Regional anesthesia is safe and effective for lower limb orthopedic surgery in patient with renal tubular acidosis and hypokalemia.

Renal tubular acidosis (RTA) with hypokalemia may precipitate acute respiratory failure and potentially fatal arrhythmias like ventricular fibrillation. Though there are random reports of respiratory failure needing mechanical ventilation and sudden death in patients with RTA and hypokalemia, the anesthetic management of these patients has not been clearly elucidated. Acidosis and hypokalemia have significant interactions with both general and local anesthetics and alter their effect substantially. Proper preoperative planning and optimization are required for the safe conduct of anesthesia in this subset of patients. We describe a case of distal RTA, hypokalemia, and metabolic bone disease in whom central neuraxial anesthesia was effectively used for lower limb orthopedic surgery with no complications.

ASSIST - Patient satisfaction survey in postoperative pain management from Indian subcontinent.

INTRODUCTION: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. SETTINGS AND DESIGN: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. MATERIAL AND METHODS: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. STATISTICAL ANALYSIS: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. RESULTS: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1-10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). CONCLUSION: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.

The effect of epidural dexmedetomidine on oxygenation and shunt fraction in patients undergoing thoracotomy and one lung ventilation: A randomized controlled study.

BACKGROUND AND AIMS: Role of epidural dexmedetomidine in providing analgesia is well documented, but its effect on oxygenation and shunt fraction is not well established. We studied the hypothesis that epidural dexmedetomidine may improve oxygenation and shunt fraction during one-lung ventilation (OLV). MATERIAL AND METHODS: After taking Institutional Ethics Committee approval, sixty patients undergoing thoracotomy and OLV were randomized to receive epidural ropivacaine with saline (RS group) or epidural ropivacaine with dexmedetomidine (RD group). Group RS received 7 ml of ropivacaine 0.5% with 1.5 ml normal saline (NS) bolus while RD group received 7 ml of 0.5% ropivacaine with 1 mcg/kg dexmedetomidine reconstituted in 1.5 ml NS. This was followed by infusion of 5 ml/h of 0.5% ropivacaine in RS group and 5 ml/h of 0.5% ropivacaine containing 0.2 mcg/kg of dexmedetomidine in RD group. Arterial and central venous blood gas parameters were obtained 15 minutes after intubation during two lung ventilation (TLV15), 15 and 45 min after OLV (OLV15, OLV45) and 15 minutes after reinstitution of two lung ventilation (ReTLV). RESULTS: RD group had better oxygenation (254.2 ± 72.3 mmHg, 240.60 ± 59.26 mmHg) as compared to RS group (215.2 ± 64.3 mmHg, 190.7 ± 61.48 mmHg) at OLV15 (P - 0.04) and OLV45 (P - 0.004) respectively. Shunt fraction in RD group was (30.31 ± 7.89%, 33.76 ± 8.89%) and (35.14 ± 7.58%, 39.57 ± 13.03%) in RS group at OLV15 and OLV45, respectively. The increase in the shunt fraction from TLV15 was significantly greater in RS group than RD group both at OLV15 (P - 0.03) and OLV45 (P - 0.03). The sevoflurane and fentanyl requirement was lower in RD group. CONCLUSION: Epidural dexmedetomidine improves oxygenation and reduces shunt fraction during OLV, in patients undergoing thoracotomy. It also reduces intraoperative anesthetic and analgesic requirement.

Effect of magnesium sulfate nebulization on the incidence of postoperative sore throat.

BACKGROUND AND AIMS: Postoperative sore throat (POST) is a well-recognized complication after general anesthesia (GA). Numerous nonpharmacological and pharmacological measures have been used for attenuating POST with variable success. The present study was conducted to compare the efficiency of preoperative nebulization of normal saline and magnesium sulfate in reducing the incidence of POST following GA. MATERIALS AND METHODS: Following institutional ethical committee approval and written informed consent, a prospective randomized double-blinded study was conducted in 100 cases divided into two equal groups. Patients included in the study were of either gender belonging to American Society of Anesthesiologist (ASA) status 1 or 2 undergoing elective surgery of approximately 2 h or more duration requiring tracheal intubation. Patients in Group A are nebulized with 3 ml of normal saline and the patients in Group B are nebulized with 3 ml of 225 mg isotonic nebulized magnesium sulfate for 15 min, 5 min before induction of anesthesia. The incidence of POST at rest and on swallowing and any undue complaints at 0, 2, 4, and 24 h in the postoperative period are evaluated. RESULTS: There is no significant difference in POST at rest during 0(th), 2(nd) and 4(th) h between normal saline and MgSO4. Significant difference is seen at 24(th) h, where MgSO4 lessens POST. There is no significant difference in POST on swallowing during 0(th) and 2(nd) h between normal saline and MgSO4. Significant difference is seen at 4(th) h, where MgSO4 has been shown to lessen POST. CONCLUSIONS: MgSO4 significantly reduces the incidence of POST compared to normal saline.

Complex pseudoaneurysm of ascending aorta: Unusual cause of right heart dysfunction-implications to the anesthesiologist.

Pseudoaneurysm of ascending aorta (PAA) is a rare complication occurring after cardiac surgery. Because of rarity of the condition, most standard teaching and anesthetic literature do not highlight on these postoperative aortic complications. Right heart dysfunction associated with PAA is scarcely reported. We describe here two cases of PAA with right heart involvement and discuss the possible anesthetic challenges.

Thoracoscore: Does it predict mortality in the Indian scenario? - A retrospective study.

Background and Aims: Preoperative risk stratification helps in better prognostication and allocation of resources. However, risk scoring models are less often used in thoracic surgery. Thoracoscore, a risk score model for thoracic surgery was originally developed on a French population and was later validated in many countries. As there is no literature on its ability to predict mortality in the Indian population, we aimed to validate Thoracoscore in Indian thoracic surgical patients. Methods: This retrospective study was carried out in a tertiary care centre after obtaining institutional ethics committee clearance. Patients who were operated for lung pathologies via a posterolateral thoracotomy incision between January 2014 and December 2018 were included in the study. Data on Thoracoscore variables and few additional factors (pulmonary arterial hypertension (PAH), redo surgery, blood loss, blood transfusion, duration of anaesthesia, one lung ventilation and surgery) was collected along with observed mortality statistics. Mortality was predicted using online calculator from the site https://sfar.org/scores2/thoracoscore2.php.Significant continuous and categorical variables in causation of mortality were identified using unpaired t-test and Chi-square tests, respectively. These variables were subjected to multivariate logistic regression to find independent risk factors for mortality. The calibration and discrimination of the Thoracoscore model was analysed by using Hosmer-Lemeshow test and area under the curve of receiver operating characteristic curves. Results: Overall observed mortality in the study was 3.2% while predicted mortality was 0.44%. The Thoracoscore had poor calibration and fair discrimination ability. PAH and re-operative surgery along with Thoracoscore were found to be independent risk factors of mortality in thoracic surgery. Conclusion: Thoracoscore fails to predict mortality in the Indian population.

High vs mid thoracic epidural analgesia - A comparative study on the ease of insertion and effects on pain, hemodynamics, and oxygenation in patients undergoing thoracotomies.

Background: Thoracic epidural analgesia offers effective perioperative pain relief in patients undergoing thoracotomies apart from attenuating stress responses. It helps in fast tracking by facilitating early mobilization and improving respiratory function. Literature on high (T1-T2 level) thoracic segmental analgesia for thoracotomy is less. Aim: The aim of present study was to compare the ease of insertion, effect on pain relief in high (T1-T2 level) vs mid (T5-T6) approach of thoracic epidural. Setting and Design: The present study was a randomized control trial conducted at our institute. Materials and Methods: About 52 patients aged between 18-65 years scheduled for elective thoracotomies under general and thoracic epidural anesthesia were randomized into two groups. Intraoperatively ease of epidural insertion, extent of blockade, and postoperatively pain relief were assessed. Ropivacaine with fentanyl was used for epidural analgesia. Statistical Analysis: Data were presented as mean ± standard deviation and analyzed by the Student's t test, Chi-square test, and non-parametric test whereever applicable. A P value <0.05 was considered statistically significant. Results: We observed that high thoracic epidural anesthesia was easier to place (time taken 123.42 vs 303.08 s) P < 0.05, with less number of attempts (1.27 vs 1.92) P < 0.05. Extent of blockade, postoperative pain scores, rescue analgesia requirement, hemodynamics, and oxygenation were comparable. Conclusion: We conclude that high thoracic epidural is easier to insert, provides adequate pain relief, and stable hemodynamics with the advantage of patient comfort and safety.

Practice patterns of left-sided double-lumen tube: Does it match recommendation from literature - A single-centre observational pilot study.

Context: Choosing appropriate-size double-lumen tube (DLT) has always been a challenge as it depends on existing guidelines based on gender, height, tracheal diameter (TD), or personal experience. However, there are no Indian data to match these recommendations. Aim: To find out whether the size of DLT used correlates with height, weight, TD, or left main stem bronchus diameter (LMBD). We also documented clinical consequences of any of our current practice. Setting and Design: Single-center observational pilot study. Subjects and Methods: Prospective, observational study of 41 patients requiring one-lung ventilation with left-side DLT. The choice of DLT was entirely on the discretion of anesthesiologist in charge of the case. Data were collected for TD, LMBD, height, weight, age, sex, and amount of air used in the tracheal and bronchial cuff. Any intraoperative complications and difficulty in isolation were also noted. Statistical Analysis: The statistical analysis was done with the National Council of Statistical Software version 11. Results: Average TD and LMBD were 16.5 ± 0.9 and 10.7 ± 0.8 mm for males and 14.2 ± 1.1 and 9.4 ± 1.1 mm for females, respectively. There was a weak correlation between DLT size and height (R2 = 0.0694), TD (R2 = 0.3396), and LMBD (R2 = 0.2382) in the case of males. For females, the correlation between DLT size and height (R2 = 0.2656), TD (R2 = 0.5302), and LMBD (R2 = 0.5003) was slightly better. Conclusion: Although there was a weak correlation between DLT size and height, TD, and LMBD, the overall intraoperative outcome and lung isolation were good.

Chronic pain following thoracotomy for lung surgeries: It's risk factors, prevalence, and impact on quality of life - A retrospective study.

BACKGROUND AND AIMS: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affect quality of life (QOL). Studies conducted across globe have found a wide variability in the risk factors predisposing to chronic pain following thoracotomy. As no study on CPTP is available from India, we aim to detect the prevalence of CPTP, assess the predisposing factors implicated in its causation and study the impact of CPTP on QOL. METHODS: After obtaining clearance from Institutional ethics committee, medical records of patients who underwent open posterolateral thoracotomy between January 2012 and December 2015 were reviewed. Data on perioperative variables, address, and contact number were collected from the patient records. All patients were mailed the Telugu translation of medical outcome study short form -36(MOS-SF-36) QOL questionnaire and were contacted telephonically to enquire about presence of CPTP and QOL. A univariate analysis was done to assess factors associated with CPTP and a multivariate logistic regression analysis was done subsequently to identify independent risk factors of CPTP. QOL indices were compared between those patients who suffered from CPTP and those who did not. RESULTS: The prevalence of pain in our study was 40.86% (85/208). The factors implicated in the causation of CPTP were diabetes mellitus, preoperative pain, rib resection, and duration of chest tube drainage with odds ratio of 9.8, 2.6, 6.7, and 1.03, respectively. The health-related QOL showed poor scores in all domains in patients suffering from CPTP. CONCLUSION: The prevalence of CPTP was high. It significantly impacts health-related QOL.

Neurogenic stress cardiomyopathy: What do we need to know.

The interaction between the heart and brain is complex and integral to the maintenance of normal cardiovascular function. Even in the absence of coronary disease, acute neuronal injury can induce a variety of cardiac changes. Recent neuroimaging data revealed a network including the insular cortex, anterior cingulate gyrus, and amygdala playing a crucial role in the regulation of central autonomic nervous system. Damage in these areas has been associated with arrhythmia, myocardial injury, higher plasma levels of brain natriuretic peptide, catecholamines, and glucose. Some patients after brain injury may die due to occult cardiac damage and functional impairment in the acute phase. Heart failure adversely influences acute stroke mortality. Troponin and NT-proBNP are elevated in acute brain injury patients, in response to the activated renin-angiotensin-aldosterone system and other neurohumoral changes, as a protective mechanism for sympathoinhibitory activity. Such patients have been shown to be associated with higher short- and long-term mortality. While thrombolysis, neuroprotection, and other measures, alone or in combination, may limit the cerebral damage, attention should also be directed toward the myocardial protection. Early administration of cardioprotective medication aimed at reducing increased sympathetic tone may have a role in myocardial protection in stroke patients. For a full understanding of the brain-heart control, the consequences of disruption of this control, the true incidence of cardiac effects of stroke, and the evidence-based treatment options further research are needed.

Mortality prediction in Indian cardiac surgery patients: Validation of European System for Cardiac Operative Risk Evaluation II.

BACKGROUND AND AIMS: Risk Stratification has an important place in cardiac surgery to identify high-risk cases and optimally allocate resources. Hence various risk scoring systems have been tried to predict mortality. The aim of the present study was to validate the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) in Indian cardiac surgical patients. METHODS: After obtaining ethics committee clearance, data on EuroSCORE II variables were collected for all patients >18 years undergoing on-pump coronary artery bypass graft (CABG), valve surgery and mixed (CABG + valve) procedures between January 2011 and December 2012. Mortality prediction was done using the online calculator from the site www.euroscore.org. The calibration of the EuroSCORE II model was analysed using the Hosmer-Lemeshow test and discrimination was analysed by plotting receiver operating characteristic curves (ROC) and calculating area under the curve (AUC). The analysis was done in the total sample, CABG, valve surgery and in mixed procedures. RESULTS: The overall observed mortality was 5.7% in the total sample, 6.6% in CABG, 4.2% in valve surgeries and 10.2% in mixed procedures whereas the predicted mortality was 2.9%, 3.1%, 2.4%, 5.1% in total sample, CABG, valve surgery and mixed procedure, respectively. The significance (P value) of Hosmer-Lemeshow test was 0.292, 0.45, 0.56 and 1 for the total sample, CABG, valve surgery and mixed procedure, respectively, indicating good calibration. The AUC of ROC was 0.76, 0.70, 0.83 and 0.78 for total sample, CABG, valve surgery and mixed procedure, respectively. CONCLUSION: Mortality of the sample was under-predicted by EuroSCORE II. Calibration of the EuroSCORE II model was good for total sample as well as for all surgical subcategories. Discrimination was good in the total sample and in the mixed procedure population, acceptable in CABG patients and excellent in valve surgeries.

Airway Management of Patients Undergoing Oral Cancer Surgery: A Retrospective Analysis of 156 Patients.

OBJECTIVE: Oral cancer patients have a potentially difficult airway, but if managed properly during the perioperative period, morbidity and mortality can be reduced or avoided. METHODS: The medical records of 156 patients who were operated for oral cancers were reviewed for airway management during the perioperative period. RESULTS: The surgical procedures ranged from excisions, wide local excisions with split skin graftings, hemiglossectomies and radical neck nodes dissections to pectoralis major myocutaneous or free fibular flaps. Intubation was assessed as difficult in 14.7% of patients because of tumour- or radiation fibrosis-related trismus, restricted neck mobility and prior similar surgeries. Twenty patients had undergone surgery for oral cancer previously and were scheduled for flap reconstruction. Nasotracheal intubation was a preferred route, and 62.8% of patients could be intubated nasotracheally after neuromuscular blockade. Tracheostomy (elective or existing) was utilised for airway control in 19.2% cases. Patients who had undergone prior radiotherapy were more likely to be tracheostomised. McCoy laryngoscopes (13.4%), gum elastic bougies (23.6%), Airtraq devices (0.006%) and fibreoptic bronchoscopes (FOBs) (0.03%) were the additional airway techniques employed. In total, 64 patients (50.7%) could be extubated immediately after surgery. CONCLUSION: Proper preoperative evaluation and planning help manage difficult airways effectively with minimal need of advanced airway gadgets. Gum elastic bougies and Magill forceps are very useful in airway management and decrease the need of elective tracheostomy in oral cancer patients.

The Effect of Position on PaCO2 and PETCO2 in Patients Undergoing Cervical Spine Surgery in Supine and Prone Position.

BACKGROUND: As per American Society of Anesthesiologists guidelines, continuous monitoring of end tidal carbon dioxide (PETCO2) is recommended as standard II basics of anesthetic monitoring especially to ensure adequate ventilation during all anesthetics. Continuous monitoring of PETCO2 can also be used as a guide to maintain the partial pressure of carbon dioxide in arterial blood (PaCO2) to desired level during the surgery. AIMS AND OBJECTIVES: To study the effect of position on PaCO2 and PETCO2 during cervical spine surgery in prone position. MATERIALS AND METHODS: Following institutional ethical committee approval and written informed consent, a prospective study was conducted in 40 patients of 18 to 60 years and of American Society of Anesthesiologists I and II scheduled for cervical spine surgery in prone position. In operating room, the patient is connected to standard monitoring and intravenous access was secured. A 20 G arterial cannula was placed. General anesthesia administered and oral endotracheal intubation done. Baseline values of systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, temperature, SpO2, Ppeak, Pmean, and Pplateau were measured in supine position. For each patient the capnometer was calibrated before use. The P(a-ET)CO2 was calculated in supine position (S1). The PaCO2 and ETCO2 were measured after prone positioning P1, at each subsequent hour (P2, P3, P4), and on completion of the procedure in supine position (S2). The mean values were used for further analysis. RESULTS: The PETCO2 and PaCO2 decreased significantly in cervical spine surgery patients with change of position from supine to prone with no significant change in arterial to end tidal CO2 gradient (P(a-ET)CO2). CONCLUSIONS: PETCO2 can be used as a reliable guide to estimate PaCO2 during cervical spine procedures in prone position.

Perioperative management of patient with intracoronary stent presenting for noncardiac surgery.

As the number of percutaneous coronary interventions increase annually, patients with intracoronary stents (ICS) who present for noncardiac surgery (NCS) are also on the rise. ICS is associated with stent thrombosis (STH) and requires mandatory antiplatelet therapy to prevent major adverse cardiac events. The risks of bleeding and ischemia remain significant and the management of these patients, especially in the initial year of ICS is challenging. The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days for drug-eluting stents. Postponement of elective surgery is advocated during this period, but guidelines concerning emergency NCS are ambiguous. The risk of STH and surgical bleeding needs to be assessed carefully and many factors which are implicated in STH, apart from the type of stent and the duration of DAT, need to be considered when decision to discontinue DAT is made. DAT management should be a multidisciplinary exercise and bridging therapy with shorter acting intravenous antiplatelet drugs should be contemplated whenever possible. Well conducted clinical trials are needed to establish guidelines as regards to the appropriate tests for platelet function monitoring in patients undergoing NCS while on DAT.

Anesthetic management for magnetic resonance imaging in a pediatric patient addicted to palm wine: An alcoholic beverage.

The incidence of drug and alcohol abuse is on rise despite increasing awareness and education about health hazards related to it. Anesthesiologist may come across patients with alcohol abuse in elective as well as emergency situations. We report a rare case of excessive requirement of anesthetics in a pediatric patient of only six years for MRI, addicted to palm wine, an alcoholic beverage created from the sap of various species of palm tree.