Indian Journal of Anesthesia and Analgesia

Late presenting Congenital Diaphragmatic hernia beyond the neonatal period though rare,,mostly misdiagnosed, mistreated and end up in life threatening complications. CDH can occur at any older age and usually present as mild respiratory symptoms to as severe as gastric obstruction or acute obstructive respiratory problems. Perhaps the error at reaching a definitive diagnosis is simply because of the fact, the possibility of CDH at an older age is totally neglected.

Context: Laparoscopic surgery technique creates certain changes in various systems presenting as post-operative side effects and symptoms. Aims: To observe incidence of post-operative neurological, ophthalmic and otological symptoms in patients undergoing laparoscopic surgery. Setting and Design: Institutional setting, retrospective observational study Material and methods: After ethical committee clearance, 100 patients undergoing laparoscopic surgery, meeting inclusion criteria were included in the study. Patients were monitored intraoperatively for haemodynamic changes;EtCO2, Ppeak. After extubation in post-operative period, patientswere monitored for signs and symptoms in PACU, after 4 hours and 2nd post-operative day and system specific symptoms noted. Statistical analysis used: Data collection done using SPSS 21.0. Analysis of collected data done using independent t test, paired t test, chi-square test and Fischer’s test. Results: Out of 100 patients,36 patients showed symptoms. 8 patients had BMI >35kg/m2, 7 out of them had neurological (p value=0.14) and all 3 neurological, ophthalmic and otological symptoms. Trendelenburg combined with lithotomy position was used in 7 patients, 6 patients showed symptoms, 5 of them showed neurological symptoms (p value=0.006) and 3 showed ophthalmic symptoms (p value=0.002). Total colorectal surgeries done were 5, out of which 4 showed symptoms. Total gynaecological surgeries done were 10, out of which 7 showed symptoms, neurological=6 and ophthalmic=3. Mean duration of insufflation in neurological symptoms- 4.06hrs (p-value 0.007), for ophthalmicsymptoms-4hrs (p-value 0.334) and otological symptoms-8hrs (p-value 0.002). Certain parameters like EtCO2, Peak airway pressures, increased during insufflation and continued to remain high even after desufflation (P value=0.0001). Age of the patients, Intra-abdominal pressure (IAP) and comorbidities did not show significant impact on incidence of symptoms. Conclusion: Trendelenburg with lithotomy position, higher BMI, longer duration of insufflation can be major factors contributing to neurological and ophthalmic symptoms in laparoscopic surgeries.

Introduction: Atrial fibrillation is one of the most common arrhythmias occuring in 0.45% of adult population and usually are not assoicated with any cardiac disease. Atrial fibrillation may be seen preoperatively in patients posted for anesthesia.

Case Report: A 48 Vyshya male patient with swelling in the neck, palpitations since two years, hypercalcemia and chronic kidney disease with irregularly irregular pulse (88 per min), BP of 110/60 mmHg and respiratory rate of 20/min. Electrocardiogram showed atrial fibrillation. Echocardiography showed non obstructive hypertrophic cardiomyopathy with dilated left atrium and right atrium , moderate pulmonary artery hypertension with ejection fraction of 60%. Patient was diagnosed to have left parathyroid adenoma and was posted for parathyroidectomy. Serum parathyroid hormone levels was 756 pg/ml. Patient was on Inj. Enoxaparin 40 mg that was stopped twelve hours before day of surgery and Amiodarone 100mg and Metoprolol 25mg which was continued on day of surgery. Continuous ECG, invasive arterial blood pressure, pulse oximetry, capnography, neuromuscular monitoring was done. After preoxygenation, induced with propofol and fentanyl.Intubation done with injection vecuronium. Anaesthesia was maintained with Isoflurane ,oxygen, nitrous oxide and vecuronium. Arterial line was established. Left inferior parathyroidectomy was done in 4 hours. Inj. Amiodarone 3mg/kg diluted in 100 ml normal saline was started before skin incision. Patient was in persistent atrial fibrillation throughout the surgery, extubation was done and the patient was sent to intensive care unit. Conclusion: Patients with atrial fibrillation secondary to hypercalcemia undergoing a crucial non cardiac surgery needs thorough understanding of hemodynamic changes, vigilant intraoperative monitoring with proper preoperative and intraoperative cardiac medication.

Introduction: Patient with tracheal tuberculosis with active lung infection requiring Intubation using Double lumen Endotracheal tube pose a challenge to anesthesiologist to prevent contamination of healthy lung. Case Report: 55 year female presented with complaints of nasal discharge for 2 weeks, cough with expectoration for one week. A diagnosis of CSF Rhinorrhoea was made. HRCT chest report showed tree in bud opacities suggestive of TB. General anaesthesia was planned. Preoperatively nebulized with Lignocaine with adrenaline; Patient was Pre medicated, Preoxygenation done with 100% oxygen. Induced with Inj Propofol. 35F Left Double lumen tube was inserted under fibreoptic guidance and was confirmed by chest rise and ETCO2 and Tube fixed in place. A portable ventilator was used with Tidal volume of 5ml per kg for the right lung and regular ventilator with same tidal volume to left lung. Intra operative vitals were stable throughout the procedure. The patient was extubated after adequate spontaneous efforts. After extubation the patient started desaturating, saturation went upto 70% on room air, immediately the patient was reintubated and shifted to ICU with ET tube insitu. The patient was extubated in ICU after 2 days and shifted to postoperative ward. Conclusion: In patients with active lung infection a plan for Double lumen ET tube may help in avoiding the infection spreading to healthy lung, intubation period is crucial to avoid most common problems such as malposition, airway trauma and tension pneumothorax caused by high ventilating pressure or large tidal volumes in patients.

Introduction: Organophosphorous compounds are chemical agents in wide spread use throughout the world in agricultural industries. This poses a major challenge to an anesthesiologist; there is accumulation of acetylcholine causing overstimulation of muscarinic
and nicotinic receptors disruption of transmission of nerve impulses in both peripheral and central nervous system.

Case Report: A 47 year old male presented with alleged history of OP compound consumption with complaints of pain and swelling on the left cheek. On examination Diffuse swelling with warmth and tenderness was present. A diagnosis of parotid abscess was made.
Systemic examination - CNS - GCS-E4M5V4 with bilateral pupil -2mm reacting to light. Pseudo cholinesterase was 380.

Anaesthetic Management: Preloaded with 500ml RL. Monitors connected. Patient wason continuous Atropine infusion, Inj Midazolam and Inj fentanyl. Preoxygenated with 100% oxygen. Induced with Inj Propofol. Laryngeal mask airway(LMA) number 5- Proseal
was inserted. Anaesthesia maintained with 50% nitrous oxide in oxygen, IV propofol with intermittent positive pressure ventilation. Inj Atropine infusion was continued at 3ml/hr and titrated according to heart rate. The haemodynamic parameters remained stable throughout the procedure. The patient was extubated, Postoperative recovery was uneventful.

Conclusion: The use of muscle relaxants can produce bradycardia and prolong the motor recovery.Volatile anesthetics can also cause bradyarrythmias. In this case report we found that patient with OP compound consumption can safely be managed under general anaesthesia with IV propofol, without muscle relaxant and inhalational volatile anaesthetics.

Introduction: Xeroderma Pigmentosum (XP) is a hereditary autosomal recessive disorder due to defect in nucleotide repair genes. In this condition patient might require multiple surgeries for removal of skin and ocular lesion. Case report: A 17 year old male patient, weighing 43 kg presented with multiple lesions over face since 2 months. He had cutaneous lesions over full body with no major neurological deficit. General anaesthesia was planned. Patient’s body protection from artificial light and eye protection given in operating room. Patient Pre medicated with Inj glycopyrrolate, Inj Midazolam and Inj fentanyl. Preoxygenation done with 100% oxygen for 3 min. Induced with Inj Propofol. After elimination of reflexes and reaching enough depth of anaesthesia laryngeal mask airway(LMA) number 3 inserted and good lung ventilation confirmed by chest rise and ETCO2 then LMA fixed in place. Anaesthesia maintained with 50% nitrous oxide in oxygen, IV Propofol with intermittent positive pressure ventilation. Further analgesia supplemented by inj.Bupivacaine 0.25% infiltration locally around wound given. The procedure lasted for 40 min. Conclusion: Xeroderma pigmentosum patients have risk of worsening neurological disorder with genotoxic drugs and volatile anaesthesia and prolongation of recovery from muscle relaxants. In this case report demonstrated that patient with XP can safely be managed under general anaesthesia with IV propofol, without muscle relaxant and inhalational volatile anaesthetics.

Introduction: Laryngomalacia is defined as collapse of supraglottic structures during inspiration. It is the most common laryngeal disease of infancy and cause of stridor in newborns. Case Report: A 17 days old child (2.75kgs) with congential laryngomalacia was scheduled for rigid tracheobronchoscopy. Child had a history of recurrent lower respiratory tract infection which resolved with intravenous antibiotics and steroids. On auscultation he had no adventitious sounds when quiet but added sounds were heard when he cried. Echocardiography showed CHD with situs solitus levocardia with 4mm ASD and 2mm PDA with dilated RA/RV. The child was administered atropine, midazolam, atracurium and ketamine. Maintainence with sevoflurane . During rigid bronchoscopy we provided adequate analgesia and sedation without clinically significant hemodynamic or respiratory adverse effects. Conclusion: In summary we noted that ketamine provided a reliable and effective method of sedating infants undergoing a rigid bronchoscopic examination in spontaneous ventilating conditions and noted no clinically significant haemodynamic or respiratory problems. When these patients do present, their care is likely to be complex and challenging. As such , a multidisciplinary approach should be adopted throughout their period of care.

Introduction: Patient with upper limb fracture with ipsilateral limb AV fistula, anaesthetic options are still challenging. Case Report: A 40 year old male patient who is an K/C/O CKD on maintenance hemodialysis and hypertensive on medication.Patient had AV fistula on the same side of the fracture, Detailed examination of the fistula was done, 1. Thrill over the fistula palpated. 2. Bruit was auscultated on the fistula side. 3. Radial pulse was palpated for volume and rhythm. 4. Fistula hand was compared with other hand for colour , any cyanosis or pallor, temperature, ulcer, edema , pigmentation or peeling of the skin and Nicoladoni Branham sign was negative Under USG, plexus was identified. Using 23G spinal needle , Bupivacaine 0.5(H) 15ml[75mg] plexus . Post supraclavicular block , both sensory and motor blockade was checked. Without tourniquet surgery was proceeded , face mask with 5L/min of O2 was given to the patient. Intraoperatively patient was hemodynamically stable, maintenance fluid of 0.5ml/kg/hr. Post procedure examination of AV fistula was repeated to check the patency. Conclusion: Use of regional anaesthesia over general anaesthesia in distal end fracture with ipsilateral AV fistula has advantage in both in management and patency of the AV fistula.

Objective: The LMA (Laryngeal Mask Airway) is a method to offer endotracheal intubation while avoiding the dangerous side effects of visualization of cords and forcing them apart. The present study is designed to compare the conditions to facilitate the insertion of LMA with the two most used agents Thiopentone and Propofol after adequate pre-induction doses of midazolam and fentanyl. Materials and Methods: A study conducted on 60 patients of either sex belonging to 18 to 50 years of age and ASA grade 1 who were to undergo elective surgeries. Patients were randomly divided into two groups. Both groups received pre-induction doses of Glycopyrrolate (0.2mg), Midazolam (0.5mg/kg) and Fentanyl (1.5mg/kg), and were induced with either Propofol (3mg/kg) or Thiopentone (6mg/kg) to facilitate insertion of LMA. Result: Conditions facilitating LMA insertion and ease of insertion were significantly greater in Propofol group when compared to Thiopentone group. The difference was statistically significant (p<0.0001). Conclusion: In view of better ease of insertion, lesser time taken for insertion and better recovery profiles associated with Propofol seems to be superior to Thiopentone in LMA insertion.