Acute intermittent porphyria: Diagnostic dilemma and treatment options.

Acute intermittent porphyria (AIP) presents with diverse group of symptoms making its early diagnosis difficult. Delaying diagnosis and treatment of AIP can be fatal or can cause long term or permanent neurological damage. We present here a case report of AIP where the diagnosis was missed. The diversity of symptoms and details concerning the treatment options for AIP are discussed.

The comparison of Proseal laryngeal mask airway and endotracheal tube in patients undergoing laparoscopic surgeries under general anaesthesia.

Aims to compare the efficacy of Proseal laryngeal mask airway(PLMA) and endotracheal tube (ETT) in patients undergoing laparoscopic surgeries under general anaesthesia. This prospective randomised study was conducted on 60 adult patients, 30 each in two groups, of ASA I-II who were posted for laparoscopic procedures under general anaesthesia. After preoxygenation, anaesthesia was induced with propofol, fentanyl and vecuronium. PLMA or ETT was inserted and cuff inflated. Nasogastric tube (NGT) was passed in all patients. Anaesthesia was maintained with N(2) O, O(2), halothane and vecuronium. Ventilation was set at 8 ml/kg and respiratory rate of 12/min. The attempts and time taken for insertion of devices, haemodynamic changes, oxygenation, ventilation and intraoperative and postoperative laryngopharyngeal morbidity (LPM) were noted. There was no failed insertion of devices. Time taken for successful passage of NGT was 9.77 s (6-16 s) and 11.5 s (8-17 s) for groups P and E, respectively. There were no statistically significant differences in oxygen saturation (SpO(2)) or end-tidal carbon dioxide (EtCO(2)) between the two groups before or during peritoneal insufflation. Median (range) airway pressure at which oropharyngeal leak occurred during the leak test with PLMA was 35 (24-40) cm of H(2)O. There was no case of inadequate ventilation, regurgitation, or aspiration recorded. No significant difference in laryngopharyngeal morbidity was noted. A properly positionedPLMA proved to be a suitable and safe alternative to ETT for airway management in elective fasted, adult patients undergoing laparoscopic surgeries. It provided equally effective pulmonary ventilation despite high airway pressures without gastric distention, regurgitation, and aspiration.

Comparison of efficacy of bupivacaine and fentanyl with bupivacaine and sufentanil for epidural labor analgesia.

OBJECTIVES: A study to compare the efficacy between fentanyl and sufentanil combined with low concentration (0.0625%) of bupivacaine for epidural labor analgesia in laboring women MATERIALS AND METHODS: Fifty full term parturients received an initial bolus dose of a 10 ml solution containing 0.125% bupivacaine. The patients were randomly divided into two: group F received 0.0625% bupivacaine with 2.5 mcg/ml fentanyl and group S received 0.0625% bupivacaine with 0.25 mcg/ml sufentanil. Verbal analogue pain scores, need of supplementary/rescue boluses dose of bupivacaine consumed, mode of delivery, maternal satisfaction, and neonatal Apgar scores were recorded. No significant difference was observed between both groups. RESULTS: Both the groups provided equivalent labor analgesia and maternal satisfaction. The chances of cesarean delivery were also not increased in any group. No difference in the cephalad extent of sensory analgesia, motor block or neonatal Apgar score were observed. Although mean pain scores throughout the labor and delivery were similar in both groups, more patients in fentanyl group required supplementary boluses though not statistically significant. CONCLUSION: We conclude that both 0.0625% bupivacaine-fentanyl (2.5 µg/ml) and 0.0625% bupivacaine-sufentanil (0.25 µg/ml) were equally effective by continuous epidural infusion in providing labor analgesia with hemodynamic stability achieving equivalent maternal satisfaction without serious maternal or fetal side effects. We found that sufentanil was 10 times more potent than fentanyl as an analgesic for continuous epidural labor analgesia.

Subdural haematoma in pregnancy-induced idiopathic thrombocytopenia: Conservative management.

Conservative management of subdural haematoma with antioedema measures in second gravida with idiopathic thrombocytopenic purpura (ITP) resulted in resolution of haematoma. We present a case of second gravida with ITP who developed subdural haematoma following normal vaginal delivery. She was put on mechanical ventilation and managed conservatively with platelet transfusion, Mannitol 1g/kg, Dexamethasone 1mg/kg and Glycerol 10ml TDS. She regained consciousness and was extubated after 48 hrs. Repeat CT after 10 days showed no mass effect with resolving haematoma which resolved completely after 15 days. Trial of conservative management is safe in pregnant patient with ITP who develops subdural haematoma.

Nausea and vomiting after ENT surgeries: A comparison between ondansetron, metoclopramide and small dose of propofol.

AIMS: To evaluate the antiemetic efficacy of ondansetron, metoclopramide or small dose of propofol following ear, nose and throat (ENT) surgery. MATERIALS AND METHODS: A prospective randomized study involving 60 patients, both children and adults undergoing elective ENT surgery under standard general anesthesia. At the completion of surgery the patients received either 0.1 mg/kg of ondansetron or 0.2 mg/kg of metoclopramide or 0.5 mg/kg of propofol intravenously. The patients were observed for 24 hrs after operation for any occurrence of nausea and vomiting. RESULTS: The incidence of postoperative nausea and vomiting (PONV) during first 24 hrs was recorded in 20%, 70%, 50% of patients who had received ondansetron, metoclopr-amide or propofol respectively (p < 0.05). Fewer patients given ondansetron needed rescue antiemetic. The incidence of PONV was higher following middle year surgery. CONCLUSION: It was concluded that ondansetron was most effective in preventing occurrence of PONV while metoclopramide was least effective. Propofol was effective only in 50% of patients, thus not recommended for routine use.

Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized double-blind, placebo-controlled trial.

PURPOSE OF REVIEW: To evaluate the efficacy of a single preoperative dose of 600 mg of gabapentin for reducing postoperative pain and tramadol consumption after minilap open cholecystectomy. METHOD: A total of 120 adult patients of either sex were randomly assigned to receive 600 mg of gabapentin or a matched placebo orally 2 h before operation in a double-blind manner. All the patients received gabapentin using the same technique. Postoperative analgesia was provided with intravenous patient-controlled analgesia with tramadol using a 50-mg initial bolus dose, 20-mg incremental dose, 15-min lockout interval and 4-h limit of 240 mg. Patients were assessed at 0, 2, 4, 8, 12, 24 and 48 h after operation for verbal analogue pain scores at rest and at movement. Consumption of tramadol on first and second postoperative days and any adverse effects were also recorded. RESULTS: Verbal analogue pain scores were significantly lower on first postoperative day at all times of observation both at rest and at movement in gabapentin group than in placebo group (P<0.01). Tramadol consumption was also reduced by 33% in gabapentin group. But pain scores and tramadol consumption were similar in two groups on second postoperative day. Sedation was common but the incidence of postoperative nausea and vomiting was significantly lower in gabapentin group. CONCLUSION: Preoperative administration of 600 mg of gabapentin resulted in significant reduction in postoperative verbal analogue pain scores at rest and at movement as well as tramadol consumption compared with placebo on first postoperative day. Lower incidence of nausea and vomiting was an additional advantage. Sedation was the commonest side effect.

A preliminary study of I-gel: a new supraglottic airway device.

SUMMARY: This preliminary study on I-gel (Intersurgical Ltd, Wokingham, U K) was conducted on 50 consecutive patients of ASA physical status I-III, to determine the ease of insertion, time to achieve effective airway, oropharyngeal seal pressure and airway stability on head and neck movement. After premedication with midazolam and fentanyl, induction was done with propofol and I-gel was inserted according to manufacturer's instruction. An effective airway was confirmed by bilateral chest movement, square wave on capnograph and SpO(2)>95%. The success rate at first attempt was 90% with a median insertion time of 11 sec (range 8-45sec). Five patients (10%) needed second attempt while none needed 3(rd) attempt. The manipulation needed to achieve effective airway were increasing the depth of insertion of I-gel in 4 (8%) cases, jaw thrust or chin lift in 2(4%) cases. Oropharyngeal seal pressure was 20 cm of H(2)O (16-40 cm of H(2)O). Gastric tube placement was done in 50% of the cases; it was easy and successful in all the cases. No significant adverse event was noted in any of the patient in perioperative period. Our initial experience showed that I-gel is a simple, easy to use supraglottic airway device with a high success rate at first time insertion.

Patient Controlled Epidural Analgesia during Labour: Effect of Addition of Background Infusion on Quality of Analgesia & Maternal Satisfaction.

Patient controlled epidural analgesia (PCEA) is a well established technique for pain relief during labor. But the inclusion of continuous background infusion to PCEA is controversial. The aim of this study was to assess whether the use of continuous infusion along with PCEA was beneficial for laboring women with regards to quality of analgesia, maternal satisfaction and neonatal outcome in comparison to PCEA alone. Fifty five parturients received epidural bolus of 10ml solution containing 0.125% bupivacaine +2 microg.ml(-1) of fentanyl. For maintenance of analgesia the patients of Group PCEA self administered 8 ml bolus with lockout interval of 20 minutes of above solution on demand with no basal infusion. While the patients of Group PCEA + CI received continuous epidural infusion at the rate of 10 ml.hr-1 along with self administered boluses of 3 ml with lockout interval of 10 minutes of similar epidural solution. Patients of both groups were given rescue boluses by the anaesthetists for distressing pain. Verbal analogue pain scores, incidence of distressing pain, need of supplementary/rescue boluses, dose of bupivacaine consumed, maternal satisfaction and neonatal Apgar scores were recorded. No significant difference was observed between mean VAS pain scores during labor, maternal satisfaction, mode of delivery or neonatal Apgar scores. But more patients (n=8) required rescue boluses in PCEA group for distressing pain. The total volume consumed of bupivacaine and opioid was slightly more in PCEA + CI group. In both the techniques the highest sensory level, degree of motor block were comparable & prolongation of labor was not seen. It was concluded that both the techniques provided equivalent labor analgesia, maternal satisfaction and neonatal Apgar scores. PCEA along with continuous infusion at the rate of 10 ml/ hr resulted in lesser incidence of distressing pain and need for rescue analgesic. Although this group consumed higher dose of bupivacaine, it did not affect maternal or neonatal safety.