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QUERIES AND RESPONSES Current Page |
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| Query (Asked by Mallikarjun Panshetty From Bidar) Kindly clarify the type of crystalloid fluid to be used during LSCS, in PIH. I am confronted with an obstetrician who insists on using 5%D during periop period as Na level is increased in PIH. |
| Response by Dr. Anjan Trikha (Posted on 4th November, 2008) The rationale of giving fluid for LSCS in patients of PIH is to preload these patients and it is not correct to preload with 5 % dextrose. The concept of preloading itself is under a controversy and standard recommendations do not advise to delay surgery for preloading. I am not aware of any studies / guidelines that have recommended the use of 5 % dextrose in such patients. In case there is documented hypernatremia then the actual therapy for hypernatremia may be instituted. |
| Query (Asked by Selvakumar From Coimbatore) I was called to asses a 6 year old girl with CKD for renal transplantation. She had nephrotic syndrome not responding to steroids and cyclosporine and developed CKD. Last week she was admitted for pulmonary edema in our icu, got relieved by dialysis and fluid removal. At that time X-ray chest showed enlarged pulmonary artery and pulmonary venous congestion. 2D echo revealed Mitral regurgitation. What is the precautions I have to take for the forthcoming transplantation? |
| Response by Dr. Anjan Trikha (Posted on 4th November, 2008) The patient in question has MR with CRF and is for renal transplant who has recently gone into Pulmonary edema. To discuss the detail management of such a case is beyond the scope of this forum and a text book can be referred to. Important points to keep in mind would be pre operative optimization with dialysis, presence / absence of pericardial effusion and institution of invasive monitoring. A few cases may need draining of the pericardial effusion. Traditionally for renal transplant artrial invasive pressures lines are avoided but I would use one in such a case. Also a central line would be on. PAC I would not advise unless it is a routine at that centre. Standard renal transplant technique with special Care on IV fluids and adequate balanced anesthesia is recommended. In case the reader wants to discuss something specific queries are welcome. |
| Query (Asked by Monalisa Datta From Kolkata) What are the preferred criterias of weaning in a patient with history of post CABG 10 years back, presenting with malignant hypertension, with frank pulmonary edema needing urgent craniotomy and is operated for evacuation of intra cerebellar hemorrhage, with runs of VPC's but fairly good ABG's on day 2,3? |
| Response by Dr. Manimala Rao (Posted on 26th October 2008) This is a difficult situation. Patient is operated for intracerebral hemorrhage in the background of CABG 10 years back. It all depends upon the neurological state and the GCS to start with. If patient is neurologically fit he can be weaned in the next two days or at the earliest. But if the patient has not recovered neurologically he needs an early tracheostomy and wean, when all other parameters for weaning are adequate. |
| Query
(Asked by K. Vijaya Kumar From Salem) Please tell the anaesthetic
management for bilateral ethmoidal polyp of a 44 years old patient with
achondroplasia |
| Response by Dr. Mary Korula (Posted on 24th October 2008) This 44 yr old achondroplasic is possibly coming for a FESS (Functional Endoscopic Sinus Surgery) for his ethmoidal polyps. Achondroplasia is the most common form of short-limbed dwarfism, a congenital skeletal dysplasia, the main problem being poor development of bones and premature ossification leading to severe craniofacial and spinal deformities. Hence both General Anaesthesia and regional techniques are difficult in these patients. Anaesthetising these patients can be a challenge depending on the degree of abnormalities present especially with airway. A high degree of awareness of the various problems associated with this condition is essential. Shortened extremities, frontal bossing and midfacial recession are common. Flexion deformities make IV access difficult. Hydrocephalous and raised ICP may require VP shunts. Chiari malformations and cervico-medullary compression may cause quadriparesis, hyper-reflexia and hypotonia, feeding problems, respiratory difficulties, central and Obstructive Sleep Apnea which could all pose problems at induction and recovery from Anaesthesia and mandates early decompression. Hypoplasia of maxilla, pharynx and narrow air passages can make ventilation and intubation quite difficult. Pectus excavatum is common with upper sternal prominence which can interfere with laryngoscopy. Atlanto-occipital dislocation is a possibility. Disc herniation at any level may be a problem as also foramen magnum stenosis with obliteration of the subarachnoid space. Hyperextension of the neck at tracheal intubation can lead to cervical cord compression and quadriplegia. Oropharyngeal airway might help with ventilation by face mask. In severe cases, an oral fibroptic intubation may have to be done. Laryngeal mask Airway may be useful, but airway protection cannot be ensured and aspiration of blood may be a problem with endoscopic surgery through the nose. Rib hypoplasia, thoracic lordosis associated with restrictive lung disease and Cor Pulmonale should be looked for. The ethmoidal polyps will add to the airway problem and the patient probably breathes through the mouth. CPAP prior to and after surgery may be required and management should be as for Sleep Apnea if this is present. Diminished respiratory reserve should be kept in mind, pre-op and post-op physiotherapy will help. Also look for other Congenital abnormalities. A good pre-anaesthetic evaluation, pre-op optimization, and pre-medication are mandatory in these highly anxious patients as their mental development is usually normal. Induction of anaesthesia can be with propofol or inahalational agents like sevoflurane. If airway doubtful, intubation can be either under deep inhalational, spontaneously breathing or with propofol without use of muscle relaxants. Once the airway is secured, GA can be maintained with intermediate acting muscle relaxants, inhalational agents and opioids. The nasal endoscopic surgery as such involves very minimal systemic changes but blood in the field makes removal of polyps difficult through the scope. So providing controlled hypotension may be a good option. Throat pack is usually inserted before surgery and removed before extubation. Nasal packs are inserted if there is bleeding after surgery. Extubation only after patient is fully awake and can maintain airway, oro-pharyngeal airway might be required, post-op monitoring for bleeding and respiratory function especially when associated with Sleep Apnea. Post-op pain relief can be provided with Inj. paracetemol or NSAIDs round the clock. |
| Query (Asked by Monalisa Datta From Kolkata) Could you give some opinion about use of Xenon in present anaesthesia practice? |
| Response by Dr. Manimala Rao (Posted on 13th October 2008) Xenon is an inert gas found in the atmosphere and has anesthetic and analgesic properties. It is a naturally occurring gas so the depletion of ozone layer and pollution does not arise. It was discovered in 1898 and used in anesthesia in 1951. It is more potent than N2O with a MAC of 71%. It acts on non competitive NMDA receptors or non GABA or non NMDA glutamate receptors. Recent studies have shown its action on K channels such as TREK 1 and TASK which modulate neuronal excitatory as potential targets of anaesthetic action. Large multicentric trial from Europe has shown many positive aspects of xenon in 224 ASA 1-111 patients. It is cardiostable, cardioprotective, analgesic and even neuroprotective. No deleterious effects on other system including the coagulation and fetus. The gas is expensive and can be used in specialized closed circuit in anesthetic machine. It is expensive at the moment. It has been shown to be useful in critical care as long term sedation and analgesia with quick recovery and no complications. Is eco friendly gas. It is a promising anesthetic with a good safety profile. More trials, better delivery systems with technology to bring down the cost may see this gas as an anaesthetic in cardiac, neurosurgical and critical care settings in future |
| Query (Asked by S. Sreenivasa Rao From Tirupathi) What are the reasons for post-operative delirium after spinal anaesthesia in elderly patients and management? |
| Response by Dr. Anjan Trikha (Posted on 26th September 2008) One of the reasons could be hypoxia in this group of patients. With increasing age patients become more sensitive to sedatives and hypnotics, recover more slowly from their effects. In elderly cardio respiratory depressant action of these drugs can cause hypoxia which leads to delirium and is further treated by sedation which further causes hypoxia. Elderly patients have decreased concentration of cholinergic fibers in the brain and this may cause them to be more susceptible to low dose anti cholinergic medications. Old age group patients are known to have depression and these patients have low levels of CNS neurotransmitters which can pre dispose these patients to confusion. Routine administration of anti cholinergics or drugs with anticholinergic properties should be avoided in these patients. If needed synthetic anti cholinergics e.g. glycopyrrolate should be used instead of atropine and hyoscine. Other causes could be metabolic insults, dehydration, anemia, acid base imbalance, dys-electrolitemia, hypocarbia, hypercarbia, hypoglycemia, hyperosmolarity, hypotension and endocrinopathies. All these are true after GA too. Strict monitoring is essential. |
| Query (Asked by Awaneesh Roy From Varanasi) Banaras Hindu University runs M.D.(Ay.) (Sangyaharan)i.e. anaesthesiology in faculty of ayurveda which is recognized by central council of Indian Medicine. I want to know about its legal technicalities of practicing anaesthesia after this course. |
| Response by Dr. S. C. Parakh (Posted on 13th September 2008) As per the Medical Council of India Act, only those persons holding qualifications registrable with MCI can practice the anaesthesiology of modern medicine. I am not sure what drugs are administered by the Sangyaharan people. If they are using ayurvedic drugs, it is perfectly legal. However, they are not supposed to use the allopathic anesthetic drugs. |
| Query (Asked by Anees Hassan From Baghdad, Iraq) Is there any hospital or institute in India which can accept me to train for epidural anesthesia for painless delivery |
| Response by Dr. Anjan Trikha (Posted on 13th September 2008) For a foreign national to come and have hands on practice in India there are standard guidelines of the Medical Council of India. The same are available on their web site. It needs to be an official visit from Iraq with clearance from various governmental organizations. A political clearance too would be required. It may take some time but it is not difficult. As a visitor he could come and see the system which can be arranged. In case you are interested and once the official clearances are there the same can be arranged at many places in the country and I can help him to find a correct place / places |
| Query (Asked by Ashish From Chennai) IJV or SVC cannulation causes frequent ectopics on ECG when RV infundibulum is irritated by guidewire. If accidental Central Arterial cannulation occurs is the guidewire long enough to reach LV and do ectopics occur from LV also? |
| Response by Dr. Yatin Mehta (Posted on 7th September 2008) It would be very unusual for the guidewire to cross the aortic valve and the operator still not being aware that he has done an inadvertent carotid artery puncture! Although occasionally it does enter the LV, it will produce ventricular ectopic beats. |
| Query (Asked by Manash Kumar Basu From Dhaka, BanglaDesh ) A young girl of of 16 years requires appendecectomy due to recurrent appendicitis. She had mitral valve replacement two years back. Recent ecg shows atrial flutter with variable block. Echocardiogram report is: LV and LA dilated. No regional wall motion abnormality seen. No intracardiac mass or thrombus seen. EF 50%. She is on tab. Warfarin, tab. digoxin, losartan and spironolactone. She can climb up to third floor with ease on foot. Please comment on her anesthetic management. |
| Response by Dr. Yatin Mehta (Posted on 2nd September 2008) What is not mentioned in your Echo report is the status of the mitral valve i.e. if a normally functioning prosthetic valve? I presume that it is a metallic valve and not a bio prosthetic valve since she is on warfare. With a normally functioning pH for any appendectomy, stop warfare and put her on i/v heparin for a few days. Both general anesthesia or spinal anesthesia may be safely administered as the heart & valve functions are normal. No invasive monitoring is required as the procedure is not that major with minimal thermodynamic changes anticipated patient can be extracted on table and warfare commenced the next day. She should be kept on i/v heparin till the INR > 2. Adequate antibiotic prophylaxis should be done |
| Query (Asked by Pratibha Deshmukh From From Nagpur) 1. Is dantrolene available in india? 2.Where are the centers for diagnostic tests for MH in India? |
| Response by Dr. Manimala Rao (Posted on 28th August 2008) Dantrolene as far as I know is not available in india. There was a recent article published in on line journal from AIIMS in which they have quoted as saying that it is not available. The tests too are not done as the anaesthesia community has not demanded either dantorlene or the tests. Please read the article published on internet journal the site ispub.com the internet journal of anesthesiology.The abstract states that we report a first case of malignant hypothermia from the indian subcontinent and raise the issue of non availability of dateline in the country where this clinical entity was thought not to exist.As far as my knowledge goes the test is usually CPK level which are very high as reported in the case. The specific tests are not available. internet journal of anesthesiology ISSN:406x |
| Query (Asked by Radha White From Ohio, USA) My mother had a severe asthma attack on July 02, 08. She was rushed to the hospital and on July 03, 08 the doctor's said that they have to insert the ventilator because the oxygen level was low in the blood. They gave her atracurium, Fentanyl, Ativan and did tracheastomy on July 10th and PEG tube was inserted on July 12 th and until today when they try to wean of the paralytics by completely letting the bag of atracurium empty and they simply sit down and watch if the peak pressures go up and vitals drop then they put her right back on atracurium. This has been the practice of the nurses under the orders of doctors. My mother suffers a lot from these steps... for example atracurium 8mcg was given and when the bag goes empty the lungs looses it strength and becomes like baloon without the air and put her back on atracurium and increase sedations. They have been reducing the Fentanyl and Ativan too, which increases so much of anxiety in my mother (I can observe from her face). Now, for the past 46 days, my mother is on the ventilator the doctor admitted yesterday that there is nothing he can offer to treat her and get her lungs come off of theparalytics. Could you please offer your medical counsel on how to titrate atracurium from this severe asthma patient who is 72 yrs and all her vital signs are normal. Are there medicines to use while titrating atracurium to ease off? Are there any steps they could use to wean of atracurim from her body. Please let us know asap. The maximum number of hours my mother could go without atracurim is 3 hours as of Friday (aug 15, 08). In the past she could only withstand for 20 min, 30 minutes or an hour. I believe she is improving and we need to give time for her lungs to repair on it's own and stregthen, what do you think. |
| Response by Dr. Manimala Rao (Posted on 25th August 2008) I can understand the anguish regarding your mother on a ventilator for a long time now. My practice is, I do not recomend muscle relaxants for more than 24 hours and not atracurium in an asthmatic patient. We parlyse the patient if required and go to sedation than relaxants. We wean the FIO2 first and bring them at the earliest to either assist control or SIMV and if the patient has good inspiratory effot and a tidal volume of more than 5ml per kilo and the TV RR ratio less than 105 we wean aggressively by pressure support ventilation. It is not possible to help from a remote location. The longer the use of relaxants there are more chances of critical illness myapathy or neuro pathy particularly if the patient is also recieving steroids. Do not have to go by just the peak pressures. Try the methods I have mentioned. The sedation should be adequate for her to have spontaneous activity and responding to our commands. Intermittant boluses of midazolam are quite adequate in the eldrly. Hope you will be able to wean her soon |
| Query (Asked by Sujeet From Aurangabad) What are the anaesthesia considerations in a patient whose haematocrit is 60.5% (Hb-18.9 gm%). Patient is not having heart disease & is posted for spine surgery. |
| Response by Dr. Mary Korula (Posted on 25th August 2008) I think the main issue here is to establish the etiology for the polycythemia (familial, congenital, primary, secondary polycythemia vera or erythropoietin independent). So, a hematology consultation is mandatory. The treatment depends on the cause. Common causes include: Smoker’s polycythemia (from hypoxia), cyanotic heart diseases high altitude, hemoglobinopathy, methemoglobinemia, chemical-induced, malignancies like renal cell carcinomas, hepatomas and cerebellar hemangiomas, endocrine disorders like phaeochromocytomas, renal cysts, polycystic kidney, Budd-Chiari, spurious polycythemia due to dehydration or vomiting, plasma loss after burns, enteropathy etc. History, Investigations and specialized testing are directed accordingly. Erythropoietin, Ferritin levels, electrophoresis, bone marrow biopsies, imaging and arterial blood gas analysis will differentiate between primary and secondary polycythemias. Major complications of polycythemia vera include thrombosis or hemorrhage – either arterial or venous, are frequent causes of mortality. Essential thrombocytemia and platelet aggregation cause recurrent thrombosis and hemorrhage. Myelofibrosis and acute leukemia are other issues. Unrecognised thrombosis of hepatic and splenic veins result in portal hypertension. History of gum bleeding and easy bruising, sometimes even severe GI hemorrhage should give a clue. Cerebro-vascular accidents, myocardial ischemia and infarction, deep-vein thrombosis and pulmonary embolism are looked for. Headache, weakness, dizziness and sweating are some symptoms associated with high hematocrits although many patients can be asymptomatic. About 40% patients have splenomegaly and severe disabling pruritis, not responding to myelosuppression. Spinal cord compression due to extra-medullary hematopoiesis and neurological symptoms have been reported as well as high uric acid levels with gout. Sternal tenderness may indicate transformation to leukemias like acute myeloid leukemia. There are no published guidelines or consensus for surgery and anaesthesia. Phlebotomy for symptomatic hyperviscosity of blood, anti-coagulants, Inteferron therapy, hydroxyurea, myelosuppression and chemical cytoreduction have all been tried with variable success, they all have their own problems and have to be looked for. Venesection for very high hematocrits and elective surgery is an option. A high platelet count is considered an indication for cytoreduction as platelet aggregation can lead to bleeding problems. Myelosuppression causes a reduction only in red cells. Diagnosis has to be confirmed and patient optimized as far as possible before surgery. Peri-operatively, most of these patients are on low dose Aspirin and low molecular weight heparins as DVT prophylaxis and to prevent cardiac and neurological complications. The most important peri-op and intra-op complications are bleeding, increase in thrombotic and cardiovascular events. Large surgical blood losses may decrease intra-op hematocrit much more than seen in normal hematocrit patients. Controlled hemodilution and vasodilatation will reduce stagnation and help maintain adequate blood flow. Since this patient is having a spine surgery and on anticoagulants, General anaesthesia with inhalation agents, controlled ventilation with muscle relaxants, normocarbia and adequate analgesia would be a good choice to prevent any systemic vasoconstriction and hemodynamic fluctuations intra-op. Peri-op blood salvage and cell-savers may be options in very major surgeries involving huge surgical blood losses. Controlled hypotension may be helpful too. Somatosensory evoked potential monitoring for assessing spinal function during intra-op manipulation, intra-arterial and temperature monitoring along with all other routine monitoring are mandatory Attention to detail is most essential in these cases. The patient should be positioned carefully avoiding excessive stretching of limbs, pressure on the the abdomen, eyeball or increasing intra-ocular pressure in prone position. These patients may have more chances of developing cortical and retinal blindness. Pressure points should be well padded and protected. Intra-op hypothermia leading to vasoconstriction is avoided, patient actively warmed with warming blankets and fluid warmers. Hypoxia, hypocarbia, hyperventilation and vasoconstriction due to any cause including pain and shivering can worsen the effects of polycythemia and should be avoided. Anti-thrombotic stockings and intermittent compression devices may be useful post-op. Post-op hematological, cardiac, vascular, neurological, temperature and respiratory monitoring are essential. Good post-op analgesia is a must, I/V opioid PCA and parecetemol are good choices. All the pre-op treatments for secondary polycythemia will have to be continued post-operatively. Early post-op mobilisation may be a good idea, continuing the aspirin and other anticoagulants. |
| Query (Asked by Baskaran From Coimbatore) Why do some children undergoing meningocele repair develop sudden hypotension after opening the sac despite adequate volume and BP? Is it related to fluid loss? How to treat or prevent this. |
| Response by Dr. V. K. Grover (Posted on 21st August 2008) The exact reason for this is not known. However there are two possible explanations:- 1) These children with meningocele have raised ICP, which may not manifest due to compliant brain as these children have open fontanelle and sutures. This raised ICP can cause catecholamine release. Once the sac is opened the ICP drops suddenly and catecholamine level also falls, which can cause sudden hypotension. 2) Due to meningocele, these children have compressed epidural veins. Once the sac is opened, the epidural veins also open up or dilate, and get filled up with blood which can cause sudden hypotension. The level of hypotension will depend on degree of epidural veins compression or level of raised ICP and catecholamine release. There is no way to prevent this because one can not cause fluid overload in these small babies. Best treatment is to administer fluids as soon as hypotension occurs. In majority of the cases this works well and hypotension gets corrected in a few minutes |
| Query (Asked by Omar From Riyadh, Saudi Arabia and Anand Tiwari From Pune) Use of internal jugular versus sub clavian in neurosurgery/head injury |
| Response by Dr. V. K. Grover (Posted on 19th August 2008) I personally prefer Subclavian Venous Cannulation (SCV) for CVP monitoring in Neuro Patients but there is no contraindication to Internal Jugular Cannulation (IJV). It should be done quickly as lowering and turning the head can raise the ICP significantly in head injured or Neuro ICU patient. Jugular Venous Oximetry is routinely used at many centers in head injured patients |
| Query (Asked by Helen Gharaee From Iran) Is previous craniotomy contraindication to spinal anesthesia. If such patient had convulsion and fever many hours after spinal anesthesia can it be related to craniotomy done 7 years back with no neurological deficit? |
| Response by Dr. V. K. Grover (Posted on 15th August 2008) Previous Craniotomy is contraindicated to Spinal Anaesthesia: 1) In immediate postoperative period, when the patient has low CSF pressure so much so that even while administering spinal anaesthesia there may not be free flow of CSF due to low pressure and the anaesthetist may end up in multiple dural punctures. 2) If the patient has post craniotomy residual intracranial lesion with features of raised ICP 3) Definitely craniotomy done 7 years ago and too with no residual neurological signs can not be blamed for convulsions and fever, which occurred many hours after spinal anaesthesia. This may be coincidental and may be due to meningitis or any other pathology. |
| Query (Asked by Vikas From Jodhpur) What is is the best way to sedate a traumatic brain injured pt. Does it affects the clinical evaluations? |
| Response by Dr. V. K. Grover (Posted on 15th August 2008) The best way to keep the traumatic brain injury patient depends on the 1) Neurological status of the patient preferably as assessed by Glasgow Coma Scale 2) Haemodynamic status of the patient 3) Airway and respiratory status of the patient. The patients who are neurologically intact and are haemodynamically stable may need continuous monitoring of vital signs in an ICU. Patients who deteriorate neurologically and are unable to maintain airway and gas exchange will need to be intubated, ventilated and sedated. Ideally the traumatic brain injured patient should be kept sedated because more the patient is agitated & restless, more the chances of rise in ICP. Sedation does affect the clinical evaluation of the patient especially if you are using narcotics like morphine, which affects papillary signs. Since short acting drugs like Midazolam and Propofol are readily available for ICU sedation, it is better to use them. In addition most of the Intensive Care Units have fixed times for assessment of traumatic brain patients, thus sedation can be titrated according to the timings for assessment of patients in ICU. I very often use low dose Morphine (3 mg every 3 hourly in adults) and Midazolam (1-2 mg every 3 hourly) and I never had difficulty in neurological assessment of these patients. Some centers use combination of Midazolam and Fentanyl also for sedation in ICU. |
| Query (Asked by Vineet From Chandigarh) Please tell the dose schedule of epidural Depomedrol |
| Response by Dr. P. N. Jain (Posted on 6th August 2008) Depomedrol can be used in 40 mgs doses. You may repeat it after 3 weeks if effective. |
| Query (Asked by Neelu From Jaipur) Can epidural clonidine be used in back ache? |
| Response by Dr. P. N. Jain (Posted on 6th August 2008) There are only very few studies on role of clonidine in chronic backache. however you may use it 50-100 mcg doses with Bupivacaine. |
| Query (Asked by Pranav Shukla From Vadodara) Sir, I have recently done Diploma in anaesthesia. I want to know about fellowship in cardiac anaesthesia in india. |
| Response by Dr. Yatin Mehta (Posted on 21st July 2008) National Board of Examinations (NBE) conducts entrance exam for post doctoral fellowship (FNB) in cardiac anaesthesia every year(see website natboard.nic.in) I think MD is the qualifying requirement. There are half a dozen institutions in India recognized by Indian Association of Cardiovascular Thoracic Anaesthesiologists (IACTA, iactaonline.org) for 1-2 year fellowship in cardiac anaesthesia(contact Dr. Rajesh Chand, Secretary IACTA, chandkaushik@hotmail.com). You need to check whether DA is good enough. Also Nizam's institute, Sri Chitra Institute etc. have their own fellowship. You need to contact the office of them. |
| Query (Asked by Gareth From Pittsburgh USA) What is your opinion of general anesthesia TIVA with propofol/fentanyl only for laser BPH surgery? The patient can't/won't tolerate inhalation agents and has had severe adverse reactions to most other agents. Estimated surgery time is 35 m. Thanks |
| Response by Dr. Mary Korula (Posted on 18th July 2008) There are different types of lasers used for trans-urethral resection of prostate (TURP) surgery. Holmium:yttrium-aluminum-garnet and potassium-titanyl-phosphate lasers make it possible to perform transurethral prostate resection with almost no absorption of irrigant and minimal blood loss as tissues are vaporised here. Subarachnoid block is usually administered for classical transurethral resection of the prostate, so that the patient can be monitored for TUR syndrome secondary to irrigant absorption. Here the irrigation fluid used is normal saline and not glycine. So you can avoid the complications of glycine absorption too. It takes much lesser time as tissues are vaporised and there is only minimal tissue damage as cauterization is not required. Postoperative pain is also said to be minimal. These are done as outpatient procedures in Mayo clinic using sedation and local blocks or light GA depending on patient's condition and options. So TIVA with propofol and fentanyl is an option if the patient is not allergic to propofol |
| Query (Asked by A.M.Joglekar From Pune) What is the present status of lignocaine heavy 5% for spinal anaesthesia |
| Response by Dr. Anjan Trikha (Posted on 13th July 2008) As far as India is concerned anesthesiologists still use it. Though in my Hospital - AIIMS - I have not even seen even an ampoule since the last 18 years. Our trainees would not have even seen it being used. There are no official recommendations in India. Internationally it is now accepted that the incidence of TNS is much more with spinal lignocaine as compared with other local anesthetics even with normal use - single bolus dose -and not continuous spinals. TNS can be caused by other local anesthetics also. There is though no evidence that this painful condition - TNS - is associated with any neurologic pathology, the symptoms disappear spontaneously by 4th - 10th postoperative day. In my opinion unless there is any specific indication for avoiding bupivacaine, lignocaine in the spinal route should not be used, though it is safe and TNS has no long lasting effects. |
| Query
(Asked by K M Standefer From Hixson, United States) I had lap band
surgery and a hiatal hernia repair on June 30th. I am a 47 y/o female
weighing 228 at 5'3. I have never had a problem with my BP. Since surgery
my BP has been anywhere from 158/99 lowest to 160/112, and just standing
up I become tachycardic 109 highest, running 98 lowest sitting down.
I am having some headaches and of course good ole gas pains under my
diaphragm secondary to the carbon dioxide they injected in my abdomen
during surgery. I don't feel I am having that much pain other than the
occasional gas pains. I have no other problems other than herniated
C5-C6 and occipital/trigeminal neuralgia and have been on neurontin
for 6 months. I am concerned why am I hypertensive. I first thought
it was because I was having pain but I took pain med and BP really doesn't
come down much. I am not really in any pain just the gas pains occasionally
and I am walking but I am afraid to do too much because of my BP. Could
the CO2 be compressing some of my vessels causing me to be hypertensive
and tachycardic? |
| Response by Dr. Anjan Trikha (Posted on 13th July 2008) In my opinion the patient's high blood pressure cannot be attributed to the carbon dioxide used for lap surgery on 30th June. Neither can the compression on the blood vessels by CO2 after so many days cause hypertension. The high blood pressure and heart rate both resting and while standing that has been diagnosed now is a totally unrelated to surgery /anesthesia. The patient has herniated C-5 , C-6 and trigeminal neuralgia also. These diseases by themselves would not cause high BP other than due to pain. In case pain has been adequately treated the new problem has to be accepted and treated as a completely un related disease that has been diagnosed after surgery. |
| Query (Asked by Haq Dad Durrani From DG Khan, Pakistan) A 5 years old male, hepatitis b -ve, cirrhotic, mild malnourishment, poorly controlled ascites, but no encephalopathy, requires inguinal herniorraphy. Please tell me the anesthetic technique, fluid regime and special precautions. |
| Response by Dr. Manimala Rao (Posted on 11th July 2008) 5 yr child for hernia repair in cirrhotic patient.You have not given the CTP classification whether the child belongs to A,B,or C group. Refractory ascites has been noted not to make much difference in mortality. Hernia operation could be done safely in CTP class A and B with low rate of recurrences, and there was no definitive increase in the operative risk in class C. In addition, refractory ascites did not increase operative risk and recurrence rate. Therefore, surgical repair might be recommended even in patients with refractory ascites and poor hepatic function to prevent life-threatening complications or severe pain (Journal of Gastroenterology & Hepatology March 2007, 22:3) Child requires the usual precautions for cirrhosis,vit k injections and platelet transfusions if indicated, 2-3 hours of NBM status. 5% dextrose with half normal saline is adequate and supplementation of 10% dextrose if required. Avoiding inhalation agents like halothane but isoflurane has been used in children with liver dysfunction. Thiopentone for induction fentanyl for analgesia atracurium for relaxation can be titrated for general anesthetic. The usual fluid regime with added losses are fine for any paediatric surgery. It is only inguinal herniorraphy, so the volume loss is minimal. Good post op recovery early ambulation and oral feeds will go a long way in the post op recovery and reduce the morbidity. |
| Query (Asked by DSG From Colombo, Sri Lanka) During a thyroidectomy which was long standing, surgeons noted that the trachea is soft and a small (>1cm tracheal damage) has occurred. What should be the future airway management? (keep the ET tube for some time? tracheostomy?) |
| Response by Dr. Manimala Rao (Posted on 19th June 2008) I will leave the endotracheal tube for a day or two and extubate her later. One has to keep all the necessary equipment for re-intubation if required. If she shows the same problem then it may require tracheostomy. One has to assess the level of tracheo malacia for the surgical procedure. 1cm damage may not require any tracheostomy. Always try keeping the tube in for two days if suspected softening in the pre and intra operative period. |
| Query (Asked by CP Han From Taichung, Taiwan) A 79 -yr-old woman suffered from acute upper airway obstruction (most likely laryngospasm) 40 min after extubation. I stand-by and talk with her; she could also expectorate well by herself during the post-extubation period. Unfortunately episode of continuous severe (irritative) cough with acute strider and dyspnea immediately occurred during inappropriate sputum suction procedure by a nurse. I think one should be very cautious and avoid the unnecessary sputum suction during this period. Please comment |
| Response by Dr. Anjan Trikha (Posted on 13th June 2008) The query is a bit vague. Yes I agree that un due suction in the post operative period should not be carried out, and in case it is done it can lead to not only spasm but also cause injury to the oropharyngeal mucosa. If the patient has a good cough reflex the patient should be asked to cough out the secretions. and the same wiped off or sucked from the lips. |
| Query (Asked by Jesse From Arnett, USA) My question is about an epidural I had with my son 2 years ago. I had to have a C-Section because he was breach. When it came time for the epidural they could not get it in. They had to make 26 attempts before getting it right. I was in severe pain for about an hour while they were doing this. My husband said it looked like someone had taken a hammer and nails to my back as I had many holes from the middle of my back to very low. Now 2 years later I have the most severe back pain. I couldn't even hold my son long enough to give him a bath because I was afraid I would drop him. My legs go so numb when I stand up sometimes I just fall to the floor. It takes 20 to 30 minutes to get the feeling back in them and my legs and back hurt constantly. Could you tell me what could have happened to cause this. Doctors in my state are not ones that usually want to help or care to. |
| Response by Dr. Anjan Trikha (Posted on 30th May 2008) It is really sad. I suggest that the patient should undergo an ortho consult, an MRI of the back and a neuro consult. The reasons for the symptoms need to be diagnosed. The spine / inter vertebral discs / spinal nerves or all of them may have been traumatized during the procedure. The patient needs to be investigated and then one can opine. In case her doctors do not have the time I welcome her to come to AIIMS and we can do the needful without her need to pay anything. |
| Query (Asked by Aarti From Bangalore) What is the method of rapid sequence induction in neonate and very sick infant with low baseline saturation and distension of abdomen/full stomach? Is 30 sec. apnea with cricoid pressure after succinyl choline is recommended? Can we ventilate the baby while cricoid in place during scoline apnea? O2 reserve is so less that exactly when you are intubating baby desaturates giving less time for laryngoscopy. Is cricoid pressure indicated in neonate? |
| Response by Dr. Anjan Trikha (Posted on 17th May 2008) Rapid sequence induction is carried out in the neonates also but it is tricky. Ideally only experienced anesthesiologists should be involved in such procedures. Orogastirc suction, IV atropine, pre oxygenation and IV induction with cricoid pressure and suxamethonium are used as in all other cases. With the cricoid pressure in place gentle IPPV may be part of the plan if the intubation fails in the first attempt. There are devices like oxyscope that have been used which minimize the incidence and severity of desaturation. There is a place of awake intubation or sedated awake intubation in such patients with local anesthesia. If such a technique is planned the throat and the epiglottis can be anesthetized with the finger tip using lignocaine jelly 2 %. The under surface of the laryngoscope blade too can be coated with the lignocaine jelly. |
| Query (Asked by T. Sujanith From Hyderabad) A 6yr old 12 kg child, malnourished,with hypoalbuminemia (2.1gm/dl), hypokalemia (3,0gm/dl), anaemia (Hb-8gm/dl) pancreatic mass with haemoperitoneum, with no pancreatitis and no other organ dysfunction posted for exploratory laparotomy and proceed. Surgery is planned this week & hardly any time for optimization, but have to do as possible. Want to know TPN in a child. Plan to continue TPN postoperative period. Surgeons hinted casually that child might need WHIPPLES!!!! Can we request for suggestions. |
| Response by Dr. S. Manimala Rao (Posted on 16th May 2008) The main problems are malnourishment, anemia and hypoalbumenemia. I would definitely correct albumin which is only 2.1gms and a packed cell transfusion to correct anemia. I will also give potassium to bring up the levels to near normal. Regarding malnutrition it cannot be corrected quickly. I will continue the parentral nutritionn according to the paediatric guidelines in the ICU. This should be done before surgery for better immunity and tolerance of the surgical procedure and anaesthesia. |
| Query (Asked by Haq Dad Durrani From D.G. Khan, Pakistan) 75 years old female with ca breast requires mastectomy. She has mitral stenosis & H/o right sided hemiplagia. ECG shows atrial fibrillation with variable ventricular response(35-55). She is taking digoxin and warfarin. Whether intra-pleural anesthesia is sufficient? Concerns for GA and necessary steps. |
| Response by Dr. Yatin Mehta (Posted on 14th May 2008) One important factor to be considered for planning this case is how severe the MS is and is it calcific or not? If it is <0.6 cm2 then any anaesthetic can be hazardous. If it can be tackled before the mastectomy with CMV or BMV that would be the best and safest option. We have performed other surgeries along with off pump CABG (OPCAB) (see references) successfully in one sitting, after CABG and reversal of heparin. Similarly MVR/CMV followed in the same sitting by mastectomy is possible. AF with slow ventricular response is an indication for stopping digoxin. Warfarin also needs to be stopped and converted to I/V heparin, before mastectomy. If the MS is not tight then mastectomy may be performed with invasive arterial/ CVP monitoring. Interpleural analgesia has been used for cholecystectomy and mastectomy and is a good option as long as pneumothorax is avoided. Thoracic epidural analgesia is debatable as the patient has h/o stroke. Intercostal block is also possible along with some sedation. Otherwise careful GA avoiding hypotension, tachycardia and fluid overload can be done. References: (1) Mehta Y, Sujatha P, Juneja R, Singh H, Sachdeva S, Trehan N. OPCAB and thyroidectomy in a patient with severely compromised airway J Cardiovascular Thorac Anesth. 2005; 19:78-82 (2) Mehta Y, Sujatha P, Rajgopal A, Meharwal ZS, Trehan N. Off pump CABG along with hip and knee replacement: Anaesthetic management – A case report. J Anaesthesiology & Clinical Pharmacology 2005; 21: 445-447 |
| Query (Asked by Raminder From Chandigarh) Sir, can spinal anaesthesia be given by a surgeon himself, if the fetal heart rate is dipping and an emergency LSCS is needed and a qualified anaethetist is not available immediately? Is this act legally allowed or will it be considered a negligent act. and if the patient dies in this process will it be civil or criminal negligence? |
| Response by Dr. S. C. Parakh (Posted on 12th May 2008) Please tell me, if there is an emergency situation, and the surgeon is not available, would you justify your self performing the surgery? It is a fact that surgeons are not trained to administer anaesthesia. Performing any act with out proper qualifications and experience amounts to negligence if it causes harm to a person on whom such act is performed. In this case it will certainly be a criminal negligence. |
| Query (Asked by Sam Saphir From Mauritius) We had to give G.A to a patient with PIH in emergency. Her BP was 240/120mmHg & pulse was 145/min. She was induced with pentothal, oxygen,and scoline. After intubation, maintained with oxygen, nitrous oxide + 0.5% halothane and atracurium. On delivery of the baby, halothane was switched off, sintocynone was given followed by iv fentanyl and five minutes afterwards by pethidine. Everything went on smoothly but at the end of the operation, before extubation, she was not opening her eyes and did not make any effort to breath. So we decided to send her to SICU intubated and ventilated. She was given only sedation and analgesia. On the next day a CT scan was done to exclude any accidental haemorrhage, which was normal. On the fourth day she started opening her eyes and respond to verbal command. She gradually regained her strength. She put on SIMV and then on T-piece she was extubated and was doing fine for the day. But at night she had to be intubated again because her SpO2 was decreasing. What could have happened and please tell me what can be done now. |
| Response by Dr. Anjan Trikha (Posted on 15th April 2008) The first scenario seems to be an abnormal response to suxamethonium. Scoline apnoea is known to cause such symptoms but the only unusual thing is that it took quite a number of days for the effect to wear off. Ideally NMJ monitoring should have been carried out in such a scenario. Plasma cholinesterase activity may be diminished in the presence of genetics abnormalities of plasma cholinesterase. Other conditions where the activity is less are - pregnancy, and myxedema. The activity could also be diminished by chronic administration of oral contraceptives, glucocorticoids or certain monoamine oxidase inhibitors and by irreversible inhibitors of plasma cholinesterase (organophosphate insecticides, echothiophate) The second intubation after about 12 hours is likely to be due to ? aspiration, VAP, chest infection or any other iatrogenic cause. - because of stay in ICU. An X ray chest, all hemat and biochemical investigations should be done. A repeat CT head should also be considered as if the BP levels had remained high. She could have had a CVA. With out other details I can only make the above guesses. |
| Query (Asked by P. Boonsong From Chiangmai, Thailand) I have a 63 yr-old man with COPD and cor pulmonale with DM and hypertension. His NYH classification is 2. His medications are enalapril, moduretic, aminophyllin, two bronchodilator inhalers and one of DM drug. His DM and HT are under controlled, his ejection fraction is 62%. He has scheduled for herniorrhaphy for treatment of indirect inguinal hernia. Please suggest the appropriate choice of anesthesia. |
| Response by Dr. Manimala Rao (Posted on 13th April 2008) I would give him an inguinal hernia block. It blocks the ilio inguinal and genital branch of genito femoral nerve and infiltration along the line of incision as well as infiltrating the local anesthetic solution at the neck of hernia to prevent any bradycardia when it is being repaired. Very minimal sedation if patient is anxious. One can keep the inhalers along with him and use if needed. The block should be given well at all three points and works very well. lignocaine with adrenaline can be used for the block and plain lignocaine for infiltration. If the surgery is longer than an hour then one can contemplate on an epidural as there is no contraindication. |
| Query (Asked by Aarti From Bangalore) I always get difficulty in intubating partially edentulous patient especially with missing upper4 and lower incisor4. Difficulty is not in visualization of glottis but in introducing the tube as there is no space. L'scope stucks in upper incisor gap. Can I keep the artificial denture in place for intubation? If so, how to prevent them from falling in mouth cavity. Folded gauge piece doesn't help as it obliterates the vision. Please guide |
| Response by Dr. Anjan Trikha (Posted on 8th April 2008) Leaving the artificial dentures in place is an accepted practice by some anesthesiologists . When in place they often help in a tight fit of the mask and help in mask ventilation. The risk of dislodgement is always there and One needs to be careful In case of single tooth dentures - upper 3 / 4 or lower 3/ 4. - Upper ones give more probs. Anesthesiologist do keep folded gauge pieces to obliterate the space and prevent the Laryngoscope getting stuck in the space and cause trauma. Personally speaking the gauge piece device does work for me but it becomes difficult for lower 3 / 4 teeth. There are tooth guard devices available that cover the natural and artificial teeth and prevent any damage to the crowns and help in preventing dislodging of the artificial teeth. If one ensures the correct and careful placement of the L scope and lifts the lower jaw very carefully trauma and dislodgement can be can be avoided. Loose tooth have been tied with the thread so that they can be retrieved once they get dislodged. The same could be tried with the dentures though the thread may not ensure dislodgement. |
| Query (Asked by Muthukumar From Coimbatore) We have a child 4 years 11 kgs, with history of retro laryngeal abscess treated with medications 3 weeks ago and was discharged from hospital. 2 days after her discharge she presented to our hospital with severe stridor and chest indrawing without fever. We had to intubate the child as she was becoming drowsy and not responding to adrenaline & steroids nebulisation. She was on ventilator for couple of days & extubated. She required non invasive ventilation very frequently and adrenaline nebulisation every 2 hours. Dynamic MRI shows inspiratory collapse of tracheal wall with cord edema done during symptom free period. She was hanging on like this for 4 days and she was again intubated for severe stridor & desaturation. How to proceed with managing this child. Pls advice. |
| Response by Dr. Mary Korula (Posted on 8th April 2008) Not sure whether the child had retropharyngeal abscess or retrolaryngeal . This required only medications and no surgical intervention. So obviously it was a small one in the beginning.Then she developed post-intubation tracheomalacia and cord edema. Tracheomalacia takes at least 3-6 months to recover. So from the history she definitely needs a tracheostomy right now for long term management, a SHEELYs tacheostomy tube which is also like a silicone tube but has an inner tube (like the metal tracheostomy tube) in addition can be used if the patient can afford.Then probably another MRI to see whether the tracheal collapse has resolved and closure of tracheostomy. An ENT surgeon will definitely be of help in such situations! |
| Query (Asked by Sid Cottrell From Swindon) I am 48 years old. I had lower back pain for 3 months The MRI findings was the disc prolapsed at L4-5. Now the pain is getting better in my leg and I am walking more further, though sometimes I do have a numbness in the foot. I am doing lots of walking and swimming now which has help me a lot. I have now got an appointment to go into hospital for a epidural injection, I don't know weather to have the injection or just carry on improving on my own speed. I spoke to a few people who have had the epidural injection and they have told me it does not last very long or work at all. |
| Response by Dr. P. N. Jain (Posted on 3rd April 2008) If you are much better on physical exercise, then it would not be a good idea to have epidural. Usually these all lumber changes heal over 2-3 months. Stick to your physiotherapy sessions religiously. You would be normal soon. |
| Query (Asked by Shabbir Hussain From Jeddah, KSA) A pt came to me for emergency LSCS with past 11 normal deliveries. Her haemoglobin was 8gm and pt was full stomach. The surgeon asked me to give general anaesthesia as he was comfortable with this technique. I tried to intubate the pt but could not do it. I called my consultant for help he could intubate after many attempts. After the surgery got over, my consultant deflated the cuff and reinflated the cuff, immediately pt desaturated.The cuff was reinflated & saturation picked up. Pt was shifted to ICU for further management where she was diagnosed as having aspiration pneumonia and ARDS. On echo she was found to have mitral regurgitation and AR. Pt was extubated after 10 days and discharged from hospital. Now the pt has filed a medico legal case against me stating that I had given overdose of anaesthesia . I want to know whether my technique was right or should I have given spinal anaesthesia . The had breech presentation also. |
| Response by Dr. S. C. Parakh (Posted on 24th March 2008) This case had two risk factors. Low haemoglobin and full stomach. Knowing fully well the consequences of full stomach, I would have insisted on a spinal. As an independent consultant it is my duty and right to select the anaesthetic technique which is safe for the patient. In case of a possible litigation court will not accept my argument that I chose an unsafe technique as the surgeon wanted it. Though the patient did not die, a suit for the extra expenditure incurred for further treatment can be filed by the patient. |
| Query (Asked by J. Rajesh From Madurai) We have a patient, 30yrs female, G3A2 (precious baby), 28 weeks gestation, now having paraplegia due to TB spine (D4 - D5). She is posted for anterior approach of spine stabilization. Our plan of anaesthetic technique is G.A, DLT, Invasive monitoring, Lateral position, FHS monitoring. Should we take any other special precautions in anaesthetizing her? |
| Response by Dr. Anjan Trikha (Posted on 18th March 2008) The scenario looks challenging. First if it is a precious baby then the surgery & anaesthesia consents should be very clear and the patient should be advised to take a second opinion and the same should be documented. I think nothing more is needed as far as the management is concerned. I would supplement my monitoring with a couple of ABGs to ensure that no respiratory acidosis is produced. I presume that the correct placement of DLT would be confirmed by a FOB. Similarly the post op period should be well managed with optimum pain control and I would use morphine or fentanyl for the same. |
| Query (Asked by Renuka From Hyderabad) Please let me know about the pain management courses conducted at tata memorial hospital. |
| Response by Dr. P. N. Jain (Posted on 17th March 2008) We do not run any courses in TMH. However, you can apply for observership in pain by writing to our director Dr KA Dinshaw, & Dr R Sareen, HOD. There are some charges also involved, Rs 2000/- for one month. |
| Query (Asked by Saji K M From Kottayam) A 69 yrs old lady waiting for repair of a huge supraumbilical hernia (it's base extends upto T6 dermatome). Her problems - COPD with Rt Heart involvement, HT, Kyphoscoliosis in Lumbosacral region, Compression fracture of T10 spine, also tender and Post Polio paralysis of left lower limb The only somewhat palpable interspinous space is T8-9. We plan to do thoracic epidural at that space and block of T6 to T12.This appears to be very difficult technically. If this fails what should be the alternatives? Is it OK,if we induce with Propofol and fentanyl,insert LMA and maintain with N2O,O2 and isoflurane.The doubt is whether the pt is to be on spont. ventilation or Can we paralyze with vcuronium and go ahead with controlled ventilation. |
| Response by Dr. Mary Korula (Posted on 4th March 2008) You need a level of atleast T4 dermatome for the surgery. After pre-op evaluation and optimization as best as you can with incentive spirometry and bronchodilators and even steroid inhalers, I would go for a full GA with endotracheal intubation with controlled ventilation. Pain control may be excellent with epidural but this need not necessarily translate to improved respiratory function post-op. Many a time, high spinals and epidurals can compromise respiratory function intra-op and your main worry is post-op pulmonary complications like atelectasis and pneumonia esp being an upper abdominal surgery. LMA may avoid the need for airway manipulation. But for upper abdominal surgery this may not be a good idea. Maintaining a good plane of anaesthesia and analgesia during induction and intra-op is essential to avoid provoking laryngo-bronchospasm. Propofol, fentanyl and vecuronium may be good choices with isoflurane or better sevoflurane which irritates the resp tract least. Hypertensive and hypotensive episodes are more easily controllable.Good hydration is maintained. Extubate in a deep plane if possible after full reversal of neuromuscular blockade. Wound infiltration will help post-op pain management. I would give intrathecal morphine -150 ugms if feasible for post-op analgesia with Inj. Paracetemol IV 4-6th hrly for breakthrough pain. Post-op pain relief should be a major concern for the respiratory and cvs function. Intra-op and post-op hemodynamic and respiratory monitoring is also mandatory. |
| Query (Asked by Nidha From Chennai) Hyperthyroid patient on Neomercazole and Propronolol for last 5 weeks. Now no tremors or weight loss. Pulse rate is 70. Current Thyroid function test still shows elevated T3 and T4 and decreased TSH. So Clinically normal but Biochemically Hyperthyroid. Surgeon wants to proceed with Total thyroidectomy. Is Biochemical Thyronormalcy needed for elective surgery? |
| Response by Dr. Anjan Trikha (Posted on 4th March 2008) Yes for elective surgery a biochemical control is essential - this is a standard teaching dictum. There are other drugs / agents available that can control rapidly the altered T3, T4 & TSH levels. The surgeons would always want to push the cases. - nothing new. |
| Query (Asked by Anshuman Singh From Lucknow) Can we hasten the neuromuscular recovery of patients on vecuronium infusion by giving diuretics? This is in context of operations lasting more than 5 hours on an average with vecuronium infusion being used for the intraoperative period ? Also can we change over from vecuronium to atracurium nearing the end of operation for promoting early neuromuscular recovery in patients undergoing neurosurgical procedures with no contraindications to use of both the above drugs? Do we need to give an initial bolus dose of atracurium when we are switching over or we can get away with the top up doses for atracurium after switching over to atracurium from vecuronium? This is in the clinical environment where neuro muscular monitoring is not available for monitoring the degree of blockade. |
| Response by Dr. Manimala Rao (Posted on 22nd February 2008) When one uses relaxants for longer duration of surgery as infusions one should select the correct dosage and titration. ideally one requires neuromuscular monitoring. In case one is unable to use, it may be advisable to use atracurium infusion than vecuroneum. The metabolic end product of vec are more active. For this reason one may use diuretics to have these products get excreted. The usage of diuretic could also lead to hypokalemia, which by itself can prolong the action of relaxants. A good titration of the dose and correct timing of the relaxants at the end of surgery and reversing it at the correct time as well as preventing factors which can prolong its effects can greatly reduce the prolonged action. There is no contraindication for switching to atracurium as a bolus dose and continue till the end of surgery. Rocuroneum infusions are given even in ICU set up in severe ARDS and MSOF till patient can be stabilized with high dose sedation and well oxygenated. This drug does not have active metabolites and preferred for longer duration in comparison to vecuroneum besides atracurium. Irrelevant usage of diuretics to decrease the activity of relaxant is not recommended |
| Query (Asked by Sameer From Satara) What should be plan of anaesthesia for a 5yrs old case of congenital spherocytosis patient posted for splenectomy? |
| Response by Dr. Mary Korula (Posted on 19th February 2008) Hereditary spherocytosis is the most common of the hereditary red cell membrane defects resulting in abnormally shaped red blood cells & hemolysis. This is a disorder of proteins (spectrin) of the RBC cytoskeleton where the RBC is more rounded, more fragile and more susceptible for hemolysis than the normal, biconcave red cells. The increased fragility causes the spleen to destroy the abnormal red cell and chronic anemia occurs. Cholelithiasis from chronic hemolysis and elevated serum bilirubin are common. So these have to be looked for and considered during anaesthesia. They have hemolytic crisis with anemia, vomiting & abdominal pain either triggered by infection or folic acid deficiency. Adequate fluid and blood replacements, analgesics and antibiotic cover are essential. Liver and Renal function tests may have to be monitored, renal protection and mannitol given if required. Folic acid supplementation is usually given. Hereditary spherocytosis is treated by splenectomy, usually by 6years of age to improve life span of RBCs. Before that age, the surgery is associated with bacterial infections especially pneumococcal. Peri-operative transfusion is rarely required as adequate compensatory mechanisms for chronic anemia have already been developed in these patients. No specific problems related to anaesthesia occur usually. Management of anaesthesia is as for any pediatric case with anemia with blood replacements according to intra-op blood loss. |
| Query (Asked by Srirangadarshan From Manchester, UK) Recently, I saw a a 32 yr old lady in the antenatal clinic who was referred for an anaesthetic consultation. She was 20 weeks pregnant, para 2. She had past history of Skeletal TB, diagnosed in June'2003. Tubercular focus was in L4 vertebra. She didn't have pulmonary foci. She received full course of antitubercular treatment in India. Subsequent MR scans showed resolving L4 osteitis and she became asymptomatic as well. In her current pregnancy she wishes to have an Epidural for labour analgesia. She wanted to know if it was safe to have a neuraxial block done. I did a literature search using pubmed and didn't get any information on safety of neuraxial blocks in patients with h/o spinal TB. I discussed this issue with one of our Respiratory physician who has special interest in TB. He was of the opinion that it would be safe as TB affects the vertebral bodies and the area where epidural/ spinal injections are done is very much posterior. What is your opinion on this issue? In clinical practice would you do an Epidural for labour analgesia in a patient with h/o spinal TB? If no why? |
| Response by Dr. Anjan Trikha (Posted on 5th January 2008) My opinion is the same - if one needs to give an epidural to a patient with past history of treated tuberculosis of the spine an anesthesiologist can go ahead and give it. I would surely talk it over to the patient and inform her about absence of any reports regarding any complications after such a procedure. There are certain facts that need to be remembered. 1. TB of spine or otherwise is a latent illness and symptoms may only be evident after an advanced stage. In the spine thoracic segments are most commonly effected. 2. Pregnancy usually does not worsen the disease. 3. Neurological problems can occur if epidural is given at the same level as the effected segment and if the posterior part of vertebra are effected. - A rare possibility. 4. There is a possibility - though not reported till date - that neurological symptoms may occur after a neuroaxial block even if given at a different space if there is an active TB lesion at a different vertebral level due to CSF pressure differences leading to cord traction. Lastly in the case scenario being mentioned in a setting of a fully treated L4 vertebral TB which has been treated fully and the radiology pictures confirm no active disease or other foci in the spine I would go ahead an give the epidural. I would still talk it over to the patient, discuss with her alternative modalities of labor pain alleviation and then proceed to do an epidural and avoid the L3./ 4/ 5. spaces. |
| Query (Asked by Ramarao From Chennai) Ideal anaesthetic technique for patient with biologic DVR with good ventricular function on ecosprin for TURP. Also on sertaline for psychiatric ailment |
| Response by Dr. Yatin Mehta (Posted on 5th January 2008) A DVR with good ventricular function is like a patient with normal heart undergoing TURP. Ecosprin is not a major problem from the point of view of surgical / epidural bleed. Anyway it can be safely stopped a few days before surgery (there is no need for heparin as its a biologic valve). Anaesthesia can be either epidural / spinal or G.A. Obviously generally regional is preferred for TURP so I would give either. Sertaline can be continued. |
| Query (Asked by Sachin Patil From kolhapur) I have 2 questions. (1) can an anaesthetist buy opioids especially fentanyl to keep in stock for practice? and (2) how to avoid shoulder pain during laparoscopy with CO2 insufflation under spinal anaesthesia with bupivacaine 0.5% heavy? |
| Response by Dr. Anjan Trikha (Posted on 5th January 2008) Regarding fentanyl - The exact laws of every state may be different regarding Opioids. In general a separate license is required to store or sell fentanyl - in fact each opioid requires a separate license. In case a doctor needs to do it is logical that a license would be required to store bulk ampoules. In Delhi there are certified shops that sell fentanyl to patients if the prescription is written on a special form and signed by a doctor with his seal, address and Medical registration council number. However in case the patient wants to buy in bulk then he can not. In my opinion a doctor can not legally buy in bulk and then store it and use it when ever required. He could be held responsible for selling it in case he does so, or get caught in one of the sting operations which are a favorites of all TV channels. I would suggest that the institution where the anesthesiologist works should get a license. However if they can not the doctor can keep some though there are no legal recommendations on the number of opioid ampoules one can keep for hypothetical patients. Regarding the second one - There are various things that can be done to reduce shoulder pain after lap chole or during this procedure done after spinal anesthesia. These are - 1. If one can maintain low pressure ( 7 - 9 mm Hg) during insufflation instead of usual 13 - 14 mmHg then the incidence of shoulder pain is less. 2. Intra operative irrigation of bupivacaine to hemi diaphragm at the end of surgery has also been shown to reduce both the intensity and frequency of shoulder tip pain after lap chole. 3. There have been reports of a decrease in incidence of this pain after a combination of low pressure insufflation and intra peritoneal saline wash out after end of surgery. 4. It has been seen that the greater the volume of residual gas in the abdomen greater is the shoulder pain after such surgeries, so simply by expulsion of maximum amount of gas before closing the abdomen one can minimize the incidence and intensity of this pain. 5. Lastly preemptive use of NSAIDS has also been seen to be helpful in such cases. Under spinal anesthesia intra operative shoulder tip pain would needed to be treated with analgesics and anxiolytics if needed. I have no experience in getting such cases done under spinal and would not really advocate this technique. However explaining this to the patient during the pre anesthesia assessment would go a long way to make the patient comfortable. |
| Query (Asked by Piyush Sharma From Banswara) I would like to know 1. whether, general anesthesia can by given by any doctor or a specialist is required for it. 2 What type of degree / certificate / education person he should have to do so. 3 What apparatus / machines a hospital should have, where patient are given general anesthesia? 4 Can you suggest books/ laws / legal bindings, related to the usage of anesthesia by doctors, available in market? 5 What types of anesthesia can by given by any doctor (non - anesthetist expert)? |
| Response by Dr. Manimala Rao (Posted on 25th January 2008) Anaesthesia can be given by one who is qualified after M.B.BS with either D.A. , M.D. or DNB in anaesthesia and is trained in the specialty. If some one is trained by anaesthesiologist in a definite diploma in anaesthesia technology they can practice this specialty under the supervision of the anaesthesiologist but not on their own. This is done in countries like the middle east and in the US the nurse anaesthetists are trained and they possess a degree. But even they are under the anaesthesiologist. Any mal practice suit is taken up by the anaesthesiologist even on their behalf. Full fledged Anesthesia machines are required to give safe anesthesia with all safety features. If there are problems during anesthesia leading to malpractice , usage of equipment other than recommended will not stand, in the court of law. Wylie and churchil Davidson has chapters written about American and British law. If one requires about Indian perspective one can refer the anesthesiologist and law by Dr. S.C parakh. ISA is strongly opposing the short term training for anaesthesia practice and they are fighting it in the court of law. If you need further information you can write to sec ISA |
| Query (Asked by S.Senthil Kumar From Namakkal) In an anesthetic apparatus the Oxygen cylinder pressure is 2200 psi when full and this is reduced to say 15 to 17 psi when it enters patient. 15 psi is approximately one atm pressure. But it is recommended to set inspiratory pressure at 20cm of water. This 20cm water does not correlate with psi pressure unit (Since 10000cm water is one atm Pressure) My question is what this 20 cm water pressure denotes? |
| Response by Dr. Manimala Rao (Posted on 20th January 2008) The framing of the question is not very clear to me. The 15 psi is at the level of flow meter. When it is at the mask level it is only at the atmospheric pressure. The pressure one applies at the mouth is the positive pressure to deliver the gas to the lungs, which overcomes the airway resistance and compliance. In case of pressure controlled ventilation, the normal lungs does not require more than 14 –15 cm H20. If it is CPAP generally one does not go above the level of 20cm H20. One need not confuse the working pressure at the anesthesia outlet and trans pulmonary pressure, which is the difference between the pleural and alveolar pressures. |
| Query (Asked by Joe From Chennai) How significant is the potentiating effect of amlodipine (or any CCCB) on Vecuronium? Recently I had a case where I had to wait for nearly 2 hrs to extubate after using 8 mg of vecuronium for a procedure which lasted for one & half hours though the patient did not have any other co morbid conditions? I could not attribute this delayed recovery of muscle power to anything else. |
| Response by Dr. Yatin Mehta (Posted on 14th January 2008) Calcium channel blockers interaction with non depolarising neuromuscular blockers is a known phenomenon. In this case as you mentioned that there were no other complicating factors I would think that prolonged duration of vecuronium was probably due to amlodipine. Did you check with TOF? |
| Query (Asked by Baikunthanath Das From Hail, Kingdom of Saudi Arabia) A 95 yrs old man with history of stroke, disoriented, old myocardial infarction of lateral wall, diabetic, under under control with insulin, ejection fraction 32%, atrial fibrillation with ventricular ectopics, more than 10 per min, PT and INR more than the double the normal value, presented for emergency amputation above knee joint. Kindly suggest for the anaesthetic management. |
| Response by Dr. Yatin Mehta (Posted on 10th January 2008) As the patient has history of stroke, is confused and has INR of mare than 2 Neuraxial block is ruled out. In absence of these factors S.A. in sitting position would have been ideal. Keeping in mind AF(ventricular rate is not mentioned) with >10 PVC's I would load him with 300 mgs. of Amiodarone followed by 150 mg. i.v. 8hrly. Also I would get a preop.CT/MRI to rule out any acute cerebral event and have a baseline, also from medico legal point of view. Get a high risk consent. There is no contraindication for G.A. Avoid Tachycardia, hypotension and fluid overload because of AF and poor LV. with old age. The case can be done with a 3 in block(Winnies technique) preferably given with a nerve detector,supplemented with either sedation, e.g. fentanyl+midazolam in small doses or light inhalational anaesthesia with mask and spontaneous ventilation. |
| Query (Asked by Nidha From Chennai) Do patients with chronic anemia require pre-op pRBC transfusion for elective surgery eg; 70 year, symptomatic old man posted for hip replacement with Hb of 7 gm/dl. Can we take him up for surgery and start with blood early into the intra-operative period |
| Response by Dr. Manimala Rao (Posted on 8th January 2008) Preoperative transfusions are becoming more infrequent. The transfusion triggers have come down to 7gms% for non cardiac and 9-10 gms% for cardiac patients. For hip replacement surgery the patient can be put on hematinics and taken up for surgery. If this is not possible with 7 gms I would take him up and give blood in the OT. The randomized controlled trials have shown blood transfusion as an independent risk factor for mortality even when the transfusion is to the tune of 2 units. Therefore it should be our endeavor to see that patient is transfused when indicated. In this particular patient we can be taken up under epidural anaesthesia if there is no other contraindication and give back the lost blood as packed cell transfusion during the surgery. |
| Query (Asked by Ashok Jadon From Jamshedpur) 52 years male with history of deep vein thrombosis in June 2007 posted for TKR of same limb. Please guide us for anaesthesia plan and anticoagulation. |
| Response by Dr. Anjan Trikha (Posted on 6th January 2008) The issues here are history of DVT,TKR and the fact that the surgery is to be done on the same limb. I presume the patient in question would had been investigated and treated for his DVT and by now he would be asymptomatic. It is also to be assured that there are no residual clots in the effected leg or any new clots in the lower limbs. In that case therapy for the same should be considered and may even include use of IVC filters. In case the patient is on oral anti coagulants then the same would have to be changed to heparin as per standard protocol over 2 -3 days under coagulation moitoring. IN case this is so then the patient should receive a general anesthetic after stopping heparin for 4hours and ensuring a normal coagulation profile. Heparin infusion / boluses can then be started in the post op after the surgeon is comfortable with the drain collection. In case the patient is not on any antcoagulants at the present time and the doppler studies of the limbs are fine, then the best would be to start the patient on LMWH a night before surgery (dose depending on the exact preparation of LMWH being used) the anesthetic technique could be a spinal, or an epidural along with if the patient insists a general anesthetic. I would give a CSE (standard LA doses for spinal & epidural) after about 12 hours of the last LMWH dose and follow it up by the next dose of LMWH on the first post op night if the drainage is not a concern and then regular LMWH on a BD schedule. I would provide low dose epidural - 0.125% bupivacaine with fentanyl for analgesia for the first 2 days along with oral pain killers. Subsequently the epidural catheter can be pulled out after a 12 hours of the last dose of the LMWH. Heparin can be continued for 7 - 10 days in the post op period. In our institution we would also use venous pneumatic pumps for such case along with heparin. Early ambulation would also be ensured. |
