A comparative evaluation of thoracic and lumbar epidural fentanyl for post thoracotomy pain.

Thirty patients undergoing closed mitral valvotomy were prospectively randomised to receive either thoracic or lumbar epidural catheter. General anaesthesia consisted of morphine sulphate 0.15 mg/kg (single dose given before skin incision), thiopentone sodium 4-6 mg/kg, vecuronium and halothane titrated to stable haemodynamics. In the immediate postoperative period, pain was assessed by VAS (visual analogue scale) and VRS (verbal ranking score) and an epidural fentanyl bolus of 1.5 microg/kg was given followed by an infusion of 0.4 microg/kg/hr. Pain was assessed after 30 min and if pain relief was still inadequate, another fentanyl bolus of 1 microg/kg was administered, followed by an increase in infusion rate to 0.6 microg/kg/hr. If two consecutive pain scores were satisfactory (VAS <4, VRS <1) maintenance dose of fentanyl was decreased by 0.2 microg/kg/hr. Thoracic group received significantly less total dose of fentanyl in 24 hrs period (446.7 +/- 101.70microg) compared with the lumbar group (705.33 +/- 181.03microg) (p<0.01). The mean infusion rate was also significantly less in the thoracic group as compared with the lumbar group (0.44 +/- 0.08microg/kg/hr vs 0.61 +/- 11microg/kg/hr, p<0.001). The side effects were comparable between both the groups and none of the patients had significant respiratory depression. The data suggest that thoracic epidural fentanyl infusion is superior to lumbar infusion for post thoracotomy pain relief because of smaller dose requirement.

Effects of variation in the timing of palatal repair on sagittal craniofacial morphology in complete cleft lip and palate children.

The complete cleft lip and palate children, ranging from 6-14 years of age were studied to evaluate the effect of variation in the timing of palatal repair on craniofacial morphology and compared to the noncleft children. It was observed that all the groups early (8 to < or = 24 months), medium (> 24 to < or = 36 months) and late repair (> 36 to < or = 78 months) had significantly larger cranial base, retruded maxillomandibular relations, skeletodental and incisal relationships compared to the noncleft children. However, intercomparison among the cleft groups showed insignificant difference amongst them suggesting that the timing of palatal repairs does not effect the anterioposterior (sagittal) relationship.

Effects of cardiopulmonary bypass on thyroid function.

Alterations in serum concentration of thyroid hormones occur even in euthyroid patients undergoing cardiopulmonary bypass. The purpose of our prospective study was to define the effects of cardiopulmonary bypass on thyroid hormones. Twenty euthyroid patients for mitral valve replacement were included in this study. Heparinised arterial sample for thyroid function tests were obtained before cardiopulmonary bypass (CPB), 30 and 60 minutes after initiation of CPB, immediate post-CPB and 24 hours after termination of CPB. T3, T4 and thyroid stimulating hormone (TSH) were estimated using radioimmunoassay method. There was more than 50% decrease in T3 levels after initiation of CPB and it remained persistently below the physiological range until 24 hours after termination of CPB. T4 and TSH remained within normal limits throughout the study period. These results indicate that CPB simulates the euthyroid sick syndrome as seen in critically ill and burn patients. Whether routine administration of intravenous tri-iodo thyronine is beneficial in the prevention of low cardiac output syndrome seen after CPB remains to be elucidated in future.

Comparison of the Effects of Sevoflurane and Halothane on Arterial Oxygenation during One Lung Ventilation.

We investigated the effect of halothane and sevoflurane on oxygenation during one lung ventilation (OLV) in 24 patients undergoing elective thoracic procedures. After induction with thiopentone, 4-5 mg/kg and morphine 0.1 mg/kg, suxamethonium 2mg/kg was administered to facilitate tracheal intubation with a double lumen tube. Anaesthesia was maintained with 1.5-3% sevolurane (group 1, n = 12) or 1.1.5% halothane (group 2, n = 12) in 02 with N20 (1:1) and pancuronium bromide. Arterial blood gases were recorded before surgery in the lateral position with two lung ventilation (2LV), 10, 20 and 30 minutes after beginning of one lung ventilation. Morphine and endtidal inhalational anaesthetic concentration were titrated to desired anaesthetic depth and haemodynamic variables. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and central venous pressure (CVP) were measured during the study period. In both the groups there was a significant decrease of PaO2 apparent at 10 minutes after initiation of OLV. Thereafter PaO2 remained stable throughout the study period in both the groups. It is concluded that oxygenation did not differ significantly with either sevoflurane or halothane during OLV. It is also concluded that decrease in oxygenation with OLV is complete by 10 minutes of its initiation.

Effects of variation of the timing of palatal repair on nasality of speech in complete cleft lip and palate children.

Nasality is related to factors like velopharyngeal closure and acoustic factors pertaining to cavities. The present investigation is a retrospective study aimed at evaluating the effects of variation in the timing of palatal repair on nasality during speech development in complete cleft lip and palate cases. It has been observed that the delay in palatal repair is associated with increase in nasality. Also, from the operated complete cleft lip and palate cases, it has been observed that the early and medium repair groups had almost similar effects on nasality of speech. (if they were operated before 36 months of age).

Sevoflurane for trans-sternal thymectomy in myasthenia gravis.

Myasthenic gravis (MG) is an autoimmune disease associated with acetylcholine receptor deficiency. Patients with MG exhibit increased sensitivity to non-depolarising muscle relaxants. In an attempt to avoid neuromuscular blockers, we used sevoflurane in two myasthenic patients undergoing trans-sternal thymectomy. Inhalation of 8% sevoflurane in oxygen using vital capacity technique produced rapid, pleasant and smooth induction and provided good tracheal intubating conditions. In both patients anaesthesia was maintained with 1.5-2% end-tidal concentration of sevoflurane and nitrous oxide in oxygen without adjunctive neuromuscular blocking agents. There were minimal changes in cardiovascular variables and recovery was faster. It is suggested that sevoflurane may be the main anaesthetic for both induction and maintenance in myasthenic patients undergoing trans-sternal thymectomy.

Comparative evaluation of cardiovascular effects of sevoflurane and isoflurane in patients with ischaemic heart disease undergoing non-cardiac surgery.

Twenty three adult patients with ischaemic heart disease undergoing elective non-cardiac surgery were studied. Induction of anaesthesia was similar for each patient and included thiopentone (4-5 mg/kg), morphine (0.1 mg/kg) and vecuronium (0.1 mg/kg). Additional morphine and vecuronium were used when necessary. All these patients were maintained with either sevoflurane (n=11) or isoflurane (n=12). The inhaled anaesthetics were titrated to achieve adequate clinical 'depth of anaesthsia' and to maintain mean arterial pressure within 20% of the pre-induction values. Heart rate, blood pressure and rate-pressure product were recorded during the maintenance phase of anaesthsia. ST-T changes were also monitored during this period. There was a tendency for heart rates to be significantly higher shortly after skin incision till the end of procedure in the isoflurane group, while in the sevoflurane group heart rate remained stable during the surgical procedure. Both systolic and diastolic blood pressure remained similar in both groups. The rate pressure product was higher in the isoflurane group than in the sevoflurane group at 30 min Post-incision. The data suggests that sevoflurane is not associated with untoward cardiovascular changes in ischaemic heart disease patients undergoing non-cardiac surgery.

Oxygenation of crystalloid cardioplegia.

A simple economical apparatus for oxygenation of cold crystalloid cardioplegic solutions is presented. It is sterile, practically feasible for use in open heart surgery, provides a PO2 of 98.7 kPa and sustains it for a period of more than 20 minutes.

ICU management of blunt chest trauma: our experience.

Blunt chest tramma is a major cause of mortality and morbidity following road side accident. An understanding of the factors affecting the mortality and morbidity will help in formulating better management strategies. The records of 40 consecutive patients presenting with blunt chest trauma (BCT) requiring ICU care from 1994-1996 were reviewed. Flail chest was the most common chest injury seen in 35 patients (87.5%). Isolated flail chest was seen in 22 patients, isolated pulmonary contusion in 2 patients and a combined injury in 13 patients. Ventilatory assistance was required in 34 patients (85%) for an average duration of 16 days (range 2-43 days). All patients with anterior flail required assisted ventilation in contrast to 75% and 88% of patients with unilateral and bilateral flail respectively. Presence of pulmonary contusion with or without flail was also associated with a high incidence of ventilatory support requirement. Chest infection (pneumonia) was the most common complication seen (65%). Adverse outcome occurred in 12 patients (30%). The main contributing factors for increased morbidity and mortality were: associated pulmonary contusion, associated extrathoracic injuries and preexisting medical illness. Statistical significance was observed only with pulmonary contusion.

Perioperative myocardial infarction in coronary artery disease patients and 'at-risk' for coronary artery disease patients undergoing non-cardiac surgery.

BACKGROUND: Perioperative myocardial infarction (POMI) carries a high mortality and occurs more commonly in patients with a history of coronary artery disease (CAD). However, there are also other patients undergoing surgery who are 'at risk' for CAD but who do not have a history of infarction or angina. We compared the incidence of POMI in these two groups. METHODS: In a prospective study of 69 men and 39 women over 30 years of age undergoing non-cardiac surgery under general or regional anaesthesia, 56 had definite CAD and 52 were 'at-risk' for CAD. All these patients were followed up with serial postoperative electrocardiography and CK-MB isoenzyme analysis for the diagnosis of POMI. RESULTS: The POMI rate was 32% in definite CAD patients and 15% in patients 'at-risk' for CAD. Mortality in patients with POMI was 17% in those with CAD and 13% in those 'at-risk' for CAD. Perioperative myocardial infarction was maximal in the first 24 hours following surgery (77%). All the POMIs were painless. Anaesthesia techniques--whether regional or general--did not influence the incidence of POMI (Chi-square, p > 0.05). The type of drugs used in the treatment of CAD such as beta-blockers, calcium channel blockers and antiplatelet agents did not cause any difference in the incidence of POMI (Chi-square, p > 0.05). Patients who had either an intraoperative hypertensive episode, tachycardia, arrhythmias or ST-segment changes had a higher incidence of POMI (Chi-square, p > 0.05). The incidence of POMI was not lower in patients undergoing transurethral resection of the prostate compared to patients undergoing other types of non-cardiac surgery (Chi-square, p > 0.05). CONCLUSION: POMI occurs in one-third of patients with a history of CAD and one-sixth of those 'at-risk'. It carries a mortality of 17% and 13% respectively. Decisions to operate on such patients should be taken with caution.

Sagittal craniofacial morphology in repaired unilateral and bilateral complete cleft lip and palate cases.

Fifty repaired complete cleft lip and palate cases (38 UCLP and 12 BCLP) in the age of 6 to 14 years were evaluated for sagittal craniofacial morphology using lateral cephalograms. A total of twenty three measurements (19 angular and 4 linear) were used in the analysis to represent a comprehensive pattern of dento craniofacial morphology. The results of comparison between UCLP and BCLP revealed differences for only the skeletodental and interincisor sagittal relationship (greater retroclination in BCLP group).

Midazolam as an induction agent in mitral stenosis patients for closed mitral commissurotomy.

In 30 patients of rheumatic heart disease with mitral stenosis (MS) belonging to NYHA class II and III scheduled for closed mitral commissurotomy anaesthesia was induced with morphine 0.15 mg/kg followed by either thiopentone (group A, n = 15) or midazolam (group B, n = 15) titrated to produce sleep. Patients were intubated with pancuronium bromide in a dose of 0.12 mg/kg. Minimum mean arterial blood pressure following induction was significantly lower in thiopentone group (77 +/- 7 mm Hg) than midazolam group (85 +/- 6 mm Hg; P < 0.05). After intubation blood pressure was significantly higher in thiopentone group (99 +/- 8 mm Hg) than midazolam group patients (89 +/- 7 mm Hg). Heart rate was significantly higher in thiopentone treated patients both before and after endotracheal intubation. During surgery, three patients in group A had hypotensive episodes (mean arterial blood pressure 20% below basal at two successive readings 5 min apart) while one in group B had a hypotensive episode. Average duration of surgery was comparable between the two groups (102 +/- 15 and 95 +/- 18 min) and postoperatively there was no significant difference in sedation score and incidence of nausea and vomiting between the two groups.

Cardio-vascular effects of vecuronium & pancuronium in patients undergoing elective closed mitral valvotomy.

Vecuronium, a monoquaternary analogue of pancuronium, the neuromuscular blocker, was compared with pancuronium in 50 patients undergoing elective closed mitral valvotomy. The patients were randomly divided into two groups of 25 each, and the muscle relaxants were administered in a dose of 0.1 mg/kg body weight. Both the agents produced identical intubating conditions at 3 min. Vecuronium showed a significantly shorter onset of action, as compared to pancuronium. The latter significantly increased the heart rate throughout the period of study whereas vecuronium significantly decreased the heart rate, 25 min after administration. There was significant increase in the mean arterial pressure (MAP) at tracheal intubation in both the groups, which persisted throughout the period of study in pancuronium group. There was a significant fall in MAP at 30 min after relaxant in vecuronium group. The incidence of arrythmias was similar and significant in both the groups. Vecuronium, thus showed a quicker onset of action with minimal haemodynamic effects, as compared to pancuronium in patients undergoing closed mitral valvotomy.

Effect of timing of palatal repair on the transverse development of maxillary alveolar arch in complete-cleft cases.

Forty cleft cases in the age range of 5-12 years where the palatal repair had been performed at 16-24 months (17 cases), 24-36 months (15 cases) and 36-72 months (8 cases) were assessed retrospectively, for the status of maxillary arch and were segregated as acceptable and unacceptable. Plaster casts were prepared from alginate impressions and their graphical reproduction using Huddart's technique, were used to measure the alveolar arch. Anterior palatal measurement (C-C') and posterior palatal measurement (P-P') of the cleft subjects were compared with that in the non-cleft matched controls. The 16-24 month group showed 41.2% acceptable and 58.8% unacceptable arch cases. The 24-36 month group showed that 73.4% had acceptable arches and 26.6% had unacceptable arches. In the 36-72 months group the arch was acceptable in 62.5% cases and unacceptable in 37.5% cases. It was concluded that palatal repair performed before 24 months of age adversely affected the maxillary growth, whereas most favourable growth of maxillary arch occurred when the repair was done between 24-36 months.

Transverse and vertical asymmetry of bilateral craniofacial structures in repaired unilateral and bilateral complete cleft lip and palate cases.

Fifty repaired complete cleft lip and palate cases (38 UCLP and 12 BCLP) in the age range of 6 to 14 years were evaluated for transverse and vertical asymmetry using postero-anterior cephalograms. A total of nine bilateral landmarks, representing upper face, mid face and lower face were used. Results showed that asymmetry was not confined to any single plane of reference but manifested in both dimensions--transverse and vertical. The UCLP group had greater asymmetry of mid face than the BCLP group. Asymmetry was found to be extending to distant areas besides the contiguous structures.

Psychiatric symptoms in patients with non-organic chronic intractable pain.

Patients (200) with chronic intractable pain were evaluated to identify various psychiatric symptoms. Identifiable psychiatric illness, commonest being neurotic depression and anxiety states, was found in 72 per cent patients. The common symptoms reported on the present state examination (PSE) were worrying (77%), depression (40%), loss of interest (31.5%), hopelessness (16.5%), loss of weight (18%), and suicidal ideas (8%) and irritability (41.5%). Two thirds of patients had both anxiety and depression.

Role of epidural analgesia on endocrine & metabolic responses to surgery.

Serum levels of cortisol, T3, T4 and blood levels of glucose, lactate and pyruvate were measured 15 min before anaesthesia, 15 and 60 min after skin incision and at 2 h after surgery, in 16 patients undergoing elective surgery on lower extremities either under epidural analgesia (group I) or general anaesthesia (group II). The results showed that as long as the effect of epidural analgesia persisted, it could inhibit the increases in cortisol and blood glucose and the decreases in T3 levels, observed under general anaesthesia. This is probably because of the blocking effect of epidural analgesia on the afferent neurogenic impulses from the area of surgery. T4, lactate and pyruvate levels were not affected to any significant extent. These observations could be of value in the operative management of patients with diabetes mellitus and others with a high surgical morbidity.

Management of pain in pain clinic (review of 1348 cases).

Our series have shown that psychotherapy and physiotherapy when incorporated with specific therapy, produced a much better relief from pain and that the functional return of ability of the affected part was quicker.