Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique.

AIMS: To compare the efficacy, complications, cost analysis and hospital stay between two methods of drainage of the kidney: double J (DJ) stent versus nephrostomy tube following open pyeloplasty for ureteropelvic junction obstruction hydronephrosis. PATIENTS AND METHODS: This was a prospective randomized study of 20 patients in each group over 14 months. Pre and post-operative (3 months) function and drainage were assessed by ethylenedicysteine scan and intravenous urogram. RESULTS: Both groups showed similar good improvement in function and drainage. Nephrostomy group had significantly longer hospital stay (P < 0.001) but incurred less cost. Complications with nephrostomy included tube breakage (n = 1) and urine leak after tube removal (n = 2). DJ stents were associated with stent migration (n = 4), increased frequency of micturition (n = 9), dysuria (n = 4) and urinary tract infection (n = 1). CONCLUSION: Both methods of drainage did not interfere with improvement after pyeloplasty. Minor complications were more with DJ stent (P = 0.0003). Although overall cost of treatment was more with stents, they reduced length of hospital stay. Optimal length of stent is essential to reduce complications secondary to migration and bladder irritation.

Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study.

INTRODUCTION: Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics. MATERIALS AND METHODS: ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg(-1)) followed by infusion of 10-20 µg·kg(-1) ·min(-1) or group M (midazolam) loading dose of (0.02 mg·kg(-1)) followed by 1-2 µg·kg(-1) ·min(-1). The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002). RESULTS: A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly. CONCLUSIONS: Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values.

A rare anatomical variation of the brachial plexus: single cord anomaly.

Anatomical variations of the brachial plexus may be important in regional anesthesia and upper limb procedures. A fused single cord of the brachial plexus, although considered rare, was discovered in 4 Indian male cadavers during the dissection of 90 brachial plexuses. All 4 cases demonstrated deviation from the usual pattern starting at the division of trunks continuing to the formation of cords. The location of these single cords was lateral to the axillary artery instead of the typical perivascular relationship. A fused single cord of brachial plexus might be more common than previously thought. The impact on the performance or success of blockade remains unknown.

Effect of lumbar epidural administration of neostigmine on lower urinary tract function.

BACKGROUND: Neostigmine is cholinomimetic and is used for postoperative analgesia. Its urodynamics effects on voiding function have not been elucidated. MATERIALS AND METHODS: Adult patients without bothersome voiding symptoms planned for rigid cystoscopy under local anesthesia were enrolled. They underwent multichannel urodynamics (filling cystometry and pressure-flow study) before and 30 min after lumbar epidural administration of Neostigmine (2 microg/kg). RESULTS: Indications for cystoscopy were check examination for follow up of carcinoma urinary bladder (n = 3), staging for carcinoma cervix (5), and removal of ureteral stent (4). Patients' mean age was 51.9 +/- 11.7 years and international Prostatic symptom score 2.34 +/- 3.41. A trend of decreased maximum cystometric capacity (MCC) was observed after Neostigmine (413.50 +/- 142.45 ml vs. 357.00 +/- 145.62 ml; P = 0.056) without any change in end-filling pressure. Five patients developed detrusor overactivity (DO) and one had increase in its amplitude (P = 0.031). Four patients developed rhythmic rectal contractions and one had increase in its amplitude (P = 0.219). There was no difference in any of the voiding parameters. Mean Visual Analog Pain Score (VAS scale 0-10) during cystoscopy for this group was significantly lower than that in a similar group of patients who did not receive Neostigmine prior to rigid cystoscopy (1.16 +/- 0.94 vs. 4.57 +/- 1.45; P = 0.0001). The drug was well tolerated in majority of the patients. CONCLUSION: Epidural Neostigmine is effective in providing analgesia during diagnostic rigid cystoscopy. It leads to development of DO and decrease in bladder capacity without any effect on voiding function. These findings may help clinicians to use it for transurethral procedure-related pain relief without apprehension of voiding difficulty.

Anatomical dimensions of larynx, epiglottis and cricoid cartilage in foetuses and their relationship with crown rump length.

BACKGROUND: Advances in perinatal care and increased use of diagnostic and interventional procedures on foetal airway demand a clear understanding of their normal anatomy and development. This study is aimed at determining the normal dimensions of larynx, cricoid cartilage and epiglottis and their correlation to age and crown rump length (CRL). METHOD: After approval from institutional ethics committee and written parental informed consent, laryngeal measurements were taken from 79 foetuses of varying CRL from 30 to 299 mm. The entire larynx from the tip of epiglottis to lowest extension of thyroid gland was isolated and preserved. In small foetuses (30-165 mm) the measurements were taken under a dissecting microscope. In foetuses above the CRL of 165 mm, the measurements were taken with help of Vernier Calliper. RESULTS: Foetuses were analysed for dimensions based on CRL. The length of the larynx significantly increased in comparison to CRL (P < 0.001). Similar measurements were observed for transverse diameter, anteroposterior diameter and inter-cartilaginous distance of larynx, the anterior height of arch and posterior height of lamina of cricoid cartilage and the length and breadth of epiglottis. The internal anteroposterior and transverse diameter of cricoid cartilage showed no correlation with CRL. CONCLUSION: All the measured parameters of larynx, epiglottis and cricoid cartilage showed positive correlation with the CRL except the internal diameters of cricoid.

Paediatric perioperative cardiac arrest and its mortality: database of a 60-month period from a tertiary care paediatric centre.

BACKGROUND AND OBJECTIVE: The analysis of perioperative cardiac arrest and mortality remains a potentially valuable method to improve clinical outcome. This survey evaluated the incidence and causes of perioperative cardiac arrests and mortality in a paediatric surgical population over 5 years. METHODS: All cardiac arrests that occurred between April 2003 and March 2008, during administration of anaesthesia at the paediatric centre of our institute, were recorded from an anaesthesia database and postsurgical ICU census register. All surgery performed under anaesthesia was included whether emergency or elective. All surgical procedures were covered except eye surgery, cardiac surgery and the procedures performed at remote locations. Data collected included patient characteristics, surgical procedures, preoperative physical status and anaesthesia-provider information, immediate cause of cardiac arrest, antecedent events, management and outcome. All cardiac arrests were grouped according to the cause of arrest into one of four groups: totally anaesthesia related, partially anaesthesia related, surgery related or child condition related. RESULTS: There were a total of 27 cardiac arrests out of 12 158 procedures. Major risk factors for cardiac arrests were children under 1 year of age (P < 0.05), ASA physical status (ASA-PS) III or more (P < 0.001) and emergency surgery (P < 0.01). There were nine cardiac arrests attributed to anaesthesia, three totally and six partially related to anaesthesia. The main causes of anaesthesia-related cardiac arrest were respiratory events (56%), followed by cardiac events (33%). Anaesthesia-related mortality was 1.2/10 000 anaesthetics in patients with ASA-PS I-II and 7.7/10 000 anaesthetics in patients with ASA-PS III-V with a survival rate of 56%. CONCLUSION: Major risk factors for cardiac arrests were age under 1 year, poor physical status and emergency surgery. Respiratory and cardiovascular-related events accounted for most of all anaesthesia-related cardiac arrests. High ASA-PS was the leading cause of perioperative mortality.

Tramadol added to bupivacaine does not prolong analgesia of continuous psoas compartment block.

The primary aim of our study was to evaluate the quality and duration of analgesia when tramadol was added to 0.25% bupivacaine for continuous psoas compartment block (CPCB) using visual analog pain scores. Thirty patients were prospectively randomized into two equal groups (n = 15). Visual analog scale pain score was not significantly different between the groups during the 48-hour follow-up period. Rescue analgesic consumption, nausea and vomiting, and the satisfaction scores were comparable between the groups (P > 0.05). Success with catheter placement adjacent to the lumbar plexus was 100%, and none of the patients developed any catheter-related complications. In conclusion, tramadol does not provide a clinically significant analgesic action as an adjunct to 0.25% bupivacaine for CPCB.

A dose-ranging study of intraarticular midazolam for pain relief after knee arthroscopy.

BACKGROUND: A variety of analgesic techniques have been used to manage postoperative pain after arthroscopic knee surgery. Intraarticular midazolam may have an analgesic effect similar to that seen when midazolam is used in a centroneuraxial fashion. METHODS: Sixty ASA status I or II patients undergoing knee arthroscopy with general anesthesia were randomized to receive intraarticular midazolam 50 mug/kg, 75 mug/kg, or isotonic saline. We assessed the efficacy of the analgesic technique with visual analog scale pain scores, time until first request for analgesics, and cumulative analgesic consumption. Patients were observed for 48 h. RESULTS: The addition of intraarticular midazolam significantly reduced visual analog pain scores in the early postoperative period compared with saline. Both doses similarly prolonged duration until first request for analgesic compared with saline (4.7 and 4.6 vs 0.7 h). There was no statistically significant difference between the two doses of midazolam or cumulative 48 h analgesic consumption. CONCLUSIONS: We conclude that when intraarticular midazolam was compared with placebo there was a reduction in pain after day-case arthroscopic knee surgery; however, this pain relief was of relatively short duration.

Anatomical dimensions of trachea, main bronchi, subcarinal and bronchial angles in fetuses measured ex vivo.

BACKGROUND: The increasing opportunities to consider fetal intervention in selected cases of life-threatening malformations have necessitated airway management of fetuses with low gestational age. This study is aimed to determine the anatomical dimensions of trachea, main bronchi, subcarinal and bronchial angles and their correlation to age and crown rump length (CRL) in fetuses. METHODS: Measurements of tracheo-bronchial dimensions including the subcarinal and bronchial angles with the vertical were taken in specimens obtained from 40 fetuses, varying in CRL from 61 to 270 mm. The incidence of different shapes at the upper end of trachea was studied. The subcarinal and angles of main bronchi with the vertical were measured radiographically with 20% barium sulfate, in another group of 21 fetuses varying in CRL from 63 to 129 mm. RESULTS: Forty fetuses (22 males, 18 females) were analyzed for the dimensions based on CRL (61-130 mm; 131-200 mm; 201-270 mm--CRL 1, 2, and 3 respectively). The internal transverse diameter of trachea was found to increase steadily from 1.87 +/- 0.56 to 2.67 +/- 0.7 mm (P < 0.001) and 3.68 +/- 0.39 mm (P < 0.001) with increasing CRL. Similarly the outer transverse and antero-posterior diameter of the trachea increased steadily with age. Tracheal length was found to increase significantly to 17.48 +/- 2.89 mm and 24.17 +/- 2.3 from 12.72 +/- 2.5 mm (P < 0.001). The length of paries membranaceous increased with gestational age. Although the length of bronchi increased significantly and linearly, subcarinal and bronchial angles did not show any significant changes with age. There was no sexual dimorphism in measurements in the fetuses of corresponding CRL. Oval shaped trachea was found in 60% and circular in 40% of fetuses. The measurements of subcarinal and bronchial angles performed by radiology were almost the same as those measured in trachea separated from fetuses. CONCLUSION: The internal transverse, outer transverse and antero-posterior diameters, length of trachea and bronchi and circumference of trachea, relate in a linear fashion to CRL and age. However, subcarinal and bronchial angles remained constant.

Dose-response study of intrathecal fentanyl added to bupivacaine in infants undergoing lower abdominal and urologic surgery.

BACKGROUND: Intrathecal (IT) adjuncts often are used to enhance the duration of spinal bupivacaine. Fentanyl is a spinal analgesic that could be a useful adjunct, and enhances the duration and quality of sensory block in adult surgical and obstetric population. However, no data exist to assess the dose-response characteristics of IT fentanyl when added to bupivacaine in infants. METHODS: Fifty-eight infants undergoing lower abdominal and urologic procedures were randomized into four groups to receive plain 0.5% hyperbaric bupivacaine F0 (<5 kg = 0.5 mg.kg(-1); 5-10 kg = 0.4 mg.kg(-1)). Groups F0.25, F0.5, and F1 groups received bupivacaine added with 0.25, 0.5, and 1 mug.kg(-1) of fentanyl, respectively. Duration of spinal anesthesia (SA) as assessed by the recovery of hip flexion in the postoperative period was the primary variable analyzed. In addition, the duration of analgesia in the postoperative period, rescue postoperative analgesic requirements and hemodynamic changes were recorded. RESULTS: Fifty-six infants were studied. The four groups were similar for age, weight, duration of surgery, onset of sensory, motor block, and the highest level of analgesia attained. The addition of 1 mug.kg(-1) fentanyl (F1) significantly increased the duration of SA (74.27 +/- 6.1 min) compared to the control group (51.21 +/- 5.2 min) (P = 0.001). Postoperative pain-free interval was prolonged (P = 0.004) and significantly less rescue analgesics were required after 1 mug.kg(-1) IT fentanyl (P = 0.032). These parameters did not show any significant difference among groups F0, F0.25, and F0.5. CONCLUSIONS: The addition of 1 mug.kg(-1) IT fentanyl to spinal bupivacaine prolonged the duration of spinal block in infants undergoing lower abdominal and urologic procedures.

Anesthesia management of a ganglioneuroma with seizures presenting as pheochromocytoma.

Ganglioneuromas (GN) are neural crest cell-derived tumors which may coexist with pheochromocytomas, secrete various neuropeptides or the symptoms may mimic that of a pheochromocytoma, producing hypertension or a hypotensive crisis during anesthesia for these tumors. We report here the case of a 7-year-old female child with an adrenal tumor suspected to be a pheochromocytoma, later confirmed by histology as a GN. This child presented with episodic headache, anxiety, palpitations and 3D helical (spiral) computed tomography of the abdomen revealed an adrenal tumor. In addition, the child was diagnosed to have a seizure disorder. She was managed as a pheochromocytoma. Although the child's preoperative catecholamine levels were normal, tumor manipulation caused a hypertensive crisis. We discuss the clinical characteristics of this unusual case, anesthesia management, and the postoperative course.

Combined continuous "3-in-1" and sciatic nerve blocks provide improved postoperative analgesia with no correlation to catheter tip location after unilateral total knee arthroplasty.

This study assessed the efficacy and duration of postoperative analgesia after continuous sciatic nerve block with and without continuous "3-in-1" block with bupivacaine after unilateral total knee arthroplasty and determined catheter tip correlation with analgesia. Thirty patients were randomized into 2 groups. Results suggested significantly reduced pain and rescue analgesic requirement in combined sciatic and 3-in-1 (group TS) compared to 3-in-1 group alone (group T). The postoperative pain-free interval and satisfaction score was significantly higher in the combined group (P < .05). The percentage of catheters in the ideal position was 53.3% for 3-in-1 and 93.3% for sciatic nerve. In conclusion, continuous sciatic nerve block when added to continuous 3-in-1 block provides a better quality of analgesia with lesser requirements of rescue analgesics without the need for routine radiographic conformation.

Preemptive gabapentin reduces postoperative pain and opioid demand following thyroid surgery.

PURPOSE: Gabapentin is reported to possess antihyperalgesic and antiallodynia properties. Recently, reports have indicated that gabapentin may have a place in the treatment of postoperative pain. In this study, we sought to determine whether preemptive use of gabapentin reduced postoperative pain and morphine demand following thyroidectomy. METHODS: In this prospective, randomized, double-blind clinical trial, we gave gabapentin 1200 mg or placebo two hours prior to induction of anesthesia to patients undergoing elective thyroidectomy. Post-thyroidectomy pain was assessed on a visual analogue scale at rest and during swallowing in the first 24 hr postoperatively. All patients received morphine 3 mg iv every five minutes until visual analogue scale scores were 4 or less at rest, and 6 or less with swallowing. Total morphine consumption for each patient was recorded from zero to 24 hr postoperatively. RESULTS: Thirty-seven patients in the gabapentin group and 35 patients in the placebo group completed the study. Overall, pain scores at rest and during swallowing in the gabapentin group were significantly lower when compared with the placebo group. Total postoperative morphine consumption in the gabapentin group was 15.2 +/- 7.6 mg (mean +/- SD) vs 29.5 +/- 9.9 mg in the placebo group (P < 0.001). No significant differences in side effects were observed between groups. CONCLUSIONS: Preoperative gabapentin decreased pain scores and postoperative morphine consumption in patients following thyroid surgery.