Indian Journal of Anesthesia and Analgesia

Introduction: Primary (IVH) is non traumatic intracerebral hemorrhage confined to the ventricular system which is relatively infrequent, but is more commonly caused by hypertensive (52%) hemorrhagic stroke, followed by trauma (15%), intraventricular arteriovenous malformation (7.5%), coagulopathy (7.5%), diabetic vasculopathy (7.5%), anterior communicating artery aneurysms (3%), and undetectable cause. Clipping of ruptured anterior communicating artery with hypertension possess anesthetic challenges in managing intra-operatively, and when it comes for an ideal neuroprotective agent, barbiturates induced anesthesia was planned.

Case Report: A 70 years old male came to our hospital with history of sudden loss of consciousness and a known case of systemic hypertension for 3 years and was on irregular medications, intubated in emergency medicine department in view of low GCS which was difficult intubation.

CT brain Angiogram was done and diagnosed as ruptured Anterior Communicating Artery Aneurysm and underwent Aneurysmal clipping of anterior communicating artery aneurysm under general anesthesia.

Emergency medications were kept ready. Intensive neuro monitoring, invasive blood pressure monitoring and to decrease the intraoperative intracranial pressure, to preserve autoregulation of cerebral blood flow, barbiturates induced anesthesia were planned (thiopentone as an induction agent and maintained with inhalational anesthetic agent). Patient was shifted to ICU for observation and extubated on next day uneventfully.

Conclusion: We present a successful anesthetic management of hypertensive patient with  ruptured anterior communicating artery who underwent clipping of aneurysm. A detailed pre-anesthetic evaluation and proper planning is utmost important to encounter the risk of ischemic injury to brain while clipping of ruptured aneurysmal vessel.

Introduction: Ludwig’s angina is a rare but life threatening cellulitis of the soft tissue involving the floor of the mouth. Although Ludwig’s angina is a rare condition, it must be kept as a differential in the clinical setup when a patient presents with a neck swelling.

Case Report: A 28 year old multigravida with 31 weeks 4 days gestational age presented with a swelling over the right side of the neck since 8 days. Patient also complains of toothache since past 5 days. The swelling was sudden in onset and progressed to attain the present size. It was associated with breathing difficulty since past 1 day. It was also associated with pain over the region. She had difficulty in eating solid food due the restriction in mouth opening due to the swelling. She was on liquid diet since past 7 days. She was diagnosed with hypothyroidism and was on Tab. Thyroxine 50 mcg.

On physical examination, she is a moderately built and nourished female, vitals were stable. Examination of the head and neck revealed a diffuse swelling of size 10x10 cm over the right side of face extending from the right mastoid till the right oral commissure. Superiorly it extended up to 1 cm below right eye and inferiorly till the sternocleidomastoid origin.

Total leucocyte count of 5.59 thousand/mm3. After admission, antibiotics were started. Incision and drainage was planned for the patient. Intraoperatively, patient was tracheostomized due to restricted mouth opening and difficult intubation. After induction, vertical incision was made and about 100 ml of pus was drained from the swelling on the right side. Post-operative period was uneventful. The patient was discharged on antibiotics and tracheostomy care.

Conclusion: Ludwig’s angina should be kept in mind with this type of presentation. It can be life threatening if the treatment is improper, but intervention and subsequent correction can clear the symptoms completely.

Introduction: Hypokalemic Periodic Paralysis is one form of Periodic Paralysis, a rare group of disorders that can cause sudden onset weakness. Although rare, Periodic paralysis must be differentiated from other causes of weakness and paralysis so that the proper treatment can be initiated quickly.

Case Report: A 72 year-old elderly male presented to the emergency room with sudden onset of paralysis. He had no respiratory or swallowing difficulty and was able to move his neck and facial muscles.

Neurologic exam revealed flaccid paralysis bilateral lower extremities which involved the proximal and distal muscles. Sensation was intact but deep tendon reflexes were slightly diminished to 3 out of 4 throughout. RFT deranged with serum creatinine level of 1.7 (0.6- 1.2mg/dl), potassium level of 1.6 (3.5–5 mmol/L), magnesium level of 0.9 (1.3-2.1meq/l).

Electrocardiogram revealed bradycardia and left axis deviation. Two hours after initiation of intravenous potassium replacement, the patient's neurologic symptoms started resolving.

The patient was diagnosed with Hypokalemic Periodic Paralysis and was started on calcium channel blocker for control of blood pressure. He was discharged home with an appointment to follow up.

Conclusion: Periodic Paralysis should be kept in mind when a patient comes with sudden onset weakness or paralysis, especially when other diseases have been ruled out. It can be life threatening if the treatment is improper, but intervention and subsequent correction of potassium abnormalities can clear the symptoms completely. The underlying etiology should be searched properly to avoid recurrence or persistence of the paralysis.

Topical application of adrenaline is commonly used in ENT (Ear Nose Throat) surgeries and some neurosurgical procedures such as sellar or suprasellar mass excision by transnasal route. Cardiac adverse effects such as arrhythmias are not commonly reported complication of topical adrenaline application by nasal packs. Here we present a case report of topical adrenaline induced ventricular tachycardia in a Craniopharyngioma patient posted for Transnasal transsphenoidal excision of lesion (TNTS) excision of lesion.

Strychnine poisoning is an quite unusual but a serious poisoning in which convulsions are the major threat to life. Convulsions are predominantly noted at the spinal level, and the key to recognizing this poison is observation of convulsive activity in the awake patient without a postictal phase. Successful treatment requires aggressive airway control and treatment of seizures with benzodiazepines or barbiturates. Neuromuscular blockade may be required. Gastrointestinal decontamination is usually indicated in recent acute ingestions but may precipitate convulsions. Recovery from strychnine poisoning is usually complete and rapid if treatment is aggressive.

Background: Increase in heart rate and blood pressure in response to pneumoperitoneum produced during laparoscopic abdominal surgeries is a challenging situation to anesthesiologists. Without adequate control of sympathetic response there is a chance of increase in morbidity of the patient during perioperative period. Aim of the study is to evaluate the efficacy of bilateral erector spinae plane block in attenuating pneumoperitoneal stretch response in patients undergoing laparoscopic abdominal surgeries under general anesthesia.

Methodology: A randomised control trial was conducted among 70 patients, who underwent laparoscopic abdominal surgeries. Under general anesthesia, 35 patients received ESP block with 20 ml of 0.25 levobupivacaine bilaterally (Group B) and 35 patients without block (Group R). This study compared requirement of opioids and response of hemodynamic parameters (Heart Rate, Mean Arterial Pressure) during pneumoperitoneal stretch. Statistical tests were applied.

Results: The intra-operative fentanyl requirement in Group B was 100.85+ and in Group R 119.375 + P value <0.001, statistically significant. The intra-operative heart rate at the time of port insertion, at 5 min, 10 min of pneumoperitoneum and at the end of surgery in Group B (91.97 ±12.09, 90.82±10.7, 92.08±10.9 and 90.857±12.5) were significant when compared to Group R (R 99.9±10.5, 94.48±13.08, 96.68±14.14 and 95.35±14.14 and same is proven statistically. (p < 0.05).

Conclusion: Ultrasound guided bilateral Erector spinae block with Levobupivacaine results in intra-operative hemodynamic stability during port insertion and pneumoperitoneum.

Supraclavicular brachial plexus block is a very popular mode of anesthesia for various upper limb surgeries, as it is easiest and most effective and has good post-operative analgesia. It is carried out at the level of trunks i.e7 at the middle of brachial plexus, resulting in homogenou spread of anesthetic agent throughout the plexus with a fast onset and complete block action.9 Dexmedetomidine, is potent, highly selective α2-adrenoceptor agonist, has been used as an adjuvant during regional and local anesthesia because of rapid onset of action and relatively short half-life up to 2 hours.

Objective of Study: To compare the effects of addition of Dexmedetomidine to Bupivacaine- Lignocaine with Adrenaline combination for Supraclavicular brachial plexus block with regards to onset and duration of sensory block, motor block. Quality of anesthesia, analgesia and Adverse reactions if any after taking written informed consent.

Observations: Onset of sensory as well as motor blockade in Dexmedetomidine group was earlier when compared to plain bupivacaine-lignocaine adrenalin group. The duration of sensory and motor blockade was significantly increased (p<0.05) in Dexmedetomidine group when compared to another group. With respect to hemodynamic parameters Dexmedetomidine group provided a higher Degree of cardiovascular stability with a lesser incidence of hypotension.

Result: There is earlier onset of action and longer duration of sensory; Motor block and Duration of analgesia (sensory block) was prolonged in dexmedetomidine group. Hence it is advisable to add dexmedetomidine as an adjuvant to local anesthetic combinations during supraclavicular block for prolonged anesthesia and to provide better analgesia