Breath on the Brink: Navigating Anaesthesia Management in a Case With a Mediastinal Mass.

Mediastinal teratomas are rare, often asymptomatic, but clinically significant neoplasms that can manifest with a spectrum of symptoms, frequently attributed to the compression of surrounding critical anatomical structures. Here, we present the case of a 19-year-old male with respiratory distress and chest pain attributed to a large anterior mediastinal mass, ultimately diagnosed as a benign mature teratoma of the thymus. Radiological imaging revealed a large, partially cystic mass compressing the pulmonary arteries, aortic arch, and left main bronchus. Surgical excision was deemed necessary due to symptomatic presentation. Anaesthesia management during mediastinal mass excision posed significant challenges, with prompt sternotomy due to ventilation difficulties after induction. Immediate decompression of the mass improved ventilation and saturation. Despite postoperative complications, including pulmonary leaks necessitating tracheostomy, the patient achieved significant recovery. Anaesthesia strategy was to prioritise avoiding muscle relaxants and maintaining spontaneous ventilation to mitigate airway collapse and hemodynamic instability during induction. Collaboration between anaesthesia, surgical, and intensive care teams is vital for comprehensive preoperative assessment, intraoperative readiness, and postoperative care. This case underscores the importance of interdisciplinary collaboration and meticulous planning to optimise outcomes in patients undergoing surgery for mediastinal teratomas.

A Study of Factors Predicting Difficulties in Transesophageal Echocardiography (TEE) Probe Insertion in Adult Patients Undergoing Cardiac Surgery.

Background and objective While transesophageal echocardiography (TEE) is crucial in cardiac surgery, the probe insertion can be challenging. This observational study aimed to identify predictive factors associated with difficult TEE probe insertion in adult cardiac surgery patients. Methods A total of 119 adult patients undergoing cardiac surgery were included in the study. Demographic variables (age, gender, and BMI) and airway factors (modified Mallampati classification, modified Cormack-Lehane grading, and thyromental distance) were analyzed. The difficulty of TEE probe insertion was categorized into three grades, and various maneuvers were assessed for difficult insertions. Results Of note, 30.3% of insertions were difficult. Male gender (OR: 1.8), BMI ≥30 kg/m2 (OR: 2.5), Mallampati class III-IV (OR: 3.2), Cormack-Lehane grade IIb-IV (OR: 2.7), and thyromental distance <6.5 cm (OR: 1.9) were significantly associated with difficult insertion. Jaw thrust was the most effective maneuver (58.3%) for difficult cases. Conclusions Based on our findings, several demographic and airway factors predict difficulties in TEE probe insertion. Understanding these factors can help clinicians anticipate challenges and prepare appropriate strategies, potentially reducing complications associated with probe insertion.

Anesthetic Management of a 24-Year-Old Male With Tracheal Stenosis Planned for Tracheal Resection and Anastomosis: A Case Report.

Tracheal resection and anastomosis are among the most challenging surgeries. Advancements in this field have made a variety of surgical, anesthetic, and airway management options possible. This procedure calls for multidisciplinary preoperative planning and close communication during surgery and recovery. Here, we present a case of a 24-year-old male who developed post-intubation tracheal stenosis. Repeated bronchoscopic dilatations were done for the same, but the symptoms persisted. Hence, the patient was planned for tracheal resection and anastomosis, the definitive surgical management. In this case report, we have discussed the anesthetic management of the same.

The psychological impact of COVID-19 among newly diagnosed patients: COVID Impact study.

BACKGROUND: COVID-19 has had adverse psychological impact on the general population. Most surveys published till date are online questionnaires targeting general population/health care providers. There is lack of data on the psychological impact of disease on newly diagnosed COVID-19 patients. METHODS: The study was conducted at a tertiary care hospital, actively involved in the management of COVID patients. Newly diagnosed COVID-19 patients who had presented to the outpatient COVID care clinic were interviewed face to face by an interviewer using 'Impact of Event Scale-Revised (IES-R)', a validated and universally accepted research questionnaire. RESULTS: Most of the respondents were males (83.2%), mean age: 40.8 years. 31.7% were graduates and 58.5% were actively employed. Fever (57.4%), cough (37.6%), and progressive breathlessness (08.9%) were the three most common clinical symptoms. The mean score on 'IES-R' was 31.8. 30.7% respondents had suffered 'severe' psychological impact, 30.7% had 'minimal' impact. 19.8% and 1.8% had 'mild' and 'moderate' psychological impact respectively. On linear regression analysis, increasing age had statistically significant corelation with increasing scores on 'IES-R scale' (p = 0.004). Educational qualifications of the patient had negative corelation (Pearson correlation=- 0.117) while none of the clinical parameters had any statistically significant correlation with the patients' psychological impact scores. CONCLUSION: COVID-19 patients are at an increased risk of suffering from disease-related adverse psychological impact. Certain risk groups especially like the elderly need close follow-up for early diagnosis and management. Future studies may be required to assess and manage 'post-traumatic stress disorder' that may arise in the aftermath of pandemic.

Comparison of prophylactic use of ketamine, tramadol, and dexmedetomidine for prevention of shivering after spinal anesthesia.

BACKGROUND AND AIMS: Shivering after spinal anesthesia is a common complication and can occur in as many as 40%-70% of patients after regional anesthesia. This shivering, apart from its physiological and hemodynamic effects, has been described as even worse than surgical pain. The aim of the study was to evaluate and compare the effectiveness of prophylactic use of intravenous (IV) ketamine, dexmedetomidine, and tramadol for prevention of shivering after spinal anesthesia. MATERIAL AND METHODS: Two hundred American Society of Anesthesiologists physical status I and II patients subjected to spinal anesthesia were included in the study. The subjects were randomly divided into four groups to receive either ketamine 0.5 mg/kg IV or tramadol 0.5 mg/kg IV or dexmedetomidine 0.5 microgm/kg IV or 10 mL of 0.9% normal saline (NS). All the drugs/NS were administered as IV infusion over 10 min immediately before giving spinal anesthesia. Temperature (core and surface), heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure, peripheral oxygen saturation were assessed before giving the intrathecal injection and thereafter at 5 min intervals. Important side effects related to study drugs were also noted. RESULTS: Shivering after spinal anesthesia was comparatively better controlled in group receiving dexmedetomidine as compared to other groups (P = 0.022). However, the use of dexmedetomidine was associated with significant hypotension which responded to single dose of mephentermine (3 mg IV). Dexmedetomidine is a better agent for prevention of shivering after spinal anesthesia as compared to ketamine and tramadol. It also provides adequate sedation and improves the surgical conditions. CONCLUSION: Dexmedetomidine is effective and comparably better than tramadol or ketamine in preventing shivering after spinal anesthesia. Dexmedetomidine also provides sedation without respiratory depression and favorable surgical conditions. However, with its use a fall in blood pressure and heart rate is anticipated.

Anaesthetic management of forearm fractures using a combination of haematoma block and intravenous regional anaesthesia.

BACKGROUND: Intravenous regional anaesthesia (IVRA) has been successfully used as a sole technique for forearm fractures and has high success rates. However, it is uncomfortable for the patient when the fresh fracture is manipulated for conduct of IVRA. Haematoma block (HB) has also been demonstrated as an effective anaesthetic technique for treatment of radial fractures in the ER. Unfortunately, HB does not provide muscular relaxation and may not be sufficient for operative intervention. METHODS: An observational case series was designed with the hypothesis that a combination of HB and IVRA would overcome the aforementioned drawbacks. A standardized protocol was followed for HB with 0.1 ml/kg of 0.5% bupivacaine preceding the conduct of IVRA, which permitted adequate exsanguination of the extremity (using compression bandage). For IVRA, 0.5% lignocaine at 3 mg/kg was used with an electro-pneumatic tourniquet. Pain scores were noted after the HB, at exsanguination and during surgery. RESULTS: 100 cases were studied. Average time of onset of block after HB was 2 min 18 s. By the time the IVRA procedure was performed, 99% of patients had a pain score of zero. The quality of surgical anaesthesia revealed that 94% of the patients did not have any pain of incision, tourniquet or positioning at any time during surgery. CONCLUSION: The use of dual technique of HB and IVRA improved patient acceptance and compliance, and the safety and efficacy of the IVRA. The combination anaesthesia was found to be easy to administer, effective and safe with no complications.

Anaesthetic management of left main bronchial glomus tumour.

Glomus tumours involving bronchus are rare. Surgical resection is the treatment of choice for this tumour, with excellent prognosis. The nature and location of tumour pose a significant challenge for perioperative anaesthetic management. However, there is a paucity of case reports on anaesthetic risks involved in case of a bronchial glomus tumour. We present a case of glomus tumour involving left main stem bronchus, subjected to bronchial sleeve resection. The various anaesthetic implications of this tumour type and airway management with right double lumen tube are discussed.

A randomized, controlled trial to compare the efficacy and safety profile of a dexmedetomidine-ketamine combination with a propofol-fentanyl combination for ERCP.

BACKGROUND AND AIMS: Moderate to deep levels of sedation and analgesia are required for ERCP. Propofol-based sedation is simple, easy to use, and effective, but is not without cardiovascular and respiratory adverse effects. The combination of dexmedetomidine and ketamine (DK) has shown promising results for sedation in other similar scenarios. The aim of this study was to compare the efficacy and safety of a standard propofol-fentanyl (PF) regimen with a DK combination. METHODS: After approval of the hospital ethics committee, 83 patients (18-75 years of age) were randomized and divided into 2 groups. Forty-two patients received a PF combination (group PF) and 41 patients received DK combination (group DK) for total intravenous anesthesia for ERCP as initial boluses followed by an infusion of PF and DK, respectively. The sedation-related adverse effects and recovery time were noted. RESULTS: The mean values of the hemodynamic and respiratory parameters were in clinically acceptable ranges, but there were more episodes of hypotension (19%), bradycardia (4.7%), and decrease in oxygen saturation (Spo(2) <80% in 11.9% and Spo(2) <90% for >10 s in 42.8%) in group PF. The procedure could be completed in all of the patients but was interrupted in 6 patients in group PF because of desaturation (5) or sudden patient movement (1). The recovery time was longer in group DK than in group PF. CONCLUSION: There were significantly fewer sedation-related adverse effects, but the recovery time was longer with DK.

Heparin: induced thrombocytopenia: incidence and laboratory approach to diagnosis in Indians.

BACKGROUND AND OBJECTIVES: One of the most common complications of heparin administration is heparin-induced thrombocytopenia (HIT) which can also lead to catastrophic thrombotic events. The problem of identifying the cause of thrombocytopenia, as due to heparin, in patients with multiple co-morbid conditions is very essential for management. Thus, the laboratory investigations for diagnosis of HIT play a pivotal role. The objective of the study was to arrive at the incidence of HIT in ethnic Indian population and provide a decision after analysis of tests used to diagnose HIT. MATERIALS AND METHODS: 125 consecutive patients (Power of study being 80%) undergoing open heart surgery and receiving unfractionated heparin were taken as subjects. Blood samples were collected a day before the surgery and days 1, 3, 5 and 7 after surgery. The cases were categorized into probable and unlikely groups depending on the clinical presentation and degree fall of platelet count. Anti-heparin PF4-associated antibodies were detected using rapid-ID gel microtyping system and ELISA tests. HIT was also tested using functional assays: heparin-induced platelet aggregation test (PAT) and the rapid luminographic assay of heparin-induced ATP release. RESULTS: Of the 125 patients, 11 patients were clinically labeled as probable HIT and 29 patients were clinically labeled as unlikely HIT. There were seven confirmed cases of HIT cases that were positive for one functional and one immunological assay. Only one case of HITT was encountered. Accordingly, the incidence of HIT was found to be 5.6% and that of HITT to be 0.8%. ELISA tests were positive in 21 cases (17%) which demonstrated the presence of anti-HPF4 antibodies in non-HIT cases as well. It was found that the rapid gel test had sensitivity comparable to functional assay with better specificity than ELISA. INTERPRETATION AND CONCLUSIONS: Incidence of HIT in ethnic Indian population is 5.6%. Patients with a drop of >50% in platelet count should be perused as a likely candidate of HIT. These cases should be subjected to the ID-HPF4 antibody assay as this is a rapid test, can be done for individual cases, and has better specificity and similar sensitivity than ELSIA. Cases with clinically probable HIT and a positive ID-HPF4 assay can be taken as confirmed cases of HIT. However, cases clinically unlikely for HIT and a positive ID-HPF4 assay should be subjected to another test to establish the diagnosis of HIT.

Pulmonary artery aneurysm with dissection and hemopericardium.

Pulmonary artery aneurysm presenting with dissection and hemopericardium is extremely rare, and we came across one such case in our center. The patient was a 22-year-old man who presented with dyspnoea, tachypnoea, and pallor. On evaluation, he was found to have a leaking pulmonary artery aneurysm with dissection and hemopericardium, and a patent ductus arteriosus. He underwent pericardiocentesis followed by successful closure of the ductus, aneurysmectomy, and reconstruction of the pulmonary artery.