ABSTRACT
Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery. Fifty patients were included in this prospective randomized study and allocated to two groups: Group A [25 patients] receiving general anesthesia alone and Group B [25 patients] receiving nerve-stimulator-guided bilateral thoracic Paravertebral Block [PVB] at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl [0.5 micro g/kg] based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia [PCA] morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups. Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A [17.6 micro g and 38.6 micro g, respectively, P=0.001]. PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A [4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P < 0.0001 at all intervals]. Pre-induction PVB resulted in improved analgesia for 24 hours following laparoscopic cholecystectomy in this study, along with a significant reduction in perioperative opioid consumption and opioid-related side effects
ABSTRACT
We discuss the clinical presentation of a patient with granular cell myoblastoma and the management of an unanticipated difficult intubation with this rare condition. Literature review of similar cases of difficult intubations due to supraglottic masses was performed and the various methods of management have been enumerated. Intubation with direct laryngoscopy may be impossible in 0.05%-0.35% patients due to an undetected supraglottic mass despite an apparently normal pre-operative airway assessment. We report a case of granular cell myoblastoma of the tongue, as a cause of an unanticipated impossible intubation. A 55-year-old ASA III male weighing 75 Kg was taken up for emergency exploratory laparotomy with perforation peritonitis. On preoperative airway examination there was no indication of difficult intubation. After induction of anesthesia [rapid sequence with rocuronium] we performed direct laryngoscopy. There was a mass arising from the base of the tongue because of which no recognizable epiglottis or glottic structure could be identified. Despite repeat laryngoscopy, optimal external manipulation and direct laryngoscopy performed by an ENT surgeon, the airway could not be secured. As no fibreoptic laryngoscope was available, a surgical tracheostomy had to be performed
Subject(s)
Humans , Male , Middle Aged , Neoplasms, Muscle Tissue , Intubation , Tongue Neoplasms/pathologyABSTRACT
There are several reports of obstetric emergencies in pregnant patients with malignant intracranial tumors precipitated by worsening of the mother's neurological status which necessitate an early delivery of the fetus before definite therapy can be administered to the mother[1-3]. We describe a patient with a sphenoid sinus tumor who developed loss of vision due to rapid tumor progression necessitating an early delivery of her twin fetuses by cesarean section. The patient had co morbidities and requested to be awake during the surgery, she was managed using a combined spinal epidural anesthesia. The advantages of combined spinal epidural anesthesia as compared to a single shot subarachnoid block, epidural block or general anesthesia are discussed in a pregnant patient with decrease in intracranial compliance