Midazolam for caudal analgesia in children: comparison with caudal bupivacaine.

BACKGROUND: Caudal analgesia is the most popular and commonly used regional anaesthesia technique for post operative analgesia in children undergoing lower limb, anoperineal and abdominal surgical procedures. It is commonly applied in all the paediatric patients undergoing the above mentioned surgery, as the goal of balanced anaesthesia is not only limited to intraoperative period but also good analgesia in post operative period. Many drugs like morphine, Pethidine, Neostigmine etc have been used as analgesic agent via the caudal route but not without their side effects. So Midazolam was used as an alternative drug as it may not be associated with the side effects encountered with the other drugs. AIMS AND OBJECTIVES: The objective of the study was to see the analgesic efficacy of caudal administration of Midazolam with comparison to Bupivacaine for post operative analgesia, and to observe for side effects if any. MATERIALS AND METHODS: This was a single blinded prospective observational study in children of age 1 to 6 years of ASA grade I undergoing elective hernia or hydrocoele surgery. The patients were allocated randomly into two groups (n=25) to receive caudal injection of either 0.25% Bupivacaine 1 ml/kg (group A) or Midazolam 50 microg/kg with normal saline 1 ml/kg (group B). In the post operative period heart rate, blood pressure, pain score, recovery to first analgesic time, total number of analgesics required in 24 hours and side effects if any were noted and analysed. RESULTS: There were no significant differences in quality of pain relief, postoperative behaviour or analgesic requirements between the Midazolam group and the Bupivacaine group. Recovery to first analgesic time though was longer in the Bupivacaine group (9.65 hr) than Midazolam group (7.32 hr); it was statistically not significant (P= 0.9). Any of the side effects such as motor weakness, urinary retention, and respiratory depression were not observed in both the groups. However in both the groups, few of the patients had post operative vomiting. CONCLUSION: We conclude that caudal Midazolam in a dose of 50 microg/kg provides equivalent analgesia to Bupivacaine 0.25%, when administered in a volume of 1 ml/kg for children undergoing unilateral inguinal herniotomy for hernia or high ligation of processus vaginalis for hydrocoele.

Cardiovascular collapse during induction of general anesthesia.

Anaphylactic reactions to anesthetic drugs, though rare, may be encountered by anyone involved. The clinical manifestation of the anaphylactic reactions, which may be different from patient to patient, is caused by the histamine released either from the mast cells or basophils or both. Laboratory investigations can determine the source of histamine release. Here, I present a case of anaphylactic reaction to sodium thiopental. The main stay of the treatment is oxygenation, fluids and epinephrine, which was applied in this case also, with successful outcome of the patient.

Combined epidural anesthesia & general anesthesia for aorto-renal bypass: two case reports.

Aorto-renal bypass surgery is associated with significant hemodynamic alterations as well as other comorbidities due to necessity of aortic cross-clamping and release during vascular anastomosis. Combined epidural and general anesthesia for the aorto-renal bypass surgeries provides not only hemodynamic stability during aortic cross-clamping but is also associated with increased graft blood flow, graft survival and decreased morbidity and mortality in intraoperative and postoperative period. Two cases of aorto-renal bypass are presented, for which combined epidural and general anesthesia techniques were applied.

Application of "the Sequential Organ Failure Assessment (SOFA) score" in predicting outcome in ICU patients with SIRS.

BACKGROUND: Various scoring systems have been developed to prioritize patient admission and management in ICU. The objective of this prospective, observational cohort study was to evaluate application of one such system, the Sequential Organ Failure Assessment (SOFA) Score in predicting outcome in ICU patients with SIRS. PATIENTS AND METHODS: Fifty patients admitted to a six bed multidisciplinary ICU with SIRS were consecutively enrolled in the study and SOFA scores were calculated at zero hour, after 48 hrs, and after 96 hrs and patients followed till discharge from hospital. RESULTS: When compared to outcome, the non survivors had high initial, mean and highest SOFA scores as compared to survivors. (p value = 0.002, <0.001, <0.001 respectively). Delta SOFA was not significantly associated with outcome. (p value= 0.117). The initial SOFA score > 11 predicted a mortality of 90%. (OR 23.72, 95%CI2.68-209.78, p=0.004). Similarly, mean SOFA score of > 7 predicted a mortality of 73.9% (OR 22.7, 95%CI 5.0 - 103.5, p<0.001) and high SOFA score > 11 predicted a mortality of 87.5% (OR 32.66, 95%CI 5.82-183.179, p< 0.001). Area under receiver operating characteristic (ROC) curve for mean SOFA was 0.825, for high SOFA was 0.817 and for initial SOFA was 0.708. Thus mean, high and initial SOFA scores were helpful in predicting between the survivors and the non survivors. CONCLUSION: The SOFA scoring system is useful in predicting outcomes in ICU and thus help in proper utilization of ICU resources.

Correlation of PAP smear findings with clinical findings and cervical biopsy.

OBJECTIVES: Carcinoma of the cervix is the most common cause of the death in Nepal. Cervical carcinoma does not develop suddenly from normal epithelium but is presented by a spectrum of intraepithelial neoplastic changes that are precancerous lesion and were termed as cervical intraepithelial neoplasia (CIN). Cervical cytological screening is designed to detect over 90% of cytological abnormalities. It has also been established that most cervical cancers can be diagnosed at the preinvasive stage with adequate and repetitive cytological screening. Keeping in view of the importance of carcinoma and the precancerous lesion (CIN) of cervix, study of different methods for the early detection of abnormalities in cervix, correlation with the clinical findings and comparison between the techniques was carried out. MATERIAL AND METHODS: Patients with suspicious cervix attending Gynaecology OPD of TUTH and Western regional hospital (Pokhara) who have undergone for pap smear cytology test along with biopsy were selected. Detail history with clinical examination was performed and the findings were correlated. RESULTS AND CONCLUSION: Unhealthy cervix with discharge was found to be common even in chronic cervicitis however bleeding and tenderness were associated with more advanced lesions. Pap smear test was found to be equally sensitive to histopathological examination for the early detection of different cervical lesions. However, it is advised to perform biopsy if any abnormalities are detected in pap smear for correlation and confirmation.

Cytology of body fluids from different sites: an approach for early diagnosis of malignancy.

Malignant effusions are a common presenting sign of malignancy and reflect dissemination. A retrospective study of all fluid samples accessioned at the Department of Pathology, TUTH from April 2000 to October 2002 were done. Over the study period, a total of 584 specimens were examined- 324 peritoneal fluid, 224 pleural fluid, 19 pericardial fluid, 9 knee joint effusion and 8 Cerebro-Spinal Fluid (CSF). One hundred and nine (18.66%) out of 584 cases were found to have malignancy, 57 were male and 52 were female. The age group of the adult male ranged from 42-78 years and female ranged from 43-62 years. Three patients were children with age ranging from 8-11 years. Adenocarcinoma was the commonest that comprised 89%, followed by Non Hodgkin's lymphoma 6.5% squamous cell carcinoma 2.7% and small cell carcinoma comprised 1.8 %. Exfoliative cytology is cheap, rapid and highly effective tool for the evaluation of body fluid and should be advised in all effusion cases.

Spirometry in evaluation of respiratory diseases.

A hospital based cross-sectional study was conducted from March 2005 to April 2006 to evaluate the distribution of various respiratory diseases by spirometry. A total of 228 consecutive cases referred for spirometry were included of which 65% were male and 35% female. COPD was the commonest referral diagnosis (40%) followed by the diagnosis of shortness of breath (22%). After spirometry the prevalence of COPD was 42%, Asthma 23.5%, Restrictive disease 3.1% and mixed obstructive and restrictive disease 3.5%. 25% of the sample population was smokers and 22% ex-smokers. Hence we conclude that spirometry is a very useful diagnostic tool for preliminary diagnosis of respiratory diseases and should be used more by general practitioners and physicians to make their diagnosis and therapy more scientific.

Functional Endoscopic Sinus Surgery (FESS).

Functional Endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure that opens up the sinus air cells and the sinus ostia with an endoscope. The use of FESS as a sinus surgical method has now become widely accepted and the term functional is meant to distinguish this type of endoscopic surgery from the nonendoscopic more conventional sinus procedure. Functional Endoscopic sninus surgery is being done regularly at TU Teaching Hospital from 2003. Total number of cases done from March 2003 till December 2005 were 94. Maximum number of FESS was done for nasal polyps, which was carried out in 80 patients, out of which, FESS for ethmoidal polyp was done in 47 patients and for antrochoanal polyps in 33 patients. Other conditions where FESS was carried out were chronic maxillary sinusitis in 8 patients, fungal sinusitis in 5 patients, and endoscopic medial maxillectomy for inverted papilloma in 1 patient.

Platelet estimation: its prognostic value in pregnancy induced hypertension.

Thrombocytopenia is an associated phenomenon of Pregnancy induced hypertension (PIH). But the accurate count of platelets either by manual, (direct or indirect methods) or by automated cell counters is not feasible for all patients at all hospitals. Therefore we have adopted the method of platelet estimation, not platelet count as an alternate procedure to estimate the degree of thrombocytopenia in patients with PIH cases. We included 30 normal pregnant women and 90 pregnant women with varying degree of PIH. Blood platelets were estimated by an accepted manual method. Platelet numbers were found to be 2.38 lacs/mm3 +/- 0.33 in control group, 2.23 lacs/mm3 +/- 0.19 in mild PIH, 1.82 lakhs/mm3 +/- 0.45 in pre eclampsia and 1.21 lacs/mm3 +/- 0.49 in eclampsia. This indicated that there is an inverse relationship between the severity of PIH and platelet numbers. So this method of platelet estimation is useful as a rapid method of assessment in PIH. This method is not only rapid and cheap but can be done even in rural hospital settings.

Practice in anesthesia: intrathecal morphine for off pump coronary artery bypass graft.

Off pump coronary artery bypass grafting is gaining popularity because of its beneficial effects like reduced inflammatory response, early extubation, reduced hospital & ICU stay, less homologous blood transfusion & reduced cost. Here we report a case of left anterior descending artery blockade who had undergone off pump coronary artery bypass grafting. In this case we used intrathecal morphine with heavy bupivcaine to provide intraoperative as well as post operative analgesia. Though intrathecal morphine has been used as analgesia in cardiac surgeries, the use of intrathecal morphine with bupivacaine is less reported. It not only provides intense analgesia which helps for early extubation & hemodynamic stability but also provides calm & quiet surgical field with slow beating heart & aids in critical time of vessel anastomosis. We have also discussed the other aspects of anesthetic management with little elaboration in surgical aspect as well.

Enteric fever: diagnostic value of clinical features.

OBJECTIVES: to evaluate the diagnostic value of clinical symptoms and signs in enteric fever and to propose a clinical diagnostic criterion. DESIGN: Prospective observational study. SETTING: Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal. MATERIALS AND METHODS: febrile patients with clinical diagnosis of enteric fever were included in the study with the aim of confirming diagnosis with blood culture, or bone marrow culture and evaluating the diagnostic accuracy of various clinical signs and symptoms. RESULTS: 64% of the clinically diagnosed cases had blood/ bone marrow culture positive. The diagnostic accuracy of the various symptoms and signs excluding fever was between 42%-75.5%. Majority of the symptom and sign did not have very high diagnostic accuracy. Hence a diagnostic criterion was proposed and clinical features with diagnostic accuracy more than 50% were taken into consideration. Major criteria included fever with diagnostic accuracy of 64%, headache with accuracy of 75.5% and relative bradycardia with an accuracy of 66%. Minor criteria included vomiting, diarrhoea, Splenomegaly, chills and abdominal pain /discomfort with diagnostic accuracy of 57%, 55%, 55%, 53% and 51% respectively. Finally after combination of various major and minor criteria a final diagnostic criterion was proposed having an accuracy of 66% and including both major and minor clinical symptom and sign. CONCLUSION: clinical diagnosis of enteric fever will be very helpful in a country like ours. Though none of the clinical symptoms and sign have very high diagnostic accuracy a diagnostic criteria may be helpful. Criteria including both major and minor signs and symptoms would be the most appropriate diagnostic tool as it includes the important abdominal symptoms and signs of enteric fever.

A case of left atrial myxoma: anaesthetic management.

Left Atrial Myxomas are notorious for their varied presentations. We describe one such case which initially presented with hemiparesis and seizures and was diagnosed as cerebral infarction and treated accordingly and decompression craniotomy with hinge flap was done for raised ICP and impending brain herniation. The main cause was a left atrial myxoma, which was diagnosed only in follow up. The myxoma has embolised to give rise to cerebral infarction. The LA myxoma was then successfully operated under general anaesthesia and Cardiopulmonary bypass (CPB).

Effectiveness of nicotinic acid and bezafibrate alone and in combination for reducing serum triglyceride level.

OBJECTIVE: To study the effectiveness of nicotinic acid and Bezafibrate alone and in combination for reducing triglyceride level. DESIGN: It was a randomised, prospective, longitudinal study. SETTING: Patients attending a private clinic, and medical department of Kathmandu Medical College, Sinamangal. METHODS: This study included 83 consecutive patients, 19 females and 64 males with hypertriglyceridaemia (defined as serum triglyceride >200mg/dl) attending the department of medicine, Kathmandu Medical College, Sinamangal and private clinic. MAIN OUTCOME MEASURES: Statistically significant reduction of serum triglyceride level. RESULT: 51 out of 83 patients completed the study in which Nicotinic acid alone reduced the serum trygleceride level from 320.62 +/- 104.23 to 182.55 +/- 46.21, which is a reduction of 138.07 +/- 85.69 (P. value = 001). Bezafibrate when given alone also reduced triglyceride level significantly from 345.25 +/- 181.03 to 203.30+/-93.59 which is a reduction of 141.95 +/- 121.130 (P value= .001). When a combination of both drugs was given the reduction of 472.73+/-247.53 (P value =.002) was achieved. CONCLUSIONS: Nicotinic acid is a very effective drug in reducing serum triglyceride level and its effectiveness is similar to Bezafibrate. There is no added benefit of giving a combination of nicotinic acid and Bezafibrate in reducing serum triglyceride level.

Lipid levels in Nepalese population.

OBJECTIVE: To study the lipid pattern of Nepalese population. DESIGN: Retrospective study Setting: Patients attending Temple of Healing for consultation. METHODS: Fasting lipid profile of 2218 blood samples was analyzed. RESULTS: Abnormal total cholesterol (TC) was found in 7.7%. High LDL cholesterol (LDL-C) was found in 5% of cases. 70% of subjects had triglyceride(TG) level more than the upper level of normal. All abnormal lipid level was found in the age group 49 to 60 years. 23% of the study group had low level of HDL cholesterol. CONCLUSIONS: abnormal triglyceride level is the commonest lipid abnormality in our population. High total cholesterol and LDL cholesterol is not very common except in the age group 40 to 49 where it is significantly high in comparison to other age groups. HDL cholesterol level did not decrease significantly with increasing age. Keywords: Lipids, Nepalese population.

Diversity of ground arthropod community at organic and chemically intensive tea plantation of Darjeeling terai.

Tea in Darjeeling foothills and terai are grown conventionally, with application of chemical fertilizers and pesticides, as well as organically without these inputs. Ground level arthropod community was collected from the above two types of tea plots using pitfall traps. Catches from these environments showed variation in the arthropod faunal structure with numerically and taxonomically greater abundance in the organic than that of the conventional plot. Coleopterans were more diverse with largest number of families and Recognizable Taxonomic Units (or morphospecies) in the organic tea plot. The diversity and similarity indices for coleopterans were comparable, in organic and conventional tea plots at species and family levels. The close relationship of the indices suggested that diversity study at family level could be used as surrogate for species level diversity; thus alleviating the laborious and expertise job of taxonomic identification of arthropod species. Faunal diversity study at ground level gave the clue that soil of the organic plantation was healthier than that of the conventional tea plot.