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QUERIES AND RESPONSES Archive- Page 4 Click for: Recent Q & A Page,
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| Query (Asked by Narendra Menon From Coimbatore) What is the current line of management of post MI VSD? Is device closure or urgent surgery better? We have done 2 cases (surgical closure of VSD + CABG) but both expired due to residual VSD with severe RV failure. Kindly suggest what is the optimal management. |
| Response by Dr. Yatin Mehta (Posted on 5th December 2007) Ideally the case should be deferred for a few weeks as surgical closure of the VSD is difficult due to friable tissues not holding the sutures. IABP should be inserted if patient is in failure. If despite medical management haemodynamic instability persists then there is no alternative but to operate with a high risk. |
| Query (Asked by G.Prabhakar From Vellore) I have a 75 year old female for a lap cholecystectomy. She is a diabetic and hypertensive and is on haemodialysis for CRF. Her urea and creat have become normal after dialysis. She has a moderate pericardial effusion and minimal bilateral pleural effusions. Should we do a therapeutic pericardiocentesis before surgery? Which induction agent will be an ideal one? |
| Response by Dr. Yatin Mehta (Posted on 3rd December 2007) A preop Echo/TEE should be done to assess if there is evidence of tamponade as evidenced by RA collapse of IVC size variation with respiration. If there is none then it may be alright to go ahead. If there is evidence of tamponade then it is advisable to do therapeutic pericardiocentesis as because of pneumo-peritoneum in lap chole there might be haemodynamic compromise. Titrating small dose of thiopentone is fine as propofol can produce more fall in BP. Ketamine can worsen the hypertension. |
| Query (Asked by K.N.Nagaraja From Bangalore) I am am suffering from Post-thoracotomy (intercostal nerve Pain). I under vent thoracotomy in 2004 because of Pleural thickening. In the last 2 and half years I have taken all medicines like pregabalin, LURICA, and gabantin and other such medicines. I also underwent acupuncture treatment. The doctor also gave epidural injections TWICE but nothing worked out. CT Thorax shows "concave-convex band of heterogeneous soft tissue attenuations, demonstrating speckled calcifications, replacing the right lower posterior/axillary costal /costo-phrenic pleural silhouettes- post operative sequel" Now the doctor has told me that the last resort will be to go for Cryoanalgesia method to freeze the nerves. Your opinion.. |
| Response by Dr. P. N. Jain (Posted on 27th November 2007) Tata Memorial Hospital does not have this facility. I am not sure whether this technique can cure your pain. Since you have already tried all possible treatments, I would suggest you to visit us or to some good pain centre for thorough exam. LIDODERM (5% lignocaine) patches on painful site may be tried. We have some patches. India does not have any distributorship at present. |
| Query (Asked by Deepa From Coimbatore) A 72 year male, case of ca esophagus underwent macewen procedure under GA. After the procedure patient was electively ventilated. He developed Atrial Fibrillation on 2nd day, treated with Amiodarone. Patient was extubated on the 4th day and was on NIV. PaO2 90 - 100 with FiO2 0.5 On the 12th postoperative day, patient became restless, saturation & pressor dropped, intubated, put on inotropes and vasopressors. ECHO showed normal LV. Thromboembolic prophylaxis given. No evidence of a septic foci. How to explain the deterioration? |
| Response by Dr. Manimala Rao (Posted on 17th November 2007) The patient was operated for CA Oesophagus and did develop AF. He had elective vent and followed by NIV. On the 12th day developed desaturation.The most probable is slight leak from the surgical site which you may not be able to detect with usual methods. You have not written about the X-ray chest,TLC and the temperature chart. If there is a mild leak it does cause problems for oxygenation. 12 post op days in icu can usually cause for nosocomial infections too. The blood cultures could be negative.The hypotension and desaturation in this setting are sufficient to say most probably infection. If the patient has deranged coagulation parameters that can be additive. Procalcitonin and lactate levels could have given you an idea. |
| Query (Asked by Bipasha Dasgupta From kolkata) 65 years old male scheduled for TURP. Known diabetic, presently on regular insulin & hypertensive on amlodipine-hydrochlorthiazide. Echo - diastolic dysfunction, EF 70%. Lab-urea:110, creatinine:3. What will be the mode of management? Can we proceed for TURP? If yes, regional or general anaesthesia? |
| Response by Dr. Anjan Trikha (Posted on 12th November 2007) The patient seems to be having DM with ?nephropathy. I would give a spinal block provided the coagulation parameters are with in normal limits. Patients with nephropathy can have altered coagulation profile. In case they are borderline then I would like to give a GA , proseal LMA or Intubate him and proceed. |
| Query (Asked by Kristin From Jakarta, Indonesia) Can rocuronium cause acidosis in ICU patients? Please give me guidelines for rocuronium infusion usage in ICU? How long can be the maximum duration rocuronium infusion? |
| Response by Dr. Manimala Rao (Posted on 1st November 2007) Rocuronium an intermediate NMBA is an useful relaxant in ICU It has minimum effects on hemodynamics,shorter duration of recovery as the end products of metabolism are not active. It can be utilized in both renal and liver failure patients in reduced doses.It can be used as bolus dose 0.6mg/kg followed by an infusion of 10 mic/kg/min. It has been used safely for five days in a multicentric trial in critically ill MOF and non MOF patients, of course using a neuromuscular monitor to titrate the drug. The former required less drug but the block was more prolonged after cessation of the drug 0.2mic/kg/min as compared to non MOF patients who required 0.5/kg/min and recovered faster.The only patients who require prolonged block for more than 48 hours are those with head injuries or those with severe ARDS and MOF with sepsis,and on PCV with inverse ratio ventilation. Titration of the dose is key to successfully using these NMBAs.In this study they were safely used for five days. As long as monitoring is utilized one can titrate the dose and use it to a length of time required. The critical illness myopathy can occur but it may not be that common as with vecuronium. One has to use it carefully in patients receiving steroids. Rocuronium per se is not implicated in acidosis. REF: South Med J 94(1):36-42, 2001. © 2001 Southern Medical Association |
| Query (Asked by Vasanti From Aurangabad) Can we use I.V. NTG drip or I.V. labetalol for control of severe hypertension & tachycardia during prolonged laparoscopic surgeries? |
| Response by Dr. Mary Korula (Posted on 28th Oct. 2007) If the hypertension is due to sympathetic stimulation, increasing the depth of anaesthesia with inhalational agents, adequate analgesia and beta blockers would be the simplest best option - either titrated doses of metoprolol or esmolol infusion according to availability! Make sure your ventilation is OK and endtidal CO2 is within normal limits. You may have to increase rate of ventilation as hypercarbia may be the cause of your hypertension and tachycardia.Try to avoid N2O for pneumo peritoneum as well as for ventilation as this can distend the bowel and make lap surgery difficult. |
| Query (Asked by Vinod Gagrani From Delhi) Kindly guide me about the time interval after which subarachnoid block may be repeated on the same individual. |
| Response by Dr. Anjan Trikha (Posted on 24th Oct. 2007) There are no standard guidelines for a repeat spinal block. There have been reports of successful blocks after the first was a failure/patchy on the same patient. Personally I would have given a few once the resident reports 'spinal not working' in spite of needle 'was' in place. A repeat spinal can be given after the first effect has worn off if a second surgery is needed with in a few hours. As long as hemodynamics are taken care of a repeat spinal block can be safely given if indicated. |
| Query (Asked by R. Muthukumar From Coimbatore) Can magnesium sulphate be used for postoperative analgesia in cardiac surgery patients . if so what maximum dose per day can be used. |
| Response by Dr. Yatin Mehta (Posted on 18th Oct. 2007) I don't think so! Magnesium is administered postoperatively in order to reduce the incidence of arrhythmias. It has additional sedative, & anti epileptic effects but one should keep in mind the vasodilatory effect also. Better, shorter acting analgesics are available so why use magnesium? |
| Query (Asked by simant kumar jha From Ranchi) A 70 yr old women with hypertension came with intertrochantric # femur. ECHO showed Hypertrophic Obstructive Cardiomyopathy. LVEF-48%, with normal valves. How to proceed with anaesthesia? A GA with halothane, nitrous, oxygen with vecuronium for both intubation & maintenance or adequate preloading with fluid with epidural anaesthesia & phenylepherine & esmolol in hand. |
| Response by Dr. Anjan Trikha (Posted on 9th Oct. 2007) I would get the case done under a continuous epidural with a very gradual administration of LA and careful preloading so that the required block height is achieved without any major hemo dynamic changes. I am sure you would not need esmolol at all and may be not even phenyl epherine. We have published cases where patients with HOCM have undergone mastectomy under a thoracic epidural with excellent results. GA however is not a contraindication specially if there is a contraindication for a neuraxial block. In case a GA is needed I would use an LMA - proseal preferably - with a barbiturate - opioid induction, halothane and vecuronium. Reversal with neostigmine and glyco. I would however monitor IBP and CVP if possible along with usual modalities. |
| Query (Asked by Nitin Waghchoure From Nashik) What is the best solution to be used for intercostal nerve block for neurolysis? If phenol, what percentage should I use and where to get it from? |
| Response by Dr. P. N. Jain (Posted on 1st Oct. 2007) You can use phenol 6% for this purpose after demonstrating good relief with local anesthetic. You can get this solution from Royal chemist in Marine Lines, Mumbai or you can get this prepared from pharmacy (carbolic acid). |
| Query (Asked by Jyoti From Anand) A 70 yr old heavy smoker and alcoholic presented with altered sensorium sudden onset GCS 3/15,and vitals showed AF with controlled ventricular rate and BP 200/110mm of Hg. Suspecting ICH, CT Head was done, which was normal. We found white fluid with smell of OP compound on gastric lavage. Relatives found 50% chlorpyriphos at the bedside. We started treating on the lines of OP poisoning with atropine and PAM as continuous infusion of 1 g per hour and reducing atropine. Even after 30 days since the event there is not much of improvement in the consciousness level. Pt is on ventilator & tracheostomised. At present he does not require atropine but PAM still continues. Please guide us. |
| Response by Dr. Manimala Rao (Posted on 28th Sept. 2007) I do not know whether you have done serum cholineterase levels, it gives an idea about the time it takes for recovery. If the serum choline levels are at least half of normal they get weaned from ventilator. Monocrotaphos takes at least 3 to 4 weeks to wean patients. Patient is hypertensive and alcoholic, with poor GCS could have had hypoxic damage. If he in a vegetative state it can be excluded with EEG and neurology consult. As I do not have all the details I am giving the options. |
| Query (Asked by Prasath From Madurai) What is the onset time of hyperventilation for intraop reduction of intra cranial tension |
| Response by Dr. V. K. Grover (Posted on 28th Sept. 2007) Normally hyperventilation reduces intra cranial tension immediately and it acts like CSF drainage. But during intra operative period several factors are at play:- 1. Choice of Anaesthetic agents: - Inhalational agents like halothane, isoflurane and sevoflurane have cerebral vasodilator effect; hence efficacy of hyperventilation to reduce ICP will be compromised. Thiopentone on the other hand has cerebral vasoconstrictor effect; hence it may have some synergistic/additive effect with hyperventilation. 2. Size of Tumour: - Hyperventilation acts on the normal areas of the brain and cerebral reactivity to carbon dioxide is disturbed in Diseased/ Tumour areas of brain. Thus larger the tumour less will be effect of hyperventilation. 3. Venous Drainage: - During intra operative period venous drainage from the brain is very important factor and if one is not careful while positioning the patient intra operatively, no amount of hyperventilation will help. In addition use of diuretics like Mannitol and Frusemide during intra operative period will also reduce ICP. Thus it is difficult to predict onset time for hyperventilation alone during intra operative period. It will depend on interplay of all these factors. |
| Query (Asked by Shalaka Gandhi From Mumbai) 55 year male, Known case of Aortic sclerosis,came with dyspnea at rest for a obstructed inguinal hernia. He had been advised a CAG and Aortic valve replacement a year back which he did not follow. His 2D echo then showed EF of 10% and PG/MG across aortic valve of 103/54. He was not on any treatment with stable hemodynamic parameters and investigations including ABG. How does one manage such a case? |
| Response by Dr. Yatin Mehta (Posted on 26th Sept. 2007) You need to specify the gradient across the valve which would indicate the severity of the aortic stenosis. Also was it AS or AR? That makes a difference to the prognosis & management. If the valve is non calcific and with a significant AS then that can be life threatening and I would advise an aortic balloon valvuloplasty followed by Ing. Herniorhaphy. Even if its calcific, its a good option (salvage) after explaining the risk of stroke to the patients family. Whatever modality you choose, you and the patient's family must realize that risk to life is very high (as with poor EF) with emergency surgery. If valvuloplasty cannot be done then one should go ahead with herniorhaphy as a life saving procedure. Inotrop monitoring should consist of direct arterial pressure and PAC/ CVP. I would recommend PA catheter. Neuraxial techniques I would not be happy with due to the possibility of vasodilation and subsequent hypotension in a patient with AS with 10% LVEF which can be disastrous. The procedure can be done under local infiltration i.e. Ing Block with some sedation. If it cannot be done under LA then it best to do it under GA. With rapid sequence induction and induction with fentanyl (100-150 mcg), midazolam small dose of thiopentone and suxamethonium after priming. Maintenance can be with isoflurane (low conc.) fentanyl, O2 + N2O and IPPV. Hypotension can be treated with I/V starch titrated by PAP/ inotropes, monitoring CO & SVR and intra-aortic balloon counter pulsation can be used. |
| Query (Asked by Mallikarjun Sidram From Kochi) I have 2 doubts to clear from you 1.In modified RSI/crash induction, is the dose of induction agent fixed or can we titrate to the effect e.g. in severe mitral stenosis pt for emergency section of postpartum atonic PPH in shock? 2. Failed intubation drill in obstetrics, head down & left lat position is recommended to prevent regurgitation but in this position is it difficult to mask ventilate and place LMA if required? Please clear my doubts as Iam preparing for practical exam. |
| Response by Dr. Anjan Trikha (Posted on 13th Sept. 2007) The dose of induction agent for RSI is fixed and not usually titrated , however in cases mentioned this is not true. For a patient in shock with PPH I would not use ketamine where again I could use a fixed dose. In case with MS both compensated and un compensated, one should keep in mind alternatives. I would prefer an opioid use along with a barbiturate in order to reduce its dose. However it would depend upon the centre as the baby may need some respiratory support. In the literature there are no standard dose reductions for RSI in cases of MS or compromised cardiac function regarding induction agents. In the exams one could speak about alternatives and discuss. The second - Mask ventilation or LMA insertion is not all that difficult in the position mentioned, though it would be easiest in a supine position. One should be trained to do so in normal patients with no risk of aspiration then the task becomes easier. |
| Query (Asked by Anand From Chennai) Does high eosinophilic count (more than 20%) has any impact on cardiac surgery patients done on CPB. If so what precautions to be taken. |
| Response by Dr. Yatin Mehta (Posted on 6th Sept. 2007) Patients with high eosinophil count may have bronchospasm at induction and intubation. There are also reports of similar reaction with protamine. We have a series of patients with eosinophilic and not had any problems. We put them on netrazan (tropics) and may be steroids for a couple of days prior to surgery. |
| Query (Asked by Ashok Jadon From Jamshedpur) A case of Takayashu disease is posted for hip artrhplasty due to avascular necrosis. She is on steroids and azathioprine. Should we stop azathioprine before operation? if yes why and when? |
| Response by Dr. Anjan Trikha (Posted on 3rd Sept. 2007) Azathioprine is an immunosupressant which can effect the NMJ. It has been reported to antagonize competitive NMJ blocking drugs by its phosphodiesterase inhibiting properties and therefore larger doses of Non depolarizing blocking agents may be needed. There are also reports of prolong action of suxamethnium with it. However clinical relevant doses do not antagonize NMJ drugs in humans. Other area of concern are its side effects - of concern to us are decrease in WBC count and Platelets and liver dysfunction. A patient who is stable on azathioprine should be regularly being monitored for these Other area of concern is its long duration of action and it usually takes 7 - 10 days for platelet count and WBC count to come to normal after its stoppage. As far as the case is concerned - Takayashu disease and steroids + azathioprine for hip elective surgery. There are no standard recommendations for this drug and the disease. I would get a complete blood count and coagulation profile including platelets. If totally an elective case I would prefer to stop it for at least 7 days. However I have no literature support to defend my plan. In case that is not possible due to urgent surgery requirement and blood coagulation is normal I would go ahead and avoid a spinal / epidural or a CSE. Standard precautions for Takayashu disease would need to be taken. There was an excellent series of this disease published from PGIMER in Anesthesia Analgesia in 2001 by Kathervil et al. |
| Query (Asked by Sara From Karachi, Pakistan)My mother has Idiopathic Pulmonary Fibrosis, which was diagnosed 4 years back. Till now she is on steroid & Azathioprin. She frequently gets infected so once or twice in a month she uses antibiotic course also. Is there any solution for this ? |
| Response by Dr. Manimala Rao (Posted on 2nd Sept. 2007) Idiopathic pul fibrosis is a continuous process. As patients are on steroids their immunity is compromised. Her main problems are repeated chest infections. Development of DM is also a possibility along with osteoporosis and easy fractures. One has to avoid any allergens which trigger post nasal drip and their by leading to chest infection. Multivitamins with antioxidants may be helpful. Yoga and pranayam exercises could be helpful on a regular basis. There is no cure and the disease is progressive. Symptomatic relief and to minimize the no. of chest infections is mandatory. Nutritious diet with supplemental antioxidants daily may be helpful. Interferon has been tried with some success. (ref: Ziesche et al (1999) N Engl J Med 341,1264-1269) Other novel agents that have been tried are antioxidants (because epithelial injury in IPF may be mediated by oxygen radicals), Glutathione (an effective scavenger of toxic oxidants that suppresses lung fibroblast proliferation in response to mitogens), taurine (a natural free amino acid), and niacin (inhibits the development of experimental fibrosis in an animal model). High-dose N-acetylcysteine, as a glutathione precursor, has been suggested as an adjunct to maintenance immunosuppression therapy in patients with IPF. Preventing lung infection by focusing on the allergen, keeping the pollution to a minimum avoiding the areas where it is high, diet rich in antioxidants and fish oil could be helpful. Pranayam and yoga exercises which do not cause a problem could be practiced on a day to day basis. |
| Query (Asked by Venetsanos Kolokouris From Piraeus, Greece )What should be done when a drunk patient (anxious,very confused, disoriented) with GCS>10/15 severing in a car accident needs a CT scan? Is it proper to sedate him (a little!!! sedation as the surgeons say)? Should he be intubated? Are there any guidelines? |
| Response by Dr. V. K. Grover (Posted on 2nd Sept. 2007) This patient has following problems to be looked in to:- 1 Patient has taken alcohol and is disoriented, confused and certainly uncooperative. 2. He has full stomach due to alcohol and otherwise also exact status is not known. 3. Has sustained head injury and needs frequent neurological assessment. First thing there is nothing like little sedation as surgeons say, patient's safety is more important. Ideally patient should be taken for full GA with short acting drugs and must undergo Rapid sequence intubation/Crash induction. One can induce with Propofol/Thiopentone, Intubate with Suxamethonium/Rocuronium 1mg/kg and then maintain with either Cisatracurium or Atracurium, Remifentanil, and Propofol infusion. At the end of procedure one should reverse with usual doses of Neostigmine and Glycopyrrolate. If per chance patient needs surgical intervention after CT, he can be moved to OR straight away. Otherwise the action of all these drugs will go away quickly and surgeon/intensivist can make neurological assessment immediately and proceed. |
| Query (Asked by A.Ravichandar From Madurai) How the muscular dystrophy (myopathy) patients will react to ketamine? |
| Response by Dr. Manimala Rao (Posted on 26th August, 2007) It has been used successfully in 32 children for muscle biopsy for various forms of MD. It is the agent of choice as it is not associated with resp or cvs depression, maintains the muscle tone and reduces the shunt.The increase in secretions can be obtunded with glycopyrrolate. IV ketamine can be given in incremental doses if there is associated cardiomyopathy. IM ketamine has shown to be unpredictable. Seizures have been reported in animals but no such reports in humans. Avoid suxamethonium and halothane so as not to trigger MH. Combining regional techniques use of LMA with spontaneous or assisted ventilation can be tried with ketamine iv in incremental doses with minimal propofol and sevoflurane or midazolam can be the choice. Good pre op assessment, adequate monitoring, judicious use of above mentioned drugs, preventing respiratory depression preserving cough reflex are the key points in management. Combining regional techniques supplemented with light GA, graded epidurals, and spinals have been used in orthopedics. |
| Query (Asked by R.Muthukumar From Coimbatore) Could you please give me the reason why some of the post cardiac surgical patients develop bronchial breathing in icu. We follow the same ventilatory & weaning protocols for all patients. Also please tell me which is the best fast tracking or overnight ventilation in cardiac surgical patients. |
| Response by Dr. Yatin Mehta (Posted on 21st August, 2007) Bronchial breathing at the bases is due to atelectesis which is common after cardiac surgery due to sternotomy (pair), increase in extravascular lung water (due to CPB), supine position, altered ciliary movements and may be diaphragmatic dysfunction. Ventilatory and weaning protocols should be the same. If the patient is haemodynamically stable with uneventful periop course, not on significant inotropes and is normothermia then he can be fast tracked in a few hrs. |
| Query (Asked by Asitendu Datta From Kolkata ) 26 yrs. old ASA1 primi was given intrathecal Bupivacaine 10mg+Fentanyl 25mcg for C.S. Uneventful surgery & fine till 48 hrs when she suddenly developed psychosis. Could this be attributed to anaesthetic procedure? |
| Response by Dr. Anjan Trikha (Posted on 21st August, 2007) It is unlikely that the spinal anaesthesia mentioned could be the cause of psychosis in the patient after 48 hours. Other factors could be looked into specially other medications. Antibiotics specially. Post partum psychosis is a known entity but is not in any way related to an epidural or a spinal block. Previous history of psychosis should also be explored and personally I have seen abnormal behaviour in Indian women who deliver 2nd or third female child. Again this is not related to the anaesthetic technique. |
| Query (Asked by Gunjan Rastogi From Delhi)Is Dexmedetomidine available in india? If yes what is your experience? |
| Response by Dr. P. N. Jain (Posted on 16th August, 2007) No. Dexmedetomidine is not available in India. |
| Query (Asked by Sanjeev Arya From Dehradun)I wish to buy a peripheral nerve stimulator/locator for giving nerve blocks. Kindly advice as to which brand of the product shall I go for. |
| Response by Dr. P. N. Jain (Posted on 15th August, 2007) You may consider purchasing"STIMUPLEX" DIG stimulator by B Braun. We have good experience using this instrument. |
| Query (Asked by Simant Kumar Jha From Ranchi)What should be the direction of needle & site of puncture in case of infraclavicular brachial block? I also want to know more about fascia illiaca block & its utility. |
| Response by Dr. Anjan Trikha (Posted on 10th August, 2007) The infraclavicular block - The needle is inserted 2.5 cm below the midpoint of the clavicle at a 45 degree angle to the skin and directed laterally and posteriorly toward the axillary artery. The fascia illiaca block - The technique consists of injecting a local anesthetic immediately behind the fascia iliaca at the union of the lateral with the two medial thirds of the inguinal ligament, and forcing it upward by finger compression. It is a simple and easy to give block and provides excellent analgesia and anesthesia. It is a very popular technique - easy and with out use of nerve stimulator. It is useful for analgesia for hip fractures and also for other surgries along with GA. |
| Query (Asked by A.Ravichandar From Madurai)A 3 month old child for cataract extraction. On exam there is a minimal indrawing in the subcostal and epigastric region, history wise a minimal snoring noise during sleep and there was abnormal breathing pattern noted by the mother when the baby had fever a month back, CVS is normal, RS-bilateral equal air entry, no added sounds, x-ray-normal, paediatrician says it is tracheomalacia. What is the diagnostic test for tracheomalacia? How can we proceed with anaesthesia? |
| Response by Dr. Mary Korula (Posted on 1st August, 2007) Congenital tracheolaryngomalacia can be part of generalized chondroplasia presenting as excessive softness and collapsibility of laryngeal, tracheal and bronchial cartilages. It can be asymptomatic, presenting at 3 – 6 mths of age and usually resolves by 2 years of age without any active treatment. Many have required long-term tracheostomy. It can present for the first time during the time of anaesthesia especially during extubation. Laryngomalacia is associated with inspiratory stridor while tracheomalacia with both inspiratory and expiratory stridor. Differential diagnosis of tracheobronchomalacia includes laryngospasm, bronchospasm, laryngomalacia, vocal cord palsy, tracheal stenosis, laryngeal or tracheal web, intratracheal tumour, external compression to the airway (e.g., vascular ring, mediastinal mass) and bronchial intubation. Auscultation, chest X-rays and endoscopy are useful to reach a diagnosis. The definitive diagnosis is made on fibreoptic examination which may be difficult in a 3 month old and would require general anaesthesia. In this case the diagnosis is already made pre op and surgery is a cataract correction which does require GA but does not mandate intubation. Avoiding tracheal intubation will prevent the coughing and risk of airway collapse upon extubation and allow for smoother recovery. In the extrathoracic or cervical tracheomalacia, tracheal collapse occurs during inspiration. Usually they are intrathoracic, and when the intrathoracic pressure becomes positive as in coughing or forceful inspiration, the affected segment of trachea narrows resulting in the audible wheeze and collapse requiring mechanical ventilatory support for prolonged periods and agitation can compound this. Though there is a theoretical risk of airway obstruction during GA, these cases can be easily managed by laryngeal masks or supraglottic devices especially for diagnostic bronchoscopy. Cobra PLUS the second generation of supraglottic devices are thought to be easier to insert and the fibreoptic view is thought to be much better with these. The airway can become obstructed after induction of general anaesthesia, while the patient is breathing spontaneously, but obstruction is generally relieved by manual ventilation. When positive pressure is applied to the airway during forced expiration, the gradient between the intrathoracic and intratracheal pressures is reduced; therefore, tracheal collapse is in theory, less likely to occur during controlled ventilation than during spontaneous breathing. Airway obstruction may occur during emergence from anaesthesia, since airway dynamics (interpleural-intratracheal pressures) may markedly change during this period. It is important not to cause straining (bucking), since forced expiration worsens the narrowing of the lower airway. If airway obstruction occurs, deepening of anaesthesia may reduce the obstruction, since the intrathoracic pressure during expiration is lower under general anaesthesia than during the awake state and it has been claimed that tracheal collapse is less severe during general anaesthesia. Continuous or intermittent positive pressure ventilation may also relieve the obstruction. Nevertheless, if hypoxia occurs, the trachea should immediately be intubated, and the lungs ventilated manually. The use of a neuromuscular blocking agent may have a role in relieving airway collapse and preventing airway reflexes but again emergence may be a problem. Trachea should be left intubated until the patient has regained consciousness and the intrapleural-intratracheal pressure relationship has becomes ‘normal’ and no attempts be made to wake up the patient to avoid causing any strain. After tracheal extubation, positive pressure ventilation via facemask can be used to prevent airway obstruction. |
| Query (Asked by K. T. George From Cochin)I have a 80 yrs old patient, posted for interlocking nailing femer. She has epilepsy on trearment, last episod 1 month back. She also has DM HTN IHD. what is the choic of anaesthesia? Any contra indication for regional? |
| Response by Dr. Anjan Trikha (Posted on 31st July, 2007) There is no contra indication for regional. The cause of epilepsy has not been mentioned. It could be a CVA or electrolyte imbalance. These issues would surely effect the anesthesia choice. If the DM, IHD and HTN are under control and patient is not on any blood thinners, she can get a Regional. Ideal choice would be a graded epidural, however a SAB or a CSE would also be acceptable. The usual monitoring for regional should be undertaken. The cause of epilepsy must be known and if it is beingn issue regional is ideal. |
| Query (Asked by Aziz From Dublin, Ireland )Is LMA safe for laparoscopic cholecystectomy? |
| Response by Dr. Anjan Trikha (Posted on 11th July, 2007) Yes, LMA both classic and proseal have been used for Lap chole all over the world. With the proseal the whole anesthesia with LMA in such situation has become safer but the risk - though small but more than that with ETT remains of aspiration. A debate or a pro / con session is conducted in many conferences on this issue and there is plenty of evidence in the literature that both these devices have been used safely for Lap surgery both cholecystectomy and gyne surgery. Personally speaking I find no advantage of this device in such situations |
| Query (Asked by Muthukumar From Coimbatore )What is your advice regarding nutrition in post cardiac surgery patients? Entral or TPN if patient is on ventilator for more than 48 hrs.? |
| Response by Dr.Yatin Mehta (Posted on 8th July, 2007) Most of the post cardiac surgical cases one should be able to manage with enteral nutrition via a nasogstric tube even those on IPPV. The only exceptions are: 1. Those on high inotropes as the mesenteric perfusion is reduced in them. 2. Those with reduced gut mobility as evidenced by large gastric aspirate or reduced bowel sounds or post laparotomy. |
| Query (Asked by Varsha Kulkarni From Jalgaon) What is the optimum dosage for use of epidural Ropivacaine in labour analgesia? |
| Response by Dr. Anjan Trikha (Posted on 20th June, 2007) The dose of ropivacaine that I had used when abroad was 0.125% a total of 12 - 20 ml as per requirements. Like all other local anesthetics - bupivacaine and L bupivacaine - fentanyl or sufentanil was used with ropivacaine for labour epidurals. A dose of 0.1% and even 0.0625% of ropivacaine has also been found to be effective with sufentanil along with it. A dose of 0.175% gives a better quality block for labour but motor block is more pronounced that is not very desirable. In my opinion a mixture of 0.125% ropivacaine with sufentanil 0.75 0r 0.5 microg/ mL should be the best dose. |
| Query (Asked by Harsoor S S)What is the incidence of Discitis following injury of IV Disc by LP Needle and accidental wrong placement of Local anesthetic in intervertebral disc? |
| Response by Dr. Anjan Trikha (Posted on 20th June, 2007) Vertebral infections/ inflammations after epidural / spinal puncture are rare and inadequately documented. The incidence of post procedural discitis is approximately 0.2%. The most common etiologic agent in case of infective pathology is Staphylococcus aureus. The incidence of Discitis does not exceed that of spontaneous epidural abscesses and a causal relation between puncture and an abscess is a controversy. Many times the inflammation is aseptic. It is unlikely to be associated with technical difficulty of the spinal or epidural procedure. Discitis has been reported after myelography, paravertebral injection and obstetrical epidural anesthesia. A case of septic discitis occurring after intradiscal therapy with chymopapain has also been reported. Patients who present with recurrent spinal pain, fever after a spinal procedure, especially those with paravertebral muscle spasm, should be evaluated for the possibility of disc space infection and inflammation. Investigations would include ESR, TLC, DLC, X-rays& MRI. |
| Query (Asked by S.N.Krishnamoorthy From Madurai) While giving an epidural steroid injection of depomedrol 2cc with 2ml of 2%lignocaine in 40ml normal saline - first 10 ml went in easily, when the next 10ml was injected patient cried out due to pain; there was however no resistance to injection nor was there any leak of csf in between injections. What could be this pain due to? pt was kept under observation after the injection there were no problems and pain subsided. |
| Response by Dr. P. N. Jain (Posted on 17th June, 2007) Pain can be caused be sudden opening up of adhesions by the injection (Adhenolysis) produced due to chronic inflammations. |
| Query (Asked by M.R.Karthikeyan From Chennai) Does colloid have any role for volume replacement in infants? |
| Response by Dr. Mary Korula (Posted on 12th June, 2007) Even neonates would need colloid replacement in volume depletion though studies have shown that in hypotensive, polycythemic neonates, adequate replacement with crystalloids are equivalent to albumin administration upto about 50ml/kg or so. After that either synthetic colloids or natural colloids are indicated. Gelatins are not usually given, starches are more popular but one has to take into account the chances of HES accumulation and storage (longterm) with these and coagulation problems (short term). Natural colloids can transmit rare infective and viral agents. For practical purposes, what I do is, if there is definite indication for blood replacement during surgery, I start of with blood products rather than first give synthetic colloids and then replace with blood which might lead to overdose and side-effects of both eventually. |
| Query (Asked by Lachit Borphukan From Guwahati) Which is a better drug - Atracurium or Rocuronium for PACU? |
| Response by Dr. Mary Korula (Posted on 12th June, 2007) I presume this is emergency intubation situation we are dealing with here in PACU and one does not want to use Scholine. Both these drugs have their advantages and disadvantages. Both have been used successfully for rapid sequence intubations using 3xED95 doses for shortest intubating conditions. Rocuronium is faster and can be reversed with specific reversal agent cyclodextrin (sugamadex) any time though its duration of action with these doses are about 100mins. Atracurium action lasts for about 40mins, but need not be reversed by any agent due to its Hoffmanns degradation. It doesn't depend on the renal route for excretion which is its big advantage, whereas with rocuronium, main route of elimination is the kidneys. Atracurium can cause histamine release, hence cis-atracurium would be a better choice, also the doses required are much less. Depending on the condition of patient and availability of drugs, both can be given in PACU. |
| Query (Asked Avijit by From Delhi) A 60 year old obese male with h/o sleep apnea, uses bipap in the night,is for elbow surgery.Last surgery for elbow 5yr back when he had hyponatremia in postop. He is hypertensive (controlled) also. Pre, per & post op. anaesthetic management of this patient ? |
| Response by Dr. Manimala Rao (Posted on 9th June, 2007) 60 yr old male obese patient with sleep apnoea using bipap for the sleep apnoea is for shoulder surgery. Before one embarks on post op management, one has to see what anesthetic management can be the best. If possible nerve stimulator guided bracheal block with bupivacaine and tramadol would be an useful technique. Gives good analgesia as well as retains his respiratory drive. One could use the bipap if required during the surgery to keep up the oxygenation. If it is not possible to use this technique one has to give general anesthesia and use drugs which have short action and still give the block for prolonged pain relief.In the post op period one can continue him on the usual bipap he uses or increase it as the need be.good chest physio and nebulizations would be very helpful and nurse in a head up position. early mobilization should be done .if bipap is not required deep breathing exercises as well as incentive spirometry can be accompaniments to prevent chest infections. |
| Query (Asked by Anand From Pune) If the fatal iatrogenic complication occurs during or after ICU interventions how should intensivist communicate it to surrogates. Are there any ethical guidelines for this issue? |
| Response by Dr.Manimala Rao (Posted on 7th June, 2007) This particular aspect is a difficult and tricky issue wherever one practices medicine. The best aspect of course is prevention in explaining detail regarding the procedures and the complication rate before the procedures. In spite of all this, when a fatal event happens, one should consider all aspects take help from the senior consultant, the primary physician as well as the legal help if available in the facility where one works. The explanations have to be crisp, humane and very caring. When you break such news it should be in a quite surroundings preferably in an exclusive room. We should allow them for emotional break down as well as give them emotional support. Each case is unique in dealing with. This is an art which one acquires over years. In our talk we should show compassion as well as humility. That despite best efforts things do go wrong. Always talk sincerely and use words cautiously. One should not be abrupt but at the same time too apologetic. If the complication is a known one give the percentage and tell them that it is most unfortunate that it happened to this patient. Now many hospitals have a legal expert who could be contacted over telephone. His assistance could be taken before breaking the news.The hospital administration also help. With increasing emotional outbursts and violence the hospital should have core team which could deal such adverse events together with the icu physicians. Critical Care Updates have dealt with breaking the bad news issues as well as end of life issues in their books and journals. But this is a tricky issue with legal implications. One should take help as suggested above. Be systematic professional and humane. |
| Query (Asked by R.Muthukumar From Coimbatore) Is epidural safe in patients taking clopidogrel (antiplatelet medications)? Is there any risk of epidural hematoma? |
| Response by Dr. Anjan Trikha (Posted on 6th June, 2007) Clopidogrel needs to be stopped 7 days prior to a Neuraxial blockade as per standard recommendations. Yes there would be a potential risk of an epidural hematoma in case the patient is on blood thinners like clopidogrel. |
| Query (Asked by Kavi From Pune) Is 5% heavy lignocaine is banned for spinal anesthesia? I am aware of its neurotoxicity but still find it useful at the remote, small, poorly equipped set up. please opine. |
| Response by Dr. Anjan Trikha (Posted on 31st May, 2007) No 5% lidocaine is not banned for intrathecal use. One can safely use it without any medico legal implications |
| Query (Asked by R.Muthukumar From Coimbatore) Is it mandatory to keep the patient flat while giving epidural opioids. Do the opioids given through epidural track down along the gravity?? Does gravity influence spread of epidural? If so how much?? |
| Response by Dr. Anjan Trikha (Posted on 10th May, 2007) Epidural local anaesthetics are affected by gravity. Usually patients are turned around (Right or left up) in case of incomplete block as the case may be. This is very common for post op pain alleviation and labour epidurals. The question BY HOW MUCH? I really cannot answer as I am not aware of any such numbers in the literature. Regarding pure opioids in the epidural space - more important is the lipid solubility than the position. Morphine given in the lumbar epidural space would alleviate upper abdominal and thoracotomy pain also, but fentanyl given in this area will not. Usually fentanyl and bupivacaine are mixed and then gravity comes into play but more because of the local anesthetics and not fantanyl. So if one is using morphine epidurally then gravity is not important clinically. Time required for adequate neuraxial block with epidural local anaesthetics is shorter with head down position.This was a paper in 2000 / 2001 in pregnant patients |
| Query (Asked by Mohan From Bangalore) Do the current preparations of rocuronium cause injection pain or withdrawal movements? |
| Response by Dr. Manimala Rao (Posted on 2nd May, 2007) Rocuronium produces intense pain in a conscious patient. This is due to direct activation of nociceptive nerve endings. The algogenic effect of aminosteroidal neuromuscular blocking drugs can be attributed to a direct activation of C-nociceptors. When compared with rocuronium alone, only the addition of saline failed to significantly reduce the pain reported by patients. The addition of fentanyl reduced the complaint of pain by 1.9 times (P<0.049) and the addition of lidocaine 2% reduced it by 3.6 times (P<0.0001). Sodium bicarbonate 8.4% reduced the reporting of pain by 18.4 times (P<0.0001). Pretreatment with dexmedetomidine is not effective in reducing injection pain of propofol, but may attenuate the hand withdrawal associated to rocuronium, as lidocaine does. (Ref: European Journal of Anaesthesiology (2003), 20: 245-253, Br J Anaesth 2003; 90: 377–9) |
| Query (Asked by Abdelkader Hijazi From Al riyadh) A case of aspiration pneumonia treated empirically by usual treatment ventilated with high peep and simv was near to be extubated then after rate 4 simv she deteriorated with fever and tight chest almost high pressure could maintain ventilation she was put on rate 20 min-v0lume 500 and peep 12 and this could maintain saturation of 88% blood gases all the time were within normal kidney function was normal but at the end she arrested and died blood was coming out from the tube? |
| Response by Dr. Manimala Rao (Posted on 24th April, 2007) The patient had aspiration and showed signs of ARDS. If one can calculate Pao2|Fio2 one can easily designate to this category.She might have come down to Simv four and did not maintain the blood gases indicates the process is still on going.In the end looks like she had non cardiogenic pulmonary oedema . If she is unable to improve oxygenation it is better to put them on pressure controlled ventilation and going to almost inverse ratio ventilation.The best way to wean them is to go down to pressure support and reduce Peep to 6. In this way even if you wean and extubate one can give support by non invasive ventilation.This particular patient was not totally out of the infective process. Therefore she has gone back to severe pulmonary oedema due to non cardiac origin. Of course I do not have the information regarding the chest X-ray,TLC and temperature on the day of weaning.All these have to be assessed together for the ideal weaning condition. |
| Query (Asked by Brijmohan Boob From Mumbai) 42 yrs male for bilateral inguinal herniorrhaphy under spinal anesthesia. Preanesthetic check up clinically & reports were normal. Atropine .6mg iv & 500ml RL preload was followed by spinal anesthesia 4ml sensorcaine heavy at L3-4 space. Few minutes later patient had intense itching at perineum, buttocks, penis, & restlessness, wheezing type respiration, cyanosis, SaO2 80%, jerky movements, & coma. Meanwhile, IV dexamethasone 8mg and avil 1amp. given. Assisted ventilation with mask not possible. Intubated after 40 mg thiopentone &100 mg suxamethonium and controlled ventilation with O2 & N2O and pavulon for relaxation. Even with 100% O2 saturation was not more than 94 to 96%. BP recorded immediately after intubation was 200/110 & pulse 171/min. I presumed this as pressor response so sublingual Depine10 mg & Nitroglycerine skin patch given, IV inj. Hydrocortisone 100+100mg & soda bicarbonate 50+50ml was given. IV fluid 2500ml urine output was 1900ml in 3.5 hours. Pulse rate was consistently 170/min & BP 160/90. Patient expired 7/8 hrs after icu transfer. Lasix 20 & mannitol given at one stage suspecting cerebral oedema to anoxia. There was no bradycardia or hypotension. Was it unintended intra vascular deposition & neurotoxic event. What went wrong? |
| Response by Dr. Anjan Trikha (Posted on 22nd April, 2007) So many things are unanswered and treatment given at various times are not the ones I would have given. First - it all seems to be an anaphylaxis reaction at the first instance. I presume before giving a spinal the patient received atropine and a preload. Preload is fine but why was atropine given prophylactically? 4 ml of bupivacaine for spinal block too is a bit strange. It could be anaphylaxis to any any of the medications (Solutions used for cleaning the back, any other premedication drugs, bupivacaine, Latex, even atropine or some contamination in IV fluid too) Use of Avil and dexamethasone too at this time is a bit surprising. Adrenalin should have been used for anaphylaxis. The vitals at this time have not been mentioned. Anti histaminics and steroids have very little role to play as far as the released histamine effects are concerned. Intubation was carried out and the high BP could be due to intubation response but the patient should have been hypotensive because of anaphylaxis prior to intubation. However, post intubation the rise could be explained. I would have used nitroglycerine drip and deepened the anesthesia with inhalationals instead of calcium blockers and NTG patch. Efcorlin and soda bicarb too were given with out any justification. In the whole scenario there are no details about the hemodynamic stability and / or hypoxic insult following a respi or cardiac event, which could have surely happened. My personal opinion is anaphylaxis that was not properly managed. Intra vascular administration of bupivacaine is unlikely when the symptoms are considered. |
| Query (Asked by Deepali Mittal From New Delhi) Can Caesarian section be performed under spinal anaesthesia in a patient with a history of prolapsed inter vertebral disc? What are the options for anaesthesia in such patients? |
| Response by Dr. Anjan Trikha (Posted on 18th April, 2007) Yes. It can be performed under spinal. There are many reports of successful spinals in such cases. The best is to avoid the space that is affected. However there is a possibility that the patient may attribute her new back ache if it occurs to the spinal and the risk benefit ratio must be explained to the patient. I would personally give a spinal in such cases if they are associated with a difficult airway. Alternatively I would give a GA. |
| Query (Asked by James From Trichur) 75 yrs old patient with H/o CVA, with Hb 9gm%, NIDDM, COPD, Hypertensive, MI 2 yrs ago, is on clopidogel, needs regional anaesthesia for hemiarthroplasty Bipolar. At what value of PT/INR can we proceed?. |
| Response by Dr. Yatin Mehta (Posted on 17th April, 2007) A patient with H/o CVA is a relative contraindication for a neuraxial block and even more so if the patient is on clopidogel. Generally if he patient is on clopidogel then 1 wk should be the time lag between clopidogel administration and neuraxial block. I would do this case with light GA + 3 in 1 (Winnie's) block. |
| Query
(Asked by B. Dhakne From Pune) Anaesthetic management of a neonate
(1day old, 3 kg), a case of imperforated anus |
| Response by Dr. Mary Korula (Posted on 17th April, 2007) The immediate treatment for imperforate anus is a colostomy and definitive surgery -posterior saggital anorectoplasty (Pena procedure), done in the prone position later during the first year of life. Apart from neonatal considerations, about 50% have associated congenital anomalies and these can pose problems for anaesthesia.10% have Eosophageal atresia +TOF, some have the VACTERL constellation of symptoms, which include cardiac, vertebral, limb, genitourinary, renal or radial anomalies. So these should be ruled out and investigated if necessary. Large intestinal obstruction causes abdominal distension and respiratory compromise if severe and dehydration due to sequestration of fluids and electrolytes in the bowel. Acidosis, electrolyte disturbances and later vomiting ensues. Intermittent bowel obstruction can cause decrease in blood supply and perforation.They can present with toxic megacolon syndrome leading to hypotension, peritonitis and septicemia.Then aggressive fluid management and aggressive peri-op monitoring are essential. Baby should be stabilised, fluids & electrolytes have to be corrected before taking up for surgery. Aspiration prophylaxis and rapid sequence intubation with cricoid pressure is required. Nasogastric tube will be required. Fluid deficits should be replaced with saline -dextrose combinations with frequent estimations for glucose. Hyponatremia and convulsions can be a problem. Hypernatremia and hyperchloremic acidosis can also occur with large quantities of normal saline,¼ or ½ N saline used. Intra-op hypoglycemia is normally not a problem assuming the neonate had a normal term delivery, though hyperglycaemia can occur if 5% glucose is continuously infused. Replacement fluids are usually Ringers lactate and colloids. Calcium and potassium supplements may be required. A central venous line would be useful for fluid management. Warming blankets and fluid warmers to prevent hypothermia is essential. Balanced GA with inhalational agents, intermediate acting relaxants and fentanyl or other opioids are manadatory. N2O should be avoided. Caudal or epidural anaesthesia can be supplemented with GA if there is no sepsis and can be continued for post-op pain relief. Post-op analgesia with fentanyl I/v infusions 0.15ug/kg/hr with a 4hr limit of 4ug/kg after a loading dose of 5-10ug/kg intra-op or morphine infusions at 10ug/kg/hr may be used with continuous respiratory monitoring. Monitoring of urine output and temperature monitoring essential. Patient may be extubated on table if stable and warm with close post-op monitoring for deterioration.If extensive surgery needed, then post-op ventilation and ICU care is mandatory. |
| Query (Asked by Santosh Darisetty From Hyderabad) What is the best block to give for pain in chronic pancreatitis. |
| Response by Dr. P. N. Jain (Posted on 16th April, 2007) Pain relief can be provided in chronic pancreatitis by coeliac plexus block if analgesics e.g.opioids fail to provide even 50% relief. Howeve, evidence does not favour neurolytic blocks for such indication due to its inherent side effects like hypotention & permanent ablation of pain fibres in the upper abdomen leading to concealment of signs of tissue damage lateron in life. |
| Query (Asked by Venugopal V M From Pune) Please clarify a few doubts regarding laparoscopic surgeries: Does the type of anaesthesia (vis-a-vis GA or GA with EA or SA with GA) have anything to do with bowel distention and in turn affect the visibility of the surgeon? Is it recommended that all laparoscopic surgeries should undergo a crash induction apparently to avoid positive pressure mask ventilation which might again lead to bowel distension? |
| Response by Dr. Mary Korula (Posted on 4th April, 2007) The anaesthetic technique of choice for upper abdominal laparoscopic surgery is definitely GA with good muscle relaxation, tracheal intubation to protect the airway and IPPV with high tidal volumes to maintain normocarbia and prevent alveolar atelectasis.The choice of anaesthetic agents used is important, isoflurane and sevoflurane preferable to halothane to prevent dysrrythmias especially when hypercarbia occurs with CO2 insufflation and higher MAC values are required. N2O is generally avoided to prevent bowel distension which hampers visibility and causes post-op vomiting. Regional anesthesia will improve surgical visibility, decrease need for large doses of MR for abdominal relaxation required to work in the abdominal cavity, decrease PONV, intra-op analgesics and post-op pain. Lower abdominal surgeries can be done with regionals alone without large trendlenberg tilts. All lap patients should have empty bowels in case bowel damage occurs intra-op and contaminates the abdominal cavity. But crash iinduction and intubation is not mandatory for all lap surgeries. At induction, care should be taken to avoid stomach inflation however which can again decrease visibility. Many introduce nasogastric tubes after induction and remove it at the end of surgery if required. |
| Query (Asked by Aaron From Manila, Philippines) Have a 53 yo/M patient with Idiopathic Thrombocytic Purpura (plt=120k) scheduled for naso-pharyngeal biopsy and neck mass excision. What should I watch out for in giving general anesthesia and peri-operatively? |
| Response by Dr. Manimala Rao (Posted on 3rd April, 2007) The problem in such case is usually uncontrolled bleeding. The patient must have received gamma globulins and steroids. If so, you have to give the steroid cover. Besides platelet counts one should also do the bleeding time. Reserve platelets and also see if platelet concentrates are available when required. Fresh blood available is also a good option. If the patient has any airway problem should be assessed. Platelets can be re estimated on the morning of surgery and during the procedure if surgery is prolonged. Transfuse platelets if the count is less than 60,000. All these precautions would help to tide over the most dreaded complication of heamorrhage due to ITP. Good monitoring of the coagulation parameters is mandatory. |
| Query (Asked by Emad From Cairo, Egypt) I am using lidocaine to fill the cuff of endotracheal tube to reduce postoperative sore throat. Is it possible to add 5 IU Hyaluronidase for each ml of lidocaine? Will it be safe? Is there any expected action of more spread of lidocaine through the wall of the cuff of ETT? |
| Response by Dr. Manimala Rao (Posted on 3rd April, 2007) Deep extubation with IV lignocaine, narcotics and local spray have all been tried. Sconzo et al indicated that endotracheal cuff might serve as a reservoir for local anesthetics. Alkalinazation and warming the solution have been shown to increase the diffusion and reduce coughing and aided in smooth emergence and reduced the incidence of sore throat (1,2,3) Alkalinization with higher doses of sodium bicarbonate showed better results (4) The possibility of cuff leak can cause irritation with sodabicarb. Hyaluronidase is used as a spreading and diffusing substance which modifies the permeability of the connective tissue. It causes rapid diffusion provided the the local interstitial pressure is adequate to furnish the necessary mechanical impulse. The rate of diffusion is proportional to amount of enzyme and extent is directly proportional to the volume It is antigenic and repeated injections are known to cause antibodies. Added to local anaesthetics is known to hasten the onset of action but has been reported to enhance the adverse events.The reaction with silicone cuff should also be kept in mind. It may be useful to study the effects in a randomized trial.The dose seems to be alright but unless compared one cannot give the correct answers. Ref: 1)acta aesthesiol 1998 jan 36(2)81-6 2)Anesth analg 2001 april 92 (4) 1075 3)Anesth analg 2002 jan 94 227-30 4)Anesth analg 2005 nov (5)101 1536-41 |
| Query (Asked by SAJI K.M. From Thinadhoo, Maldives) I would like to discuss about the airway management and prevention of regurgitation & aspiration of gastric contents in a morbidly obese pt coming for L.S.C.S. HERE IN THESE ISLANDS,sometimes we get such pt's and we don't have even a trained assistant also. So I consider the following for such a situations. A Folleys catheter no 22 inserted through one nostril to oesophagus...this will be a safe outlet for the gastric contents without soiling the pharynx and air entering stomach during mask ventillation also will go out. Next I will insert a nasopharyngeal airway or an ETT Size 6 softened by boiling through the other nostril, to overcome the airway obstruction which may follow after induction of anaesthesia. If I fail to intubate, and surgery should be proceeded without delay, I hope that I will be able to maintain anaesthesia by mask, though I never had to try this. Please let me know whether this is practically possible. |
| Response by Dr. Anjan Trikha (Posted on 29th March, 2007)This technique is not heard of, however it all depends on the anesthesiologist if he is comfortable with it. I would still suggest a spinal as the first option. Even in obese patients it is a good option - in morbid obesity the usual needles are able to deliver. In case longer needles are required, metallic ones can be used which can be later autoclaved. However I would prefer disposable longer needles. If a GA has to be given - Standard rapid sequence intubation and in case one is not able to intubate a proseal LMA is a better and ideal option. If in maldives LMA are not in use one can make a begining and in case you need help invite us we would be more than happy to conduct an airway workshop for anesthesiologists in Maldives. It is high time that anesthesiologist in this part of the world do an internationally accepted practice - keeping in consideration loco regional issues. |
| Query (Asked by shady elmasry Fom Riyadh, Saudi Arabia) 76 years old women is awaiting of hip replacement, she has osteoarthritis & history of COPD. Will you useNn2O? why? |
| Response by Dr. Anjan Trikha (Posted on 29th March, 2007)I would personally give a neuraxial block - single shot spinal or CSE. However in case all these fail GA would be the last option. |
| Query (Asked by Nidha) Is Isolyte-P the fluid of choice for intra-operative fluid therapy for infants & children. Is dextrose necessary to avoid hypoglycaemia Iso-P is hypo-osmolar so will it stay in the Intravascular space? |
| Response by Dr. Mary Korula (Posted on 19th March, 2007)Isolyte P is the maintenance fluid of choice for neonates and younger children but may not be so for older children who may need more sodium and calories. There are different other isolyte solutions according to needs like Isolyte G, M etc. Isolyte-P may be hypotonic with respect to sodium but is iso-osmolar with respect to body fluids. Younger children may not be able to handle high sodium loads, so normal saline is not a good choice, besides there is the possibility of hyperchloremic acidosis if NS is used in huge amounts. Isolyte-P in 5% dextrose would give enough calories (170 cals/l)without causing hyperglycemia, has sodium acetate which would convert to bicarbonate, has potassium, chloride magnesium and phosphate in adequate quantities. For major surgical losses you may have to resort to Ringers lactate and colloids. Additional dextrose needs to be given only in documented hypoglycemia which is not found to be common as was thought earlier. There are concerns about incompatibility with diclofenac sodium when isolyte-P is given concomitantly. |
| Query (Asked by Mohammad Reza Pipelzadeh From Iran) We had a 28 year old male patient with congenital bilateral bronchiectasis. He had shortness of breath since 8 years age. Pulmonology work up suggested thoractomy and right lobectomy of affected middle lobe. No Hx of cardiac disease. 30 minutes after smooth induction & intubation (20 minutes after surgical incision) by double lumen mallinkrot tube patient developed hypoxia ( Spo2=70 ) and hypotension (BP 50/30). Volume expansion did not improve pressure. Ephedrine corrected BP to 100/60 and SpO2 to 80. Shunt was suggested. Surgery was continued in hope of clamping the lobar artery and minimizing shunt . Hypoxia and hypotension recurred and responded partially to ephedrine. 3 liters of ringer and 1 unit of pack cell were transfused and surgeon felt heart was dilated & full. Despite FiO2 100% patient arrested and open massage and IPPV was not helpful. Do you have any clue why this could have happened. We presume a massive emboli or dilated cardiomyopathy as suggested causes. |
| Response by Dr. Yatin Mehta (Posted on 15th March, 2007) It would have been better if the patient had undergone cardiac echo to look for congenital cardiac anomaly and to measure pulmonary artery pressure and right heart pressures (RV pressures). This was important in view of shortness of breath for 8 years as patient may be having cor-pulmonale. Also these patients have congenital cardiac disease like TOF or VSD resulting in pulmonary artery hypertension and RVH. Also nothing is mentioned about pulmonary function tests which are important for patients undergoing lobectomy. According to the information provided patient developed hypoxia and hypotension 30 min after induction (and 20 min after surgical incision). At this time patient must have been on one lung ventilation. The collapse of the right lung meant all the gas exchange was being done by the left lung. The shunt thus created led to hypoxia. Because of hypoxia patient must have developed pulmonary artery hypertension and added to the right ventricle workload leading to this picture. Also overzealous fluid infusion (3 lt of RL and 1 unit of packed cells) added to the RV load and it failed. Other possibility is that after opening the right pleura and with one lung ventilation, patient may have developed left pneumothorax, (due to rupture of some bronchiectatic part or some bulla) and led to hypoxia and hypotension and then resulting in the given sequence of events. With this limited data provided, it is difficult to think of something else. |
| Query (Asked by Emcee From Philippines) What is the anesthesia of choice for embolectomy and above knee amputation in a septic patient with Diabetic nephropathy, Coronary artery disease, Hyperkalemia and bleeding? |
| Response by Dr. Manimala Rao (Posted on 13th March, 2007)The patient with diabetic nephropathy with high potassium levels and septic shock with bleeding is in no position to undergo the regular anesthetic either general or regional. above knee amputation can be be done under ring block with lignocaine .The patient should have all the necessary monitoring and informed consent.The level of hyperkalemia is not noted .If it is more than six calcium to antagonize and sodium bicarbonate should be used in the emergency to tide over the crisis. IF IT IS NEARING 7meq then on may have to dialyse the patient.If the amputation is for sepsis and the bleeding is due to DIC the only way one can do is to give a ring block and make the surgeon to do guillotine amputation .use analgesic dose of ketamine of 0.1 or0.2 mg per kilo which can help for analgesia and maintain the blood pressure. Regarding the embolectomy you have not written where is the embolus and why an embolectomy when you are amputating.This is my take on the problem.The patient can be grouped in ASA grade 4 or even 5 with an emergency added. This gives reasonable explanation regarding the risk and outcome. |
| Query (Asked by Vanita Mande From Vashi) Can fentanyl be given nasally? what is the dose? From what age group can it be given safely? |
| Response by Dr. Mary Korula (Posted on 9th March, 2007)Transmucosal delivery of fentanyl especially through nasal route has been described as one of the alternatives to intravenous fentanyl but not many studies have been done using this drug in children, though sufentanil has been used in many trials. I have not used it personally.The drug delivery system is different and higher concentrations of drug have to be used to achieve a concentration of 1.5-2 mics/kg as only about 1/4th of the drug is absorbed through mucosa. There are studies with 2yr olds and above using concentrations like 150mics/ml at the dose of upto 15-20 mics/kg. I don't think we have such preparations in India unfortunately. |
| Query (Asked by Julianna) Scenario:Patient is undergoing surgery for incision of a pericardial window. Shortly after induction patient goes asystole, the chest is opened and the surgeon performs cardiac massage. Attempts to resuscitate goes on for quite sometime. The patient is intubated and on ventilator. The ETCO2 is reading in the teens to low 20's(there is correct ETT placement). ABG shows a elevated PCO2 level. Do you adjust vent settings to the actual ETCO2 reading on the vent or to the ABG? Rationale? |
| Response by Dr. J. Divatia (Posted on 3rd March, 2007)It is vital to understand that the ETCO2 is a composite of CO2 production, cardiac output (moving CO2 from the tissues or venous blood to the lungs), the alveolar ventilation (eliminating the CO2 reaching the lungs), and of course, the breathing circuit. In the setting of cardiac arrest or severely decreased cardiac output, as in this case, the amount of CO2 reaching the lungs from the tissues is very low. This will result in a low ETCO2. The arterial - ETCO2 gradient is widened, as is the arterial - Venous CO2 gradient. In this case, ventilation should not be adjusted on the basis of the ETCO2, but on the arterial PCO2. As the cardiac output and hemodynamic condition of the patient improves, more CO2 will reach the lungs and the ETCO2 will increase on the same ventilator settings. In fact, under conditions of constant lung ventilation, ETCO2 monitoring can be used as a monitor of pulmonary blood flow |
| Query (Asked by Sanjiv Bais from Nagpur) Please give me guidelines for a case of V.S.D. with scoliosis posted for emergency LSCS. |
| Response by Dr. Anjan Trikha (Posted on 18th February, 2007)The best choice in this case is an opioid based GA provided a good neonatal ICU is present for neo natal ventilation in the post operative period. Nalaxone may be required for the neonate. If the VSD is not severe and scoliosis is minimal, a graded continous epidural can be thought of. |
| Query (Asked by Sateesh from kurnool) We recently had a case of pheochromocytoma posted for right sided adrenalectomy. Patient was diagnosed to have catecholamine secreting tumor of 7.5cms in rt.adrenal gland. Preoperatively on prazosin, atenolol, amlodipine with 120/80 BP; pulse 84/min. Patient developed hypotension during recovery at 70/50mm Hg, which was sustained and refractory for 2 days postoperatively in ICU. What could be the cause for post-op hypotension and how to treat? what are the best drugs to treat intraop fluctuations of hemodynamics. |
| Response by Dr. Anjan Trikha (Posted on 18th February, 2007) Such patients are known to have hypotension / hypertension / or normotension in the post op period. In addition these patients could have hypoglycemia in the post op. All these are due to varying levels of catecholamines. In the case mentioned dopamine / dobutamine / nor adrenalin / adrenalin should have been continued in the post operative period along with infusion of crystalloids and / or colloids so that the CVP (corrected cvp in case the patient was getting IPPV) could be maintained at 10 - 12 cm. In addition the anti hypertensives that the patient was getting should have been stopped (I presume that would have been done). It is not unusual for such infusions being required for 1- 3 days. The best drugs for managing intra op blood pressure high and lows in a case of pheo varies. I usally use - SNP/ NTG/ esmolol / inhalational agents/ magnesium / dopamine/ dobutamine / nor adrenalin / adrenalin, depending upon the situation. |
| Query (Asked by Anjol Saikia from Guwahati)I recently encountered a hypersensiyivity reaction to oral Omeprazole, 20 mg, (administered as premedication on the morning of the surgery) in an elderly patient planned for TKR surgery. Patient had severe hypotension, syncope and required immediate resuscitation measures. She also had facial flushing.The only other medication she had received that morning was a plain water enema. Please give your vasluable opinion. |
| Response by Dr. Mary Korula (Posted on 11th February, 2007)Omeprazole can cause hypersensitivity like all proton pump inhibitors. Steven Johnsons syndrome and severe angioneurotic edema have been reported. Omeprazole can even cause cross sensitivity to lansprezole, its isome. The treatment is symptomatic. Long term use is known to cause hypotension and seizures due to overdose of sodium bicarbonate present in the mixture |
| Query (Asked by Bali from Jalandhar) Is there any antidote for buprinorphine available in india? |
| Response by Dr. Mary Korula (Posted on 11th February, 2007)As far as I know there is no antidote for buprenorphine |
| Query (Asked by Abhishek Jain from Gandhinagar) I want to know 1) What is the average breath holding time at total lung capacity and residual volume (TLC & RV) for Indian males and females, 2) Is their any categorisation say poor to excellent for the same, and 3) What does breath holding help to estimate - oxygen conserving capacity or exercise tolerance? |
| Response by Dr. Manimala Rao (Posted on 7th February, 2007) The breath holding time on an average is around 10 second which is required to equalizing the gases across the alveolar membrane. DlCo is a measure of diffusion and the average values are given in standard text books.The breath holding time done to assess the single breath count is done at bed side to assess the respiratory function. The patient is asked to take a deep breath and asked to count.> than 20 count will be adequate respiratory function and if the count decreases to 16 and below one has to look at other tests and they may require some form of respiratory support. When breath holding is done the mean alveolar p02 decreases linearly with time and its rate of change is function of the decline in mixed venous P02. As alveolar P02 decreases the whole body P02 falls and this in turn will facilitate the anerobic metabolism. C02 enters the lungs in proportion to both pulmonary blood flow and diffusion gradient for C02, between mixed venous C02 and alveolar C02. The rate of transfer of C02 is initially high but decreases rapidly and approaches the mixed venous value. Further C02 production increases and this further increases the mixed venous value, allowing the alveolar C02 to raise. The point at which the high PC02 resumes breathing is refered the break point. This point can be extended to certain extent by hyperventilation and oxygen therapy. The oxygen store is not notably increased by hyperventilation but it increases the breath holding time but at the same time it can cause profound hypoxia before C02 raises to break point. So it can give a certain indication for the oxygen capacity as well as the respiratory reserve |
| Query (Asked by Gigi from Philippines) My son is experiencing his first toothache @ 4 y.o. his youngest sister was diagnosed with g6pd and therefore we treat the two older boys as such. He may need to be sedated for a dental work, what anesthesia do we need to be aware of as being dangerous to g6pd kids? |
| Response by Dr. Manimala Rao (Posted on 7th February, 2007) G6PD deficiency is an autosomal recessive inheritance with many variants. Most common of the inherited enzyme deficiency initiates the hexose monophosphate shunt.This shunt produces NADPH the major reducing component of RBC. With out this the red cell is susceptible to damage by oxidation, which produces denaturation of globin chains of hemoglobin and leads to premature erythrocyte destruction. This oxidative destruction is caused by many drugs namely antimalarials, antibiotics, analgesics and antipyretics, injecteble vitamin k, as well as methylene blue. Sodium nitroprusside and prilocaine should not be administered as they produce meth hemoglobin which cannot be reduced by these patients. Bacterial infections also trigger the haemolysis . Tourniquets to be avoided. Anesthetics have not been implicated, but there are anecdotal reports that halothane , ketamine and suxamethonium have induce acidosis and fever have been described. Narcotic analgesics have not been implicated. The most important aspect for anesthetic management is to have the Spo2 monitored all the time and see that the saturations are in the range of 98-100% . Avoid acidosis , hypercarbia and hypoxia at all costs. Oxygen with sevoflurane seems to be a safe bet. See that the infection is well controlled before taking up for surgery. Aspirin and phenacitin have to be avoided. Paracetemol is found to be safe for pain relief |
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Query (Asked by Murthy US from Hyderabad) Could you suggest the vendor to buy Iontophoresis devices. |
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Response by Dr. Mary Korula (Posted on 31st January, 2007) The original iontophor devices for anesthetic use came from Life Tech, Ltd, US. Those are the small hand held ones I have shown in the picture. It depends on what you want to use it for! For hyperhydrosis, various devices are available in India: 1. DermaIndia Ltd. at Basant Nagar. Chennai-used mainly in Derm Units including ours. 2. Cellotherm, India 3. Centre for Biomedical Engineering, Indian Institute of technology , N. Delhi will give you the latest in India. The recent fentanyl transdermal system FITS-IONSYS- Alza Corporation-Ortho Mc Neil. There are laser appliances now available, -Moor appliances and Inovio Biomed corporation. German companies are many. Many rehab centres in India, In Bombay- I think one is Bombay Hospital, have innovated giving drugs over cotton wools and applying current thru them. |
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Query (Asked by Sajid from Bgm) Which technique is best in identifying epidural space: loss of resistance OR Hanging drop technique? |
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Response by Dr. Anjan Trikha (Posted on 7th January, 2007) Loss of resistance to saline would be best in my opinion though I am the loss of resistance to air man, as that's the way I learnt it and am gradually changing over. Loss of resistance to saline is the best as per the literature. The feel is the better and the chances of air related problems are absent. However there would be anesthesiologists who would follow either of these and would vouch for their choice. Regarding hanging drop method I just practice it for demonstrating it to residents. I am not aware of any post graduate program in the recent past that would advocate this method. I personally feel it is technically difficult and at times if the patient is straining or moving it is not a very ideal method to practice. |
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Query (Asked by Shantanu Samanta from Kolkata) What are the measures to prevent AUTO-PEEP? |
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Response by Dr. J. Divatia (Posted on 7th January, 2007) Auto-PEEP is a result of dynamic hyperinflation due to gas trapping. This occurs when there is insufficient time for the expired gas to leave the lungs, and the inspiratory gas flow of the following breath commences before completion of the previous expiration. This stacking of breaths leads to hyperinflation, with an increase in the end-expiratory pressure and the development of auto-PEEP. Auto-PEEP typically develops when 1)there is increased expiratory flow resistance, e.g. asthma, exacerbation of COPD. If an adequate expiratory time has not been set, inspiration commences before expiration is complete, leading to dynamic hyperinflation and auto-PEEP. 2)increased inspiratory time. During inverse ratio ventilation, the inspiratory time is deliberately set greater than the expiratory time (e.g. I:E ratios 2:1, 3:1). 3)low peak inspiratory flow rates. This can prolong the inspiratory time. In patients with bronchospastic conditions, high peak airway pressures are often observed during volume controlled ventilation. If an attempt to reduce the peak airway pressure is made by reducing the peak inspiratory flow rate, it can lead to a considerable increase in auto-PEEP. 4)high respiratory rates reduce the expiratory time 5)high tidal volumes increase the magnitude of hyperinflation and auto-PEEP. It is easy to imagine that in patient with severe bronchospasm, ventilation using high respiratory rates and tidal volumes (to maintain normocarbia) and low peak inspiratory flow rates (to decrease peak airway pressure) can result in development of high auto-PEEP levels with all its deleterious consequences. One of the major aims in ventilating patients with severe expiratory airflow obstruction is to minimize the development of auto-PEEP. Once we understand the mechanism of auto-PEEP, its prevention / treatment follow: 1) Increase expiratory time, decrease Respiratory rate 2) Increase inspiratory flow rate. This allows more time for expiration in the same breath. Peak airway pressure may rise due to higher flow rates, however the plateau pressure (equivalent to the alveolar pressure) will not increase. 3) Decrease tidal volume. This will reduce the volume of trapped air. 4) Reduce circuit & tube resistance 5) Treatment of bronchospasm 6) Reduce ventilatory requirements by controlling fever, shivering, providing sedation, analgesia, relaxants |
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Query (Asked by Haq Dad Durrani from DG Khan, Pakistan) A patient for elctive operation has specific ST- elevation in anterior leads. He is not diabetic. No history of chest /shoulder/arm/jaw/neck pain. TRP-t negative. CK-MB normal. Should we precede as usual or do any measure or wait? |
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Response by Dr. Yatin Mehta (Posted on 1st January, 2007) How old is the patient and what elective surgery you are planning? Major / Minor. Also ST elevation primarily can occur either in evolving MI or in pericarditis. Both need to be ruled out before elective surgery. Echocardiogram and 'CT' or coronary angiogram are indicated to be safe. |
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Query (Asked by Farrukh from Aurangabad) Sir, I am a practicing anaesthetist . I would like to know where in India there are courses for pain management. |
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Response by Dr. P. N. Jain (Posted on 1st January, 2007) We in Tata Memorial Hospital give observership in pain charging Rs 1500/ per month. Dr Dureja in Delhi has one course for one month in Delhi Pain Management center. His mobile no 98101 34924. Rest, there are no dedicated pain centers in India. |
