Post-dural puncture headache after spinal anaesthesia for caesarean section

Objective: To find out the frequency and severity of post-dural puncture headache [PDPH] after spinal anaesthesia for caesarean section using 25G Quincke spinal needle

Study design: Descriptive case series

Place and duration of study: Department of Anaesthesiology, Surgical Intensive Care and Pain Management, Civil Hospital Karachi, Dow University of Health Sciences Karachi, from July 2010 to June 2011

Methodology: Pregnant women, aged 18 to 40 year, ASA I and II, presenting for elective or emergency caesarean deliveries under spinal anaesthesia were included. Spinal anaesthesia was performed with standardized technique using 25G Quincke spinal needle. Patients were followed for three consecutive days postoperatively for the frequency and severity of postdural puncture headache

Results: Out of four hundred and fifty parturient, 337 underwent emergency operations while 113 operated electively. In more than 93% cases spinal anaesthesia was instituted in first attempt. Thirty nine out of 450 patients [8.7%] developed post-dural puncture headache after spinal anaesthesia for caesarean section with 25G Quincke spinal needle. Thirty one had mild headache while eight parturient developed moderate headache

Conclusion: The frequency of post-dural puncture headache was in conformity to what has been reported in literature using 25G Quincke spinal needle

Efficacy of pre-incisional peritonsillar infiltration of ketamine for post-tonsillectomy analgesia in children

To assess the efficacy of pre-incisional peritonsillar infiltration of two doses of ketamine on postoperative analgesia compared with peritonsillar normal saline in children undergoing tonsillectomy. Double blind, randomized controlled trial. Department of Anaesthesiology, Surgical Intensive Care and Pain Management, Civil Hospital, Karachi, Dow University of Health Sciences, from August 2008 to January 2009. Seventy-five ASA physical status one patients, aged 5-12 years scheduled for tonsillectomy were enrolled in this study. Patients were divided into three groups of 25 each. Group-A received normal saline, Group-B, ketamine 0.5 mg/kg while group-C ketamine 1 mg/kg respectively. All medications were 2 ml and were applied 1 ml per tonsil; 3 minutes before tonsillectomy incision. Anaesthesia was induced and maintained with standard technique. All patients were monitored throughout surgery. The Children's Hospital of Eastern Ontario Pain Scale [CHEOPS] and Wilson sedation scale were used to evaluate pain levels and sedation respectively after operation. Mean duration of analgesia was significantly higher in group-C [17.28 +/- 5.33 hours] as compared to group-B [11.36 +/- 4.15 hours] and A [3.2 +/- 0.71 hours] as well as group-B was also significantly higher than group-A [p < 0.05]. Group-A had significantly higher pain scores than group-B and group-C. Both B and C groups had comparable pain scores, which were statistically significant at 6 and 8 hours. Single 0.5 or 1 mg/kg injection of ketamine given before surgical incision by peritonsillar infiltration provides efficient pain relief during postoperative period without significant side-effects in children undergoing tonsillectomy

New single use supraglottic airway device with non-inflatable cuff and gastric tube channel

To assess ventilatory characteristics and airway complications associated with the use of I-gel in patients undergoing gynaecological surgeries. Experimental study. Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital, Dow University of Health Sciences, Karachi, from July 2008 to June 2009. One hundred adult female patients aged 15 - 75 years, ASA-I and II scheduled for elective gynaecologic surgical procedures under general anaesthesia with controlled ventilation were included in this study. After insertion of device, ease of insertion, time of insertion, peak airway pressure, leak pressure were noted. After proper placement of device, gastric tube was also passed in every patient. Pharyngolaryngeal morbidities [sore throat, dysphagia, dysphonia, neck pain and coughing at 1 hour and 24 hours postoperatively] were also noted. I-gel was inserted in the first attempt in 92% patients while second attempt was required in 8% of patients. Average time of insertion was 9.68 +/- 2.69 seconds. Average leak pressure of 22.48 +/- 2.07 cm H[2]O. After removal of I-gel no blood staining was found on any device. Coughing was noted in 6% patients after removal of device and mild sore throat was noted in only one patient after 24 hours of surgery. I-gel is a simple and easy to use supraglottic airway device. Its insertion do not require laryngoscopy and airway can be maintained in very short time in adult female patients

Comparison of performance and safety of i-gel with laryngeal mask airway [classic] for general anaesthesia with controlled ventilation

To compare ease of insertion, effectiveness of the positive pressure ventilation and airway complications of i-gel with laryngeal mask airway-classic [LMA] for general anaesthesia with controlled ventilation. This study was conducted in the Department of Anaesthesiology, Surgical intensive care unit and Pain Management, Civil Hospital Karachi, Dow Medical College, Dow University of Health Sciences, from July 2008 to December 2008. One hundred adult patients aged 15 to 75 years, ASA I and II, Mallampati I and II, scheduled for various elective general or orthopaedic surgical procedures under general anaesthesia with controlled ventilation were included in the study. The patients were divided into two groups e.g. i-gel group or LMA group by systematic random sampling technique. Anaesthesia was induced and maintained with a standard gasrelaxant-IPPV technique. Ease of insertion was noted on a 3-grade scale. After insertion of the device vital signs and oxygen saturation were monitored non-invasively. Effectiveness of the positive pressure ventilation was compared. Pharyngolaryngeal morbidity, e.g. sore throat, dysphagia, dysphonia, blood on device, neck pain and cough were noted immediately on removal of the device, and by patient interviews at 1 hour and 24 hours postoperatively. In this study both LMA-classic and i-gel were easy to insert and did not require laryngoscope for insertion. Patients of i-gel group had comparatively less pharyngolaryngeal morbidity [blood on device] than patients of LMA group [18% in LMA group while none in i-gel group]. Both supraglottic devices, LMA [classic] and i-gel can be used safely and effectively in selected patients for general anaesthesia with controlled ventilation with almost no morbidity

Perioperative anesthetic management of a patient with severe von Willebrand disease for major gynecological surgery

Perioperative management of patient with severe von willebrand disease [vWD] especially from major surgery is always a challenging task for the anesthesiologists. Wer report a case of a 17 year old female, diagnosed as a case of vWD at 8 years of age, who was scheduled for exploratory laparotomy for ruptured ovarian cyst with hemoperitonium. She was successfully managed with factor VIII, fresh frozen plasma [FFP] and tranexamic acid administration. Intraoperatively, more than 2 liters of clotted blood was removed and 1.5 liters of fresh blood was lost, which was replaced by red cell concentrate [RCC], colloid and crystalloid solutions. Post-operatively, cryoprecipitates and RCC were transfused. Postoperative serum coagulation studies remained within normal limits. She was transfused with cryoprecipitates and factor VIII till 5 th day. Patients with vWD do not carry an increased operative risk during elective procedures if appropriate prophylactic and corrective therapy is administered. Apart from the administration of cryoprecipitate and other blood products; factor VIII is needed for patients with severe vWD

Recovery profile - a comparison of isoflurane and propofol anesthesia for laparoscopic cholecystectomy

To compare the recovery profile in terms of time of extubation, eye opening, orientation and mobility and frequency of Postoperative Nausea and Vomiting [PONV] between propofol and isoflurane based anesthesia in patients undergoing laparoscopic Cholecystectomy with prophylactic antiemetic. Quasi-experimental study. Department of Anesthesia, Civil Hospital and Dow University of Health Sciences, Karachi, from January to April 2007. After informed consent, a total of 60 ASA I-II patients scheduled for laparoscopic Cholecystectomy were divided in two equal groups I and P. Anesthesia in all patients were induced by Nalbuphine 0.15 mg/kg, Midazolam 0.03 mg/kg, Propofol 1.5 mg/kg and Rocuronium 0.6 mg/kg. Anesthesia was maintained with Isoflurane in group I and propofol infusion in group P, while ventilation was maintained with 50% N[2]O/O[2] mixture in both the groups. All patients were given antiemetic prophylaxis. Hemodynamics were recorded throughout anesthesia and recovery period. At the end of surgery, times of extubation, eye opening, orientation [by modified Aldrete score] and mobility [recovery profile] were assessed. PONV was observed and recorded immediately after extubation, during early postoperative period [0-4 hours] and late period [4-24 hours]. Antiemetic requirements were also recorded for the same periods in both the groups. Propofol provided faster recovery [extubation and eye opening times] and orientation in immediate postoperative period with statistically significant differences between the groups [p<0.0001]. Recovery characteristics were comparably lower in group I. More patients achieved full points [8] on modified Aldrete score at different time until 30 minutes in group P. Postoperative nausea and vomiting in early and late periods were significantly reduced in group P. Moreover, requirement of rescue antiemetic doses were significantly lower in group P in 24 hours [p<0.0001]. In this series, recovery was much faster with earlier gain of orientation with propofol anesthesia compared to isoflurane in the early recovery periods. Propofol is likely to be a better choice of anesthesia because of its better anti-emetic property that persists long into postoperative period and reduces the risk of PONV