hemophiliacs.What
you are worried is the bleeding problem. In a tertiary care centre with a
good hematology department backup , this is not a major problem. What we
normally do is, these hemophilics are worked up and factor VIII levels
determined. The aim for minor surgeries like uncomplicated dental
extraction being atleast 20% activity. For major surgeries like open
dental workup, we need 80% factor activity. If these are not sufficiently
enough in the patient, we provide factor VIII concentrates about one hour
before surgery to cover for the surgery and the activity lasts for about 8
hours. If after surgery , there is any doubt, then levels can be
determined again and factor VIII replaced to adequate levels. The other
problem we should look for in these patients is factor VIII antibodies
which needs other treatment like topical thrombin and fibrin sealants or
glues etc to stop bleeding at the local sites. E-aminocaproic acid 50-75
mg /kg every 6 hrs and tranexamic acid 25 mg/ hr every 8hrs for 5days have
been used prophylactically before small procedures to decrease bleeding.
Bovine thrombin has been shown to initiate antibodies to thrombin,
fibrinogen and factor V and is not recommended any more. |
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Query (Asked by S.P.Maharajan from Madurai ) 1)how do you measure the length of the tube used for transpyloric feeding clinically? 2)which is best for bier's block-prilocaine or lignocaine? 3)does lignocine+ketorolac is used for intravenous regional anesthesia? |
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Response by Dr. Anjan Trikha 1) The best way is to place it under an image intensifier and in modern ICU I have seen it being done. A It is not advisable to measure the length of the tube clinically by noting the distance between mouth / nose and some specific point on the abdomen. Conventional methods of placement include turning the patient on the right side and the use of drugs that stimulate peristalsis to promote transpyloric passage. The same needs to be confirmed by an abdominal X rays. Special tubes with guide wires are available in India too for such placements and enteral feeding. 2) Prilocaine is the drug of choice for IVRA and not Lidocaine. World over Prilocaine is used and I my self have regularly used it for IVRA many times. It is less toxic and one need not wait for a long time as in lidocaine for deflating the tourniquet. 3) Yes U can use Ketrolac and Lidocaine for IVRA. About four years ago my PG had done a thesis on this itself. if interested I can send the results. |
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Query (Asked by Jagjiwan Singh from Delhi ) Are there any side effects of giving oral ephedrine to caesarian patients to prevent spinal block induced hypotension and how significant are they? |
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Response by Dr. Anjan Trikha I have never used it but yes it has been used in doses of 30 and 50 mg orally for preventing post spinal hypotension. There were reports in the literature regarding this. However I am not aware of its use in pregnant patients under going Sections. There should be no side effects as far as the fetus is concerned. I am also aware of its use in the epidural space for preventing hypotension after a spinal for caeserians. |
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Query (Asked by Theresa Alcantara from quezon city Philippines) Recently, a 34 y/o male was presented to our anesthesia section for possible thoracotomy left upper lobectomy due to persistent hemoptysis. He has situs inversus as diagnosed by chest x-ray and CT scan. Our dilemma is what tube to use in this patient. Would you recommend a DLT? If yes, should it be the left sided or right sided? How about a bronchial blocker? Note: we only have the Fogarty catheter, Univent and Arndt tube are not available. |
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Response by Dr. Manimala Rao Kartageners syndrome is part of ciliary dyskinesia syndrome charecterised by autosomal recessive pattern of inheritance but there is genetic heterogenicity. Bronchiectasis develops in child hood and is associated with recurrent pneumonias. It is a subset of the ciliary syndrome. In addition there is situs inversus, paranasal sinusitis and bronchiectasis. The case is rather rare and when presented with all the problems mentioned by you, it may be advisable to use a single lumen tube with a bronchial blocker. If one is definite, about the bronchial anatomy with the available CT scans one can venture on the double lumen tube in an adult patient. One can use left sided tube as is done in regularly Situs inversus is usually dextrocardia and the intestines. The lungs do not have a problem . It may be prudent to insert the fogarty under vision and use a single lumen tube. The reference quoted is from Paediatric Anaesthesia 13 (8), 714-717 doi: 10.1046 in which a child of 8 years is anaesthetized for the kartageners syndrome with single lumen tube uneventfully |
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Query (Asked by Sameer from Pune) When a vaporiser of inhalational agent is set at a particular concentration say 1% what does it mean in terms of MAC, meaning what mac value is achieved, how to calculate it? |
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Response by Dr. Manimala Rao The MAC value depicts the minimum alveolar concentration of the anaesthetic required to keep 50% subjects not responding to noxious stimuli at atmospheric pressure. It literally denotes the potency, that is you require that much of the concentration in the alveoli. It is always possible that what concentration we set on the dial may not be correct due to various reasons like a leak or the vaporizer not in working order etc. What is important is to understand the mac values of every anaesthetic agent and try to keep the end tidal levels nearer to that figure to maintain anaesthetic conc. That is how the endtidal values of inhalational agents along with CO2 have become an important monitoring during anaesthesia. The mac values decrease with use of N2O,opioids, hypoxia. Various noxious stimuli have been used other than skeletal muscle movement. A suggestion has been made that that the dose of anaesthetic preventing the response to noxious stimuli in 95% of subjectsAD95 more nearly approximates clinical anaesthetic requirement. For induction we may require higher mac values and maintenance we can come down to the minimum. Unless one has this monitoring we cannot say what mac the patient is getting by just using the percentage. In practice the conventional MAC must be exceeded by a factor of 1.25 –1.3 to assure surgical anaesthesia in most patients. The Mac awake is the the dose at which response to the command, open your eyes ouccurs. The alveolar concentration is approximately half of the regular MAC value. MAC bar is to block the adrenergic response. It is 1.5 times the standard MAC value. By knowing these one can safely understand the percentages set on the dial for induction and maintenance. |
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Query (Asked by Srikanth Reddy from Davangere) What is the expense or iantophoresis equipment. |
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Response by Dr. Mary Korula The Iontophor which is shown in the article is about 550 US dollars. Accessories and electrodes with drugs have to be taken separately depending on the site and cause, mainly used This is manufactured and marketed by LIFE -TECH and mainly used by rehabilitation. Any website on iontophor will give you all the details. There are cheaper iontophoretic machines available in India Dermatology India etc mainly for hyperhydrosis. These cost around Rs5ooo and available in Chennai etc. Hope these will help you. I know there are centres in India -Bombay where they use modified electrodes cotton drug soaked applicators etc to decrease cost. |
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Query (Asked by Sunoor Jain from Anand) a 30yrs/f, undergoing trans cervix resection of endometrial in Spinal. within 30min 3200ml of 1.5%glycine chloride was absorbed, pt. had cardiac arrest for 2min. & developed ARDS. Immediate intra op electrolyte: S.Na=106, S.K=3.1, S.Ca=6.4, S.Mg=1.1meq/l. Pt. revived & put on ventilatory support. over 2days electrolyte & fluid imbalance was gradually corrected, pt. extubated on 2nd post op day, maintaining spo2 100% on venti mask, inotrops removed, electrolytes became WNL, oral started, but pt. had s.alb=2.3, s.glob=0.3, sgot=243, sgpt=245, APTT C/T=14/22sec on 3rd post op day, kindly adv. cause & further treatment of deranged LFT. |
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Response by Dr. Mary Korula The probable diagnosis and cause for cardiac arrest here is air embolism. I wish we had more information about the pre-operative situation. Patient was lucky to have survived! It would have been nice to follow up the case and know what the sequelae is if possible. The usual cause of cardiac arrest following TCRE is embolus, mostly air, sometimes tumour embolus too! If the pressure system used for pushing fluid during the procedure is air-driven, there is every chance of this happening. A very careful watch is essential as once the fluid is over, air gets sucked in. The pressure required in these cases is much more than required for TURPs. Usually a hysteromat is used-this does not contain air. Even if the system is OK, as in TURP, veins are open and air can get sucked in from the exterior. Glycine can theoretically cause toxicity but not usually again at this dose . In TURPS we use higher doses but lesser pressures are enough. The initial electrolyte values show hemodilution which can occur with any fluid( 3.5L glycine) and hence very low electrolyte values. Cardiac problems can occur at those ranges mentioned. Arrhythmias with hyponatremia and hypokalemia are to be expected and if not treated promptly can cause cardiac arrests. The arrest would have caused a hypoxic state in which all the organs including the liver will be involved even though transiently. That's why the liver functions and enzymes are deranged, including the coagulation parameters. Systemic inflammatory response to an extent may also be responsible for this. Serum Albumin may have been low earlier, not sure whether LFT was done pre-operatively. From the history, it looks like the patient was improving, out of danger and will come out of the mishap without further sequelae. Supportive treatment is all that is now required with aggressive post-operative monitoring. The next set of investigations would have been normal, surely. TCRE needs some expertise, at one time it was very popular but now easier techniques have come in like Thermal Ablation which needs lesser skill. Avoid air driven fluid pushers in these type of cases in the future! High degree of suspicion and awareness, prompt intervention, intense monitoring including end tidal CO2 monitoring, inotropic and ventilatory support is all that we can do from the anaesthetic side. |
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Query (Asked by Shamik Nandi from Kolkata) Is it a good practice to tilt the head-end of the table downward to make spinal anaesthesia more effective? How far upward does the 'heavy' bupivacaine travel? What could be the consequences? |
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Response by Dr. Anjan Trikha I personally do not practice a head down tilt to make the spinal anesthesia MORE EFFECTIVE. To make the block denser and to avoid any patchy block addition of a opiate like fentanyl is advisable. The head down position for increasing the level of the spinal block can be tried. I personally do that some times. A 10 degree head down tilt can often increase the spinal block height by 1 to 2 dermatomes. The other implications on the head down tilt after the spinal are the blood pressure changes. It has been seen that hypotension following spinal can be marginally improved ( BP may increase ) after a 10 - 15 degree head down tilt after hypotension following spinal. However there is no role of prophylactically giving a head down tilt to avoid hypotension after spinal. Coming back to the question while using hyperbaric bupivacaine for spinal, a head down 10 degree tilt can increase the block by 1or 2 dermatomes. Hypothetically when a head down tilt is given an increase in block level may increase the fall in blood pressure. No controlled randomised trial as per my knowledge have published that have correlated all the three things - head down tilt greater than 10 - 15 degree, spinal block and the change in heart rate & blood pressure. |
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Query (Asked by Shamik Nandi from Kolkata) What is the current opinion regarding preloading with crystalloid in caesarean section under spinal anaesthesia? |
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Response by Dr. Anjan Trikha Pre loading with crystalloids prior to a caesar under spinal is one of those topics that would continue to be a tool for discussion. World over protocols at the delivery rooms are that a litre of crystalloid is infused prior to giving a block with a wide bored cannula and by the time the sympathetic block happens about a litre of fluid is already in. The same would be true in India. There are however a large number of Obs anaesthesiologists who would after giving the spinal also inject a small dose of ephedrine either bolus or in the infusion bag prophylactically to avoid any hypotension. If one sees the literature there are still no guidelines stating that crystalloids should be sparingly used prior to a spinal or colloids should be infused instead. Cost and allergy is an issue. There is data to support that colloids may be marginally better if not equally good for preloading but I have yet to come across a protocol of any hospital or an anesthesiologist who would use them routinely instead of crystalloids. There are also studies where ephedrine or mephentramine has been used prophylactically to avoid hypotension after spinal. BUT STILL THIS IS NOT A STANDARD RECOMMENDATION. Till the time such recommendations are made I think preloading with crystalloids prior to giving a spinal for caesar or for anything else should be practiced. It is totally upto the individual anesthetist if he would want to use a small dose of ephedrine or any such drug prophylactically. Personally I do not do so and continue to preload with crystalloids. There would be still a group of patients that would land up in hypotension and once the lateral tilt is given to prevent supine hypotension I would use a vaso pressor. IT IS OFTEN TAUGHT THAT ONE NEEDS TO CHASE THE THE BLOOD PRESSURE AND HEART RATE AFTER SPINAL AND TREAT THE FALLING TREND THAN TO WAIT FOR THE FALL TO TAKE PLACE. |
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Query (Asked by Dr. Sameer Jahagirdar from Pune) What is oculo-cardiac reflex, relex arc, role of atropine in its prevention and treatment, role of retrobulbar block in it's prevention. |
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Response by Dr. Manimala Rao Oculocardiac reflex was described in 1908 by Bernard Ashner and colleagues. It is triggered when pressure is applied to the globe or extra ocular muscles specially the medial rectus. The afferent limb is trigeminal and the efferent is vagus. The incidence is variable ranging from 16-82%.higher incidence is seen in paediatric population undergoing squint surgery. Severe bradycardia and various arrhythmias have been reported, including cardiac arrest. Glycopyrrolate and atopine are recommended for prevention or in the treatment when it occurs. The dose ranges from 0.01 -0.04mg per kg body weight. Retrobulbar block is also implicated in triggering the reflex. It blocks the afferent limb of the arc. Intavenous atropine is the standard treatment when it occurs. It can be given orally to prevent or bring down the incidence. Intraglossal atopine has found to be successful in reducing the incidence.(1) Peribulbar block has shown promise in reducing the incidence and complications. It gives post op analgesia, reduces nausea and vomiting.(2)In study which undertook to compare Various anaesthetic techniques have shown that ketamine was better in reducing the incidence of oculocardiac reflex(3) I do hope you got the answer in a nutshell References:1. Brit Journal of opthalmology 1975 vol 59 518-24 2. Deb k Paed Anaesth2001 march april (2) 161-67 3. Habnem k Paed Anaesth 2001 10 (6) 601-8 |
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Query (Asked by Dipanjan chatterjee from Cuttack) What is correct dose of butorphanol if used intrathecally with hyperbaric bupivacaine 0.5%, in ASA I/II patients? does it have any advantage over other opioid additives used intrathecally? Is it's use approved in India? Please let me know some published references in this regard. |
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Response by Dr. Manimala Rao Butorphanol is an opioid agonist and antagonist drug. Therefore it has ceiling for both analgesia and respiratory depression. I have myself not used the drug intrathecally. The intrathecal use at present is limited. The dosage which has given the best results is 0.8 mg. They found less respiratory depression pruritis in comparision to morphine. The analgesia is good but did not last that long as morhine. Higher or lower doses did not give any beneficial results. The work is mainly for its usage in patients undergoing caesarian section, for post op analgesia. Reference: anaesth analgesia 2000 91 601- 605. It may give you the necessary answers to some of the your queries. As far as my knowledge goes it is not approved in India for intrathecal use. |
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Query (Asked by Dr Waseem Rabbani from Multan Pakistan) Role of mannitol in head injury? mostly a free radical scavanger or to shrink brain?? |
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Response by Dr. H. H. Dash Mannitols usefulness in reducing brain bulk is due primarily to its hyperosmolality(20%soln-1280mosm\Kg) which will dehydrate brain tissue across an intact blood brain barrier (BBB). In addition it may further decrease ICP by reductions in CBV and rate of CSF formation. For the above reason mannitol is being used world over in patients with head injury(HI) to decrease intracranial hypertension. In severe HI however, it may not be useful because of severence of BBB. High dose Mannitol(2gm\Kg) has been used for brain protection in experimental animals via enhancing CBF and scavenging free radicals produced during episodes of neuronal damage. Human data are lacking. While using high dose mannitol one must remember its deleterious effect that is, it may cause pontine hemorrhage or myeline disruption. |
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Query (Asked by Dr Milind Bindu from Aurangabad) I am into private practice since last 8yrs. In recent past I encountered 3 episodes of pulmonary oedema. first one was a 6yrs old boy for DCR surgery under GA, i gave him pentothal + scoline ETT of 5.5 no cuffed inflated and maintained with O2+N2O+halothane+ pavulon 2mg top ups of 1mg and the anaesthesia time was around 1hr & just before reversal the patient started having resistance & then lot of secretions. i gave immediately around 40mg of lasix + inj aminophylline 200mg in drip+hydrocort 100mg + continued ventilation with same ETT and with top ups of pavulon after around 6hrs his secretion dried up and then i could extubate him and send him to post op room. preoperatively the patient had no medical illness & empty stomach. i would like to have your comments |
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Response by Dr. Manimala Rao Your case does not give much help. I think one of the causes for pulmonary oedema in the setting you have described could be the light anesthesia without any analgesic. You have not mentioned what his heart rate was. if the child got very high heart rates, one could expect the odema to occur. You have mentioned that the bag was tense at the end of the surgery. I am not sure what circuit you used for the child. If there was any mild kink or obstruction in the circuit it could lead to pulmpnary oedema .The drugs which you have used do not have any anaphylactic potential. But we should keep them in mind if you have used any starches or colloids during the procedure to cover the fluid loss. This is only a contention. If the boy had any upper respiratory infection in the recent past this could also give rise to reactive airways and cause inpissated secretion and could also lead to a problem. Any aspiration from the surgical site could also lead to pulmonary odema. these are a few of my way of looking at the aetiology. |
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Query (Asked by Dr Yash Javeri from Aligarh) Anaesthetic implications of biliary atresia in neonate with/without altered LFT |
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Response by Dr. Mary Korula Jaundice in the neonate and young infant is the most difficult and crucial diagnosis for the neonatologist to make. Of these, extrahepatic biliary atresia and neonatal hepatitis are the two major causes for conjugated hyperbilirubinemia. Both are due to pansclerosis during development of the duct and may continue to occur after birth. Neonatal hepatitis due to maldevelopment often leads to death while the extrahepatic biliary atresia is amenable to surgery - the Kasai procedure and has a good outcome if done before 10 weeks of life. Late diagnosis can lead to liver failure requiring liver transplantation. Intrahepatic biliary atresia may be associated with congenital heart disease too. These neonates are malnourished, septic and may require multiple interventions as for diagnostic procedures like liver biopsy, endoscopy, placement of central venous lines and Broviac catheters. Definitive procedures include portal enterostomies and liver transplantation if the initial correction is not done early enough. Coagulopathy and portal hypertension are often present. IV access may be a problem due to frequent blood sampling and intravenous therapies. Blood products like FFP for coagulation defects and adequate volume correction for blood loss are essential. Intensive monitoring may be essential which includes intra-arterial blood pressure (also for ABG analysis), CVP measurements along with urine output. These lines may be difficult to secure. Adequate splinting may be required. No one anaesthetic drug or technique has been found to be superior. Halothane can theoretically cause hepatic damage, though there is no real evidence but it is prudent to resort to isoflurane or sevoflurane if available. Ketamine IV and thiopentone can be used as induction agents. Nitrous oxide and narcotics have been used safely remembering hepatic metabolism may be deranged. All the muscle relaxants can be used judiciously, vecuronium and atracurium would be better choices than pancuronium due to its biliary excretion. Intra-operative haemorrhage can be a problem due to portal hypertension, difficult surgical access, proximity to the venacava and portal vein and should be well prepared to deal with this problem with enough IV accesses. Hypotension can occur due to surgical traction, secondary to venacaval compression either due to retractors or sponges and the surgeon should be alerted if this happens. All considerations required in neonates coming for major surgeries should be followed here too. Warming and padding up the baby, warming the IV fluids, peritoneal irrigation fluids, anaesthetic gases (humidifier) are mandatory. Thermostasis should be maintained. Other considerations include correct placement of the right-sized endotracheal tube, adequate relaxation and ventilation, suctioning via nasogastric tube, using air instead of nitrous oxide if surgery is prolonged to prevent gaseous distension and difficulty in closure of the abdomen. Adequate fluid therapy with replacements of electrolytes and dextrose if required as these neonates may be hypoglycaemic. 10%dextrose with 0.2 N saline is often infused. Large amounts of colloids, cryoprecipitate and platelets may be required too. Cholangitis is a frequent complication, so peri-operative antibiotic cover is essential, so also strict asepsis. Small amounts of inotrope infusions (dopamine) may be required in the very sick. Abdominal distension along with a large incision might cause respiratory embarrassment, making reversal of anaesthesia difficult. Abdominal surgery is often associated with increased intra-abdominal pressure which will decrease liver and splanchnic blood flow, thereby decreasing metabolism of narcotics and their clearance. Adequate anaesthetic levels are required to decrease the stress response and improve outcomes. Intensive care monitoring and pain relief are essential, sometimes post-operative ventilatory support till the baby is optimised and able to ventilate adequately. Thus anaesthetic management of these neonates can be quite challenging. |
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Query (Asked by Dr Mohan PP from Salmiya, Kuwait) What is the role of hypertonic saline in management of head injury? Please suggest relevant references. |
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Response by Dr. HHDash Crystalloids may be made hyperosmolar by the inclusion of electrolytes (eg, Na+ and Cl, as in hypertonic saline), or LMW solutes, such as mannitol, or glucose. Hyperosmolar solutions exert their beneficial effects by osmotically shifting water from the nervous tissues (intracellular & interstitial) to the intravascular compartment. This effect has been demonstrated in brain tissue with a normal blood brain barrier (BBB) & is the cornerstone treatment of intracranial hypertension. Furthermore, the increased serum osmolality reduces cerebrospinal fluid secretion rate, & this effect can contribute to improve the intracranial compliance. Different strength of hypertonic saline have been used in clinical practice (eg, 3%, 7.5%, 9%, 18% and 23.4%) This physiological mechanism of hypertonic saline has prompted clinicians to use hypertonic saline in refractory cases of intracranial hypertension (not responding to mannitol or thiopentone) following severe head injury. Anecdotal case reports have been published. Advantages: 1. Small volume resuscitation in patients with haemorrhagic shock reduces brain volume, maintains ICP, restores blood pressure and minimizes brain oedema. 2. Efficacious in prehospital transfer in patients with Head Injury. 3. Improve outcome in Head Injured patients. 4. It lower ICP and improve CPP. 5. CNS effects of Hypertonic Saline is more or less similar to Mannitol but it does not produce diuresis and it is much more useful in patients with low blood pressure. Disadvantages: 1. It induces hypernatremia and its side effects, the worst being, pontine demylinolysis. Hyperchloremia is also observed. 2. It has the potential to cause rebound intracranial hypertension. Comments :- No doubt it is a wonder drug in the face of refractory intracranial hypertension in patients with severe head injury. It is very useful in patients with concomitant hypotension. However, its routine use has to be deferred till its utility has been proved through a randomised controlled studies carried out in large number of patients with severe head injury. But, the silver lining is, it has been recommended very recently for the acute management of severe traumatic brain injury in infants, children and adolescents. References: (1)Cooper DJ, et al: Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomised controlled trial. JAMA 291: 1350-7;2004. (2)Kramer GC: Hypertonic resuscitation: physiological mechanism and recommendations for trauma cases. J Trauma 54: S89-S99,2003. (3)Guidelines for the acute medical management of severe .... Pediatric brain injury. Pediatr Crit Care Med 4(3 suppl): S40 - 4,2003. |
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Query (Asked by Dr M Z Islam from Dhaka, Bangladesh) Is their any device available to protect loose teeth from insults of laryngoscopy? |
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Response by Dr. Anjan Trikha There are many devices available patented and some non patented. Teeth guard something like what the rugby players wear is available. They are made of medical grade rubber both for upper and lower jaws. They are ideally to be disposed after single use. |
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Query (Asked by Dr. Madhu M from Mysore) Can post dural puncture headache cause systemic hypotension after one day of anaesthesia? |
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Response by Dr.
Anjan Trikha I am not aware of any such instances were prolonged and
significant hypotension requiring treatment has been caused by post dural
puncture headache. How ever the following would have to be
considered: |
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Query (Asked by Sami Adam Koko from Khartoum, Sudan )An obese lady (32years) with B/p 140/95 mmHg was given GA with ETT for caesarean. Given i/v Atropine 1.0ml, Thio 500mg & Scoline 100mg for induction. Intubated successfully at 1st attempt. Then Pavlon 6.0mg was given & operation started. After removal of the normal baby, the lady was given i/v 0.5mg ergometrine & 10units oxytocin. Few minutes later the obstetrician noticed that the blood became dark & the anesthetist detected an increase in bag resistance. Patient resuscitated for more than 15 minute without success. The comment of the senior anesthetist who has been called for consultation death confirmation was: 1. Severe cerebral hypoxia due to a total ETT block, probably related to induced pulmonary hypertension & pulmonary edema following ergometrine injection in a relatively obese hypertensive lady. 2. An amniotic fluid embolism. The questions are: 1. The total or partial ETT block. Is it possible to occur? 2. Is it possible for ergometrine to initiate pulmonary hypertension & edema in a patient with marginal blood pressure? 3. In case of total blockage to the ETT during anesthesia is it wise to replace the ETT or to apply suction over the previously inserted ETT? |
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Response by Dr. Anjan Trikha 1.When a patient develops pulmonary oedema under GA, there can be a lot bloody frothy secretions in the ETT but in my practice of anaesthesiology I have never seen a total blockage of the ETT tube with the pulmonary oedema, cerebral hypoxia and death. 2. It is possible for this patient to develop pulmonary oedema. I am aware of mild hypertensive patients developing pulmonary oedema after small doses of ergometrine. 3. In my opinion it is not a wise thing to change the ETT in such a setting. It would be better to continue IPPV along with other pharmacological treatment modalities. If needed one should carry out a short, crisp ETT suction. The secretions usually “Dry Up” with IPPV though the pressure needed at times may be as high as 40cm. One should not think of changing the ETT in such instances. The patient is obese and pregnant – both causes of difficult intubation and once the tube is pulled out it may be difficult to intubate such a patient again. The risk of aspiration too is high in such a setting. In this case use of 1mg atropine at induction too is debatable and I would not have used it and its use prophylactically in obese, hypertensive patients is no longer recommended. I would have not done so. Similarly use of ergometrine – I would have surely not used it and have stopped using it as a routine drug for cesarians. Lastly resuscitating this patient for just 15 minutes is just not acceptable. The basic and advanced life support measures should be continued for at least 30 – 45 minutes specially in patients who have a witnessed cardio respiratory event. |
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Query (Asked by Ibrahim from South Wales UK) Do the experts in this forum think that negative pressure ventilation will have a comeback for ventilating patients with ARDS? Thank you. |
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Response by Dr.
Anjan Trikha These devices were used in 1930s and a few decades after
that and if one were to see them in various museums one would really
wonder about the ICU set ups they were used in and the difficulty in
nursing care of the patients they were used on. However with the
availability of better materials for providing perfect seal and better
quality high power rotatory pumps that can compensate for the airloss
there is a resurgence and some interest generated again for these devices.
One must always realize that any mode of ventilation that would avoid
intubation or tracheostomy would always be very useful and effective in an
intensive care setting or for long term respiratory support. I am sure
that if the cost can be curtailed and some trials are again initiated we
could see another important modality coming back. |
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Query (Asked by Dr. Madhu M from Mysore) What are the anesthetic implications of nephrotic syndrome? |
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Response by Dr. Manimala Rao Nephrotic syndrome is a complex syndrome characterised by increase in urinary protein, decrease in serum protein, and swelling, more pronounced in the face. It occurs more in the childhood between the ages of 1to 8 years. It also is seen in adult life. The associated problems are hypertension, hypoalbuminemia, hypercholesterolemia, hyponatremia, renal compromise and anemia. The anesthesiologist must keep all of this in mind while doing the preoperative check up. Check the necessary investigations that are both relevant and additive. Pre-op control of BP is very important. The patient may be on various medications like alpha and beta-blockers, ace inhibitors, steroids and cytotoxic drugs. One must remember the action of various drugs and their interaction with the anesthetic drugs. Use of non-invasive monitoring to very minor procedures and invasive BP and CVP monitoring for all major procedur |
