Indian Journal of Anesthesia and Analgesia

Introduction: Achondroplasia is most common cause of dwarfism caused by FGFR-3 gene mutation. It possess  anesthetic challenges due to multiorgan system involvement, spine abnormality, difficulty in mask ventilation and  endotracheal intubation. Case Report: A 38yr old, female, case of achondroplastic dwarfism with history of bronchial asthma and  hypothyroidism was posted for abdominal hysterectomy. She weighed 30 kgs and 43 cm in height. Spine examination showed thoracolumbar kyphoscoliosis. Airway assessment revealed large tongue, receding  mandible, Mallampatti class IV. Pulmonary function test suggested mild restrictive disease. Difficult intubation trolley was kept ready. Routine monitoring, radial artery cannulation done for invasive blood  pressure monitoring. Patient was given general anesthesia. On laryngoscopy, CL grade III view was obtained, with  the aid of bougie endotracheal tube was placed. Delayed recovery time from general anesthesia was encountered,  neuromuscular monitoring was doneandreversed and extubated uneventfully. Conclusion: we present a successful anesthetic management of a dwarf patient with bronchial asthma and  hypothyroidism who underwent hysterectomy. We emphasize the risk of neurological injury while extending the  neck during laryngoscopy for tracheal intubation due to anatomical abnormalities in these patients. A detailed  pre anesthetic evaluation evaluation and planning is utmost important and the anesthetic technique has to be  individualized based on the patients anatomical characterstics and associated co-morbidities. Keywords: Dwarf, Asthma, Hypothyroidism. Key Messages: A 38 yrs old female patient with achondroplastic dwarfism (43cm tall) with associated  comorbidities like bronchial asthma and hypothyroidism, thoracolumbar kyphoscoliosis and mild restrictive  lung disease posted for abdominal hysterectomy possesses various anesthetic challenges. Since multiple systems  are involved preanesthetic evaluation, preoperative optimization of the patient and planning of anesthesia  is important. As the spread of drug in regional anesthesia is unpredictable, we planned general anesthesia. A  successful management of major abdominal surgery in such patients, with anesthetic challenges and implications  in these patients are reviewed in this case report

Introduction : Ultrasound guided pericapsular nerve group block is an approach to block the articular branches  of femoral, obturator and accessory obturator nerves that supply the anterior hip capsule and has been found to  provide good perioperative analgesia. Case Report: An 86 year old male, who suffered fracture neck of femur after an alleged slip and fall, was  posted for emergency corrective surgery. Perioperative evaluation revealed ischemic heart disease, status post  PTCA with preserved LV systolic function and on oral anticoagulant rivaroxaban and antiplatelet medication  clopidogrel. Coagulation profile was within acceptable range. Cardiac Troponins and Brain Natriuretic peptide  (BNP) were measured. General anesthesia was planned to this patient in view of relative contraindication to central  neuraxial block i.e. patient being on anticoagulants. Perioperative analgesia was provided with ultrasound guided  pericapsular nerve group block for fracture site pain and lateral femoral cutaneous nerve block for surgical incision  pain. Patient had stable hemodynamic with improved pain score (VAS & lt; 3) in the immediate postoperative  period. There was no evidence of post-operative delirium and perioperative myocardial injury. Conclusion : Ultrasound guided superficial regional nerve group block such as Pericapsular nerve group block,  lateral femoral cutaneous nerve block can provide effective postoperative analgesia in patients where central  neuraxial blocks are contraindicated. Keywords : Anticoagulants, Hip fracture, Regional anesthesia. Key Messages: Acute pain management in elderly patients is quite challenging to anesthesiologists due to  medical comorbidities such as ischemic heart disease patients who experience greater pain are at increase risk  in post operative period and patients on anticoagulants where central neuraxial blockade are contraindicated.  Perioperative analgesia helps in intraoperative hemodynamic stability and post operative analgesia.

Introduction: Mediastinal tumor are uncommon entity they present a major anesthetic challenges due to major  airway and vascular compression. Case Report: A 60yr, old diagnosed with posterior mediastinum tumour at C7 level. Airway assessment revealed  mallampatti class IV. Blood investigations were within normal limit. Pulmonary function test revealed mild  obstructive disease. CT shows lesion in posterior mediastinum extending to right IJV with complete thrombosis  displacing trachea and thyroid. Triple lumen CVP line was secured. Difficult intubation trolley with tracheostomy  set was kept ready. Routine monitoring, left radial artery cannulation done. Patient was Preoxygenated,  Premedicated and Induced. 37F Left Double lumen tube was inserted and tube position confirmed with paediatric  fiberoptic bronchoscope. Patient was hemodynamically stable in the intraoperative period. Patient was reversed  and extubated uneventfully. Conclusion: Mediastinal tumor resection surgery is a very complicated and requires a team effect anesthesiologists,  surgeon and intensivist. A thorough pre-operative assessment of the patient should be done before the conduct of  anesthesia to avoid the complications due to posterior mediastinal mass. Keywords: Thoracotomy, One-Lung Ventilation, Mediastinal Tumor. Key Messages: Anesthetic management of patient with mediastinal tumor posted for thoracotomy and tumor  excision requires a double lumen ET tube for lung isolation and decrease in lung atelectasis. In this case a 60  year old male presented with mild symptoms and we highlight the usage of one lung ventilation in patient with  posterior mediastinal tumor

Introduction: Wolff–Parkinson-White syndrome (WPW) is an uncommon cardiac disorder where there is an  abnormal band of atrial tissue that connects atria and ventricles. Continuous spinal anesthesia is preferred to avoid  multidrug administration and stimulus due to laryngoscopy. Case Report: A 47 yrs old female, known case of WPW syndrome was posted for hysterectomy. Pre-anesthetic  evaluation was done. A 12 lead ECG was done which showed left axis deviation, short PR interval and delta waves.  The 2D – Echo showed thickened MV leaflets with grade-1 MR with normal LV systolic function and EF of 60%.  The case was planned to be taken under continuous spinal anesthesia. The Anti-Arrhythmic drugs and  Defibrillator were kept ready. Intermittent boluses of Inj. Bupivacaine (H) 0.5% was given through catheter to  achieve sensory and motor blockade. Inj. Fentanyl 25mcg was given at the end of the procedure as analgesic dose.  Intra operative vitals were stable. Postoperative period was uneventful. Conclusion: Patient with WPW Syndrome can be managed successfully by continuous spinal anesthesia  technique which uses low dose of anesthetic helps in maintaining cardiovascular stability intraoperatively and  duration can be extended if surgery is prolonged. Keywords: Continuous Spinal Anesthesia, WPW Syndrome, Ventricular Tachycardia. Key Messages: Hemodynamic changes can occur with WPW syndrome with arrhythmias. This can be avoided  with definitive treatment like Radiofrequency ablation. Our patient came with WPW Syndrome with stable  hemodynamics so continuous spinal anesthesia can offer stable hemodynamics with minimum use of local  anesthetics. We are reporting a case of WPW Syndrome with successful anesthetic management

Introduction: Tumours of the pituitary gland and sellar region represent 10-15% of all brain tumours. Pituitary  macroadenoma is the most common suprasellar mass in adults and is the commonest indication for transnasal  trans-sphenoidal hypophysectomy. Case Report: A 41-year-old patient presented with right-sided loss of vision and right-sided headache for 3  months and posted for the Transnasal Trans-sphenoidalhypophysectomy. The patient previously underwent a  similar surgery for an invasive non-functioning pituitary adenoma 2.5 years back. He is a known hypothyroid, with  normal vitals and class III Mallampati. The possibility of a difficult airway was considered because of the enlarged  tongue. Other system examinations were normal. The hemogram and biochemistry measurements were normal.  MRI brain showed a mass lesion measuring 5.2 x 5.6 x 4.7 cm in the sellar, supra, and parasellar regions. We were  prepared for all the intraoperative complications of pituitary macroadenoma that can happen. Difficult airway cart was made available. 18-gauge IV cannula secured. Pre-oxygenated and premedicated with  IV Glycopyrrolate 0.01mg/Kg and IV Fentanyl 2 mcg/Kg. Induced with Propofol 2mg/Kg, checked ventilation  and Vecuronium 0.1mg/Kg was administered. Intubated with 8.5 mm cuffed endotracheal tube using Video  laryngoscope. Right Subclavian vein cannulated and Invasive BP monitored through Radial artery cannulation.  Anesthesia was maintained with Oxygen-Nitrous oxide, Isoflurane, Vecuronium, and Dexmedetomidine infusion.  The patient was hemodynamically stable throughout the procedure. At the end of the procedure, reversal was  given and extubated after ensuring adequate recovery. Conclusion: Appropriate assessment before anesthesia and perioperative adequate monitoring and preparation  are important in the management of anesthesia of patients with pituitary macroadenoma. Keywords: Anesthetic concerns in pituitary adenoma, Neurosurgical Anesthesia, Pituitary Tumours, Pituitary  Macroadenomas. Key Messages: Patients coming for recurrent pituitary macroadenoma need appropriate preoperative  assessment and perioperative anesthesia management. This surgery requires a multidisciplinary team that includes  an anesthesiologist, an endocrinologist, a neurosurgeon and a radiologist for better patient care and outcome. We  are presenting a case report of recurrent pituitary macroadenoma and its successful management.

Objectives: To compare the anxiety level of patients who have received pre-operative counselling, tablet  Diazepam 10 mg previous night of surgery and patients who have neither received any anxiolytic medication nor  pre-operative counselling, To monitor preoperative, intraoperative and post-operative pulse rate, blood pressure  of study groups, to note the length of hospital, stay of the patient post operatively. Methods: Three hundred ASA 1/2 patients admitted for elective surgical procedure requiring anesthesia were  assigned into one of the three groups. •Group C =Pre-Operative counselling done, •Group D =Tab. Diazepam 10mg HS 1day prior to Surgery. •Group NC= Non-counselled patients.The study group C patients are counselled in respects of the type of anesthesia, operative procedure. The study group D is given tab. Diazepam 10 mg a night  prior to surgery. The study group NC is neither given pre-operative counselling nor given tab Diazepam. They are  non-counselled group.Data is collected by means of a questionnaire given to the patients in the form of Spielberger’  state – Trait Anxiety Inventory scale (STAIS). The patients anxiety levels were measured.  Result: In our study the three groups had high STAIS score before surgery with normal baseline haemodynamic  values. Patients who received counselling and tab. Diazepam pre operatively were haemodynamically stable  during intra and post operative period and had a low to moderate anxiety score during post operative visit as  compared to group NC which neither received pre operative counselling nor tab. Diazepam and had unstable  pulse rate, systolic blood pressure, diastolic blood pressureduring intra and post operative period. Their STAIS  score after surgery remained high as compared to their pre operative score. Group C and D had mean hospital stay  of 4.04 ± 0.65 to 4.75 ± 0.97 days which is less than group NC with mean hospital stay was 6.55 ± 0.67 days. Conclusion: Lack of information related to possible pre-operation and post-operation conditions increases  the anxiety level of patients. This causes intra operative instability in haemodynamic, post-operative emotional  problems and thus increase hospital stay. Personal interview and previous night anxiolytic (Tab. Diazepam) are  good at alleviating the anxiety throughout the perioperative period. Transfer of knowledge and information  through counselling to be more effective in decreasing the anxiety and apprehension. It is more helpful in patients  who are illiterate and who do not actively participate in the interview. Hence, a personal interview along with an  anxiolytic previous night of surgery is a good option in allaying the anxiety. This study has critically examined and found that preoperative patient education significantly reduces intra  operative haemodynamic instability, postoperative anxiety and length of hospital stay. This study strongly  recommends preoperative patient education so as to have better outcome, less morbidity and less healthcare cost.