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QUERIES AND RESPONSES Archive Page-2 Click for: Recent Q&A Page, Archive Q&A: Page- 4, 3, 1 |
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Query (Asked by Jitendra S. Bapat from Mumbai) Please tell about the Evidence based Guidelines for minimum NBM period required for burns patients undergoing repeated burns dressings under GA in order to prevent aspiration ? What kind of oral supplementation is ideal to meet high metabolic demand? |
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Response by Dr. Mary Korula (Posted on 20th April, 2006) Don't know whether there are evidence -based guidelines for NBM in burns patients. I would presume they would need the same starvation orders as other patients. Like any trauma patient, their gastric emptying may be delayed due to various reasons including pain, but the dressings are done only once or twice a day. In our institution, they are not done under GA normally, under ordinary sedation or ketamine. Abroad they do them with isoflurane and opioids taking the same precautions for a full stomach patient. Again as anesthetists, we don't look after their metabolic requirements, we have a special Burns unit who takes care of these patients. This is what we follow. Oral intake to meet the high demand may not be possible, so usually these patients get nasogastric feeds. The Curreri formula is employed. This is body weight X 25 + 40 X % of burns. Protein requirement is generally taken as 2 gms /kg of body weight and is based on nitrogen requirements. A simple formula used here is : For protein requirement of 70gms and calories of 1750 Ingredients for oral intake: rice flour - 75 gms complan - 120gms proteinase - 30gms milk - 900ml sugar -60gms - as daily infusion. |
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Query (Asked by Nicholas from Michigan, United States) Do you have any suggestions for the weaning of Propofol? A few articles state an abrupt wean is likely to cause delirium, agitation, and anxiety, but others state an abrupt wean will likely result in a rapid release of the injection from the fat cells and result in rapid awakening, without mention of side effects. Any comments? |
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Response by Dr. Manimala Rao (Posted on 16th April, 2006) As yourself have stated that abrupt wean leads to agitation particularly if you have used the infusion for minimum of 24 hours. I have always advocated on a slow wean in a matter of an hour. It definitely makes the patient calm and listen to our suggestions & conversation. The abrupt wean has ended a few times in self extubation. From then on I am a staunch supporter of slow weaning. What one strives at all time is safety and I am sure this is the reason for the question |
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Query (Asked by Jaisree Gopinath from Thrissur) What are the causes of supraventricular tachycardia in post operative patients |
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Response by Dr. Yatin Mehta (Posted on 16th April, 2006) Supraventricular tachycardia (SVT) occurs due to enhanced automaticity in rapidly depolarizing foci or reentrant impulses with in the atria. A susceptible underlying substrate has to be triggered. Substrate can be fibrosis, volume overload, atrial ischemia or an incision in the atria. Trigger is atrial ectopic. Other arrhythmogenic factors in this setting include catecholamine release, inflammation, autonomic disturbances, change in atrial volume. Predictors include: Male , elderly, hypertension, valvular heart disease, enlarged left atrium Digoxin / beta blocker withdrawal Preop atrial fibrillation CHF Right coronary artery disease Low T3 levels |
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Query (Asked by Eyayalem Melese from Ethiopia) What is the anaesthetic management of patient with Deep Vein thrombosis during-1. Emergency situation,2. Elective situation? |
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Response by Dr. Manimala Rao (Posted on 16th April, 2006) When any patient is diagnosed to have deep vein thrombosis they are either on low molecular weight heparin or unfractionated heparin. The dose is adjusted to prevent pulmonary embolism. In an emergency there is no time, so the patient is taken up after an informed consent. I would definitely go for a general anesthetic depending on the type of surgery. All precautions will be taken for full stomach and atraumatic intubation. PT, INR will be noted and will keep fresh frozen plasma and fresh blood in case of uncontrolled bleeding. If the patient is on regular heparin one should keep protamine in case it is urgently required. The minimum surgical time and quick control of bleeding are mandatory. Elective surgery need not be taken up if a patient is having DVT. Control of DVT by therapy and explaining the risk benefit would go a long way in preventing the dreaded complication pf P.E. Even for an elective operation the patient may continue to be on anticoagulants. In that case one has to stop the oral anti coagulants and switch over to heparin for the surgical procedure. PT, APTT, INR platelets give you a good idea regarding the coagulation. Keeping all these in view one can tailor the anesthetic to either general ,or regional. The same guidelines for anticogulation hold good for different type of surgical procedures. |
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Query (Asked by Sebrina from Cairo, Egypt) What is the exact danger of anesthesia on a patient had spleen enlargement and liver diseases? and what are the complications of anesthesia? |
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Response by Dr. Mary Korula (Posted on 6th April, 2006) I have already answered a part of it as reply to some question before. The complications depend on what the surgery is for, is it surgery on the liver and spleen? Is the spleen enlargement a part of the liver disease and portal hypertension? Is it for Idiopathic thrombocytopenic purpura(ITP), hereditary spherocytosis etc?? C/c liver disease can cause fluid and electrolyte imbalances leading to refractory edema and ascitis. Along with hypoalbuminemia and portal hypertension, this will cause abdominal distension and intravascular hypovolemia. Decreased FRC, atelectasis and hyoxemia are the end results. Secondary hyperaldosteronism can exacerbate this and cause generalized edema (anasarca). Gastro-intestinal problems include portal hypertension, varices and jaundice. Acute hepatic failure and delayed gastric emptying can increase the risk of regurgitation and gastric aspiration. Major risk of bleeding from esophageal and gastric varices and increased risk of peptic disease and bleeding. Hepato-renal syndrome, renal failure due to obstructive cholestatic jaundice and renal vasoconstriction should be looked for and avoided. Cardiopulmonary problems including hyperdynamic circulation and hypoxemia leading to A-V shunts, pulmonary hypertension, cardiomyopathy and arrythmias, sepsis, myocardial ischemia and pulmonary edema. Hematological problems like coagulation factor reduction factor VII deficiency and thrombocytopenia due to impaired synthesis by liver and hypersplenism which can decrease all types of blood cells and lead to massive bleeding and coagulation problems. Nutritional and metabolic problems like hypoalbuminemia, malnutrition, hypoglycemia, infection and catabolic effects of hepatic failure. Encephalopathy and neuropathy are neurological complications . With fulminant hepatic failure, coma and acute cerebral edema can set in leading to death. Pharmacological effects include increased free or active fraction of albumin bound drugs because of decrease in albumin. Doses of drugs like thio and benzodiazepines have to be decreased and titrated according to needs. Drugs depending on hepatic biotransformation and elimination have to be avoided like neuromuscular agents, opioids etc. If hypersplenism is present, all the blood cells and platelets administered intra-op can be sequestered within the spleen and generally not given till splenic vein is ligated if splenectomy is also being done. A thorough pre-op evaluation of pre-op risk (Child-Pugh classification) and preparation is mandatory. Prolonged bleeding parameters must be corrected as far as possible by vitamin K and FFP. In severe ascites and coagulopathy, regional anasethesia is contraindicated. All volatile agents and hypercarbia decrease hepatic blood flow which should be maintained at all times. Anticipate bleeding and have enough blood products cross-matched. Also avoid hypoxemia and renal failure by ensuring adequate fluid therapy and renal perfusion. Anaesthetic emergence can be delayed, full intra and post-op monitoring till patient is fully awake and extubated. Monitor for early signs of hepatic failure and encephalopathy and prompt expert treatment essential. ICU care will be required till patient stabilizes and all the above problems are anticipated and treated. This is only a brief list of complications , its better to refer to any std textbook for detailed explanations. |
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Query (Asked by J Douglas Luiz from Bangalore) What is arytenoid subluxation and how is it caused...? |
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Response by Dr. Mary Korula (Posted on 4th April, 2006) Arytenoid subluxation (AS) and dislocation (AD) are rare laryngeal injuries caused by instrumentation of the upper airway or GI tract. They are sometimes used interchangeably to describe disruption of the crico-arytenoid cartilages. Subluxation occurs more commonly and implies partial separation within the joint space while dislocation is full separation of the arytenoid cartilage from the joint space and is associated with severe laryngeal trauma . It is an uncommon complication after endotracheal intubation, incidence being around 1/1000. Cases have been described with use of large double lumen tubes. Can also be associated with blunt or penetrating injuries of the larynx. It presents as hoarseness of voice, reduced mobility of vocal cord and incomplete glottic closure. Dysphagia, sore throat and cough are other symptoms. Anterior displacement can occur when the blade of the laryngoscope hits it when inserting or when the tip of the ETT hitches and pulls it along when it enters the airway. Posterior displacement can occur during extubation due to a partially inflated cuff of ETT or strong paroxysms of cough, also due to a posteriorly directed blow on the anterior aspect of the neck. The arytenoid processes can also get caught inside the tip of the ETT and get displaced during ETT introduction. It should be differentiated from recurrent laryngeal nerve injury as treatment is different for both. Early endoscopic reduction is usually effective in AS. The crico-arytenoid joint controls abduction, adduction of cords and phonation. Rheumatoid arthritis, laryngomalacia, diabetes, acromegaly, denegenerative diseases may be predisposing factors. Early treatment includes indirect laryngoscopy and direct laryngoscopy and reduction of the subluxation after confirmation with MRI. Resubluxation can occur. Steroids and recently botulinum toxin have also also been infiltrated. Late treatment involves medialisation thyroplasy of the cords. Delayed treatment or unrecognized subluxation can cause cricoarytenoid fibrosis and joint ankylosis. Paulsen et al in their review article tries to review the pathomechanics of AS and suggests the change in terminology from arytenoid subluxation to post-intubation crico-arytenoid joint dysfunction.Anesthesiology 1999 Sept vol91, page 659. |
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Query (Asked by Rohit Tyagi from Delhi) Is it mandatory to use preservative free tramadol in caudal epidural? What if we use tramadol which is not preservative free? |
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Response by Dr. Anjan Trikha (Posted on 3rd April, 2006) Yes it is mandatory to use preservative free medications in the epidural and spinal spaces. I am aware that in India such rules are not followed. I too have used, morphine with the preservative in the epidural space but I have stopped doing so for the last 7 - 8 years. There are a few published reports of medications with preservative used with out any problem in the spinal and epidural space but one could land in trouble if such cases are taken to court. use of such medications in terminally ill patients can be justified in case the there are no other alternatives but on a legal front this too could land an anesthetist in trouble. |
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Query (Asked by S. N. Krishnamoorthy from Madurai) Is there an entity called "high spinal"? what are the indications for this technique? Is it safe to use it as a routine for upper abdominal surgery? |
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Response by Dr. Anjan Trikha (Posted on 3rd April, 2006) The term is self explanatory. High spinal is not defined in the literature on the basis of the dermatomes involved. Any spinal block that leads to difficulty in breathing or inability to cough is usually labeled as High spinal. Routine use of spinal for upper abdominal surgery is not acceptable in modern day anaesthesia. I am aware that such a practice is on at many places in our country probably due to economic gains. In 1970s and early 1980s high spinal blocks were used along with a general anaesthetic to produce hypotensive anesthesia and I still remember my thesis guide Late Professor Hariwir Singh telling us about such techniques during one of his classes at PGIMER. I think there are no indications for such a technique in modern anesthesia. One can get cholecystectomy and even gastrectomy done under a spinal but this technique should be discarded. I am not aware of any indication of a planned high spinal any more. |
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Query (Asked by Sandeep from Mohali) I want to know about the current status of Pancuroneum. Should it be used or it be abandoned. |
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Response by Dr. Manimala Rao (Posted on 1st April, 2006) Pancuroneum has still got some use. It can be used when you want to have a slightly higher heart rates. We find it useful in CABG surgeries where they are on betablockers and induction is with high dose narcotic and sedatives as well as propofol. Use of vecuroneum further reduces the heart rate. Even rocuroneum which has very stable hemodynamics can give low rates. Patients with known bradyarrythmias could do better with pavulon. However the usage of this relaxant is very much curtailed. with the advent of rocuroneum the usage of this relaxant is on the wane. I think it is still a good relaxant when the patients are well beta blocked and one uses propofol and fentanyl for induction. It is cheaper relaxant and many smaller hospitals still use it as the first choice in our country |
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Query (Asked by Sanjith from Pune) Is there any danger in infusing mannitol to a pt with an extradural haematoma? (i.e will the EDH increase in size as a result of brain shrinkage) |
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Response by Dr. H. H. Dash (Posted on 29th March, 2006) Ideally the answer is yes. Because, infusion of mannitol leads to shrinkage of the brain thereby exposing the bleeding vessels to bleed more which, in turn may aggravate the extradural haematoma. This clinical situation only occurs if the extradural haematoma is very fresh. Usually in India, patients attend the hospital very late where the bleeding vessels are totally clogged so in that situation mannitol may not induce any harm. Ideally one should administer mannitol once the dura is exposed so that if any bleeding occurs the Neurosurgeon can handle the situation. On scientific ground I think your idea of not transfusing mannitol in extradural haemotoma prior to exposure of the dura is logical. |
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Query (Asked by Zahran from Amman, Jordan) What is the ideal method to reduce the brain edema intra operatively other than hypocapnea, diuretics and deep anaesthesia |
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Response by Dr. H. H. Dash (Posted on 28th March, 2006)1). The ideal methods to reduce the brain edema intra operatively starts from positioning of the patient after induction and maintenance of Anaesthesia. The head of the patient has to remain slightly elevated(10-50o) which helps in reducing intracranial pressure. 2). As an Anaesthesiologist please take care of the neck veins so as to avoid compression of these veins. If there occurs slight compression of the neck veins it may increase brain edema by decreasing venous return from the intracranial compartment. 3). Balanced anaesthesia has to be maintained during surgery so that the hemodynamic disturbances are avoided. Intraoperative hemodynamic disturbances may increase ICP. 4). If hyperventilation and use of mannitol fails then we may resort to low dose furosemide (10mg I.V). Despite use of the above modalities if brain swelling occurs intraoperatively then use 2-3mg/kg thiopentone. In the event of failure of thiopentone then one may resort to mild hypothermia (33 - 34oC). |
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Query (Asked by Dr. Jagdish from Bangalore) To enable better healing what vasodilators can I put in the epidural space in a patient of diabetic foot receiving a flap rotation. Please give info about drugs available in India |
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Response by Dr. Anjan Trikha (Posted on 27th February, 2006) Modalities that are routinely carried out for improving the outcome of grafts are - Epidural infusions of Local Anaesthetics: All local anaesthetics are vasodilators, except cocaine, ropivacaine and levobupivacaine, which are vasoconstrictors; Epidural clonidine with local anaesthetics: Tried but it is not used regularly as the results are not promising and injectable clonidine is not available in India. Sympathetic blocks: repeated or continuous are useful and are used. Other medications are Dextrans and aspirin, both are available in India. Low-molecular-weight dextran has been widely used for prophylaxis due to its properties of volume expansion and enhanced microrheology. Significant systemic morbidity (pulmonary morbidity, cardiac morbidity, anaphylaxis) is known to occur with use of low-molecular-weight dextran |
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Query (Asked by Dr. A. K. Roy from Chittaranjan) The problem of laryngospasm in a child after extubation is very frequent and very troublesome. Though the child ventilates well before extubation, the laryngospasm sets in after extubation and it is really very difficult to reintubate. Please suggest. |
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Response by Dr. Anjan Trikha (Posted on 26th February, 2006) Laryngospasm is a condition that needs to correctly handled by all anesthesiologists. Most of us would have our personal ways to deal with it or to prevent it. The best is to try to prevent it. The way to do that is to extubate the patient either in a deeper plane or when the patient is fully awake. It sounds very simple but it is not so. I personally would extubate paeds patients when they are fully awake. Another issue to be taken into consideration is the size of the tube (was it a very tight fit) and the trauma / edema if any caused by the procedure of intubation. Once the patient has gone into spasm - then the treatment has to be fast. It is always better to call for help if one is alone as this is the time the child would be able to pull out the IV cannula and his pulse oxy probe. It is better to let the EKG electrodes and the connecting leads to be the last ones to be removed - so that atleast the EKG is being monitored. Other things that would need to be done are - To try to ventilate with slightly higher inspiratory pressures If unable to do so suxmethonium - can be given to facilitate ventilation / intubation. There is likely possibility that by the time sux is been given the patient would be hypoxic so if intubation is to be done it should be done by an expert. At all times while dealing with kids till the end of surgery diluted sux must always be available for such problems. In case sux is contraindicated Mivacurium or atra or vecu or rocu should be available diluted as per requirements |
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Query (Asked by Sudhakar from Madurai) 10year old boy admitted for appendicectomy. He is on risperidone, trihexyphenidil and carbamazebine for behavioural abnormality. Now the child is calm quiet. Investigations are normal. Which is ideal regional anaesthesia or general anaesthesia. In general anaesthesia which drug should be avoided. |
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Response by Dr. Manimala Rao (Posted on 23rd February, 2006) Ten year old for appendectomy will not allow you for any regional anaesthesia. The safe bet is general anesthetic. Patients with behavioural abnormality are given the drugs mentioned. I would prefer to give a general anesthetic with thiopentone. I will give a brief account of resperidone and its side effects as well as interactions which will help you to think about a better anesthetic management. Respiridon is a benzisoxazole derivative and is a novel antipsychotic medication. It has high affinity for alpha2 adrenergic receptors, serotinin5h2 receptors, dopamine2 receptors. Its affinity to serotonin receptors is 200 times more than haloperidol .It is indicated in managing schizophrenia. 1mg dosage is recommended to start with and slow increase .Safety is not analyzed in pediatric age group. Contraindicated in pregnancy and lactation and hypersensitivity. The side effects are sedation, agitation, insomnia, extrapyramidal symptoms, anxiety and dizziness. The drug interacts with levodopa ,dopamine, carbamazepine, and clozepine. The dosage is 1mg twice daily and increase to 3mg twice daily by the third day. Looking at the profile the drug side effects It may be prudent to use thio induction and control respiration with rocuroneum. and use fentanyl for analgesia. The post operative course could be stormy and one should be prepared with good analgesia and sedation if required with midazolam. Child must be watched in a high dependency area with spo2 monitoring besides the other routine monitors. Since the child is getting the drugs which can potentiate its affects it is recommended that a close watch for any extra pyramidal symptoms in the post op period |
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Query (Asked by Dr Tarun Agarwal from Gurgaon) I had attended a multitrauma patient with chest injury. Her Blood Group was A negative which was unavailable at that time. Chest tube insertion there was approx 1.5 litres of fresh blood. Are there any guidelines for autotransfusion in these patients? |
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Response by Dr. Mary Korula (Posted on 21st February, 2006) Peri-operative blood salvage that is –collection and reinfusion of blood can be done pre-operatively, intra-operatively or post-operatively. Even upto 50% of RBCs can be recovered with proper techniques. It involves use of cell savers –consisting of centrifugal flow devices with disposable aspiration and anti-coagulation tubing , a reservoir and filter for washing the RBCs to remove free Hb and tissue debris, collection bags for the washed RBCs and waste bags to collect fluids and debris after washing. Normal saline can be used. Blood collected this way can be transfused straight away or preserved. These cell savers have not become popular in India for several reasons, mostly the cost and the complications involved, mainly: Air and fat embolism, Pulmonary dysfunction due to debris infused, Coagulopathy as coagulation proteins and anti-thrombin are removed while washing, Renal dysfunction Sepsis and malignancy dissemination. Blood that collects in the thoracic cavity in traumatic hemothorax can be collected via chest drains without washing and does not require anticoagulants as it is defibrogenated. Fibrin degradation products and cardiac enzymes can be detected in unwashed blood, so a false diagnosis of DIC or MI can be made. Electrolytes and catecholamine levels are usually normal. Suction devices without washing assembly are cheap and easy to use. It is believed that less than 2litres can be safely transfused without processing making sure there is no previous infection, no contamination with intestinal contents, no bacterial peritonitis, especially in massive blood losses when no allogenic blood is available. |
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Query (Asked by Abdelkader Hijazi from Saudi Arabia) Postoperatively I prefer patient head down position until reflexes return back to normal then I elevate the head if necessary. Is this practice wrong. |
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Response by Dr. Manimala Rao (Posted on 29th January, 2006) At the end of Anaesthesia one would not extubate unless the reflexes have come back. what we are worried is the gag and cough so that they can protect their airway. I and many of us keep the head in the normal position neither head up or down at extubation. If by chance there is vomiting or severe nausea then we get the head down to prevent aspiration. Head down position always increases the ICP and one would not like to it at the end of surgery. The practice of nursing patients in head down position after spinal anaesthesia is given up. In case there is hypotension one is justified in having a head down tilt. At the end of surgery good suction in the oropharynx would prevent the problems. |
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Query (Asked by Dr. Kapil from Jaipur) Is sublingual nitroglycerine spray better drug as compare to sublingual nifedipine for attenuation of presser response to intubation |
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Response by Dr. Anjan Trikha (Posted on 27th January, 2006) A lot of drugs have been used for attenuation of hemodynamic responses to intubation and laryngoscopy. Each one has its own benefits but somehow as a routine none is used. Regarding Sublingual nifedipine versus nitroglycerine - Both may be used however the duration of action of calcium blocker would be more than that of nitroglycerine. I personally find nifedipine tachycardia a problem at times and the literature has many reports of severe tachycardia after use of sublingual nifedipine as treatment of severe hypertension in A & E departments. We at AIIMS too have had many cases in our Casualty Department. Another concern would be availability - nifedipine is freely available where as nitroglycerine spray may not be freely available in various parts of India. I was regularly using Nifedipine for treatment of intraoperative hypertension but have stopped doing so for the past 4 - 5 years. I prefer to use nitroglycerine for this now. I do not regularly use any drug for obtunding the intubation responses now. My personal drug to choose between the two would be sublingual nitroglycerine. |
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Query (Asked by Jan Eastwood from Cairns, Australia) I have been told by a colleague that the administration of nitrous oxide to pre op orthopaedic patients increases the risk of air embolism. Could you please verify this? I am unable to find any articles on this issue. |
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Response by Dr. Anjan Trikha (Posted on 22nd January, 2006) There is no risk for air embolism if nitrous oxide is used. But surely in presence of a air filled cavity e.g. pneumatocoele, pneumothorax, this cavity can increase in size rapidly and can be hazardous for the patient if nitrous is used. It is best avoided in such cases. Otherwise it is very safe. |
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Query (Asked by Ram from Madurai) What are the advantages of stress attenuation during extubation? Is this practiced universally? when to administer those drugs (either before or after giving reversal)? |
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Response by Dr. Mary Korula (Posted on 6th January, 2006) Tracheal extubation has always received little emphasis and is associated with it’s own problems and complications. Coughing during emergence can result in hypertension, tachycardia, myocardial ischemia, increased intraocular and intracranial pressures. These features are particularly undesirable in patients undergoing neurosurgical or ophthalmic procedures or those who are at increased risk of adverse cardiovascular effects. Haemodynamic responses are brief and are well tolerated by the majority of patients. But they can be detrimental and cause significant clinical problems in susceptible patients. There are 2 options for blocking the extubation responses: (1) attempt to suppress this response after it has occurred, or (2) prevent its occurrence at the outset. In the former, the sympathetic outflow can be suppressed once it occurs by deepening the level of anaesthesia, or its effect may be blocked by the use of alpha and beta blockers. In the latter, increased sympathetic outflow can be prevented by the use of analgesia, both topical and systemic, before noxious stimuli occur. Various strategies have been employed to blunt the haemodynamic responses like tracheal extubation under deeper plane of anaesthesia, administration of various drugs like lignocaine, esmolol, propofol, labetolol, fentanyl, prostaglandin, calcium channel blockers, NTG and SNP and recently dexmedetomidine. Each method has its own advantages and disadvantages. |
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Query (Asked by Thomas Matthew from Brandon, Canada) What is the incidence of Malignant Hyperthermia in India? Is Dantrolene routinely stored in the hospitals where GA is administered and if so what is the cost of the drug? |
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Response by Dr. Mary Korula (Posted on 3rd January, 2006) The incidence of Malignant Hyperthermia (MH) seems to be very low in India. I couldn't get a figure or any statistics, hence the delay in reply. I have asked around in a few Neuro centres down south and no one seems to know or have actually had a proven case of MH. Besides there are no centres doing caffeine or halothane contracture tests here. There have been cases of malignant hyperpyrexia syndrome though! They have been associated with sepsis and severe muscle damage and clinically can present the same picture. Dantrolene is not routinely stored in our hospitals . Tablet Dantrolene is available in our pharmacy, not very expensive. But Injectable Dantrolene-50mg vials cost Rs 8500/as Dantrium via Smith-Klime Beecham Ltd and can be made available within 15 days from abroad. |
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Query (Asked by Dr. Arockia Arul from Nagercoil) Can we use preservative free morphine along with bupivacaine intrathecally for LSCS. Do the side effects really affect the parturient? What is your opinion? |
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Response by Dr. Anjan Trikha (Posted on 28th December, 2005) Morphine with the preservative should not be used in the epidural space and intrathecally. However in India & many developing country it is being used and anesthesiologists would insist that no side effects are seen. BUT I strongly feel that it should not be used other than in patients who are terminally ill. Medico legally too it is a wrong practice and I am sure some day some one would land into problems. Now Preservative free morphine is available with us at AIIMS and I suggest that every body should start using the correct preparation. |
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Query (Asked by Dr. CMK Reddy from Chennai) A 38-yr healthy woman (average built, nondiabetic, normotensive, no IHD) was operated for fibroid uterus on 23/12/05, under spinal anesthesia, using Bupivacaine. She experienced severe backache, immediately after the injection of the anesthetic agent, which lasted for half an hour, but she never recovered from the spinal paralysis. The surgery (total hysterectomy by Pfannensteil incision) went on well. She was brought to me on 24th and we found she had total sensory/motor loss with areflexia, upto the lower chest, but respirations unaffected. An MRI of dorso-lumbar spine done on 24th revealed crowded thickened nerve roots, suggestive of arachnoiditis. No SOL nor cord ischemia noted. LP was done on 24th, the fluid was turbid but not under tension. 10-12 WBC & 6-8 RBC were seen. Count : 88/cmm, mostly polymorphs. Sugar : 78mg%, protein : 2.8gm% Chloride : 130mg%, Globulin +++ She was started on high antibiotics and methyl prednisolone 250mg IV 6 hrly immediately on the advice of neurologist, but now it is over 48 hrs, there is no neurological improvement. I'd be much obliged, if you can me give any further suggestions in the management of this woman. |
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Response by Dr. Anjan Trikha (Posted on 28th December, 2005) The case is really very interesting. I think I have nothing to add as far as the treatment options are concerned. Antibiotics and steroids are the main stay along with supportive management. I would advice that the batch numbers of the drug be noted and the ampoules of the same batch be kept on hold and an alert be sounded atleast in the hospital / city regarding the case and likely hood of drug being a problem. May be this would prevent any further cases. I would surely be interested in the course of the patients disease and would request you to let us know the details regarding the outcome. |
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Query (Asked by Dr. H .N. Chansoria from Jhansi) What is the best and safe post operative analgesic in infants? |
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Response by Dr. Mary Korula (Posted on 24th December, 2005) The most safe route would be oral or rectal route with drugs like paracetemol and NSAIDs. A multimodal technique would be ideal as for adults with local infiltration, local nerve blocks and NSAIDs for later post-op care. Adequate blood analgesic levels have to be attained earlier, hence its better to start these along with induction of anaesthesia though they may not be sufficient for intra-op analgesia and stronger opioid analgesics may be required intra-operatively. For major surgeries, like for lower abdominal and limb surgeries, caudal blocks would be ideal ,addition of opioids or ketamine as adjuncts can prolong blockade and decrease post-op analgesic requirements. These can be used even in premature neonates without major problems. I prefer preservative free pethidine 0.5 - 1mg/kg for one-shot caudals which usually provides analgesia for 6-8hrs at least with no problems. If longer periods are warranted, then caudal catheters and bupivacaine -opioid infusions through these are the best. Intrathecal, lumbar and thoracic epidurals have also been safely used in appropriate cases but one should monitor these kids intra-operatively and post-operatively as eliciting paresthesia is not possible with them. The risk of spinal cord injury and intravascular injections of local anaesthetics are more with these kids and also incidence of spinal headaches are thought to be higher and more difficult to record. Newer drugs like ropivacaine and levobupivacaine will probably help reducing toxic effects of local anaesthetics. Severe bradycardia and cardiac arrest have been reported after neuraxial blockade through any route. Transnasal, transdermal, transmucosal, subcutaneous routes for post-op fentanyl and other opioids are all being employed, all have their own advantages and disadvantages. The important thing is choose the safest technique in your hands, according to the type of surgery and requirements. |
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Query (Asked by Dr. Paranjyothi from Chennai)What would be the plan for a post operative analgesia in scoliosis surgical patients? |
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Response by Dr. Anjan Trikha (Posted on 13th December, 2005) I personally do a lot of scoliosis and the age group varies from 18 months to 25 years. The youngest in my list has been a 18 Kg child. Thus the post operative plan would vary by age. Invariably for all, the first post operative day, analgesia is provided by a continuous infusion of morphine the rate varying from 0.5 - 3 mg per hour. After the first 12 - 18 hours I normally add an NSAID (depending on the collection in the drains) and oral paracetamol. Over the next 2 - 3 days morphine is tapered off and NSAIDS, tramadol and paracetamol are used. Other technique that I use - An initial intrathecal dose of preservative free morphine the same been given by the surgeon and then I vary the rate of intravenous morphine infusion. This is to be done with caution and only under continuous saturation monitoring as both intrathecal and iv opiate is being used. Another popular technique that I also use is an initial post op bolus of morphine, basal infusion of 0.5 - 1 mg of morphine and a PCA of morphine in adults. The standard PCA setting that I use are Morphine dilution of 1:1, bolus of 1 mg i.e 1 ml, loc out of 5 minutes and maximum dose of 12 mg in any one hour period. We have also tried using epidural catheters with epidural morphine the same being placed by the surgeon prior to closing the wound but some how the surgeons at our institute are not very enthusiastic for this technique thus we have abandoned it though it is also very effective. |
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Query (Asked by Dr. Sanjith from Mumbai) I have noticed that during the intrathecal administration of Midazolam, when few mls of csf is being aspirated in the syringe containing the drug the content turns milky (precipitates). How can we assume that the drug is working? |
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Response by Dr. Anjan Trikha (Posted on 13th December, 2005)That is a fact and thus such a practice is always debatable and not very popular. |
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Query (Asked by Dr. Arokia Arul from Nagercoil) 37 yrs male,89 kg, MPIII, hypertensive-for SMR and turbinectomy. Adequate fasting, no premed. GA induced with pethidine 50 mgm, midaz 1.5 mgm, Vec 1mgm 5 mts later propofol and suxa. surgery lasted 20 mts, no further relaxant required, extubated after 10 mts (nose blocked). Patient was alert, lash +,tidal volume adequate, had drooping of eyelid. My questions are,1)What is the defasciculating dose of vec? 2)Can we give reversal to this patient? |
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Response by Dr. Mary Korula (Posted on 2nd December, 2005) The recommended defasciculating or precurarising dose with nondepolarisers is 10-15% of the intubating dose with that nondepolariser. So 1 mg vecuronium for a 90 kg man should be OK. We know neostigmine can partially inhibit pseudocholinesterase& prolong scoline blockade. Neostigmine by itself has weak depolarising effects, which may have prolonged the succinylcholine blockade. So I don't think giving neostigmine and reversals will really help, in fact this may worsen the situation. Extubate after you are sure patient can maintain his airway and the pharyngeal reflexes are back. There are reports of weakness and distress following even small precurarising doses if patient is not induced immediately, so be careful while administering nondepolarisers before depolarisers in difficult airway cases as it can also prolong the action of depolarisers and may land you in trouble when you may not be able to intubate or secure the airway by other means. |
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Query (Asked by Dr. Siddharth Bhati from Sriganganagar) Role of Pralidoxime (PAM) in OrganoPhosphorus Poisoning. |
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Response by Dr. Manimala Rao (Posted on 30th November, 2005) Pralidoxime is given to patients with organo phosphate compound poisoning. The usual dose practiced by many in adult patients is 1gm four times a day for three days. We do follow the same regimen. However WHO recommendations are 30mg per kg as bolus followed by 8mg /kg as infusion till the symptoms decline and the target blood levels are attained viz 4mg per litre. In children the recommended dose is 25-50 mg per kilo. There were two RC Trials done from Vellore and they found that mortality is higher in patients receiving PAM. They have not followed the WHO recommended dose. It should be given to only org phosphste compounds. First dose should be started at the earliest without knowledge about the compound but once it is known that it is either organo chlorine or carbamate , it can be discontinued. We still use it only for three days as 1gm QID |
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Query (Asked by Dr. Naresh from Jodhpur) Use of low dose ketamine before the reversal. Can improve the patient's comfort? |
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Response by Dr. Manimala Rao (Posted on 30th November, 2005) Ketamne is a powerful NMDA receptor antagonist and thus cause its potent analgesic action. It prevents the central sensitization for pain perception. Given in a low dose .2 mg /kg before induction of anaesthesia has shown to reduce the dosages of narcotic drugs like morphine and fentanyl in the post operative period. In this dosage it does not cause hallucinations or emergence delerium. Combination with low dose has found an useful place in the day care surgery. There are large no of reports of using it at the time of induction in low dosage. Giving it at the end of surgery or at reversal may not be ideal timing but can be tried for good post op analgesia and reduction in the post op medications. I have not come across any study where it was given with reversal. |
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Query (Asked by Dr. Mohammad Waseem Rabbani from Multan, Pakistan) Role of Mannitol 20% in patients of severe Eclampsia.. Whether to use it in every patient or selected ones? |
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Response by Dr. H. H. Dash (Posted on 29th November, 2005) Only in documented case of brain oedema in Eclampsia mannitol can be used. For documentation along with clinical signs one can rely on CT scan. |
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Query (Asked by Dr. Babatunde Osinaike from Osogbo, Nigeria) Kindly suggest the best technique for a 34year old post polio paraplegic presenting for Caesarean section at term. Patient has severe chest wall deformity and severe scoliosis as well. |
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Response by Dr. Anjan Trikha (Posted on 27th November, 2005) This patient has the following problems - Paraplegia, Severe chest wall deformity, Severe scoliosis, Full stomach. Unless one is aware of all the details of the chest deformity and scoliosis one can not talk about the details of the technique. However such a case is to be managed at a tertiary care center with facilities of ICU. I would proceed with GA, Sux would be a problem as could be a difficult airway in view of her paraplegia and scoliosis. I would still use GA, a fiberoptic guided awake intubation under local and then post op ventilation if needed. |
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Query (Asked by Dr. Jaisree Gopinath from Thrissur) Poly trauma patient in haemorrhagic shock transfused 15 units of whole blood & 5 units of pack cell intraoperatively showed a TC of 2500cells/cmm, platelet count of 27000, INR 2.084. How to go about & how much one unit of platelet would increase in the count. |
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Response by Dr. Mary Korula (Posted on 26th November, 2005) For a person who hasn't been exposed to blood products or platelets and it is the first transfusion,1 unit of platelets (PRP-platelet rich plasma) increases the count by 10,000. When multiple exposures, it may increase to only 5000. For this particular patient, a fibrinogen level has to be done. If it is below 200mg%, then cryoprecipitate has to be given along with platelets as the high INR can be because of fibrinogen depletion as well as coagulation factor depletion. Now if the fibrinogen levels are normal, fresh frozen plasma and platelets are to be given as if more fibrinogen is given, it can precipitate thrombosis in the patient. Regarding total count, we don't have to worry too much, keep monitoring the patient as sepsis itself can bring down the counts and if required antibiotics will have to be given according to disease process, organisms cultured and microbiology picture. |
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Query (Asked by Dr. Moussa Naser from Tehran, Iran) Recently we had a C02 crossover in anesthesia machine. Do you know of any similar case and patient outcome? |
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Response by Dr. Manimala Rao (Posted on 25th November, 2005) We are very happy to state that we never had CO2 cylinders on our anesthesia machines. So cross over has never happened in my 35 years of anesthesia practice. However in days gone by there were some reports that co2 was given with disastrous result. In a case report it was identified and corrected. I wonder that in modern anesthesia machines CO2 is not used. Monitoring the Etco2 will be able to note the increase and take necessary measures. Sorry cannot add more |
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Query (Asked by Melita Tucker from UK) I have to have steroid injections in my back and leg. Is there a time limit to go back to work and what should I expect from this procedure? |
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Response by Dr. P. N. Jain (Posted on 23rd November, 2005) Steroid inj usually starts providing its good desired effect of optimum analgesia in 48 hrs. Therefore, you should be able to attend the office by that time. Further you may ask your pain physician about his plans because I do not know for what condition he is treating you. |
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Query (Asked by Dr Ramamoorthy from Madurai ) What will be the exact time after giving a spinal with 0.5% bupivacaine,a change in posture (lithotomy, head down etc) would not cause an increase in level of block? Is there anything like fixation time for a local anaesthetic? |
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Response by Dr. Anjan Trikha (Posted on 21st November, 2005)Spinal bupivacaine should ideally get "fixed" with in 3 - 5 minutes and no increase in block height should be seen after this time. It would be safe to position the patient in a lithotomy position after this time. The older books do describe the term fixation time of a spinally given local anesthetic. However I have personally seen a few cases where the height of the spinal block has increased till about 15 minutes but all these patients had received hypobaric bupivacaine. In India we do not get the hypobaric preparation of this medication. |
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Query (Asked by Dr Priya Ramakrishnan from Coimbatore) Relationship between dial concentration on the vaporiser and mac |
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Response by Dr. Mary Korula (Posted on 19th November, 2005) MAC is the minimum alveolar concentration of an inhalational agent required at 1 atmosphere. After induction and equilibration within a short period of time of about 15 min, it represents the partial pressure of an anaesthetic in the CNS and is independent of uptake and distribution to other tissues. Constant alveolar concentration reflects constant level of anaesthesia. The inspired air concentration (FI) should approach this alveolar concentration (FA) which should be the output from the vaporiser (FD). Now an ideal vaporiser with a fixed dial setting should have a constant output and concentration regardless of the varied flow rates, temperature, backpressure, carrier gases etc which can all affect output. Modern vaporisers approach this ideal state if there are no leaks but still have their limitations ie FD/FA = FI/FA. The vaporiser setting may correlate poorly with FA: (1)early in anaesthesia with all anaesthetic agents (2)later in anaesthesia for closed circuits or low inflow rates. (3)later in anaesthesia for more soluble agents like isoflurane even at higher inflow rates. The vaporiser setting will correlate well with poorly soluble agents like desflurane and sevoflurane 30-60 mins after induction. FD/FA may still be 1.2 even with flows 1-2L. The FI/FA ratio we know can also be altered by ventilatory changes, cardiac output, ventilation-perfusion abnormalities. If these are kept constant, FD and FI are the same but this cannot happen with a rebreathing circuit with low flows as the FI becomes lesser than from the machine due to washout in the circuit, depletion of anaesthetic in the rebreathed gases due to uptake of anesthetic and loss to plastic and sodalime etc. Above 5 litres, rebreathing will not affect the concentration. If you adopt a closed circuit technique, there will be a lot of difference between the dial setting, inspired and alveolar concentration and dial settings will need to be changed according to the end tidal agent concentration. With low flow techniques, this is more constant though! After the inflow rate exceeds the minute ventilation, further increases in inflow does not affect concentration. Then FD/FA=FI/FA. So the recommendations are that a reasonably good correlation of MAC with modern vaporiser dial setting can be achieved with low flow delivery systems starting with 4-6lL applied early at induction coming down to 2-4L, 5-15mins after induction and flows of 1L thereafter. |
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Query (Asked by Dr Chetan Mehra from Mumbai) Anaesthesia of choice for a patient with dilated cardiomyopathy with an ejection fraction of 25% posted for fracture neck femur fixation |
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Response by Dr. Manimala Rao (Posted on 13th November, 2005) You have not mentioned the age and any other co morbidities. How ever my choice for this patient is a very light general anesthetic with controlling the respiration with rocuronium minimal sedation with midazolam. For induction I have tried ketamine in doses of 0.5 mg per kilo. Of course one has to understand that there could be a little myocardial depression. In the dose I have mentioned we rarely come across the problem. I would prefer GA with arterial and CVP monitoring besides the non invasive. Must maintain the temperature and the fluid balance correctly. Post op pain relief with femoral block and tramadol in combination with paracetamol would be quite adequate. |
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Query (Asked by Dr Jaisree Gopinath ) 6yr old child with h/o of medulloblastoma operated at the age of 3 being admitted with seizures & unconsciousness planned for ventilation to prevent aspiration&hypoxia due to continuous seizures. What mode of ventilation & sedation would you suggest. |
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Response by Dr. Manimala Rao (Posted on 13th November, 2005) Six yr old continuously having convulsions and the focus is previously operated meduloblastoma with poor prognosis. I would control the ventilation with vecuronium in the beginning and add midazolam drip and adjust both drugs to prevent any further convulsions. Only after a day or two I would think of going on to assist control or SIMV with midazolam as the sedation. If the prognosis is poor and the surgical exercise is not planned then an early tracheostomy is planned to wean the ventilator provided of course the convulsions are controlled. |
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Query (Asked by Dr Sunny Bhasin from Davangere) A 21 years primigravida with the gestational age of 32 weeks who was admitted to our hospital with the complaints of severe headache, nausea and vomiting and irritability. Examination by the gynecologists in consultation with the neurophysician revealed aphasia and neck rigidity. CT scan revealed a well enhanced pontine angioma. For better neurological outcome, caesarean section was planned. Unfortunately under the pressure of gynaecologists we performed spinal anaesthesia. Immediate post op period was uneventful. After 24 hours she started developing disorientation to relatives, aphasia, lateral rectus nerve palsy and diplopia. Post op CT scan was unremarkable (no coning). Postoperative deterioration of this patient made us to refer her to NIMHANS Bangalore where the patient was diagnosed as tubercular meningitis case (for this LP was done to analyze CSF) and treated accordingly. She improved and was discharged. I have to present this case...Can i justify my technique (spinal.)? |
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Response by Dr. Anjan Trikha (Posted on 8th Nov. 2005) I think it is not correct to do a spinal in this case with a pontine angioma with neck rigidity etc. The TBM diagnosed later on could have been present at the first instance itself which could be the cause of neck rigidity. I just do not accept that on the instance of the surgeon Spinal was given. Any Pathology associated with possibility of an increased ICP requiring anesthesia should preferably get GA. In case the patient had a TMJ ankylosis I would have opted for an awake fiberoptic guided intubation. Awake intubations have been done without Fibreroptics too. |
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Query (Asked by Dr Aboobacker from Doha, Qatar) A 12 yr old male boy posted for bilateral K wire fixation for( # bilateral lower end femur). On PAE pt was having a H/O of bronchial asthma in the past but asymptomatic for the last nine months and not on any medication for the same at present. Premedicated with inj. Midazolam 4mg im one hour before induction. Induction with Fentanyl/propofol/sevoflurane with cisatracurium as relaxant, maintained with N2O/O2/sevo plus infusion of both cis atracurium+ remifentanyl. Intubated with 7.0 mm cuffed ETT. 20-25 minutes after intubation there was a sudden increase in air way pressure to 45- 60.On examination found severe bronchospasm. Spo2 started falling (up to 60). There was also sudden tachycardia with rate above 120/mt and hypotension (SBP 80-90mm Hg). I want to know what was the problem. ET CO2 was 45-48 after the event. Pt was shifted to ICU & recovered uneventfully with supportive measures. |
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Response by Dr. Anjan Trikha (Posted on 8th Nov. 2005) This looks to be a case of light anesthesia or an anaphylaxis to any of the agents being used. Minor embolism could be a possibility but ETco2 was with in normal limits after the event though its value during the event has not been mentioned. Of interest would be the stage of surgery at the time and the fact that any medication was given prior to the event. |
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Query (Asked by Dr Arokia Arul from Nagercoil) 55 yrs male, known RHD-severe AS (transvalvular grdt 115mm of Hg) and moderate MS. His HR90bpm;regular;sinus,bp-140/120, on digoxin not in CCF. EF was 65%.This man had a tibia fractured (closed) following an accident. If this man comes for a closed interlocking nailing, what would be the best form of anesthesia. |
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Response by Dr. Anjan Trikha One could discuss the pros and cons of both GA & Continuous epidural. What would be important is the monitoring that needs to be instituted. Putting in lines arterial and Neck line - PCWP or just CVP would be areas of concern as would be the length of time the surgeon's take and the patients willingness. Personally speaking I would prefer a continuous epidural with slow, cautious preloading and incremental doses of LA so as to avoid any major CVS changes. This would be a great case to be done in a continuous Spinal block using a spinal catheter. In a peripheral set up I would suggest to avoid doing it unless basic monitoring are available. |
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Query (Asked by Dr A. Marzouk from Mansoura, Egypt) Can nalbuphine /tramadol be given I/T? Their dose & side effects. |
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Response by Dr. Anjan Trikha I have no personal experience of Intrathecal tramadol. There was a report which had mentioned negative results of intrathecal tramadol and is not routinely used. Nalbuphine is used in doses 0.4, 0.8 or 1 mg intrathecally for post operative pain. The duration is less than that of intrathecal morphine The side effects are same as with intrathecal opiates but are less in magnitude and frequency. |
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Query (Asked by Dr Rajendra from New Delhi) A gunshot injury to abdomen, 45 kg patient is hyperventilating. He is well sedated with morphine 5mg/hr, his respiratory rate is 45-55/min on SIMV18,Vte350, PEEP5, FiO2 0.4; HR:100/min, BP110/65, SPO2100%, temp 98.6F, ABG: :respiratory alkalosis, PCO2 :20, no metabolic acidosis, I tried varied combinations of SIMV rate, with&without pressure support, stand alone PSV, nothing seems to be working , what should I do? |
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Response by Dr. Manimala Rao The patient is hyperventilating and needs either good sedation or a shot of relaxant like vecuronium to controll and slowly bring him to SIMV after sedating with a combination of midaz and fentanyl. Once the patient is sedated you can reduce the vecuronium and slowly bring him with sedation and convert to SIMV. Since the patient is hyperventilating, met acidosis is getting corrected. The best bet is a few hours CMV and then go back to SIMV on sedation and analgesia. |
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Query (Asked by Dr Yash Javeri from Delhi) Is there any relation between mannitol administration and dural incision? |
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Response by Dr. H. H. Dash Ideally administration of mannitol should complete 10 minutes prior to dural incision to have the best effect. |
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Query (Asked by Dr Saroj Pattnaik from Chennai) How to calculate supplemental steroid doses in pts, on steroid or recently stopped taking steroid, during intraoperative period? |
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Response by Dr. Manimala Rao The supplementation in adults is quite simple. We give 50 mg 8th hourly in the first three days in moderate risk surgeries and 100 mg for very high risk surgical procedures. It is tapered to 50 mg tid for another day or two if the patient is unable to take orally. One goes back to prednisolone 5mg daily or their usual dose regimen. For minor surgical procedures where the stress response is minimal one does not need any supplementation. |
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Query (Asked by Dr Rajendra from Delhi) What is 'stress index' in respiratory mechanics, how to calculate this and how it is useful for tailoring ventilatory strategy? |
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Response by Dr. Manimala Rao Respiratory mechanics are usually measured during dynamic conditions in the ICU (as static/semistatic methods have never gained any popularity) but this is done in a very crude and simplified manner. Usually airway pressure is only measured at the ventilator or at the Y-piece not taking into account the huge effect of endotracheal tube resistance on dynamic measurements. The inspiratory part of such measurement will mainly reflect the high resistance of the endotracheal tube and the expiratory part the low resistance of the expiratory valve of the ventilator. Also measurements of compliance are only performed between endpoints of inspiration and expiration, requiring end-inspiratory and end-expiratory pauses, not considering events there between. Different approaches have been suggested to improve dynamic measurements, using Y-piece pressures, calculated tracheal pressures or directly measured tracheal pressures. The stress index technique has been developed by Ranieri and colleagues . This technique analyses the profile of the airway pressure curve measured at the Y-piece during constant flow inflation (i.e. volume controlled ventilation). A progressive decrease of the slope of the curve may reflect alveolar recruitment and a progressive increase of the slope reflects overinflation. Accordingly the ideal ventilator setting would be where the slope of the curve is linear. The technique assumes that the resistance of the respiratory system is constant during inspiration, but it is in fact volume dependent, so resistance varies within the breath. Conclusions: The measurements continuously sample and display data during on-going ventilator treatment. It uses ordinary monitoring equipment with the addition of simple and inexpensive methods for direct monitoring of the tracheal and oesophageal pressures and a straightforward algorithm to analyze the data. It allows measurement of alveolar P/V-curve on-line and partitioning of the total respiratory system into lung and chest wall components. Individual ventilator adjustment is possible and it may reduce the risk of ventilator-induced lung injury. This will be useful in patients with ARDS as it is shown that the mortality in ards is brought down from 40% to 31% in ARDS net trial. If used correctly these methodology will reduce VILI and thereby reduce the mortality. It is a difficult question and I will give you the link so that you can look up for more information. Ref: European Society of Anaesthesiology Refresher course Pr/vol Curves in ARDS old and new aspects 12Rc 8 |
