Congenital rubella syndrome and rubella in Vellore, South India.

Rubella, a mild, vaccine-preventable disease, can manifest as congenital rubella syndrome (CRS), a devastating disease of the fetus. To emphasize the inadequacy of the existing rubella vaccination programme in India, we evaluated epidemiological evidence of rubella virus activity with data available from a tertiary-care centre. The proportion of suspected CRS cases that were laboratory confirmed increased from 4% in 2000 to 11% in 2008. During the same period, 329 clinically suspected postnatal rubella cases were tested of which 65 (20%) were laboratory confirmed. Of women (n=770) of childbearing age, 12·5% were susceptible to rubella.

Effect of controlled hypercapnia on cerebrospinal fluid pressure and operating conditions during transsphenoidal operations for pituitary macroadenoma.

Controlled hypercapnia was assessed for its effectiveness in raising cerebrospinal fluid pressure to enable descent of the suprasellar portion of pituitary macroadenomas during transsphenoidal surgery. The result was compared in a randomized, single blind trial with intermittent boluses of saline injected intrathecally. Intrathecal pressures were monitored in both groups. Twenty-seven of 29 patients in the study group and 25 of 28 patients in the control group reached the target pressure of 20 mm Hg. The mean ETCO2 at the time of maximum pressure was 42.34 +/- 4.75 mm Hg in the study group and 29.81 +/- 2.61 mm Hg in the control group, (P< .001). Mean arterial carbon dioxide was 46.90 +/- 6.55 and 31.42 +/- 4.87 mm Hg, respectively. Surgeons blinded to the technique assessed the descent of the tumor. The operating conditions were judged by the surgeons to be satisfactory for 20 patients in the study group and 17 patients in the control group. Both techniques were equally effective in raising intracranial pressure and in providing descent of the suprasellar component of the tumor. No untoward side effects occurred while using either technique. The authors conclude that controlled hypercapnia is effective in producing descent of the suprasellar portion of a pituitary adenoma.

Anesthetic management for a combined Cesarean section and posterior fossa craniectomy.

A 33-year-old primigravida presented with intracranial tumor during the third trimester of pregnancy. She underwent a ventriculoatrial shunt and a combined cesarean section and posterior fossa craniectomy during this period. The neuroanesthetic requirement for this patient is prevention of rise in intracranial pressure with a slow and smooth induction and maintenance. Cesarean section demands rapid induction with minimum anesthetic until the delivery of the baby. Achieving these contradictory requirements at the same time can be challenging to an anesthesiologist. We report the anesthetic management of this patient during the above surgical procedures. Perioperative management of such patients with regard to use of uterine stimulants and prevention of venous stasis also are discussed.

Effect of intrathecal saline injection and Valsalva maneuver on cerebral perfusion pressure during transsphenoidal surgery for pituitary macroadenoma.

Cerebrospinal fluid pressure (CSFP) was monitored through a lumbar intrathecal catheter in 32 patients undergoing transsphenoidal excision of pituitary macroadenomas. In the first 20 patients, standardized intermittent Valsalva maneuvers were followed by intrathecal saline injections in 2.5-ml increments. Their effects on CSFP, mean arterial pressure (MAP), and therefore, cerebral perfusion pressure (CPP) were compared. The increase in CSFP produced by one Valsalva maneuver (4 +/- 2 mm Hg) was similar to that produced by a single increment of intrathecal saline (4 +/- 2 mm Hg), but the effect of saline was more sustained. With Valsalva maneuvers, the maximum CSFP produced was 13 +/- 4 mm Hg, and the CPP decreased to 50 +/- 14 mm Hg, whereas with saline, the maximum CSFP was 25 +/- 7 mm Hg, and the CPP decreased to 59 +/- 13 mm Hg. Because the increase in CSFP was greater and better sustained with intrathecal saline, Valsalva maneuvers were omitted in the next 12 patients. Peroperative data, including surgical conditions, and post-operative morbidity, with special reference to low-pressure headache and meningeal infection, were analyzed in all 32 patients. Operative conditions produced with intrathecal saline were judged excellent or good in 75% of patients. However, because this technique can decrease the CPP excessively, we recommend that it be used only with continuous CSFP monitoring.