Paraplegia after Pneumonectomy - A Rare Complication.

ABSTRACT: Cardiac metastases of lung cancers are common and are associated with serious complications. Locally aggressive lung tumors have the potential to extend into the left atrium via pulmonary veins, which can further complicate by embolizing into the systemic circulation. Pulmonary blastoma (PB) is one of the rare forms of primary lung malignancy and is locally aggressive. We report a rare case of 30 years old male patient who underwent left pneumonectomy for PB. During resection, the tumor was embolized into the descending thoracic aorta, leading to an acute circulatory compromise of both the lower limbs.

Anesthetic Considerations for Adult Patients With Both Down Syndrome and Congenital Heart Disease Undergoing Noncardiac Surgery: A Review Article.

The population of adult patients with both Down syndrome and congenital heart disease is increasing due to better medical and surgical care. This cohort presents with multiple unique comorbidities, secondary to both progressions of health conditions associated with the aging of patients with Down syndrome, as well as due to pathophysiologic effects of uncorrected, corrected, or palliated congenital heart disease. These patients need frequent medical care and interventions requiring multiple anesthetics. This review focuses on the various factors relevant to the perioperative medical care of adult patients with both Down syndrome and congenital heart disease, founded on existing literature. Various anesthetic considerations for the different patterns of noncardiac and cardiac comorbidities are reviewed, and a systematic approach for the perioperative anesthetic management of these patients is presented.

Postoperative hemodynamics after high spinal block with or without intrathecal morphine in cardiac surgical patients: a randomized-controlled trial.

PURPOSE: There is some evidence for the use of intrathecal morphine as a means to provide prolonged analgesia in selective cardiac surgical patients; however, the hemodynamic effects of intrathecal morphine are not well defined. This study was designed to study the effect of intrathecal morphine on hemodynamic parameters in cardiac surgery patients. METHODS: In a prospective, double-blind study, 100 adult cardiac surgical patients were randomized to receive either intrathecal 40 mg of 0.5% hyperbaric bupivacaine alone (intrathecal bupivacaine [ITB] group, n = 50) or intrathecal 250 µg of morphine added to 40 mg of 0.5% bupivacaine (intrathecal bupivacaine and morphine [ITBM] group, n = 50). Hemodynamic data, pain scores, rescue analgesic use, spirometry, and vasopressor use were recorded every four hours after surgery for 48 hr. The primary outcome was the incidence of vasoplegia in each group, which was defined as a cardiac index > 2.2 L·min-1·m-2 with the requirement of vasopressors to maintain the mean arterial pressure > 60 mmHg with the hemodynamic episode lasting > four hours. RESULTS: Eighty-seven patients were analyzed (ITB group, n = 42, and ITBM group, n =45). The incidence of vasoplegia was higher in the ITBM group than in the ITB group [14 (31%) vs 5 (12%), respectively; relative risk, 2.6; 95% confidence interval [CI], 1.0 to 6.6; P = 0.04]. The mean (standard deviation [SD]) duration of vasoplegia was significantly longer in the ITBM group than in the ITB group [8.9 (3.0) hr vs 4.3 (0.4) hr, respectively; difference in means, 4.6; 95% CI, 3.7 to 5.5; P < 0.001]. CONCLUSION: Intrathecal morphine added to bupivacaine for high spinal anesthesia increases the incidence and duration of vasoplegia in cardiac surgery patients. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02825056); registered 19 June 2016.

RéSUMé: OBJECTIF : Certaines données probantes appuient l'utilisation de morphine intrathécale pour une analgésie prolongée chez certains patients de chirurgie cardiaque; cependant, les effets hémodynamiques de la morphine intrathécale ne sont pas bien définis. Cette étude a été conçue pour évaluer l'effet de la morphine intrathécale sur les paramètres hémodynamiques de patients de chirurgie cardiaque. MéTHODE : Dans une étude prospective et à double insu, 100 patients adultes de chirurgie cardiaque ont été randomisés à recevoir 40 mg de bupivacaïne hyperbare 0,5 % intrathécale (groupe bupivacaïne intrathécale [BIT], n = 50) ou 250 µg de morphine intrathécale ajoutés à 40 mg de bupivacaïne 0,5 % (groupe bupivacaïne et morphine intrathécales [BMIT], n = 50). Les données hémodynamiques, les scores de douleur, l'utilisation d'analgésiques, la spirométrie et l'utilisation de vasopresseurs ont été enregistrés toutes les quatre heures après la chirurgie pendant 48 heures. Le critère d'évaluation principal était l'incidence de vasoplégie dans chaque groupe, définie comme un index cardiaque > 2,2 L·min-1·m2 nécessitant des vasopresseurs pour maintenir la tension artérielle moyenne > 60 mmHg avec une durée de plus de quatre heures. RéSULTATS : Quatre-vingt-sept patients ont été analysés (groupe BIT, n = 42, et groupe BMIT, n = 45). L'incidence de vasoplégie était plus élevée dans le groupe BMIT que dans le groupe BIT [14 (31%) vs 5 (12 %), respectivement; risque relatif, 2,6; intervalle de confiance [IC] 95 %, 1,0 à 6,6; P = 0,04]. La durée moyenne (écart type [ÉT]) de la vasoplégie était significativement plus longue dans le groupe BMIT que dans le groupe BIT [8,9 (3,0) h vs 4,3 (0,4) h, respectivement; différence de moyennes, 4,6; IC 95 %, 3,7 à 5,5; P < 0,001]. CONCLUSION : L'ajout de morphine intrathécale à la bupivacaïne pour une anesthésie rachidienne haute augmente l'incidence et la durée de la vasoplégie chez les patients de chirurgie cardiaque. ENREGISTREMENT DE L'éTUDE : www.clinicaltrials.gov ; (NCT02825056); enregistrée le 19 juin 2016.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial.

BACKGROUND: Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults. METHODS: The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988. FINDINGS: Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI -6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups. INTERPRETATION: A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences. FUNDING: National Institutes of Health and Cancer Center Support.

Role of radiofrequency ablation in unresectable hepatocellular carcinoma: An Indian experience.

AIMS: To evaluate the role of radiofrequency ablation (RFA) as an ablative technique in patients with unresectable hepatocellular carcinoma (HCC). SETTINGS AND DESIGN: A tertiary care center, prospective study. MATERIALS AND METHODS: The subjects comprised 31 patients (30 males, one female; age range 32-75 years) with HCC (41 lesions) who were treated with image-guided RFA. The follow-up period ranged from 3 months to 6 years, and included a multiphasic computed tomography (CT) at 1, 3 and 6 months post-RFA, and every 6 months thereafter. Patient outcome was evaluated and the tumor recurrence, survival and complications were assessed. STATISTICAL ANALYSIS USED: Discrete categorical data were presented as n (%) and continuous data as mean ± SD. Pearson correlation coefficient was used to determine the relationship between the different variables. Kaplan-Meier survival curve and Log-rank test were used to test the significance of difference between the survival time of the different groups. RESULTS: The ablation success rate was 80.5% (33/41 HCC lesions). 12.2% (5/41) of the lesions were managed with repeat RFA due to tumor residue. 4.9% (2/41) of the lesions were managed with repeated RFA and transarterial chemoembolization. Eight patients had tumor recurrence (five patients (16.1%) had local recurrence and three patients (9.6%) had distant recurrence). Eleven patients died within 3.5-20 months post-RFA. The survival rate at 1 year in patients who completed at least 1 year of follow-up was 63.3%. There was one major complication (1/31, 3.2%) in a patient with a subcapsular lesion and ascites. This patient developed hemoperitoneum in the immediate postprocedure period and was managed with endovascular treatment. She, however, had hepatic decompensation and died 48 h post-RFA. CONCLUSION: RFA is an effective and safe treatment for small unresectable HCC.

Comparison of haemodynamic responses following different concentrations of adrenaline with and without lignocaine for surgical field infiltration during cleft lip and cleft palate surgery in children.

Surgical field infiltration with adrenaline is common practice for quality surgical field during cleft lip and palate repair in children. Intravascular absorption of adrenaline infiltration often leads to adverse haemodynamic responses. In this prospective, double-blinded, randomised study the haemodynamic effects, quality of surgical field and postoperative analgesia following surgical field infiltration with different concentrations of adrenaline with and without lignocaine were compared in 100 American Society of Anesthesiologists physical status I children aged six months to seven years undergoing cleft lip/palate surgery. A standard anaesthesia protocol was used and they were randomised into four groups based on solution for infiltration: adrenaline 1:400,000 (group A), adrenaline 1:200,000 (group B), lignocaine + adrenaline 1:400,000 (group C) and lignocaine + adrenaline 1:200,000 (group D). Statistically significant tachycardia and hypertension occurred only in group B as compared to other groups (P <0.001). The peak changes in heart rate and mean arterial pressure following infiltration occurred at 4.3 ± 2.4, 3.8 ± 1.5, 5.7 ± 3.2 and 5.9 ± 4.9 minutes in groups A, B, C and D respectively. Surgical field was comparable among all groups. Postoperative pain scores and rescue analgesic requirements were lesser in the groups where lignocaine was added to the infiltrating solution (P <0.05). We found that 1:400000 or 1:200000 adrenaline with lignocaine 0.5 to 0.7% is most suitable for infiltration in terms of stable haemodynamics, quality of surgical field and good postoperative analgesia in children.

Comparison of hospital versus rural eye cAMP based pediatric cataract surgery.

PURPOSE: To compare the outcomes of pediatric cataract surgery with intraocular lens (IOL) implantation in an eye camp setting and tertiary care center. MATERIALS AND METHODS: Children aged 5-16 years with visually significant cataract underwent phacoaspiration with IOL implantation in an eye camp (eye camp group) or tertiary care center (TCC group). All surgeries incorporated contemporary microsurgical techniques with implantation of polymethyl-methacrylate (PMMA) IOL. Major postoperative complications were managed at a tertiary care center. Postoperative complications, visual acuity and compliance were evaluated using the Chi-square test. A P value less then 0.05 was considered as statistically significant. RESULTS: The cohort comprised 59 children in the eye camp group and 48 children in the TCC group. Thirty two of fifty nine (54.23%) eyes in the eye camp group and 30/48 (62.5%) eyes in the TCC group achieved 20/40 or better best corrected visual acuity (BCVA) postoperatively. Postoperatively, 36 (61%) eyes in the eye camp group and 22 (45.83%) eyes in the TCC group required Nd: YAG laser capsulotomy or a pars plana membranectomy. (P> 0.05) The most striking feature was loss to follow up. In the eye camp group, loss to follow was 20% at one year, 49% at two years, 62% at 3 years and 67% at 4 years compared to 12.5, 21, 27 and 33% respectively in the TCC group (P<0.05, all cases). CONCLUSIONS: The outcomes of camp and tertiary care center (hospital) based pediatric cataract surgery were similar. However, the major drawback of camp based surgery was loss to follow up which eventually affected the management of amblyopia and postoperative complications.

Intraoperative myocardial ischemia during renal transplantation caused by anomalous origin of the right coronary artery.

Anomalous origin of the right coronary artery (AORCA) is a rare congenital anomaly with an incidence of 0.92% during routine cardiac catheterization. Its presence raises an important concern to the anaesthesiologist because it can lead on to myocardial ischaemia manifesting as either angina pectoris or myocardial infarction, or sudden death in young patients with minimal exertion, even in the absence of atherosclerosis. Patients with AORCA may be intolerant to stress and the high cardiac output condition owing to volume loading. Such a therapeutic manoeuvre may be desirable during renal transplantation to enable better perfusion of the renal graft immediately after grafting the kidney, in order to improve its function. Hence, haemodynamic goals in renal transplant recipient with AORCA can be contradictory during surgery, thereby rendering anaesthetic management challenging. We report a case of acute myocardial ischemia precipitated by fluid loading conditions in a patient with AORCA during renal transplant that was successfully treated with emergent intra-aortic balloon pump therapy intraoperatively. Judicious intraoperative fluid replacement is recommended, and volume overload must be avoided in AORCA patients undergoing surgery.

Comparison of hemodynamic changes after acute normovolemic hemodilution using Ringer's lactate versus 5% albumin in patients on beta-blockers undergoing coronary artery bypass surgery.

OBJECTIVE: Acute normovolemic hemodilution (ANH) is used cautiously in coronary artery disease (CAD) patients because of concerns of compromised coronary blood flow. This study aimed to compare hemodynamic changes by using either Ringer's lactate or albumin for ANH in CAD patients receiving beta-blockers. DESIGN: Prospective, randomized study. SETTING: Postgraduate teaching hospital. PARTICIPANTS: Thirty patients undergoing coronary artery bypass graft surgery (CABG) (hemoglobin >12 g/dL, on chronic beta-blocker therapy). INTERVENTIONS: Monitoring, induction, and anesthesia followed a routine protocol for CABG surgery including pulmonary artery catheter placement. Patients were randomly included in group 1 (ANH by Ringer's lactate) or in group 2 (ANH by 5% albumin). A hemodynamic calculation software program was used for parameters recorded before and after ANH. MEASUREMENTS AND MAIN RESULTS: ANH could not be completed in 5 patients (33%) in group 1 because of a fall in mean arterial pressure (MAP) of more than 25% from baseline. In both groups posthemodilution MAP, heart rate, systemic vascular resistance, and oxygen delivery index decreased, whereas stroke volume index, cardiac index, and tissue oxygen extraction increased significantly as compared to baseline values (p < 0.05). Hemodynamic parameters were better maintained during the study period in group 2 than group 1. CONCLUSIONS: Hemodynamic stability was better maintained by 5% albumin than Ringer's lactate for ANH in chronic beta-blocked CAD patients. Despite an increase in cardiac index, systemic oxygen delivery was decreased irrespective of the hemodiluting fluid used. ANH to a hemoglobin value of 10 g/dL in chronically beta-blocked CAD patients was well tolerated.

Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening.

Submental intubation is useful for airway management during maxillofacial surgery when both nasal and orotracheal intubation are deemed unsuitable and to avoid a tracheostomy, especially when long-term ventilatory support is not required in the postoperative period. Adequate mouth opening is a prerequisite for all the techniques described for submental intubation, as the initial step is orotracheal intubation. Hence, this procedure has never been reported in a patient with the inability to open the mouth. We describe the technique of retrograde submental intubation with the help of a pharyngeal loop assembly for the first time in a patient with maxillofacial trauma and restricted mouth opening in whom oral and nasal intubations were not possible and tracheostomy was the only alternative. In this case report, with successful retrograde submental intubation, the potential complications associated with a short-term tracheostomy were avoided, as there was no indication for keeping a tracheostomy during the postoperative period.

Comparison of regional nerve block to epidural anaesthesia in day care arthroscopic surgery of the knee.

Day care minimally invasive surgery demands minimal complications with anaesthesia. Nerve blocks are increasingly being employed for surgical procedures on the lower limb, and we attempted to evaluate their benefits and drawbacks in a prospective randomised study in patients undergoing knee arthroscopy. We compared the effectiveness, onset time, duration of analgesia, patient acceptance, failure rate and post-operative comfort of epidural anaesthesia (with 20 ml of 2% lidocaine with adrenaline 1 in 200000) and peripheral nerve blocks (combined 3-in-1 and sciatic nerve block, with 50 ml of 1% lignocaine with adrenaline 1 in 200000, using nerve stimulator). Forty nine cases were randomised to receive either single shot epidural anaesthesia (Group-I, n = 23) or combined 3-in-1 and sciatic nerve block (Group-II, n = 26). The anaesthesia procedure and analgesia onset time was longer in Group-II (p < 0.001), with skin incision being significantly delayed as compared to group-I (45.2+/-6.2min vs 30.0+/-5.4 min respectively) (p < 0.001). Haemodynamic changes were comparable in both groups during the study period. All patients had complete analgesia at skin incision in group-I as compared to 89.1% in group-II (p < 0.05). However 52.2% of patients in group-I required rescue analgesia postoperatively, as compared to only 18.7% in group-II (p < 0.05). We concluded that even though combined 3-in-1 and sciatic nerve block technique has longer anaesthesia induction time, the lesser need for postoperative rescue analgesia, and lesser potential complications like inadvertent spinal puncture, retention of urine and late onset of back pain, make this an attractive option for day care arthroscopy. The use of a nerve stimulator ensures accuracy, patient counselling allows good cooperation, and advance planning can include potential skin incision delays.

Difficult retrograde endotracheal intubation: the utility of a pharyngeal loop.

UNLABELLED: Direct laryngoscopy and tracheal intubation remains the technique of choice to achieve control of the airway. Alternative or additional techniques of airway control are required whenever an airway is deemed difficult because of anatomical and/or technical reasons. The retrograde intubation technique is an important option for gaining airway access from below the vocal cords in such situations (1). We report successful management and the problems encountered while gaining the upper airway by the retrograde catheter method in a patient having bilateral fibrous ankylosis of the temporomandibular joint (TMJ). IMPLICATIONS: A 30-yr-old woman presented for redo-release of bilateral temporomandibular joint ankylosis under general anesthesia. During the previous anesthetic for primary release of ankylosis, tracheostomy was done, as conventional blind nasotracheal and retrograde intubation attempts failed several times. This case report describes the method for overcoming the difficulties of a retrograde intubation procedure in removing the guiding catheter nasally by using a pharyngeal loop assembly.