Impact of intraoperative fluid administration and complications in head and neck cancer free flap surgery at a tertiary care hospital of a low and middle-income country.

Perioperative fluid administration plays an essential role in head and neck cancer free flap surgery. The impact of intraoperative fluid administration on postoperative complications in head and neck cancer free flap surgery remains ill-defined. All adult patients who underwent a free flap surgery for head and neck cancer between January 2014 and December 2018 were included in the study. A total of 224 patients met the inclusion criteria. The mean age of patients was 45.0 years, and the majority were male (85.7%). Buccal mucosa squamous cell carcinoma (83%) was the most common diagnosis, and anterolateral thigh flap (46.4%) was the most routinely performed procedure. Perioperatively, ringer's lactate was used most abundantly (68.3%). A total of 101 complications were reported in the postoperative period, consisting of 67 medical complications and 34 surgical complications. In conclusion, there is no statistically significant association between the quantity of fluid administration and postoperative complications.

Perioperative Hypertensive Response In A Patient With Implanted Deep Brain Stimulation Device: A Case Report.

This case report features unique anaesthetic management of a patient with implanted deep brain stimulation (DBS) device undergoing abdominal surgery. It features the intraoperative measures taken for this patient for the implanted DBS. After turning off the DBS preoperatively, the patient showed an exaggerated sympathetic response which was very much resistant to medicines. It was unique to this patient that restarting the device alleviated refractory hypertension. The report also includes review of literature for anaesthetic management of patients with implanted DBS.

Management Of Endotracheal Tube Air Leak-A Simple Yet An Effective Manoeuver.

The management and maintenance of an airway can prevent life threatening complications. The handling of airway, especially in difficult airway and trauma patients, requires extreme caution. We have demonstrated a simple technique in the management of emergency airway, who was getting hypoxic due to severed endotracheal tube (ETT) cuff inflation line. A 20 G intravenous cannula was used, the leak was stopped, and the ETT balloon was inflated. Hence, the leakage and eventually hypoxia settled. We were able to manage emergency airway with this peculiar technique. The use of 20 G intravenous cannula can help to inflate a damaged ETT cuff inflation line. This is an inexpensive and effective manoeuver.

Anticipated vs. Experienced Pain at Site of Spinal Needle Insertion in Patients Undergoing Elective Lower Segment Caesarean Section: Perspective from Resource-Limited Region.

Background: Despite significant advantages, approximately 20% of pregnant patients refuse spinal anaesthesia in caesarean section due to fear of spinal needle prick. Studies have shown that the patient's expectation of pain is higher than what they experience in real. The objective was to evaluate the difference between anticipated and actually experienced pain at the spinal needle insertion site in spinal anaesthesia for pregnant women undergoing elective lower segment caesarean section (ELSCS). Method: The cross-sectional study was conducted in a labour room suite of a tertiary care hospital. Results: A total of 50 patients scheduled for ELSCS were included. The median experienced pain at the site of spinal needle insertion was significantly low as compared to anticipated pain (P value < 0.01). For the identification of predictors impacting the anticipated and experienced pain, univariate and multivariate regression models were applied. Amsterdam Preoperative Anxiety and Information Scale ≥11 for anticipated pain showed a statistically significant positive correlation in univariate (coefficient: 2.59; 95% CI: 1.49 to 3.68; P value < 0.001) and multivariable analyses (coefficient: 2.51; 95% CI: 1.36 to 3.67; P value < 0.001). Thus, anxiety was associated with statistically significant higher anticipated pain. Conclusion: In conclusion, there is a remarkable difference in the obstetric population between anticipated and actually experienced pain at the site of spinal needle insertion in ELSCS.

Anaesthetic Challenges in a Paediatric Patient with Escobar Syndrome-Difficult Airway and Postoperative Pneumothorax.

Escobar syndrome (ES) is an autosomal recessive disorder characterised by the presence of pterygia in cervical, antecubital and popliteal regions. Anaesthesiologist encounter notable challenges in this syndrome, especially airway management due to associated malformations like cleft lip/palate, micrognathia, syngnathia, ankyloglossia, neck contracture, cervical spine fusion, limited neck extension and craniofacial dysmorphism. In addition to difficult airway, anaesthesiologist may encounter other perioperative challenges. Here, we report a paediatric patient with ES, who required general anaesthesia for laparoscopic inguinal hernia repair and orchidopexy. Initial attempt with video laryngoscope failed due to inability to visualise epiglottis. Subsequent attempt with fibreoptic bronchoscope also failed due to rapid decrease in oxygen saturation. He was finally intubated with fibreoptic bronchoscope along with oxygen insufflation with a 3mm internal diameter polyvinylchloride endotracheal tube inserted nasally and connected to oxygen supply. Further perioperative challenges faced were intraoperative hyperthermia and postoperative pneumothorax with mediastinal shift. To the best of our knowledge, this is the first case reporting pneumothorax with mediastinal shift as a postoperative complication and use of oxygen insufflation through nasal tube during fibreoptic intubation in paediatric patient with ES.

Anaesthetic management of patients undergoing deep brain simulation: A retrospective review of 8 cases from a tertiary care center of Pakistan.

OBJECTIVES: To review anaesthesia related outcome, perioperative complications and overall length of stay (LOS) in hospital for patients who had deep brain stimulation (DBS). METHODS: The study was retrospective review of patients medical records diagnosed with Parkinson disease (PD) and underwent DBS at The Aga Khan University Hospital, Karachi from 2017-2019. Data was reviewed from file notes and patient chart and recorded on predesigned Performa. Frequency and percentages were used to present the data. RESULTS: All patients were anaesthetized using Sleep-Awake-Sleep technique (SAS). Dexmedetomidine was mainly used for conscious sedation. Bispectral index monitor (BIS) was used to monitor the depth of sedation, and kept between 70-85 during sedative phase. All patients had successful intraoperative neurological monitoring, stimulation, and placement of electrodes. Total duration of anesthesia varied significantly in between the patients. Maximum duration was 600 minutes. None of our patient had any intraoperative event related to anaesthetic management. Overall five patients had some adverse events during ward stay. Mean LOS in hospital was four days. CONCLUSION: Anaesthetic management of DBS is well-tolerated. It requires dedicated team. The SAS technique is excellent for intraoperative neurophysiological monitoring. Careful selection of sedative agents and monitoring depth of anaesthesia using BIS would be beneficial in terms of improving related outcomes.

Anaesthetic Management of Cerebral Arterio-venous Malformation Excision Using Awake Craniotomy: Initial Experience of Two Cases.

This case series summarises the successful management of two cases with cerebral arterio-venous malformation (AVM). In first patient, it was located superficially in right frontal cortex, while the second one had this in left parieto-temporal region. Both were excised successfully using awake craniotomy. The patients had their assessment and psychological preparation by neuro-anesthetist and neurosurgeon. Along with the routine monitoring, invasive arterial line, and bispectral index monitoring was used to monitor the sedative effect of propofol. Intraoperative analgesia was provided using scalp block. The anaesthetic management was helpful in facilitating intraoperative neurological monitoring using verbal and motor responses. Patients remained pain-free and hemodynamically stable during resection phase. The postoperative period showed adequate pain control, decreased postoperative nausea/vomiting and shorter length of stay in the hospital. Both patients had 100% obliteration of AVM confirmed via cerebral angiography.