Clinical outcome of orbital apex syndrome in COVID associated mucormycosis patients in a tertiary care hospital.

AIM: To share clinical pattern of presentation, the modalities of surgical intervention and the one month post-surgical outcome of rhino-orbito-mucormycosis (ROCM) cases. METHODS: All COVID associated mucormycosis (CAM) patients underwent comprehensive multidisciplinary examination by ophthalmologist, otorhinolaryngologist and physician. Patients with clinical and radiological evidence of orbital apex involvement were included in the study. Appropriate medical and surgical intervention were done to each patient. Patients were followed up one-month post intervention. RESULTS: Out of 89 CAM patients, 31 (34.8%) had orbital apex syndrome. Sixty-six (74.2%) of such patients had pre-existing diabetes mellitus, 18 (58%) patients had prior documented use of steroid use, and 55 (61.8%) had no light perception (LP) presenting vision. Blepharoptosis, proptosis, complete ophthalmoplegia were common clinical findings. Seventeen (19.1%) of such patients had variable amount of cavernous sinus involvement. Endoscopic debridement of paranasal sinuses and orbit with or without eyelid sparing limited orbital exenteration was done in most cases, 34 (38.2%) patients could retain vision in the affected eye. CONCLUSION: Orbital apex involvement in CAM patients occur very fast. It not only leads to loss of vision but also sacrifice of the eyeball, orbital contents and eyelids. Early diagnosis and prompt intervention can preserve life, vision and spare mutilating surgeries.

Airway devices in paediatric anaesthesia.

Airway devices were first used in children since 1940 and thereafter an increasingly large number of paediatric airway devices have come into our armamentarium. To control and protect the airway in children during anaesthesia, in intensive care unit or in emergency department either tracheal intubation is performed under direct or indirect visualization of vocal cords with the help of laryngoscopes or video-laryngoscopes respectively or it can be done blindly or by using special instruments such as fiberoptic laryngoscope, lighted stylet or Bullard laryngoscope to name a few. Airway also can be maintained with the help of Laryngeal mask airways, oropharyngeal and nasopharyngeal airways. Updating our information and knowledge regarding these developments is pivotal to our practice of paediatric anaesthesia. With a thorough search of books, MEDLINE, MEDNET, clinical trials.gov.in, this article aims at focusing and understanding a brief basis of paediatric devices and their use.

Caudal-epidural bupivacaine versus ropivacaine with fentanyl for paediatric postoperative analgesia.

BACKGROUND AND AIMS: Caudal-epidural, the most commonly used regional analgesia technique, is virtually free of measurable hemodynamic effects, thus adding a new dimension to the evolving necessity of pediatric postoperative pain management. Though, bupivacaine is the most commonly used drug for this purpose, ropivacaine has emerged as a safer alternative, with the addition of opioids, like fentanyl, increasing the effective duration of analgesia. With this overview, our present study was designed to compare the postoperative analgesic efficacy of bupivacaine-fentanyl and ropivacaine-fentanyl combinations by caudal-epidural technique in pediatric infraumbilical surgeries. MATERIALS AND METHODS: Totally, 60 pediatric patients, of either sex, aged between 2 and 8 years, American Society of Anesthesiologists physical status I and II, undergoing elective infraumbilical surgeries were assigned into two groups, Group BF receiving bupivacaine 0.25%, 0.7 ml/kg and Group RF receiving ropivacaine 0.25%, 0.7 ml/kg with fentanyl 1 µg/kg added to each group. Assessment of pain was done using "Hannallah pain scale." Consumption of the total amount of rescue analgesic and time to requirement of the first dose, as also duration of motor blockade were noted. Perioperative hemodynamics and any adverse effects were monitored at regular intervals. RESULTS: The RF Group experienced significantly longer duration of effective postoperative analgesia, with significantly shorter duration of motor blockade and lesser total analgesic requirement in comparison to the BF Group. Hemodynamically, patients in both the groups, were equally stable. CONCLUSION: Ropivacaine, with an equipotent analgesic efficacy and a lesser duration of motor block, can be used as an alternative to bupivacaine for pediatric postoperative pain care through the caudal route.

Anaesthetic management in a case of huge plunging ranula.

Plunging ranula is a rare form of mucous retention cyst arising from submandibular and sublingual salivary glands, which may occasionally become huge occupying the whole of the floor of the mouth and extending into the neck, thus, restricting the neck movement as well as disfiguring the normal airway anatomy. Without fiberoptic assistance, blind or retrograde nasal intubation remains valuable choices in this type of situation. Here, we present a case of successful management of airway by blind nasal intubation in a patient posted for excision of a huge plunging ranula.

Successful emergency airway management in a case of removal of foreign body bronchus in a pediatric patient.

Foreign body (FB) aspiration into the respiratory tract is a common incident, especially in the pediatric age group and can, sometimes, pose a real challenge to the anesthesiologists as far as the airway management is concerned. Here, we report a case of FB bronchus in a 3 year 2 months old boy, presenting to the emergency in a cyanosed and comatosed condition with severe respiratory distress. In spite of the unavailability of a pediatric fiberoptic bronchoscope in our hand, the gradual declining condition of the baby made us to take the challenge. The FB was successfully removed through a tracheotome using a nasal endoscope.

Effects of intrathecal hyperbaric ropivacaine versus hyperbaric bupivacaine for lower limb orthopedic surgery.

BACKGROUND: Regional anesthesia, increasingly used for infraumbilical surgery, has advantages of decreased stress response to surgery, nausea, vomiting, and cardio-respiratory depression with improved postoperative analgesia, in comparison to general anesthesia. Intrathecal isobaric ropivacaine (RP) had been found, in various clinical studies, to be shorter acting in comparison to bupivacaine (BP). Our present study was, hence, aimed to compare the anesthetic and analgesic efficacy of intrathecal hyperbaric RP relative to hyperbaric BP in lower limb orthopedic surgery. MATERIALS AND METHODS: A total of 100 patients aged ranges between 18 and 60 years of either sex, ASAPS 1 and 2, undergoing elective lower limb orthopedic surgeries were divided into two groups, RP group and BP group receiving intrathecal 0.75% RP 3 ml and glucose 50%, 0.5 ml and 0.5% hyperbaric BP 3 ml and 0.9% normal saline 0.5 ml, respectively. The efficacy in terms of onset and duration of anesthesia and analgesia were assessed along with the heart rate, blood pressure at regular intervals throughout the perioperative period. RESULT: The two study groups were comparable in terms of demography and duration of surgery. Patients in group RP experienced significantly late onset and shorter duration of sensory and motor block in comparison to patients in group BP. There were clinically insignificant differences in perioperative hemodynamics and side-effects noted in each group. Hence, it was observed in this study that equipotent dose of hyperbaric RP had shorter duration of analgesia and anesthesia than with equipotent dose of hyperbaric BP.

A comparative study of the efficacy of intravenous Paracetamol and Dexmedetomidine on peri-operative hemodynamics and post-operative analgesia for patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Unrelieved post-operative pain may result in the physical suffering as well as multiple physiological and the psychological consequences, which may adversely affect the peri-operative outcome and contribute to increase the length of stay in hospital. OBJECTIVES: We designed this study to evaluate the effect of IV Paracetamol and Dexmedetomidine as multimodal analgesic technique on post-operative analgesia and to reduce the consumption of the systemic opioid and its adverse effects in cases of laparoscopic cholecystectomy. MATERIALS AND METHODS: Eighty consenting, American society of Anesthesiologist-physical status-I (ASA-PS-I), female patients, aged 19-60 year was randomly assigned to one of the following two groups: Group P (n = 40) received IV 1 g Paracetamol infusion over 10 min pre-operatively and 6 hourly thereafter and Group D (n = 40) received IV Dexmedetomidine 1 µg/kg bolus over 10 min pre-operatively and 0.2-0.4 µg/kg/h thereafter for 24 h. Peri-operative hemodynamic variables, post-operative pain scores, and the need for rescue analgesics were recorded and compared. RESULTS: Profiles of intra-operative hemodynamic changes were similar in both groups in respect to heart rate (HR), diastolic blood pressure, mean arterial pressure except in the systolic blood pressure where Dexmedetomidine significantly reduced it in compare to Paracetamol (P = 0.014). Post-operatively 4(th) h and 24(th) h changes in mean HR between two groups was a statistically significant (P < 0.05). Visual analog scale scores were significantly lower in the Group P compared with Group D at 8(th), 16(th), and 24(th) h (P < 0.001). Sedation score were statistically higher in the Group D compared with the Group P at post-operative 4(th), 8(th), 16(th), and 24(th) h (P < 0.006). CONCLUSION: Adjunctive use of both Paracetamol and Dexmedetomidine infusion reduced opioid use. However, Paracetamol peri-operatively provides adequate analgesia with the less sedation whereas Dexmedetomidine provides analgesia and co-operative sedation.

Detection of hypoxia in the early postoperative period.

The aim of this study was to determine the incidence of early postoperative hypoxia after general anesthesia and to evaluate the need of oxygen supplementation. A total of 150 patients aged between 18-60 years belonging to ASA I or II were studied. Patients were alternately allocated to two groups of 75 each. Group-I (n=75) patients received 2 L of oxygen via nasopharyngeal catheter during transfer from operation theatre to recovery room and in the recovery room for a period of 4 h. Group-II (n=75) patients did not receive oxygen either during transfer or in the recovery room. Twenty percent in Group-II developed hypoxaemia during transfer from operation theatre to recovery room out of which 24% developed mild (SaO2 86-90%), 2.66% moderate (SaO2 85-81%), and 1.33% extreme (SaO2 <76%) hypoxaemia. None of the patients in Group - I, who received oxygen supplementation, developed hypoxaemia in the early postoperative period.

Clonidine as an adjuvant in axillary brachial plexus block for below elbow orthopedic surgeries: A comparison between local and systemic administration.

BACKGROUND: Axillary brachial plexus block for below elbow orthopedic surgery provides a safe and low-cost technique with the advantage of prolonged postoperative analgesia. Clonidine, with selective partial agonist activity on α2 adrenergic receptors, has significantly demonstrated its role in this regard as an adjuvant to local anesthetics. The current study compares the locally administered clonidine with systemically administered control group in terms of onset and duration of sensory block, motor block, and analgesia; hemodynamic variability; sedation; and other side effect profile. MATERIALS AND METHODS: Seventy patients (ASA I or II) scheduled for below elbow orthopedic surgeries were randomly allocated in equal numbers to receive either 30 ml of 0.5% plain bupivacaine with 150 µg (1 ml) of inj. clonidine locally in the axillary sheath and 1 ml of normal saline (NS) subcutaneously (Group L) or 30 ml of 0.5% plain bupivacaine with 1 ml of NS locally and 150 µg (1 ml) of inj. clonidine subcutaneously (Group S). Standard monitoring of vital parameters was done. Duration of sensory and motor block, analgesia, hemodynamic changes, and any adverse effects were observed and recorded for different duration up to 24 h. RESULTS: Duration of sensory block (625 ± 35 min), motor block (690 ± 38 min), and analgesia (930 ± 45 min) was significantly longer in Group L than in Group S [sensory block (480 ± 30 min), motor block (535 ± 25 min), and analgesia (720 ± 30 min)] (P < 0.05). Significant alteration of heart rate, systolic blood pressure and diastolic blood pressure, and mean arterial pressure in Group S was observed compared to Group L (P < 0.05). Side effects like nausea and vomiting were comparable, but highly significant sedation score (χ(2) = 47.75 and 49.51 at 120 and 240 min, respectively; P < 0.01) was observed between the two groups. CONCLUSION: Compared to systemic administration, local clonidine as an adjuvant in axillary block resulted in significant prolongation of duration of sensory and motor blockade, and analgesia without any hemodynamic alteration, probably by locally mediated mechanism of action.

Ondansetron, ramosetron, or palonosetron: Which is a better choice of antiemetic to prevent postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy?

BACKGROUND: Postoperative nausea and vomiting (PONV) is a serious concern in patients undergoing laparoscopic cholecystectomy (LC), with an incidence of 46 to 72%. The purpose of this study was to compare the antiemetic efficacy of intravenous (iv) ondansetron 8 mg, ramosetron 0.3 mg, and palonosetron 0.075 mg for prophylaxis of PONV in high-risk patients undergoing LC. MATERIALS AND METHODS: In this prospective, randomized, double-blinded study, 87 female patients, 18 to 70 years of age (ASA I and II) and undergoing elective LC under general anesthesia were randomly allocated into three equal groups, the ondansetron group (8 mg iv; n=29), the ramosetron group (0.3 mg iv; n=29), and the palonosetron group (0.075 mg iv; n=29), and the treatments were given just after completion of surgery before extubation. The incidence of complete response (patients who had no PONV and needed no other rescue antiemetic medication), nausea, vomiting, retching, and need for rescue antiemetics over 24 hours after surgery were evaluated. RESULTS: The number of complete responders were 19 (65.5%) for ramosetron, 11 (37.9%) for palonosetron, and 10 (34.5%) for ondansetron, representing a significant difference overall (P=0.034) as well as between ramosetron and ondansetron (P=0.035). Comparison between ramosetron and palonosetron also showed a clear trend favoring the former (P=0.065). CONCLUSION: Ramosetron 0.3 mg iv was more effective than palonosetron 0.075 mg and ondansetron 8 mg in the early postoperative period, but there was no significant difference in the overall incidence of nausea suffered.