Effect of pneumoperitoneum on intracranial pressure during supratentorial craniotomy: a case report.

Laparoscopic surgery has become the method of choice for many procedures previously performed by open techniques. However, its use in patients with a potentially decreased intracranial compliance warrants caution. We report a case of combined glioma excision and laparoscopic cholecystectomy procedures with evaluation of the effects of pneumoperitoneum on ICP and operative field. The clinical implications, safety and recommendations of conducting laparoscopic surgeries in neurosurgical patients are discussed. Performing pneumoperitoneum in patients with marginal intracranial compliance needs interdisciplinary discussions and ICP monitoring is mandatory.

Intrathecal neostigmine with bupivacaine for infants undergoing lower abdominal and urogenital procedures: dose response.

BACKGROUND: Intrathecal (IT) neostigmine produces dose-dependent analgesia in adults. However, the dose of spinal neostigmine has not been investigated in infants. The purpose of this study was to assess spinal anesthesia (SA) duration provided by four doses of spinal neostigmine added to bupivacaine for lower abdominal and urogenital procedures in infants. METHODS: Seventy-five infants were randomized into five groups. The control group B received IT plain 0.5% hyperbaric bupivacaine. Groups BN.25, BN.50, BN.75, and BN1.0 received bupivacaine with 0.25, 0.5, 0.75, and 1 microg/kg of neostigmine, respectively. The primary variable was the duration of anesthesia assessed by recovery of hip flexion. Postoperative pain with facial expression, leg activity, arm activity, crying and consolability scale score, and rescue analgesic requirements were the secondary variables measured, and the side effects were noted. RESULTS: Seventy-three infants completed the study. There was a significant linear increase in SA duration with IT neostigmine to 65.2 (4.3) min with 0.5 microg/kg (P<0.01), 88.2 (5.1) with 0.75 microg/kg (P<0.001) and 92 (4.3) with 1 microg/kg (P<0.001) from 52.4 (4.3) min with bupivacaine alone. SA duration showed no significant difference between plain bupivacaine and BN.25 (P=0.100) or between groups BN.75 and BN1.0 (P=0.451). Groups BN.75 and BN1.0 had significantly reduced pain scores, and the median duration before the first dose rescue analgesic was requested prolonged significantly (P<0.001) compared with the other three groups. CONCLUSIONS: IT neostigmine at a dose of 0.75 microg/kg added to bupivacaine significantly prolonged SA duration with reduced postoperative pain scores and rescue analgesic requirements in infants undergoing lower abdominal and urogenital procedures. No additional benefits were provided on increasing it to 1 microg/kg.

Dose-related effect of propofol on pancreatic enzymes and triglyceride levels in patients undergoing non-abdominal surgery.

Various case reports have indicated a possible relationship between propofol and pancreatitis. However, it is not clear whether this relationship (if any) is dose-related or idiosyncratic. Therefore, a prospective study was conducted to evaluate the effect of different doses of propofol on postoperative pancreatic enzymes and serum triglyceride levels. One hundred and fifty patients, aged 18 to 60 years, belonging to ASA physical status I and II, undergoing non-abdominal surgery were divided into three groups. Anaesthesia was induced with propofol 2 to 2.5 mg/kg in all groups. It was maintained with isoflurane in group I, propofol infusion < 5 mg/kg/h in group II and propofol infusion > or = 5 mg/kg/h in group III. All three groups also received nitrous oxide in oxygen for maintenance of anaesthesia. Serum amylase, lipase and triglyceride were estimated before propofol administration and at 24 and 72 hours postoperatively. The mean values of serum amylase, lipase and triglyceride remained within the normal range in the three groups. These values did not differ significantly in between the groups even despite the significantly different doses of propofol in the three groups (P < 0.001). None of the patients in the three groups developed any feature suggestive of acute pancreatitis in the postoperative period. These findings indicate that propofol administration at recommended doses does not produce dose-related increases in pancreatic enzyme and triglyceride levels in ASA physical status I and II patients.

Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery.

BACKGROUND: Intrathecal ketamine produces a short period of analgesia with stable haemodynamics. Midazolam with bupivacaine prolongs the duration of analgesia when administered intrathecally but does not prevent hypotension. The objective of this study was to assess the effect of a combination of intrathecal bupivacaine, ketamine and midazolam on the duration of analgesia and haemodynamic parameters. METHODS: A prospective, randomized, double-blind study was carried out in 60 ASA I and II patients undergoing lower limb surgery under spinal anaesthesia. Patients were divided into three groups of 20 each. Patients in all the three groups received 3 mL of hyperbaric bupivacaine (0.5%) intrathecally. In addition, patients in Groups II and III received intrathecal ketamine (0.1 mg kg-1) and the same dose of ketamine along with midazolam (0.02 mg kg-1), respectively. All patients were evaluated for block characteristics, duration of pain-free period, total rescue analgesic requirement in the 24-h postoperative period, total dose of mephenteramine to treat hypotension and any central or neurological complication. RESULTS: No patients in Group II required mephenteramine while 40% of patients in Group I and 10% in Group III required mephenteramine to maintain blood pressure after spinal anaesthesia. The mean +/- standard deviation duration of pain-free period was 331.5 +/- 89.9, 369.7 +/- 124.2 and 730.5 +/- 81.5 min in Group I, II and III, respectively. The pain-free interval was significantly greater in Group III compared to Groups I and II (P < 0.001). No patient had any complications. CONCLUSION: A low dose of midazolam and ketamine with bupivacaine intrathecally results in prolonged analgesia and less haemodynamic fluctuations. However, the safety of this combination needs to be proved before its use in clinical practice.

Phrenic nerve palsy in severe tetanus.

Unilateral or bilateral raised hemidiaphragms were observed on chest X-ray in three patients with severe tetanus. Diaphragmatic movement was absent on ultrasonography and fluoroscopy. Nerve conduction study confirmed phrenic nerve palsy. Bilateral involvement caused delayed weaning from the ventilator, whereas unilateral involvement was asymptomatic. There was complete recovery from phrenic nerve palsy in all patients.