An unusual presentation of Goodpasture syndrome.

Goodpasture disease is an anti-glomerular basement membrane (anti-GBM) disease that manifests as progressive glomerulopathy and alveolar hemorrhage. Our case was a 68-year-old female who presented with decompensated liver disease (DCLD) with no prior history suggestive of liver disease. She had dyspnea, bilateral pitting edema, icterus with normal renal parameters, and elevated liver enzymes. Ultrasonogram revealed shrunken liver, ascites, and portal hypertension with normal renal cortex echogenicity. Over the next three days, she developed progressive oliguria, hematuria, and breathlessness, with arterial blood gas showing hypoxia with acidosis and hyperkalemia. Bronchoscopic alveolar lavage was suggestive of hemorrhagic fluid. The patient succumbed to the disease in 24 hours. Anti-GBM antibodies came positive by immunofluorescence assay which confirmed the diagnosis of Goodpasture syndrome. Unusual presentation of DCLD in our case resulted in a delay in diagnosis that could have been crucial in altering the outcome.

Randomised Comparison between the Efficacy of Two Doses of Nebulised Dexmedetomidine for Premedication in Paediatric Patients.

OBJECTIVE: Nebulised dexmedetomidine can be an easy alternative for preoperative sedation in paediatric patients, but data regarding its efficacy are very limited. METHODS: This prospective, randomised, double-blind study included 66 patients aged between 1 and 8 years. Patients were divided into two groups as D2 and D3. The D2 group received 2 µg kg-1 of nebulised dexmedetomidine, and the D3 group received 3 µg kg-1 of nebulised dexmedetomidine preoperatively. All the patients received general anaesthesia and caudal epidural analgesia with 0.75 mL kg-1 of 0.2% ropivacaine. Parental Separation Anxiety Scale at 30 min after the end of nebulisation, Mask Acceptance Score (MAS) during induction, haemodynamic variables, emergence agitation and duration of caudal analgesia were compared between the groups. Statistical analysis was done using Mann-Whitney U test and chi-square test. A p-value <0.05 was accepted as significant. RESULTS: All the parameters were comparable between the D2 and D3 groups; however, significantly more number of younger children was observed in the D3 group. Hence, further analysis was done after division into the lower age (1-3 years) and higher age (4-8 years) groups. In lower age group children, satisfactory parental separation was achieved in 100% of the patients in the D3 group compared to 20% of those in the D2 group (p=0.00). MAS was significantly better in the D3 group in both the lower (p=0.019) and higher (p=0.036) age groups. CONCLUSION: We conclude that nebulised dexmedetomidine in a dose of 3 µg kg-1 provides better parental separation and mask acceptance in younger children.

Efficacy of the Stellate Ganglion Block Through the Lateral Approach Using Ultrasonogram and Fluoroscopy.

OBJECTIVE: Stellate ganglion (SG) block can provide pain relief in sympathetically mediated painful conditions. SG block at the sixth cervical (C6) vertebra level through lateral approach under the ultrasonogram (USG) guidance is very safe but may spare the fibres supplying the upper limb. When the drug is given at the C6 subfascially, it spreads along the cervical sympathetic chain, blocking the head/neck and upper limb. In this study, we assessed the efficacy of the SG block given at the C6 level after confirming the subfascial needle position under USG and downward spread of dye under fluoroscopy. METHODS: Ten patients with sympathetically mediated painful conditions belonging to the American Society of Anesthesiologists (ASA) Class I and II and aged between 18 and 60 years were included in the study. The SG was approached laterally under the USG guidance, and the dye was injected after confirming the subfascial needle position. A downward spread of dye was confirmed on fluoroscope, and 4 mL of 0.25% of bupivacaine with 40 mg of methylprednisolone was injected. Patients were assessed in terms of the pain relief, an increase in axillary temperature and adverse events after 30 minutes. A statistical analysis was done with Student's t-test and paired samples t-test. RESULTS: There was a statistically significant reduction in the post-block pain scores with the rise in temperature in the ipsilateral arm (p=0.000). The dye spread was observed from the fourth cervical vertebra to the first thoracic vertebra in all patients. Transient hoarseness was seen in 20% of patients, and the sensation of a lump was seen in 10% of patients. CONCLUSION: We conclude that SG can be blocked effectively and safely through the lateral approach at the C6 level under ultrasonogram and fluoroscopic guidance.

Randomized comparison between dexmedetomidine and midazolam for prevention of emergence agitation after nasal surgeries.

BACKGROUND: Emergence agitation (EA) in nasal surgeries is seen in around 22% of patients, which can go to dangerous levels. Dexmedetomidine is effective in prevention of EA in such patients. Midazolam given as premedication fails to prevent EA due to its short half-life. In this study, we compared efficacy of dexmedetomidine and midazolam by intravenous infusion for prevention of EA in adult nasal surgeries. MATERIALS AND METHODS: Seventy patients belonging to American society of anesthesiologist Status I and II, between 18 and 60 years of age posted for elective nasal surgeries were randomly divided into two groups. Group D received intravenous dexmedetomidine 0.5 mcg/kg over 15 min followed by 0.1 mcg/kg/h. Group M received intravenous midazolam 0.02 mg/kg over 15 min followed by 0.02 mg/kg/h. EA scores, emergence times, and hemodynamic parameters were monitored and compared between the groups. Statistical analysis was done by independent t-test, Mann-Whitney U-test, and Chi-square test as applicable. RESULTS: Incidence of EA was comparable between the groups (P = 0.23). Two patients in midazolam group developed dangerous agitation while none in dexmedetomidine group. Patients in midazolam group (12.4%) were agitated even in postoperative period, which was not seen with dexmedetomidine group. Hypotension and bradycardia were seen more in dexmedetomidine group. CONCLUSION: Efficacy of midazolam when given as an intravenous infusion is comparable to dexmedetomidine in prevention of EA in nasal surgeries.

A Comparative Study of Transversus Abdominis Plane Block versus Quadratus Lumborum Block for Postoperative Analgesia following Lower Abdominal Surgeries: A Prospective Double-blinded Study.

CONTEXT: Traditional truncal blocks are devoid of visceral analgesia. Quadratus lumborum (QL) block has shown greater efficacy in providing the same. AIMS: This study was done to compare the efficacy of transversus abdominal plane (TAP) block versus QL block in providing postoperative analgesia for lower abdominal surgeries. SETTINGS AND DESIGN: This was a prospective, randomized, double-blinded study. SUBJECTS AND METHODS: Seventy adult patients were randomly allocated into two groups, where Group A received TAP block with 20 ml of 0.25% ropivacaine on each side (n = 35) and Group B received QL block with 20 ml of 0.25% ropivacaine on each side (n = 35). The time of block, duration of surgery, Numerical Pain Intensity Scale (NPIS) score at the 1st, 2nd, 4th, 8th, 12th, 16th, and 24th postoperative hours, and the total analgesic drug requirements were noted and compared between the two groups. STATISTICAL ANALYSIS USED: Data were analyzed with SPSS version 23 (IBM corporation, Armonk, NY, USA) with independent t-test and Chi-square test as appropriate. P < 0.05 was considered statistically significant. RESULTS: The time for first analgesic requirement was 243.00 ± 97.36 min and 447.00 ± 62.52 min and the total analgesic consumption (morphine in mg) was 5.65 ± 1.55 and 3.25 ± 0.78 in Group A and Group B, respectively, both of which were statistically significant (P < 0.01). There was a significant difference in postoperative pain scores (NPIS scale 0-10) at rest, between the two groups, up to 16 h. CONCLUSIONS: Patients who received QL block had a significant improvement in postoperative pain relief with reduced consumption of opioids.

Comparative Evaluation of Ropivacaine and Ropivacaine with Dexamethasone in Transverse Abdominis Plane Block for Lower Abdominal Surgeries: A Prospective, Randomized, Double-Blinded Study.

CONTEXT: Dexamethasone as an adjunct to ropivacaine has shown promising results in prolonging the duration of analgesia in transverse abdominis plane (TAP) block. Only limited studies evaluated the effects of dexamethasone with ropivacaine in TAP block in specific population. AIMS: The effects of adding dexamethasone to ropivacaine on the quality and duration of TAP block in lower abdominal surgeries in multiple specialties were studied. SETTINGS AND DESIGN: This was a prospective, randomized, double-blinded study. SUBJECTS AND METHODS: Seventy adult patients undergoing lower abdominal surgeries were allocated into two groups to receive general anesthesia with TAP block with 20 ml 0.25% ropivacaine with 8 mg dexamethasone (2 ml) (Group A, n = 35) or 20 mL 0.25% ropivacaine with 2 ml saline (Group B, n = 35) each side. The analgesic efficacy in terms of pain scores, morphine consumption, and occurrence of nausea and vomiting was compared between two groups. STATISTICAL ANALYSIS USED: Data were analyzed with SPSS 23 with independent t-test and Chi-square test as applicable. P < 0.05 was considered statistically significant. RESULTS: The duration of analgesia was significantly prolonged in Group A (P = 0.000). The total morphine consumption was significantly lesser in Group A (P = 0.000). The pain scores (numerical pain intensity scale) were significantly lesser in Group A till the 8th postoperative hours. The occurrence of nausea and vomiting was comparable between the groups (P = 0.3821). CONCLUSIONS: Addition of dexamethasone to ropivacaine significantly improved the quality of analgesia with reduced consumption of opioids as compared to plain ropivacaine in TAP block.

Randomized Comparison of Isoflurane versus Sevoflurane and Desflurane for Maintenance of Ambulatory Anesthesia.

BACKGROUND: Ambulatory surgeries demand safe anesthesia with faster recovery which makes it expensive due to the cost of inhalational anesthetic agents such as sevoflurane and desflurane. Isoflurane is inexpensive agent but can cause delayed recovery. The aim of this study was to evaluate cost-benefit ratio of all three agent with respect to recovery and safety profile. MATERIALS AND METHODS: Patients posted for elective ambulatory surgeries were divided into three groups. Suitable size laryngeal mask airway was inserted following induction with propofol and vecuronium. Anesthesia was maintained on low-flow anesthesia with inhalational agent as isoflurane for Group I, sevoflurane for Group II and Group III received desflurane. Patients were monitored for recovery as per modified Aldrete score and as per postanesthesia discharge scoring system for discharge from hospital. Cost analysis was done by Dion's formula. Statistical analysis was done with analysis of variance for recovery profile, Chi-square test for safety profile and Kruskal Wallis test for cost comparison between groups. RESULTS: Patient characteristics and duration of anesthesia were similar in all three groups. Time to eye-opening was significantly less with desflurane than sevoflurane and isoflurane (P = 0.001). Time to home readiness was similar in all three groups (P = 0.451). The incidence of airway irritation, pain, and nausea/vomiting was similar in all three groups. Cost of Group I was statistically lower than other two groups (P = 0.00). CONCLUSION: Home readiness and safety profile were comparable between agents; the cost involved was the least with isoflurane.

Capnographic Analysis of Minimum Mandatory Flow Rate for Hudson Face Mask: A Randomized Double-blind Study.

BACKGROUND: Oxygen supplementation through Hudson type face mask is frequently used in perioperative settings. Hudson mask is a variable rate performance device with the risk of rebreathing. Studies using capnography to find out an actual fraction of rebreathing in spontaneously breathing patients are not available. AIMS: In this study, we analyzed the effects of different flow rates through Hudson mask with capnography on fractional inspired carbon dioxide (FiCO2). SETTING AND DESIGNS: Forty patients posted for minor surgeries under monitored anesthesia care were divided into four groups. They received oxygen flow rate of 3 L/min, 4 L/min, 5 L/min, and 6 L/min as per group division, through Hudson mask. MATERIALS AND METHODS: Parameters such as pulse rate, noninvasive blood pressure, oxygen saturation, respiratory rate (RR), end-tidal carbon dioxide (EtCO2), and FiCO2 were noted at baseline. After starting oxygen supplementation, these parameters were monitored every minute for ten minutes. Statistical analysis was done using analysis of variance and Kruskal-Wallis test. Pearson correlation was used to establish a relation between RR and FiCO2. RESULTS AND CONCLUSIONS: EtCO2 and FiCO2 were comparable in all four groups with no statistical significance. There was strong positive correlation seen between RR and FiCO2 at a flow rate of 3 L/min while negative correlation in other groups. We conclude that FiCO2 is similar at all flow rates while breathing through Hudson mask. Increase in RR can cause increase in FiCO2 at lower flow rate, which is within physiological tolerance limits.

Comparative evaluation of intrathecal morphine and intrathecal dexmedetomidine in patients undergoing gynaecological surgeries under spinal anaesthesia: A prospective randomised double blind study.

BACKGROUND AND AIMS: Inrathecal opioids like morphine added to local anaesthetic agents have been found to be effective in achieving prolonged post-operative analgesia. Intrathecal dexmedetomidine may be devoid of undesirable side effects related to morphine and hence, this study was designed to evaluate analgesic efficacy, haemodynamic stability and adverse effects of both these adjuvants in patients undergoing gynaecological surgeries. METHODS: This was a prospective, randomised, double blind study involving 25 patients in each group. Group M received 15 mg of 0.5% hyperbaric bupivacaine with 250 µg of morphine while Group D received 15 mg of 0.5% hyperbaric bupivacaine with 2.5 µg of dexmedetomidine. Characteristics of spinal block, time for first rescue analgesic and total dose of rescue analgesics were noted. Vital parameters and adverse effects were noted perioperatively. Data analysis was done with independent two sample t-test and Mann-Whitney U test. RESULTS: Time for first rescue analgesic (P = 0.056) and total analgesic demand were similar in both groups. Duration of sensory (P = 0.001) and motor (P = 000) block was significantly higher in dexmedetomidine group. Itching was noticed in 36% and nausea in 52% of patients in the morphine group, either of which was not seen in dexmedetomidine group. CONCLUSION: Intrathecal dexmedetomidine produces prolonged motor and sensory blockade without undesirable side effects but intraoperative hypotension was more frequent in dexmedetomidine group.

Myocardial stunning after resuscitation from cardiac arrest following spinal anaesthesia.

Cardiac arrest associated with spinal anaesthesia has been well researched. Myocardial stunning after successful resuscitation from cardiac arrest is seen in up to 2/3(rd) of in-hospital cardiac arrests. Myocardial stunning after resuscitation from cardiac arrest associated with spinal anaesthesia has probably not been reported earlier. Our case, an ASA physical status I lady, posted for tubal reanastomosis surgery developed bradycardia followed by asystole, approximately 5 minutes after giving subarachnoid block. Return of spontaneous circulation (ROSC) was achieved within 2 minutes with cardiopulmonary resuscitation (CPR) and defibrillation for pulseless ventricular tachycardia. Patient developed delayed pulmonary oedema, which was probably due to myocardial stunning. In the present case, inadequate preloading could have precipitated bradycardia progressing to cardiac arrest which, after resuscitation led to reversible myocardial dysfunction. We conclude that early vasopressor infusion, titrated fluids and echocardiography should be considered in immediate post cardiac arrest phase following spinal anaesthesia.