Perioperative Management of an Obstetric Patient with Eisenmenger Syndrome and Pre-Eclampsia Using Milrinone.

ABSTRACT: Pregnancy in a patient with pulmonary hypertension carries a high risk of mortality. It poses multiple problems in the management of pregnancy, labor, and postpartum, thereby emphasizing the need for a multidisciplinary team for a successful outcome. We describe the successful management of a case of Eisenmenger syndrome who developed pre-eclampsia during her 28 weeks of pregnancy. As far as our knowledge, this is the first case report that describes the use of milrinone in a parturient for a successful outcome.

Shivering and changes in body temperature in patients undergoing caesarean section under spinal anaesthesia with bupivacaine vs bupivacaine and fentanyl: A randomized clinical study.

Background and Aims: Shivering is common after spinal anesthesia in patients undergoing cesarean section. Various drugs have been used for its prevention. The primary aim of this study was to assess the efficacy of adding a small dose of fentanyl intrathecally (12.5 µg) in reducing the occurrence of intraoperative shivering and hypothermia and note any significant side effects in this subset of patients. Material and Methods: In this randomized controlled trial, 148 patients undergoing cesarean section under spinal anesthesia were included. In 74 patients, spinal anesthesia was administered with 1.8 mL of hyperbaric bupivacaine (0.5%), and the remaining 74 patients received 12.5 µg of intrathecal fentanyl with 1.8 mL of hyperbaric bupivacaine. Both were compared to find the incidence of shivering and change in nasopharyngeal and peripheral temperature along with the temperature at the onset of shivering and the grade of shivering. Results: The incidence of shivering was 9.46% in the intrathecal bupivacaine plus fentanyl group, which was significantly less than the group with intrathecal bupivacaine alone (41.89%). The nasopharyngeal and peripheral temperature showed a decreasing trend in both groups but were greater in the plain bupivacaine group. Conclusion: The addition of 12.5 µg of intrathecal fentanyl to bupivacaine in parturient undergoing cesarean section under spinal anesthesia significantly reduces the occurrence and intensity of shivering without its adverse effects such as nausea, vomiting, and pruritus, etc.

A study on the effect of intraoperative continuous positive airway pressure (CPAP) on the postoperative pulmonary function in overweight patients undergoing lower limb, lower abdominal or vaginal surgeries under spinal anesthesia.

INTRODUCTION: Spinal anaesthesia, supine position and higher BMI are risk factors for pulmonary atelectasis. NIV, PEEP and CPAP are employed in ICU's to treat atelectasis postoperatively. However, we wanted to investigate whether CPAP was protective against atelectasis when used intraoperatively, in high risk patients. MATERIAL AND METHODS: This study was a randomized controlled trial. Overweight patients, who were to undergo surgeries under spinal anesthesia were included in the study. After informed consent, 126 patients underwent preoperative pulmonary function tests (PFT: FEV1, FVC, PEFR). Following the onset of spinal anaesthesia patients were randomised into group E (n = 63, received CPAP) and control group, group C ( n =63, received nil intervention). Postoperative PFT was done at 20 minutes, 1 hour, 2 hours and 3 hours after surgery. Patients were followed up till discharge for pulmonary complications. RESULTS: We observed significant reduction in pulmonary function (FEV1, FVC and PEFR) postoperatively compared to base-line. CPAP group had better pulmonary function when compared to control group, the difference being significant 20 minu-tes after the surgery(p < 0.05). No postoperative pulmonary complication was reported among the 126 patients studied. CONCLUSION: Intraoperative use of CPAP in overweight patients undergoing surgeries under spinal anaesthesia could be beneficial in improving pulmonary function in the immediate post-operative period.

Microcuff Pediatric Endotracheal Tubes: Evaluation of Cuff Sealing Pressure, Fiber-optic Assessment of Tube Tip, and Cuff Position by Ultrasonography.

BACKGROUND: Use of uncuffed tubes causes lots of morbidity, and there is a surge in the use of microcuff pediatric endotracheal tubes. These tubes are not evaluated in the Indian population. AIMS: The study aimed to evaluate the pediatric microcuff endotracheal tubes in terms of cuff sealing pressure, fiber-optic assessment of tube tip, and cuff position to assess postextubation airway morbidity. SETTINGS AND DESIGN: Study design involves follow-up analytical study. SUBJECTS AND METHODS: Thirty-four children in the age group of 2-12 years were studied. Patients with leak pressure >20 cm H2O were exchanged with smaller size tube and excluded. Cuff pressure, fiber-optic assessment of tube tip to carina distance in neutral and flexion, ultrasound assessment of cuff position, and postextubation airway morbidity were assessed. STATISTICAL ANALYSIS USED: Parameters expressed as the median with the interquartile range. Nonparametric data were analyzed using the Wilcoxon signed-rank test. RESULTS: The tracheal leak pressure was <20 cm H2O (median 14.5 cm H2O) in 30 children. Tube exchange was required in four patients. A complete seal was achieved in 30 patients with cuff pressures ranging from 6 to 8.25 cm of H2O (median 8 cm of H2O). The median caudal displacement is 0.8 cm (0.47-1.22 cm) with flexion. There was no airway-related morbidity in any of these patients. CONCLUSIONS: The microcuff pediatric endotracheal tubes when used according to the age-based formula had a higher tube exchange rate in our study population. However, in children in whom the tube size was appropriate, the tubes provided good sealing without increasing airway morbidity. Further studies with a larger sample size might be required to confirm the findings.

Comparison of meperidine, tramadol and fentanyl for post-spinal shivering prevention during cesarean delivery: A double-blind randomized controlled trial.

AIM: To assess the effects of intravenously administered meperidine, fentanyl and tramadol in reducing the incidence, onset time and severity of the shivering response in parturients during cesarean delivery under spinal anesthesia. Secondary outcomes included patient satisfaction and sedation scores. METHODS: After Ethics board approval and informed written consent, 350 parturients (ASA physical status I or II), between 20 and 40 years of age, undergoing emergency or elective cesarean delivery under spinal anesthesia were recruited. Parturients were then randomly allocated to seven study groups: normal saline (control), low-dose meperidine (0.5 mg/kg), high-dose meperidine (0.75 mg/kg), low-dose fentanyl (0.5 mcg/kg), high-dose fentanyl (0.75 mcg/kg), low-dose tramadol (0.5 mg/kg) and high-dose tramadol (0.75 mg/kg). The incidence, onset time and severity of shivering, along with patient satisfaction and sedation scores were measured. RESULTS: All study drugs showed significant reduction in incidence, onset time and severity of shivering and greater satisfaction scores compared to the control group (P < 0.01). Within each drug class, no significant differences in shivering were found between the high-dose and low-dose groups. Among study drugs, low-dose tramadol was superior due to shivering prevention and significantly reduced sedation. CONCLUSION: Intravenously administered meperidine, fentanyl and tramadol reduce shivering incidence, onset time and severity in parturients undergoing cesarean delivery following spinal anesthesia. Importantly, low-dose intravenous tramadol (0.5 mg/kg) allowed shivering prevention and low sedation scores, thereby offering greater parturient satisfaction and better maternal-newborn bonding.

Comparing epidural and wound infiltration analgesia for total abdominal hysterectomy: A randomised controlled study.

BACKGROUND AND AIMS: Continuous wound infiltration (CWI) is emerging as an alternative to continuous epidural infusion (CEI). This study compared postoperative pain scores of CEI with CWI in patients undergoing total abdominal hysterectomy (TAH). METHODS: This prospective randomised controlled trial included 102 patients planned for TAH who were randomised into either Group E (CEI) or Group L (CWI). The catheter (epidural/wound infiltration) was inserted in Group E before induction) and Group L at the end of surgery. General anaesthesia was administered according to standard protocol. At the end of surgery, both groups received 10 mL bolus of 0.2% ropivacaine followed by infusion at 6 mL/h through the respective catheters. They also received intravenous patient-controlled analgesia with morphine. The primary outcome was the visual analogue score at rest (VASR) and at deep breathing (VASDB) post-operatively. Secondary outcomes were post-operative morphine consumption, side effects and patient satisfaction. RESULTS: The mean VASR between two groups were comparable up to 8 h. Group E showed significantly reduced VASR compared to Group L at 12 h (2.32 ± 0.59 vs 2.62 ± 0.67, P = 0.019) and 24 h (2.30 ± 0.58 vs 2.62 ± 0.57, P = 0.006). Group E showed significantly reduced VASDB compared to Group L at 5 min and from 4 to 24 h. Total morphine consumption, side effects and patient satisfaction were comparable. CONCLUSION: We conclude that CEI is a superior analgesic technique compared to CWI in total abdominal hysterectomy in terms of reduced pain scores.

Role of Methylene Blue in the Maintenance of Postinduction Hemodynamic Status in Patients with Perforation Peritonitis: A Pilot Study.

CONTEXT: Methylene blue is an inhibitor of guanylate cyclase and hence prevents vasoplegia mediated by nitric oxide in patients with sepsis. AIMS: This study aimed to analyze the effect of methylene blue on blood pressure maintenance following induction of anesthesia in patients presenting with peritonitis. SUBJECTS AND METHODS: Thirty patients diagnosed to have perforation peritonitis were randomized into two groups (Group MB, Group NS). Patients in Group MB were given injection methylene blue 2 mg/kg over 20 min and patients in Group NS were given 50 ml of normal saline over 20 min, before induction. Heart rate, mean arterial pressure (MAP), cardiac output, and systemic vascular resistance (SVR) were recorded every 5 min for 1 h after infusion. STATISTICAL ANALYSIS: Hemodynamic parameters were analyzed using repeated-measures analysis of variance with Bonferroni's test. Blood gas analysis was analyzed using independent Student's t-test, and P < 0.05 was considered statistically significant. RESULTS: MAP was lower at all-time points in Group NS than Group MB; however, it was statistically significant immediately, and 5 min the following induction. MAP fell from 94.8 ± 11.8 mmHg to 89.2 ± 16.0 mmHg immediate postinduction in Group MB and from 92.1 ± 9.8 mmHg to 74.1 ± 12.6 mmHg in Group NS. MAP and SVR were significantly higher in Group MB, 5 min following induction. No adverse events attributable to methylene blue were noted. CONCLUSIONS: Methylene blue contributes to the maintenance of postinduction hemodynamic stability in patients with perforation peritonitis.

Comparing slow and rapid bolus of ephedrine in pregnant patients undergoing planned cesarean section under spinal anesthesia.

BACKGROUND AND AIMS: While ephedrine was the preferred drug for treating spinal-induced hypotension in pregnancy, its use has declined because of resultant fetal acidosis. The objective of this randomized control trial was to compare the effects of a slow and rapid bolus of ephedrine on fetal acidosis, maternal blood pressure, and heart rate (HR) during cesarean section performed under spinal anesthesia. MATERIAL AND METHODS: Eighty full-term parturients scheduled for cesarean section under spinal anesthesia were randomly allocated into two groups. While both groups received 6 mg of ephedrine to treat hypotension, Group R (n = 40) received it as a rapid intravenous bolus and Group S (n = 40) received it slowly over 20 s with an infusion pump. The maternal vital parameters were recorded until delivery of the baby using a video camera. Umbilical cord blood was obtained using the three clamp method. Hemodynamic parameters, fetal acidosis, total number of ephedrine bolus used, peak HR after the ephedrine bolus, and occurrence of postoperative nausea and vomiting (PONV) were compared between the groups. RESULTS: Mean increase in HR and blood pressure were significantly higher in Group R than the Group S after the first ephedrine bolus. Umbilical artery pH was significantly lower in Group R than in Group S (7.2 [6.8-7.3] vs. 7.3 [7.3-7.4], P < 0.01). A total number of ephedrine boluses were comparable in the two groups. 35% of the patients had PONV in Group R, whereas none had it in Group S (P < 0.01). CONCLUSION: Slow bolus of ephedrine is better than rapid bolus to treat spinal-induced hypotension during cesarean section in view of less fetal acidosis.

A survey of a population of anaesthesiologists from South India regarding practices for rapid sequence intubation in patients with head injury.

BACKGROUND AND AIMS: Evidence and utility of the individual steps of the rapid sequence induction and tracheal intubation protocols have been debated, especially in the setting of traumatic brain injury. The purpose of this survey was to determine preferences in the current approach to rapid sequence intubation (RSI) in head injury patients among a population of anaesthesiologists from South India. METHODS: A questionnaire was E-mailed to all the members of the Indian Society of Anaesthesiologists' South Zone Chapter to ascertain their preferences, experience and comfort level with regard to their use of rapid sequence intubation techniques in adult patients with head injury. Participants were requested to indicate their practices for RSI technique for a head-injured patient upon arrival at the Emergency Medical Services department of their hospital. RESULTS: The total response rate was 56.9% (530/932). Of the total respondents, 35% of the clinicians used cricoid pressure routinely, most respondents (68%) stated that they pre-oxygenate the patients for about 3 min prior to RSI, thiopentone (61%) and propofol (34%) were commonly used prior to intubation. Rocuronium was the muscle relaxant of choice for RSI among the majority (44%), compared to succinylcholine (39%). Statistical analyses were performed after the initial entry onto a spreadsheet. Data were summarised descriptively using frequency distribution. CONCLUSION: In a rapid sequence intubation situation, the practice differed significantly among anaesthesiologists. Owing to disagreements and paucity of evidence-based data regarding the standards of RSI, it is apparent that RSI practice still has considerable variability in clinical practice.

Spinal anesthetic for emergency cesarean section in a parturient with uncorrected tetralogy of Fallot, presenting with abruptio placentae and gestational hypertension.

A subarachnoid block is an effective way of providing anesthesia for cesarean sections. However, it can be considered relatively contra-indicated in parturients with uncorrected tetralogy of Fallot (TOF). We report a case of a 22-year-old female patient with TOF and gestational hypertension, who presented for an emergency cesarean section for placental abruption. The surgery was successfully conducted under a spinal anesthetic with a combination of low dose bupivacaine and fentanyl. Fentanyl combined with small-dose bupivacaine in the subarachnoid space can be considered as an alternative technique to general anesthesia, in selected parturients with uncorrected TOF presenting for cesarean section, especially in cases where the risks of administering a general anesthetic are deemed high.

Comparison of Propofol and Ketamine versus Propofol and Fentanyl for Puerperal Sterilization, A Randomized Clinical Trial.

BACKGROUND: Puerperal sterilization requires a rapid recovery of the mother so that she can take care of her child. Propofol with fentanyl (PF) is an option, but is associated with intraoperative hypotension, respiratory depression and an unsatisfactory postoperative recovery profile. Propofol with ketamine (PK) appears to be an alternative in terms of haemodynamic stability and analgesia. MATERIALS AND METHODS: This randomized clinical trial involved 60 patients who were scheduled to undergo puerperal sterilization, who belonged to American society of anaesthesiologists (ASA) physical status 1. Patients were randomly allocated to receive either ketamine - propofol infusion in a concentration of 8mg/ml each (group PK) or fentanyl 2µg/kg intravenously, followed by an infusion of propofol in a concentration of 8mg/ml (group PF). In both the groups, the infusion was started at 300ml/hr till patient lost consciousness. Subsequently, the rate was set at 1.5ml/kg/hr for group PF and at 0.75ml/kg/hr for group PK. After the initial 10 minutes, the infusion rate was reduced to 1ml/kg/hr for group PF and to 0.5ml/kg/hr for group PK. Blood pressure and saturation were the primary outcomes which were measured. RESULTS: Patients from group PF recorded a significant drop in the systolic blood pressure from the 5(th) minute, in diastolic pressure from the 10(th) minute and transient oxygen desaturation, as compared to group PK. Patients in group PK had adequate surgical conditions and better recovery profiles in terms of pain and sedation. CONCLUSION: The combination of ketamine and propofol is a safe and possibly superior alternative to propofol - fentanyl combination in patients who undergo puerperal sterilization, in terms of haemodynamic stability and respiratory depression.

Case report: telelaryngoscopy-guided flexible fiberoptic intubation for laryngeal rhinosporidiosis.

Rhinosporidiosis is a chronic granulomatous disease endemic in India and Sri Lanka. The causative microorganism, Rhinosporidium seeberi, remains a poorly understood pathogen, which has been described as an aquatic protistan parasite. Rhinosporidiosis presents as multiple polypoidal lesions affecting the mucosa of the nasal cavity, nasopharynx, and oropharynx. Intralaryngeal rhinosporidiosis is a rare entity and poses a challenge for management of the airway. In this case report, we highlight our technique in the management of the airway in a case of laryngeal rhinosporidiosis using a combination of fiberoptic bronchoscope and an endoscope. The technique was atraumatic and also avoided the potential for autoinoculation, which is a frequent cause of recurrence of this disease.