Ultrasound-guided peripheral and truncal blocks in pediatric patients

Ultrasound has added a feather in the cap of the anesthesiologists as real-time nerve localization and drug deposition around the nerve structure under real-time guidance is now a reality, as the saying "seeing is believing" has been proven true with the advent of ultrasound in anesthesia. Pediatric patients are a unique group regarding their anatomical and physiological features in comparison with adults; regional blocks in adults with the anatomical landmark and surface marking are almost uniform across the adult population. The landmark technique in pediatric patients is not reliable in all patients due to the variability in the age and size; the advent of ultrasound in assisting nerve localization has changed the way regional blocks are achieved in children and the range of blocks performed on adults can now be performed on pediatric patients; with advances in the technology and dexterity of ultrasound equipment, the chances of success of blocks has increased with a smaller dose of the local anesthetic in comparison to the traditional methods. Anesthesiologists are now able to perform blocks with more accuracy and avoid complications like intravascular injection and injury to the pleura and peritoneum during routine practice with the assistance of high-frequency transducers and top of the range portable ultrasound machines; catheters can be inserted to provide a continuous analgesia in the postoperative period. This review article describes the common peripheral blocks in pediatric patients; the readers are encouraged to gain experience by attending workshops, hands-on practice under supervision, and conduct random controlled trials pertaining to ultrasound-guided blocks in the pediatric age group. The recent literature is encouraging and further research is promising; a wide range of blocks being described in detail by many prominent experts from all over the world

Ultrasound-guided supraclavicular brachial plexus block in patient with halo device

Ultrasound guided regional blocks are on the rise, many institutes are training their staff to master this technique of regional anesthesia. Regional anesthesia in case of an emergency surgery or elective surgery can be the best choice. The case described here is an example - patient with a halo fixation device after motor vehicle accident scheduled for surgery of the extremity. The main aim of management of this case is to achieve a safe anesthesia with minimal interference of the cervical fixation. Supraclavicular brachial plexus block is a good choice for surgeries of the arm and hand and use fo an ultrasound to guide the block adds to the safety profile of this versatile block. It has been described as "spinal of the upper limb". Patients with co-morbidities and injuries to the cervical spine are challenging cases to anesthetixe, as regional anesthesia is a very attractive option, failure of the regional block will expose the patient to all adverse sequelae, which were being avoided by planning for a regional anesthesia. Ultrasound has revolutionixed the way regional anesthesia is practiced and the proper drug can be placed at the right place in the hands of an experienced anesthesiologist and the block will help in avoiding all the complkcaitns of endotracheal anesthesia in these cases

Recovery profile for magnetic resonance imaging in pediatric day case- Sevoflurane vs. Isoflurane

Magnetic resonance imaging [MRI] is gaining ground over other investigations particular in study of brain and soft tissues. The MRI procedure is painless but requires an immobile patient for a successful study. Children are required to be sedated or anesthetized for this procedure. We compared two inhalational anesthetics, namely sevoflurane and isoflurane, for the recovery profile of each with aim to determine the ideal drug for early discharge of children. 100 patients aged 3 yrs to 10 yrs [ASA I and II] were divided into Group S [Sevoflurane], Group I [Isoflurane]. The induction time, duration of the MRI study, recovery and discharge times were recorded. The data were subjected to Students t-test and Levene's test for equal variance. In Group S, 27 male and 23 female were enrolled in comparison to 30 male and 20 female in Group I. The induction time in Group S resulted in a mean of 133.7 seconds [ +/- 19.32], Group I yielded a mean of 157.44 seconds [ +/- 24.20] p > 0.05]. The mean recovery time with Group S was 124.4 seconds [ +/- 31.57] when compared with Group 1 a mean of 376.46 seconds [ +/- 58.20] p < 0.05. The mean discharge time in Group S was 25.20 minutes [ +/- 5.71] in comparison to a mean of 37.40 minutes [ +/- 7.43] p < 0.05 in Group I. Sevoflurane can be an ideal inhalational anesthetic for Volatile Induction and Maintenance Anesthesia [V1MA] in children under going day case MRI examinations

Anesthesia for encephalo-trigeminal angiomatosis [Sturge-Weber syndrome]

A case report of rare congenital disease of encephalo-trigeminal angiomatosis [Sturge-Weber Syndrome] [SWS], is presented to alert the anesthesiologist of its potential risk. The case was anesthetized for emergency orthopedic surgery. Anesthesia management is directed towards observing the clinical manifestations of localized superficial skin lesions, extensive systemic involvement, evaluating its associated anomalies and anticipating difficult intubation due to angiomas of the mouth and upper airway and be a ware of concurrent therapy. The authors reviewed the English-language literature and reported findings regarding the SWS pathophysiologic features, interventions, and outcomes, with emphasis on issues relevant to anesthesiologists. This patient tolerated balanced anesthesia well. Anesthesia should be planned to avoid trauma to the hemangiomata, increases in intraocular and intracranial pressure, and be cognizent of current anticonvulsant therapy

Effect of small dose intravenous dexmedetomidine and/or local anaesthetic infiltration on haemodynamic responses to skull pin placement

Fixation of skull pins during craniotomy may cause acute haemodynamic changes. We evaluated, in this randomised double blind placebo controlled trial, the effects of small dose of dexmedetomidine [Dex] infusion in attenuating the haemodynamic profile during skull pin placement. Twenty-eight patients ASA I and II undergoing elective craniotomy were studied. Anaesthesia induced with sufentanil and sodium thiopentone [STP]. Cisatracurium was given to facilitate endotracheal intubation. Patients were randomly allocated to one of four groups [each 7 patients]: dex, lidocaine, dex-lidocaine and placebo [groups I, II, III, and IV respectively]. Groups I and III received intravenous Dex 0.25 meg/kg infusion and local infiltration with normal saline [NS] in group I and with 1% lidocaine in group III. Groups II and IV received intravenous NS and local infiltration at each pin insertion site with 1% lidocaine in group II and NS in group IV. The protocol started with intravenous medications to the assigned groups followed [after 8 min] with local infiltration of the scalp. Two minutes later [10 min after intravenous medication], scalp pinning was performed. Variables recorded were heart rate [HR], systolic blood pressure [SBP] and mean blood pressure [MBP] at different times. After opening the dura, brain status was assessed by the surgeon. Repeated measures of variance of HR, SBP, and MBP showed statistically significant interaction between group assignment and assigned time for groups I and III. In conclusion, our results showed that use of small doses of dex has resulted in obtunding the haemodynamic response to skull pin placement

Anesthetic implications for video assisted thoracoscopic thymectomy in myasthenia gravis

Thymectomy is an established therapy in the management of generalized myasthenia gravis [MG]. However, the optimal surgical approach to thymectomy has remained controversial. There are advocates for transternal, transcervical approaches for "maximal" thymectomy. Video-assisted thoracoscopic thymectomy [VATT] presents new approach to thymectomy. By minimizing chest wall trauma, VATT not only causes less postoperative pain, shortens hospital stay, gives better cosmetic results but also leads to wider acceptance by patients for earlier surgery. Anesthesia for thymectomy in MG is challenging. Currently we are using non-muscle relaxant technique [NMRT] which we adopted in 1994, for maximal thymectomy. In this paper, we present our limited experience with two cases of VATT using two different NMRTs. Two cases of MG underwent VATT under general anesthesia [GA] and one lung ventilation [OLV] using double lumen tube [DLT]. In both cases NMRT was used which encompass, light GA plus thoracic epidural analgesia [TEA] in one case and without TEA in the other case. We believe that the use of NMRT provides good operative and postoperative conditions. In this report we have described two different NMRTs, one with TEA and the other without. Further studies are needed on large number of cases to establish an anesthetic protocol for VATT