Laparoscopic Cholecystectomy in a Patient with Glenn Shunt-Aided with Erector Spine Block.

The bidirectional (BD) Glenn shunt or hemi-Fontan procedure has been used to temporarily improve cardiac function in patients with severe structural heart disease which feature single ventricular physiology. Subsequently, more of these patients present for noncardiac surgical interventions, which present as an anaesthetic challenge. Erector spinae block (ESP) is an effective analgesic modality used in various thoraco abdominal surgeries, which can also be given safely in such patients. A case of a 17-year-old female patient with complex congenital heart disease (CHD) who underwent BD Glenn shunting with main pulmonary artery ligation in childhood, presently admitted for laparoscopic cholecystectomy done under general anaesthesia. With detailed preoperative workups, close haemodynamic monitoring and use of ESP for analgesia during perioperative period, the patient had successful outcome. We outline the anaesthetic management and the concerns of laparoscopy in such patients. A comprehensive understanding of physiology of Glenn's shunt and implications of the proposed surgical procedure is necessary to plan the anaesthetic and analgesic agents, cardiovascular drugs and ventilation strategies in patients with CHD with shunt procedure done.

Wandering paravertebral catheter detected during thoracoscopy.

We report a case of intrapleural migration of paravertebral catheter inserted under ultrasound guidance, detected during video assisted thoracoscopic surgery.

Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases.

Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.

Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases.

Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.

Is midazolam superior to triclofos and hydroxyzine as premedicant in children?

BACKGROUND: Search for an ideal premedicant drug for children is still on. A prospective, randomized trial was conducted to compare the efficacy of midazolam, triclofos and hydroxyzine as premedication in children undergoing lower abdominal surgeries. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists I or II patients 2-8 years of age, scheduled for elective lower abdominal surgery were included. The patients were randomly divided into three groups M, T and H of 20 children each who received midazolam 0.5 mg/kg, triclofos 75 mg/kg and hydroxyzine 0.5 mg/kg respectively, orally 60 min before surgery. The acceptability of drugs, level of sedation, anxiety during separation and on mask application was assessed. RESULTS: The acceptability of midazolam and hydroxyzine was better than triclofos. Hydroxyzine was found to have lesser sedative effect as compared to both midazolam and triclofos. No major adverse effects were observed. CONCLUSION: Midazolam was found to be a better premedicant in terms of sedation, anxiolysis and safety.

Combined spinal epidural and epidural volume extension: Interaction of patient position and hyperbaric bupivacaine.

BACKGROUND: Previous trials have documented failure of block augmentation with epidural volume extension, when applied after the intrathecal injection of hyperbaric bupivacaine was made in sitting position. However, there is no study comparing the effect of change in patient position during block performance, on the results of epidural volume extension. MATERIALS AND METHODS: The study was conducted in two parts in American Society of Anesthesiologists physical status I or II parturients scheduled for elective cesarean section under regional anesthesia. In the first part, 28 patients were randomized to one of the two groups, depending on whether epidural volume extension was applied following the block in sitting (group SE) or lateral position (group LE) (n=14 each). In the second part of the study another 28 patients were recruited and randomized to receive the block in sitting (group S) or lateral (group L) position (n=14 each), without epidural volume extension. All patients received combined spinal epidural block using needle-through-needle technique with intrathecal injection of 9 mg hyperbaric bupivacaine (0.5%) and 10 µg fentanyl. Epidural volume extension was performed using 5 ml normal saline in groups SE and LE. RESULTS: In the first part of the study, the maximum sensory block level was higher in group LE vs. SE (P<0.05). In the second part of the study, no significant difference was seen in the maximum sensory level between group S and group L (P>0.05). CONCLUSIONS: If epidural volume extension is being applied with intention of rapid extension of sensory block when hyperbaric bupivacaine has been injected intrathecally, the combined spinal epidural block should be performed in lateral position rather than in the sitting position.

Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study.

BACKGROUND: Thoracic epidural analgesia (TEA), a commonly used analgesic technique in patients with multiple fractured ribs, is technically demanding and associated with certain side effects or complications. Thoracic paravertebral block (TPVB) is a simple and effective method of providing continuous pain relief in these patients. However, it has never been compared with TEA in terms of efficacy and outcome in patients with fractured ribs. METHODS: Thirty adult patients of either sex, having three or more unilateral fractured ribs, were randomized to receive continuous bupivacaine infusion through either thoracic epidural or thoracic paravertebral catheter. Visual Analog Scale scores at rest and on coughing, respiratory rate, peak expiratory flow rate, and PaO2/FIO2 ratio were measured before and after administration of block at regular intervals. Morphine requirement for rescue analgesia, duration of bupivacaine infusion, length of intensive care unit and hospital stay, development of pulmonary complications, and complications of the two techniques were also recorded. RESULTS: Both TEA and TPVB provided good pain relief and improved respiratory function, as evident by improvement in Visual Analog Scale scores at rest and on coughing, respiratory rate, and peak expiratory flow rate. However, no significant intergroup differences were found. Duration of bupivacaine infusion, morphine requirement, length of intensive care unit and hospital stay, and incidence of pulmonary complications were also similar in the two groups. Incidence of hypotension was more in TEA group. CONCLUSIONS: Continuous bupivacaine infusion through TPVB is as effective as through TEA for pain management in patients with unilateral fractured ribs and the outcome after two techniques is comparable.

The microcirculation in sepsis.

SUMMARY: Sepsis is a leading cause of mortality in critically ill patients. The pathophysiology of sepsis involves a highly complex and integrated response, including the activation of various cell types, inflammatory mediators, and the haemostatic system. Recent evidence suggests an emerging role of the microcirculation in sepsis, necessitating a shift in our locus away Irom the macrohaemodynamics to ill icrohaemodynanmics in a septic patient. This review article provides a brief overview of the microcirculation, its assessment techniques, and specific therapies to resuscitate the microhaemodynamics.

Autonomic dysfunction and adrenal insufficiency in thoracic spine tuberculosis.

While autonomic dysfunction has been reported in patients with spinal TB, little is known of the consequences. We matched 25 paraplegic patients with thoracic spine tuberculosis scheduled for spinal surgery (Group S) with 25 nontubercular American Society of Anesthesiologists Grade I patients scheduled for nonspinal surgeries (Group C) under identical operative conditions. All patients underwent four autonomic tests in the operating room, and a preoperative adrenocorticotropic hormone stimulation test was performed for patients in Group S. Compared to Group C, Group S had higher resting heart rate (103 +/- 20 beats/minute versus 81 +/- 10 beats/minute), lower expiratory:inspiratory ratio (1.14 +/- 0.11 versus 1.22 +/- 0.10), and higher heart rate variability (20 +/- 12 beats/minute versus 14 +/- 7 beats/minute), indicating probable parasympathetic dysfunction along with a relative sympathetic overactivity. Eight of the 17 patients who received an adrenocorticotropic hormone stimulation test had evidence of adrenal insufficiency. Incidence of hypotension in Group S and Group C was 100% and 44%, respectively. Mean systolic and diastolic blood pressure in Group S showed substantial decrease after induction and positioning of patients not associated with compensatory tachycardia. Coexisting pulmonary tuberculosis appears an important determinant of surgical approach as well as postoperative respiratory morbidity.