Perioperative cardiac risks in myasthenia gravis.

Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction. The primary pathology in MG involves the presence of autoantibodies to acetylcholine receptors (AChRs), which results in qualitative and quantitative reductions in the availability of functional AChRs. Cardiac muscles are also affected, resulting in various perioperative cardiac complications. Antistriational antibodies are commonly reported in MG cases with cardiac involvement. In the presence of thymoma, the prevalence of cardiac manifestations in patients with MG increases to approximately 10%-15%. Cardiac involvement in MG may range from asymptomatic electrocardiogram changes to ventricular tachycardia, myocarditis, conduction disorders, heart failure, and sudden death. Increased incidence of atrial fibrillation, ventricular and supraventricular extra systoles, and prolonged QTc have also been reported in patients with MG. Clinicians should consider the evaluation of autonomic dysfunction and risk of cardiovascular disease in patients with MG.

Unusual Presentation of Reversible Transient Vision Loss After Caesarean Section Under Subarachnoid Block: A Case Report.

A transient vision loss is not commonly encountered during the postoperative period following a caesarean section. Although numerous causes have been suggested for transient vision loss, when loss of vision is associated with seizures and headaches, the differential diagnoses include hemolysis, elevated liver enzymes, low platelet syndrome, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome (PRES), dural venous thrombosis, and central retinal arteriolar occlusion. We report a case of a 35-year-old patient who underwent an elective caesarean section under spinal anaesthesia and developed a headache followed by loss of vision and seizures during the postoperative period. An MRI scan of the brain on the same day revealed subtle hyperintensity in bilateral parieto-occipital lobes in the cortical and subcortical areas and bilateral cerebral hemispheres, which indicates PRES. Rapid and complete resolution of symptoms was observed with supportive treatment. Therefore, prompt suspicion and effective management of PRES are of paramount importance to prevent short- and long-term neurological deficits.

Effect of Tourniquet Deflation on Intracranial Pressure Measured by Ultrasound of the Optic Nerve Sheath Diameter in Patients Undergoing Orthopedic Surgery Under Spinal Anesthesia: An Observational Study.

Background Orthopedic surgeries of the lower extremities frequently require exsanguination and the use of pneumatic tourniquets. However, the deflation of the tourniquet is accompanied by predominant metabolic changes such as an increase in PaCO2. Prior studies have reported the existence of a correlation between tourniquet deflation and an increase in intracranial pressure in patients undergoing surgery under general anesthesia. However, there is a dearth of literature demonstrating such relationships among patients undergoing surgery under subarachnoid block in the Indian setting. The present research was conducted to study the variations in intracranial pressure after the deflation of the tourniquet by measuring the optic nerve sheath diameter (ONSD) using ultrasound among patients undergoing orthopedic surgery of the lower limb under spinal anesthesia at a tertiary care hospital in eastern India. Methodology After obtaining clearance from the Institutional Ethics Committee, this prospective observational study was conducted among 45 patients undergoing orthopedic surgeries of the lower limb using a pneumatic tourniquet. Changes in intracranial pressure following tourniquet deflation were recorded by measuring ONSD by ultrasound in these patients. Heart rate (HR), mean arterial pressure (MAP), SpO2, EtCO2, and ONSD were noted 15 minutes before administration of subarachnoid block (T0), just before tourniquet deflation (T1) and at 5, 10, and 15 minutes after tourniquet deflation (T5, T10, and T15, respectively). Results The ONSD varied significantly at each point of observation (p < 0.05). The ONSDs at 5 and 10 minutes after the deflation of the tourniquet were significantly greater than that at T0 (p = 0.002). EtCO2 showed a significant increase compared to baseline values at every point of observation intraoperatively whereas MAP showed a significant decrease (p < 0.05). For all parameters (ONSD, HR, systolic blood pressure, diastolic blood pressure, MAP, and EtCO2), the most significant change in observation was noted at T10, i.e., 10 minutes after the deflation of the tourniquet.   Conclusions The significant finding in this study was that the ONSD measurements recorded by ultrasound were increased after the deflation of the tourniquet and that this change can be attributed to an increase in EtCO2. However, the results obtained cannot be validated outside the present research owing to the observational nature of the study and limited sample size. Thus, it is difficult to arrive at a definitive conclusion. Further large-scale multicentric studies may be needed to substantiate the findings of this study.

A Prospective, Comparative Study to Evaluate the Diagnostic Accuracy of Mallampati Grading in Supine and Sitting Positions for Prediction of Difficult Airway.

Background & aim Difficult airway is a major concern for all anaesthesiologists because failure to secure airway could lead to devastating complications or may increase morbidity and mortality. Airway assessment, therefore, is of paramount importance and anticipating a difficult airway prior to anesthetic administration, could help us in better preparation as well as avoidance of life-threatening complications. There are various tests available to assess the airway, out of which, modified Mallampati test (MLPT) is one of the common, easy and reliable methods to predict difficult airway. Mallampati test, usually is done with patient in sitting position. However, in certain group of patients in whom sitting position is not possible (suspected cervical spine injury, pelvic injury, patients in shock, etc.), the Mallampati test can be done in supine position. Few studies were available which concluded that Mallampati test in supine position was not only reliable but also superior to sitting position, whereas, few other studies contradicted this opinion. We, therefore, wanted to address this issue and tried to find out whether Mallampati test in supine position could offer better diagnostic accuracy or not. Materials & methods Mallampati test (MLPT) in sitting position was done in 100 patients initially in preoperative period and subsequently in supine position inside operating room prior to induction of anesthesia. During laryngoscopy, Cormack-Lehane (CL) grading was noted in all patients. Correlation of Mallampati test in sitting and supine position with Cormack-Lehane grading was obtained. A receiver operating characteristics (ROC) analysis was done to determine the area under the curve, the sensitivity and the specificity. Positive predictive value (PPV) and negative predictive value (NPV) were also calculated to analyse the diagnostic accuracy of Mallampati score (MLPT) in sitting and supine position. Results A toal of 22.2% of patients had difficult intubation (CL grade 3) although MLPT of these patients in sitting position anticipated a non-difficult airway (MLPT 1 and 2) and there was no significant correlation between MLPT grade in sitting position with the Cormack-Lehane grade. In comparison to sitting position, MLPT in supine position had significant correlation with the Cormack-Lehane grading and all patients with supine MLPT 1 and 2 (non-difficult airway) had easy intubation (CL grade 1 and 2). ROC analysis also showed that MLPT grade in supine position had superior correlation and better diagnostic accuracy than MLPT in sitting position for assessment of airway as indicated by higher sensitivity and better positive as well as negative predictive values. Conclusion Mallampati test done in supine position has far greater sensitivity and is superior in predicting difficult intubation as compared to MLPT done in conventional sitting position.

Self-Resolving Mobitz Type II Second-Degree Heart Block (Atypical Wenckebach Block) After Cesarean Section Under Subarachnoid Block: A Case Report.

The majority of the perioperative arrhythmias in patients undergoing cesarean section under spinal anesthesia are benign. We report a case of a 30-year-old full-term parturient with a history of an uneventful previous cesarean section. She had no preexisting comorbidities. She subsequently underwent another emergency cesarean section three years later due to abdominal pain and scar tenderness indicative of impending rupture. Two hours after an uneventful surgery, the patient developed epigastric pain with a prolonged PR interval (280 ms) and intermittent second-degree AV block with two consecutive blocked P waves, which was consistent with Mobitz type II second-degree heart block (atypical Wenckebach block). However, she remained hemodynamically stable throughout. Serial electrocardiogram (ECG) did not demonstrate any evidence of ST-T wave changes, and normal troponin I and echocardiography excluded myocardial ischemia as a potential cause for the arrhythmia. Normal serum electrolytes and the resolution of the sensorimotor block caused by the spinal anesthesia excluded other known causes for such ECG changes. The PR interval gradually decreased to 240 ms on the second postoperative day and normalized to 200 ms on the fifth postoperative day. Such patients, especially those with a wide QRS complex, are susceptible to developing dangerous ventricular arrhythmias that can adversely affect circulatory function. Close vigil is the key to avoiding adverse perioperative outcomes.

Effectiveness of Granisetron in Prevention of Hypotension Following Spinal Anaesthesia in Patients Undergoing Elective Caesarean Section.

BACKGROUND AND AIM: Spinal anesthesia is the most common type of anesthesia administered for caesarean section and it is frequently associated with hypotension. When post-spinal hypotension is accompanied with bradycardia, the condition may become more complicated. Numerous pharmacological agents have therefore been tried for prevention of hypotension and 5HT3 antagonists are the latest in the armamentarium. However, studies have shown conflicting evidence regardings the effectiveness of 5HT3 inhibitors (ondansetron and granisetron) in preventing spinal hypotension. We have tried to address this controversy and also wanted to explore the adverse effects of granisetron on the foetus, if any. MATERIALS AND METHODS: Two hundred patients were included in the study and divided into two groups of 100 patients each. Group S patients received 5ml of 0.9% normal saline while Group G patients received IV granisetron 1mg (diluted to 5ml) 10 minutes prior to administration of spinal anesthesia. Analysis of variance (ANOVA) test was used for comparing the data, Student t-test was applied to compare the difference between the two means and Chi-Square test was used to test significance of difference of proportions. RESULTS: The incidence of hypotension in Group S was 69%, whereas it was 37% in Group G (p<0.001), hence patients of Group S required a significantly higher (p=0.001) amount of mephentermine. Haemodynamic parameters were well maintained throughout the study period in patients of Group G. The neonatal outcome was assessed by Apgar score at 0 minutes, one minute, and five minutes after delivery, and it was comparable between the two study groups. CONCLUSION: Intravenous granisetron 1mg if administered before administering spinal anesthesia can effectively attenuate hypotension in parturients without any adverse effects on the mother and the neonate.

Comparative analysis of APACHE-II and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy.

BACKGROUND: Laparotomy remains one of the commonest emergency surgical procedures. Early prognostic evaluation would aid in selecting the high-risk patients for an aggressive treatment. Awareness about risks could potentially contribute to the quality of perioperative care and optimum utilization of resources. Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) and the acute physiology and chronic health evaluation II (APACHE-II) have been the most widely used scoring systems for emergency laparotomies. It is always better to have a single scoring system to predict outcomes and audit healthcare organizations. AIM: To compare the ability of APACHE-II and P-POSSUM to predict postoperative morbidity and mortality in patients undergoing emergency laparotomy. METHODS: All patients undergoing emergency laparotomy at the Tata Main Hospital, Jamshedpur between December 2013 and November 2014 were included in the study. In this observational study, P-POSSUM and APACHE-II scoring were done, and the outcome analysis evaluated with mortality being the primary outcome. RESULTS: For P-POSSUM, at a cut off value of 63 to predict mortality using receiver operating characteristics curve analysis, the area under the curve was 0.989; and for APACHE-II, at the cut off value of 24, the area under the curve was 0.965. CONCLUSION: Because the ability of APACHE-II to predict mortality was similar to P-POSSUM and APACHE-II does not need scoring for intra-operative findings and histopathology reports, APACHE-II can be used pre-operatively to assess the risk in patients undergoing emergency laparotomy. However, for audit purposes, either of the two scoring systems can be used.

Perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on multiple antihypertensive medications / Choque anafilático refratário perianestésico com cefuroxima em paciente com história de alergia à penicilina recebendo vários medicamentos anti-hipertensivos

Abstract We report a case of perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on regular therapy with atenolol, losartan, prazosin and nicardipine. Severe anaphylactic shock was only transiently responsive to 10 mL of (1:10,000) epinephrine and needed norepinephrine and dopamine infusion. Supportive therapy with vasopressors and inotropes along with mechanical ventilation for the next 24 hours resulted in complete recovery. She was successfully operated upon 2 weeks later with the same anesthetic drugs but intravenous ciprofloxacin as the alternative antibiotic for perioperative prophylaxis.

Resumo Relatamos um caso de choque anafilático refratário no período perianestésico com cefuroxima em paciente com história de alergia à penicilina em terapia regular com atenolol, losartan, prazosina e nicardipine. O choque anafilático grave foi apenas transitoriamente responsivo a 10 mL de epinefrina (1:10000) e precisou de infusão de norepinefrina e dopamina. A terapia de apoio com vasopressores e inotrópicos, juntamente com ventilação mecânica por 24 horas, resultou em recuperação completa. A paciente foi operada com sucesso duas semanas mais tarde, com os mesmos agentes anestésicos, mas com ciprofloxacina intravenosa como antibiótico opcional para a profilaxia perioperatória.

Perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on multiple antihypertensive medications.

We report a case of perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on regular therapy with atenolol, losartan, prazosin and nicardipine. Severe anaphylactic shock was only transiently responsive to 10mL of (1:10,000) epinephrine and needed norepinephrine and dopamine infusion. Supportive therapy with vasopressors and inotropes along with mechanical ventilation for the next 24hours resulted in complete recovery. She was successfully operated upon 2 weeks later with the same anesthetic drugs but intravenous ciprofloxacin as the alternative antibiotic for perioperative prophylaxis.

[Perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on multiple antihypertensive medications]. / Choque anafilático refratário perianestésico com cefuroxima em paciente com história de alergia à penicilina recebendo vários medicamentos anti­hipertensivos.

We report a case of perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on regular therapy with atenolol, losartan, prazosin and nicardipine. Severe anaphylactic shock was only transiently responsive to 10mL of (1:10000) epinephrine and needed norepinephrine and dopamine infusion. Supportive therapy with vasopressors and inotropes along with mechanical ventilation for the next 24hours resulted in complete recovery. She was successfully operated upon 2 weeks later with the same anesthetic drugs but intravenous ciprofloxacin as the alternative antibiotic for perioperative prophylaxis.

Convulsões tardias após herniotomia inguinal em bebê prematuro: relato de caso / Delayed onset seizures after inguinal herniotomy in a premature infant: a case report

Relatamos um caso de recém-nascido prematuro, nascido com 34 semanas e operado com seis semanas de idade, que desenvolveu convulsões, aparentemente inexplicáveis, dez horas após o final da cirurgia sob injeção única de analgesia epidural caudal com bupivacaína e lidocaína combinadas com anestesia geral.

We report a case of a premature neonate born at 34 weeks and operated at 6 weeks of age developing unexplained seizures 10 hours after the end of surgery under single shot caudal epidural analgesia with bupivacaine and lidocaine combined with general anesthesia.

Relatamos aquí, el caso de un recién nacido prematuro, con 34 semanas, y operado con seis semanas de edad, que desarrolló convulsiones, aparentemente inexplicables, diez horas después del final de la cirugía bajo la inyección única de analgesia epidural caudal con bupivacaína y xilocaína combinadas con la anestesia general.

Delayed onset seizures after inguinal herniotomy in a premature infant: a case report.

We report a case of a premature neonate born at 34 weeks and operated at 6 weeks of age developing unexplained seizures 10 hours after the end of surgery under single shot caudal epidural analgesia with bupivacaine and lidocaine combined with general anesthesia.

General anesthesia in a patient with Gilbert's syndrome.

Gilbert's syndrome, caused by relative deficiency of glucuronyl transferase is the commonest cause of congenital hyperbilirubinemia. We report anesthetic management in a case of Gilbert's syndrome for laparoscopic cholecystectomy under general anesthesia. Avoiding drugs which use this enzyme for its metabolisim or excretion, and minimizing the stress during the perioperative period allows safe conduct of anesthesia for these patients.