Peri-anal surgery under saddle block anaesthesia comparing three different doses of hyperbaric 0.75% bupivacaine

Objective: To compare three doses of hyperbaric 0.75% bupivacaine and measuring time for home readiness after day care perianal surgery under saddle block anaesthesia

Study Design: Non randomized controlled trial

Place and Duration of Study: The study was conducted at the department of Anaesthesia, CMH Rawalpindi from Jun 2014 to Apr 2015

Material and Methods: In this study 90 patients who presented for perianal day care surgery, were divided in three equal groups. Group A received 7.5 mg, group B 6.0 mg and group C 4.5 mg of hyperbaric 0.75% bupivacaine. Intrathecal injection was given in L4-5 space by 25 G spinal needle in sitting position. Lithotomy position was made after five minutes. After surgery patients were monitored in recovery room. After fulfilling ambulatory and discharge criteria patients were allowed to go home with attendants. Time of intrathecal injection, assessment of above criteria and time of discharge were noted and analyzed

Results: Male patients were 85.6% and females were 14.4%. Mean time of surgery was 48 +/- 10.59 min. Mean time of discharge in minutes for group A was 235.86 +/- 49.38, for group B 217.7 +/- 42.49 and for group C 205.76 +/- 32

Time of discharge was significantly different between group A and group C [p=0.02]

While it was not significantly different between group A and group B [p=0.29] and between group B and group C [p=0.819]

Conclusion: Lower dose of hyperbaric bupivacaine can reduce the time for home readiness compared to higher dose. Time of discharge is mainly dependent on time to micturate after saddle block anaesthesia

Unilateral spinal anesthesia for major lower limb surgery in patients with cardiac failure

Objective: To determine the safety of unilateral spinal anesthesia in elderly patients with cardiac failure undergoing major lower limb surgery

Study Design: Prospective, quasi- experimental study

Place and Duration of Study: Department of Anesthesiology, Combined Military Hospital Rawalpindi, during the period of October 2012 to December 2013

Material and Methods: In this study, 20, American Society of Anesthesiologists [ASA] III and IV patients with different severities of heart failure due to previous myocardial infarction [MI], aged between 60-110 years undergoing unilateral lower limb orthopaedic surgery were included by non probability consecutive sampling. All patients received unilateral spinal anesthesia using hyperbaric 0.75% Bupivacaine 7.5mg. They were given preload of 2ml/kg colloid. Patients were placed in the lateral position with fractured limb on lower side and kept in this position for 10 minutes. Haemodynamic variations were monitored and recorded for the whole duration of procedure. Dobutamine, Ephedrine and Atropine were used as vasopressor/inotropic agents

Result: In this study 20 patients were included. Sixteen [80%] were male. Mean age of group was 80.8 +/- 12.5 years. The mean duration of surgery in our patients was 63.55 +/- 16.47 minutes. Ephedrine was needed in 12 patients, atropine in 4 patients. One patient required Dobutamin infusion and one patient required norepinephrine infusion for 15 minutes. Two patients did not require inotropic or vasopressor support. The average percent fall in mean arterial pressure from prespinal value was 20.59%. The block remained unilateralin all cases. Motor blockade was adequate in the limb to be operated

Conclusion: Unilateral subarachnoid block with hyperbaric bupivacaine does not produce adverse hemodynamic changes. Under controlled setting and meticulous monitoring elderly patients with variable degree of heart failure can be safely given unilateral spinal anesthesia for major lower limb orthopaedic surgery. Unilateral subarachnoid block with hyperbaric bupivacaine does not produce adverse hemodynamic changes. Under controlled setting and meticulous monitoring elderly patients with variable degree of heart failure can be safely given unilateral spinal anesthesia for major lower limb orthopaedic surgery

Late presentation of a patient with an anorectal malformation [ARM]

Vestibular fistula represents the most common type of anorectal defect seen In girls with anorectal malformation. Adult presentation of this malformation is rare. The following is a case of adult presentation of anorectal malformation with a vestibular fistula in a 23 years old female, who came because of cosmetic and fertility concerns before her marraige. The patient complained of having an anorectal malformation since birth and passage of fecal matter through the fistula. The patient was continent for feces, but had leakage of flatus. She had no other associated anomaly. The patient subsequently underwent a surgical procedure where anal transpositioning was done with an intact skin bridge. Post-operatively, these developed an anal stenosis which was successfully treated through anoplasty, and the patient is now continent both for feces and flatus for the last 6 months

Tubercular fistula-in-ano

To determine the frequency of tuberculosis in recurrent fistula-in-ano. Case series. This study was conducted in Surgical Ward-3, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from 1998 to 2007. The study included 100 cases of recurrent fistula-in-ano not responding to conventional surgery. Patients with other co-morbidities such as diabetes mellitus, bleeding disorders or with the evidence of pulmonary, abdominal or intestinal tuberculosis were excluded from this study. Fistulogram was performed in all patients. All the patients were subjected to fistulectomy followed by histopathology of the resected specimen. Thereafter, confirmation of the disease, anti-tuberculous treatment was immediately started and response to treatment was observed after 6 months. Out of the 100 studied patients, 11 cases had biopsy proven tuberculosis in the fistula. All the patients were male. The fistulae were low type, single and usually located posteriorly [n=9] with everted margins. Ten were located within 3 cm of anus. Fistulogram revealed single internal opening. Comparative statistics of tuberculous fistula-in-ano with fistulas due to specific inflammation revealed no major differences. The diagnosed patients of tubercular fistulae-in-ano were observed for at least 6 months after starting anti-tuberculous treatment. They all responded well to anti-tubercular treatment and the fistulae healed without any complication such as recurrence or anal stenosis within 6 months. Tuberculosis should be suspected in case of recurrent fistulae-in-ano, so as to avoid unusual delay in the treatment and miseries to the patient. Appropriate anti-tuberculous therapy leads to healing within 6 months