Indian Journal of Anesthesia and Analgesia

Not available.

Background: The failure of direct laryngoscopy to provide an adequate glottic visualization, coupled with a major pressor response, has led to the development of newer intubation devices. Present study was planned to find out the efficacy and safety of conventional laryngoscope compared with video laryngoscope for endotracheal intubation in adult patients. Material and Methods: Present study was Hospital based prospective randomized single blinded study, conducted in patients of age 18 to 60 years, either gender, ASA grade 1 & 2, weight 50-70 kg, Mallampatti grade 1 & 2, underwent general anaesthesia, Patients were allocated as group DL (intubated with conventional Laryngoscope) & group VL (intubated with Video Laryngoscope. Results: Number of attempts required for intubation for Group DL single in 80% as against 100% for Group VL. This difference was statistically significant (p<0.05). Optimization maneuver used for intubation for Group DL single in 100% as against 10% for Group VL. This difference was statistically significant (p<0.05). We observed that mean SBP in Group DL was significantly higher as compared to Group VL after intubation 10 and 15 minutes as well as up to post operatively 30 minutes. Conclusion: Video laryngoscope is a superior device than the conventional direct laryngoscope (Macintosh). It can be used as a teaching tool for novice intubators and offers approach to tracheal intubation.

Context: Labor is one of the most painful experiences a woman may face during her lifetime. Labor pain is excruciating and a significant contributor of stress and anxiety. Epidural analgesia is the most effective method of intra-partum pain relief and provides excellent safety profile for both the mother and the foetus. The present study was designed to compare the dural puncture epidural technique and the standard epidural technique for labor analgesia. Aims: To compare dural puncture epidural technique for labor analgesia with conventional epidural technique. The primary outcome measures were onset of analgesia and patient satisfaction; secondary outcome measures being duration of analgesia, number of top-ups required, APGAR score, side effects. Settings and Design: A prospective randomized double-blind trial was conducted at Dr. Bheem Rao Ambedkar Memorial Hospital, Raipur on 50 uncomplicated term primigravida in active labor. Methods and Material: Double-blind randomization to the dural puncture epidural group and standard epidural group was accomplished by means of Toss method. The procedure was carried out by one anesthesiologist while the observations were done by the second one who was not present at the time of the procedure. Statistical analysis: The statistical analysis was carried out using Statics Kingdom Calculator in stat software and Medcalc’s statistical calculator. Results: The mean VAS at 15 minutes was 1.32±0.48 and 1.76±0.44 in group DPE and group E respectively (p < 0.0001). The mean time of onset of analgesia was significantly earlier in group DPE (16.76 ± 1.39 vs 18.56±1.47 minutes). The mean duration of analgesia was significantly prolonged in group DPE (81.04 ± 4.69 vs 78.32±3.94 minutes) (p = 0.03). The mean number of top-ups of local anaesthetic was significantly lesser in group DPE (1.64 ± 0.49) than in group E (1.96 ±0.2) p < 0.0001). There was no incidence of nausea, vomiting, pruritus, hypersensitivity, shivering, respiratory depression or urine retention in any group. The patient satisfaction score in group DPE was excellent in 80% and good in 20% while in group E it was excellent only in 32%, good in 60% and fair in 8% patients. Conclusions: The dural puncture epidural technique has a rapid onset and prolonged duration of analgesia as compared to conventional epidural technique without any significant maternal or neonatal adverse effects.

Management of blood sugar levels in perioperative period is critical. Effect of surgical stress and anaesthesia have unique effect on blood sugar level, which is taken in consideration to maintain blood sugar level. It is challenging aspect of preoperative patient’s care. Anxiety changes the physiological response to anaesthesia and surgery. There is overall effect on the perioperative anaesthesia outcome. Various methods are available for reducing patient anxiety before surgery. Among them are educating the patient about their surgery, preoperative counselling, music therapy in form of nature sounds, relaxation exercises, and use of anxiolytic drugs. The present study was undertaken to evaluate the efficacy of anxiolytic agent when given preoperatively in patients undergoing operative procedures under spinal anaesthesia and compared to those without anxiolytic or placebo preoperatively.

Muscular dystrophies and myopathies are inherited disorders that affect the neuromuscular junction.Limb-girdle muscular dystrophy (LGMD) is a rare neuromuscular condition that includes a variety of disorders with heterogeneous causes, as well as mutations within the same gene that can result in different phenotypic expressions. As the natural course of the disease progresses, the risk of surgery increases concomitant with the increased comorbid conditions associated with the later phase of the disease. Notably, perioperative complications do not correlate directly with the severity of the disease, as they can manifest even in patients with mild symptoms. Therefore, it is essential for patients to receive thorough preoperative consultations and evaluations. Factors such as the severity of the condition, age at onset, and specific characteristics of LGMD can differ significantly among individuals.Pregnant women with LGMD are particularly susceptible to obstetric complications, especially if they experience significant weakness in the pelvic girdle muscles and respiratory insufficiency. Symptoms may worsen during pregnancy, leading to increased respiratory compromise. Additionally, the progression of the disease is observed during this period. The various anaesthetic challenges presented by a patient with LGMD complicate the anaesthetic management. However, with thorough pre-operative evaluation and a judicious selection of anesthesia and anaesthetic agents, it can be managed safely.Here we discuss a case of pregnant patient diagnosed with LGMD scheduled for elective caesarean section under spinal anesthesia.

Introduction: Spinal anaesthesia is a widely used anaesthetic technique. But sometimes the failure of spinal anaesthesia occur because of reasons like obesity, poor positioning, spinal deformity like kyphosis, misplaced injection and local anaesthetic resistance. Resistance to local anaesthetic is one of the reason. The mechanism of action of local anaesthetics is through sodium channels and mutation in the sodium channel could be one of the possible reasons for the resistance. Case Report: A 52-year-old man who has been experiencing excruciating stomach ache for three days. After receiving a diagnosis of acute appendicitis, he was scheduled for an open appendectomy while under spinal anesthesia. His laboratory results and general physical examination during the pre-anesthesia evaluation were normal, with an ASA grade I. A 25G Quincke’s spinal needle was used to do a lumbar puncture at the L3-L4 area while the patient was seated and under aseptic precautions. The subarachnoid area was injected with 30 mcg of buprenorphine and 0.5% hyperbaric bupivacaine. The patient was then placed in a supine position. General anesthesia was administered for the procedure after two successive attempts at spinal anesthesia failed, as demonstrated by the pinprick method or by motor block, as demonstrated by lower limb movements. The surgery and immediate post-operative period was uneventful. The patient described a scorpion bite that occurred a year ago when asked about his medical history. Conclusion: Scorpion stings can lead to resistance to local anesthetics due to the venom’s effect on sodium channels, potentially causing failure or delay in spinal anesthesia. Awareness of a patient’s history of scorpion envenomation is crucial for effective anesthetic management.

Introduction: Intracranial hydatid cysts are rare supra-tentorial lesions in the neurosurgical population of India. Methodology: In this report, we presented a case of a 18 year old male patient with midline shift, posted for excision of hydatid cyst in brain. The use of dexmeditomidine alongwith sevoflurane for anesthetic induction helped in achieving optimal intra-operative brain relaxation and a good surgical outcome for this patient. Results: Neuroanesthetic monitoring for this patient encompassed the state entropy monitoring, cerebral blood flow velocity monitoring, non-invasive intra-cranial pressure monitoring and analgesia monitoring in conjunction to the standard ASA monitoring. Conclusion: The authors advocate similar management for achieving optimal standard of care while operating giant cystic lesions in supra-tentorial compartment.

Regional anaesthesia is often used as a technique of choice for managing both intraoperative surgical procedure and postoperative analgesia in patients with upper extremity injuries. For providing extended pain relief continuous peripheral nerve block (CPNB) is an appropriate anaesthetic technique. The use of CPNB allows rapid establishment of analgesia sufficient for surgical interventions and provides excellent pain control while decreasing the need for opioids and other pain medications after operation.1 We report a successful use of ultrasound-guided supraclavicular CPNB in a case of accidental cut injury to right forearm for intraop surgical procedure and postop analgesia. This case demonstrates the utility of ultrasound-guided CPNB in anaesthetic management of traumatic injuries in which general anesthesia can be precarious due to severe cardiac pathology. We report a case of 30-year-old male with accidental cut injury to middle 1/3rd of right forearm who underwent wound exploration and artery/nerve/tendon repair. During pre-anaesthetic evaluation, he was found to have ‘pulsus parvus et tardes’ and an ejection systolic murmur in aortic and pulmonary areas. Clinically, however, the patient appeared stable with MET score of >4 and gave no history fatigue, shortness of breath or chest discomfort. He was not previously evaluated for any cardiac disorders. The 2D echo done, revealed severe aortic stenosis. Cardiologist was consulted regarding the same, who opined that the patient carries high risk for perioperative adverse cardiac events. Pre-operative VAS as described by the patient was5. Before performing the anaesthetic procedure, patient was sedated with injection Midazolam 2mg and injection Fentanyl 30mcg. Under strict aseptic precautions, skin infiltrated with Inj Lignocaine 2%. Under ultrasound guidance using the in-plane technique, the tip of an 18G tuohy’s needle was positioned at the brachial plexus and a catheter was sited. After negative aspiration, 20ml of Inj Bupivacaine 0.5% was injected. Adequate motor and sensory block was achieved after 15 minutes with VAS, now reduced to, 0. Intra-op, after 4hrs of initial local anaesthetic dose patient complained of pain, top-up of Inj Bupivacaine 0.5%, 5cc was administered. A 5-lead ECG was used for continuous cardiac monitoring for optimal identification of adverse cardiac events. NIBP was used to monitor intraop BP, and since, significant fluid/blood loss was not anticipated in this case, an arterial line wasn’t sited. The surgical procedure was 5 hours long. Vitals were stable throughout. The catheter was removed in the immediately after completion of the procedure before shifting the patient to PACU (post anaesthesia care unit). The patient was monitored in PACU and discharged with an Aldrete score of 9 and VAS of 1. Post-op analgesic effect lasted for 5 hours, after which rescue analgesia (Inj Diclofenac 75mg, slow IV) was administered.

Introduction: The most common cause of cardiac disease in pregnancy includes rheumatic heart disease, valvular heart disease and congenital heart disease. ASD is the most common acyanotic congenital heart defect. Prompt diagnosis and repair of antepartum cardiac problems is of prime importance for maternal foet al. health. Hypothyroidism is widely prevalent in pregnant women. Since hypothyroidism is easily treated, timely detection and treatment of the disorder could reduce the burden of adverse foet al. and maternal outcomes, which are very commonly encountered. Case Report: A 25-year-old female diagnosed with G2P1L1 with 36 weeks 4 days gestation presented with hypothyroidism. During assessment, ASD was identified with right bundle branch block (RBBB). Laboratory tests were normal. The patient was closely monitored, 16G peripheral intravenous catheter placed. Lactated Ringer’s solution was started, followed by Inj ranitidine, Inj metoclopramide, and Inj midazolam. The Caesarean-section was carried out under spinal anaesthesia. With the patient seated, hyperbaric bupivacaine (10 mg) was administered L4-5 interspace. The patient was then laid supine, and an oxygen mask delivering 3 litres per minute was applied. The surgical procedure commenced once the sensory block reached the T6 level. Five minute after baby delivery, mother had respiratory distress despite stable hemodynamic findings. Subsequently, hypotension, bradycardia developed and SpO2 dropped below 85%. By the tenth minute of the surgery, blood pressure gradually fell to 90/50 mmHg and heart rate of 45 bpm prompting the administration of Inj Atropine 0.6 mg. patient supplemented with oxygen and fluid resuscitation was done. Patient stabilized, Surgery lasted for 50min and shifted to HDU for monitoring, later uneventful. Conclusion: In the ASD patient planned for section, the most ideal anaesthetic method that would best enable hemodynamic stability should be selected by considering elective and emergency condition of the surgery.

Chronic myofascial pain of cervical spine and shoulder is often related to faulty posture. Extended period of screen usage, faulty posture and sedentary lifestyle exacerbate tightness and weakness of back and core muscles. Excessive strain on the surrounding muscles and cervical spine leads to inter vertebral strain and spinal misalignment, and spine shaped like a “question mark” exaggeration of lumbar spine lordosis and excessive kyphosis of the thoracic spine. A bad posture can cause the musculature of the neck and upper back to strain excessively, which can irritate the spinal accessory nerve (SAN) and dorsal scapular nerve (DSN). A 5-in-1 trigger point and hydro-dissection technique has been described by Tang et al that specifically target trapezius, rhomboids, levator scapulae, and hydro dissecting the DSN and SAN to provide pain relief. We report ten patients of chronic myofascial upper back and neck pain managed by 5-in 1 block. Conclusions: 5-in 1 block is a good treatment option for patients suffering from chronic upper back and, neck pain and multidisciplinary approaches are essential.

Systemic toxicity of local anesthetics results from excessive plasma concentrations of these drugs, most often from accidental intravascular injection. Systemic reactions primarily involve the CNS and the cardiovascular system. In general, the CNS is more susceptible to the actions of systemic local anesthetics than the cardiovascular system is, and thus the dose or blood level of local anesthetic required to produce CNS toxicity is usually lower than that resulting in circulatory collapse[1]. Here we present the case of a 45-year-old male patient who had ultrasonography guided supra-clavicular brachial plexus block. The patient had an episode of seizure immediately (with-in 30 sec) after administering the local anesthetic (13 ml given in 5 ml aliquots injected after negative aspiration). He was treated with intravenous midazolam (2 mg stat) and supplemental oxygen via facemask. He had no neurological symptoms afterwards. All laboratory tests and radiological investigations were normal. This case report records the occurrence of local anesthetic toxicity observed as seizure activity, after ultrasound guided brachial plexus block due to accidental intravascular injection, as negative aspiration of the syringe does not always exclude intravascular placement.

Turner syndrome, a chromosomal disorder characterized by partial or complete loss of X chromosome, presents unique challenges during pregnancy and anesthesia management due to associated comorbidities such as cardiac anomalies and musculoskelet al. abnormalities. A 30-year-old primigravid woman with mosaic Turner syndrome underwent an emergency cesarean section at 38 weeks and 2 days of gestation due to arrest at the second stage of labor with fet al. distress. The pregnancy was considered high-risk due to gestational hypertension, hypothyroidism, and premature rupture of membranes (PROM). Physical characteristics of Turner syndrome, such as short stature, low-set ears, and a broad chest, were present, though no major cardiac abnormalities were identified. Spinal anesthesia was administered using 2 ml of 0.5% bupivacaine, achieving a T5 sensory block. The procedure was uneventful, resulting in the delivery of a healthy male infant. Postoperative recovery was smooth, with no cardiac complications. This case emphasizes the importance of thorough preoperative evaluation, vigilant monitoring, and tailored anesthetic techniques to minimize risks.

Introduction: Tracheo-oesophageal fistula with or without oesophageal atresia is a congenital anomaly with an incidence of 1 in 3000-4000 births worldwide. Although congenital cardiac disease is the most frequent congenital anomaly, up to 50% of infants have TOF in addition to other congenital abnormalities. Case Report: At 3 day old the baby was planned for one lung ventilation with right thoracotomy + trachea-oesophageal repair in view of trachea-oesophageal fistula with oesophageal atresia. On examination, the general condition of the child was poor. He was tachypneic with a respiratory rate of 62/min along with chest retraction and nasal flaring. In the operating room, standard monitors were attached. Two intravenous line was secured with 24-gauge cannula on both dorsum of hands. Intravenous anesthesia drugs were loaded using insulin syringe according to baby’s weight. Induced with ketamine 4 mg and fentany l4 μg. After confirmation of bag and mask ventilation, succinylcholine 4 mg was given to facilitate end otracheal intubation. Trachea was intubated successfully with uncuffed endotracheal tube of internal diameter 3.0 mm confirmed by auscultation of chest and capnography. The child was ventilated with low tidal volume and high rate. Anesthesia was maintained with oxygen, isoflurane and atracurium. The child was positioned in the right lateral position and thoracotomy was done. At the end of surgery, trial of extubation was done and due to insufficient respiratory effort baby was shifted with ET tube in-situ to NICU. Conclusion: The anesthetic approach for neonates with TEF with or without EA should primarily concentrate on airway management and ventilation techniques. Maintaining airway patency, ensuring proper ventilation, and adequate oxygenation rely on effective communication between the pediatric surgeon and the anesthetist during the procedure Neonates are typically recommended to remain intubated endotracheally for a specific duration following surgery, necessitating the arrangement of an NICU bed in advance for these infants before definitive repair.

Cervical Vagal Schwannoma is a rare, slow-growing nerve-sheath tumour often associated with neurofibromatosis types I and II, both autosomal dominant disorders. Though these tumours are typically benign, but present with unique challenges in parturients, especially concerning airway management and selection of appropriate anaesthetic techniques. In this case, a 25-year-old pregnant female, presented at 37.6 weeks for an emergency lower segment caesarean section with a history of a Cervical Schwannoma & no other comorbidities, Airway examination MPC grade III. Due to the absence of intradural extension of the tumour, limited neck movement and reduced mouth opening, subarachnoid block was chosen over general anaesthesia. The surgery was uneventful, with slight autonomic dysreflexia managed intraoperatively. The patient delivered a healthy baby, and the postoperative course was stable with no neurological deficits. This case highlights importance of thorough preoperative neuroimaging and careful anaesthetic planning in managing pregnant patients with Schwannomas to minimize complications.

Introduction: Myocarditis is usually difficult to diagnose because its clinical behaviour may be entirely asymptomatic. It is defined as inflammatory changes of the myocardium and could be associated with myocyte necrosis. Patients with myocarditis are regarded to be of high risk for perioperative complications, necessitating diligent anaesthetic management. Case Report: A 26-year-old male diagnosed with acute appendicitis, known history of cardiomyopathy and sub clinical hypothyroidism. Patient had history of palpitations and syncope since 2 years, consulted cardiologist diagnosed as cardiomyopathy with suspected myocarditis. He had preceding viral infection 2weeks ago. He was athletic and had satisfactory daily activity. pre-operative evaluation ECG showed sinus bradycardia, second degree atrioventricular block and T wave abnormality. 2d echo showed preserved ejection fraction 55% with LV dilation and normal chamber dimensions and normal pulmonary artery pressure. Patient was induced as per the standard anaesthesia protocol and maintained on O2, N2O and Isoflurane. blood pressure about 130/80 mm hg. Intraoperatively Blood pressure was maintained around 130 - 140 systolic BP. During laparoscopy, little fluctuation in HR and BP was managed well, extubated with out any problems. The main concerns of this surgery were to avoid intra operative arrhythmia and atrioventricular block and ST segment elevation. Utmost care was taken for fluid management and pain, patient was on post-operative observation to see for any signs of dyspnea and ST elevation. Conclusion: As the patient was posted for acute appendicitis with known history of myocarditis. Early intensive hemodynamic management and support was extremely useful to these patients. In view of haemodynamic collapse due to arrythmias, the anaesthetic management was planned successfully without any consequences.

Not available