A cadaver study of four approaches of ultrasound-guided infraclavicular brachial plexus block.

BACKGROUND AND AIMS: The ultrasound-guided infraclavicular brachial plexus block (USG ICBPB) is a popular technique for forearm surgeries distal to the elbow. Our study details the ultrasound (US) characteristics of this block and the structures encountered by the needle in four approaches to the infraclavicular area - lateral infraclavicular (LICF), costoclavicular medial to lateral (CML) and lateral to medial (CLM) and retroclavicular (R) by anatomical dissection. METHODS: USG ICBPB was performed in 10 cadavers-5 on the right side and 5 on the left side by each of four approaches and with an 18 gauge Tuohy needle kept in situ, and US characteristics were noted. Anatomical dissection was done and important structures were described in detail. RESULTS: Needle tip and shaft visibility were least with LICF approach and best in R approach. Needle angle correlated with chest and neck circumference in LICF and CML groups. During dissection, in all approaches, neurovascular structures have been observed in the near vicinity of the needle, especially the thoracoacromial artery (TAA) or its branches. In the R approach, the 'blind spot' behind the clavicle is an area where neurovascular structures were present. CONCLUSION: The R approach gives better visibility of needle shaft beyond the clavicle, but the clavicle acts as a 'blind-spot' for the US beam obliterating important neurovascular structures. The various neurovascular structures the needle traverses or in its immediate vicinity, do not necessarily make the CML, CLM or R approach any better than the LICF approach.

Analysis of Changes in Right Ventricular Systolic Function by Point-of-Care Ultrasound in Patients Undergoing Corrective Surgeries for Femur Fracture.

BACKGROUND: Fat embolism syndrome (FES) following major orthopedic injuries and surgeries is a well-known phenomenon where acute depression of right ventricular (RV) systolic function is a potential possibility. Clinical presentation of FES may vary from mild self-limiting nature to severe life-threatening multiorgan dysfunction syndrome with pulmonary manifestations being most common. AIMS: This study was aimed to know whether perioperative assessment of RV function by measuring tricuspid annular plane systolic excursion (TAPSE) with point-of-care transthoracic echocardiogram will identify patients at risk of developing FES and its sequelae. SETTINGS AND DESIGN: This was a prospective observational study. MATERIALS AND METHODS: This study was carried out in 142 patients with femur fractures posted for correction surgeries of both genders who require intramedullary (IM) reaming. TAPSE was recorded four times perioperatively. Time taken for IM reaming was also recorded. STATISTICAL ANALYSIS USED: Recorded data were analyzed using professional statistics package Epi Info 7.0 version for Windows. Descriptive data were represented as mean ± standard deviation for numeric variables, percentages, and proportions for categorical variables. Repeated-measure ANOVA was applied to assess the changes in TAPSE from baseline to immediate postoperative, after 6-h postoperative, and after 24-h postoperatively. Pearson's correlation was utilized to be applied to assess the relationship between TAPSE and other numerical variables. RESULTS: All four readings of TAPSE were well above 17 mm (mean of 19.06, 19.05, 19.04, and 19.04, respectively). Mean reaming time was found to be 6.92 min. None of the patients developed any postoperative pulmonary complications. CONCLUSION: Assessment of RV function can be done with relative ease using TAPSE as a noninvasive method without any complications. Reaming time not exceeding 12 min did not produce any changes in RV function as measured by TAPSE as well as any postoperative pulmonary complications.

Obstetric hemorrhage in a case of hypertrophic obstructive cardiomyopathy with automatic implantable cardioverter defibrillator: Anaesthesia and intensive care management.

The physiological changes occurring during pregnancy and labor may reveal or exacerbate the symptoms of hypertrophic obstructive cardiomyopathy (HOCM). The addition of obstetric hemorrhage to this presents a unique challenge to the anesthesiologists and intensivists managing these patients in the operation theatres and the Intensive Care Units. Here we present a case of HOCM with automatic implantable cardioverter defibrillator in situ and postpartum hemorrhagic shock.

Effect of pneumoperitoneum and Trendelenberg position on oropharyngeal sealing pressure of I-gel™ and ProSeal LMA™ in laparoscopic gynecological surgery: A randomized controlled trial.

BACKGROUND: A sustained and effective oropharyngeal sealing with supraglottic airway (SGA) is required to maintain the ventilation during laparoscopic gynecological surgery in the Trendelenburg position. This study was conducted with I-gel™ and ProSeal LMA™, two prototype SGA devices with a gastric access. MATERIALS AND METHODS: We enrolled 60 American Society of Anesthesiologists physical status I and II patients and randomized to either I-gel or ProSeal LMA (PLMA) group. After induction of anesthesia using a standardized protocol, one of the SGA devices was inserted. The primary objective of this study was to compare the oropharyngeal leak (sealing) pressure of I-gel™ and ProSeal LMA™ after pneumoperitoneum and Trendelenberg position. The secondary objectives were to compare ease of insertion, cuff position as assessed by the fiberoptic view of the glottis, adequacy of ventilation and incidence of complication. RESULTS: The baseline (before pneumoperitoneum) oropharyngeal leak pressure of I-gel was less than the PLMA (mean (standard deviation [SD]) 24 (4) vs. 29 (4) cmH2O, respectively; P < 0.001). After pneumoperitoneum, the leak airway pressure in I-gel group was significantly less than that of PLMA group (mean [SD] 27 (3) vs. 34.0 (4) cmH2O, respectively; P < 0.001). Peak airway pressure was increased after pneumoperitoneum compared to baseline in both the groups. However, end-tidal carbon dioxide was maintained within normal limits. The insertion parameters, fiberoptic view of the glottis, fiberoptic view of the drain tube, and complications were comparable between the groups. CONCLUSION: Both I-gel and PLMA are effective for ventilation in gynecological laparoscopic surgeries. However, PLMA provides better sealing as compared to I-gel.

Vincristine-induced acute life-threatening hyponatremia resulting in seizure and coma.

We report a case of a four-year-old boy with stage 1 Wilms tumour, who developed Vincristine-induced acute life- threatening hyponatremia, which presented as generalized tonic clonic seizures and coma. He was intubated and mechanically ventilated. There were no localizing neurological signs. CSF study showed no cells and CSF proteins were 20 mg%. Electrocardiography, chest X-ray, echocardiography, CT scan and liver function tests were normal. Evaluation of electrolytes and arterial blood gas showed serum sodium of 113 mEq/L with mild metabolic acidosis. Serum osmolality was 260 mOsm/L (normal value 285-295 mOsm/L) and urine osmolality was 625 mOsm/L (normal range 300-900 mOsm/L), urine sodium 280 mEq/d (normal range 100-260 mEq/d), serum potassium, blood urea, blood sugars were normal. Serial blood cultures showed no bacterial growth. Patient was treated with fluid restriction, hypertonic saline (3%) and other supportive care. Patient improved clinically over three days and was extubated on the third day and shifted to the ward on the fifth day.