Graded Epidural Anaesthesia for Lower Segment Cesarean in a Parturient with Very Low Ejection Fraction.

Dilated cardiomyopathy is characterized by left or biventricular dilatation with impaired ventricular contractility. It is associated with systolic dysfunction with decreased left ventricular ejection fraction and congestive progressive heart failure. Anaesthetic management of such condition is very challenging and requires highest level of expertise, strategy and precaution. We present such a case of dilated cardiomyopathy with a very low ejection fraction of 12% who underwent lower segment cesarean section under epidural anaesthesia with successful outcome.

Ethnic Variations of Blood Groups in a Medical College of Eastern Nepal.

Background Red blood cells contain antigens in its membrane which are inherited according to Mendelian law. ABO and Rhesus blood group systems are considered the most important blood group systems for clinical procedures, blood transfusion, organ transplantation, anthropological study and medico-legal purposes. Determination of ABO and Rhesus blood groups and its frequency distribution in a multiethnic country like Nepal is important for effective management of blood banks, safe blood transfusion services. The trend of blood groups and its ethnic distributions in the eastern part of Nepal is still unknown. Objective To find the distribution of blood groups among the subjects of different ethnic groups of eastern Nepal. Method A cross-sectional perspective study was carried out among the subjects visited in the laboratory of Nobel Medical College, Biratnagar, Nepal for a period of one year from August 1, 2015 to July 30, 2016. Result The 11,960 subjects were included in the present study, among which 5012 were males and 6948 were females. The study revealed that in ABO system, blood group distribution was 34.80% O, 28.66% A, 27.66% B and 6.89% AB. With regard to Rh blood group system, Rhesus +ve was 96.79% and Rhesus -ve was 3.21%. O blood group dominant ethnic groups were Brahmin, Bhujel, Biswakarma, Shah, Gurung, Marwari, Magar, Mahato, Mandal, Newar, Sanyasi, Tamang, Terai Brahmin and Yadav. Similarly, blood group A dominant ethnic groups were Chhetri, Dhimal, Limbu, Rai and Muslim. Howerver, blood group B was dominant in ethnic groups, namely Biswakarma, Rajput, Satar and Tharu. Conclusion The frequency distribution pattern of ABO blood group was observed as O > A> B > AB and in Rhesus system, Rhesus +ve > Rhesus -ve. Variation in blood groups distribution was observed in various ethnic groups.

Postoperative Analgesic Effect of Morphine Added to Bupivacaine for Transversus Abdominis Plane (TAP) Block in Appendectomy.

Background Transversus abdominis plane (TAP) block with local anaesthetics produces effective pain relief following lower abdominal surgeries. Although opioids have been found to have effects through peripheral receptors also, reports on their effect when used as additive to local anaesthetics for TAP block are lacking. Objective To assess the analgesic effect of peripherally administered morphine with bupivacaine for ipsilateral TAP block in patients undergoing emergency appendectomy under general anaesthesia. Method Sixty patients undergoing appendectomy were randomized to undergo ipsilateral TAP with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 ml of intravenous (IV) saline (Group TB) or with 20ml of 0.5% bupivacaine plus 2 mg (2 ml) of morphine (total 22 ml) and 2 ml of NS IV (Group TBM) or with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 mg (2 ml) IV morphine (Group TB-IVM). Pain severity was measured using Visual Analogue Scale (VAS) preoperatively (Baseline) and at 30 min, 6h, 12 h and 24 h postoperatively. Inj. tramadol 50 mg IV was used as rescue analgesic when postoperative VAS was 4 or more. The duration of analgesia (time to first analgesic) and the postoperative 24 h tramadol requirement was recorded. Result The mean duration of analgesia in Group TBM was significantly longer (801.50 ± 74.92 min, p=0.002) than in Group TB (720.00 ± 42.17 min) and Group TB-IVM (712.70 ± 40.94 min). The mean postoperative 24 h tramadol requirement was also less in Group TBM (69.23 ± 25.31mg) than in Groups TB (100.00 ± 38.34 mg) and TB-IVM (95.00 ± 39.40 mg) but did not reach the level of statistical significance (p=0.057). Significantly less ondansetron was required in Group TBM (3.80 ± 2.04 mg) than in Group TB (6.80 ± 2.93 mg) and TB-IVM (6.00 ± 2.75 mg) (p=0.002). Conclusion Morphine added to bupivacaine effectively prolongs the analgesic duration of TAP block in appendectomy.

Multiple intestinal strictures with perforation in a patient under antitubercular treatment for abdominal tuberculosis.

UNLABELLED: Abdominal tuberculosis (TB) constitutes about 12% of the extrapulmonaryTB. Abdominal TB can present with varying signs and symptoms likevague abdominal pain, abdominal mass, ascites and intestinal obstruction. Intestinal perforation is a relatively uncommon but a serious complication of abdominal TB. Antitubercular drugs are considered extremely effective but their role in the presence of a stenotic lesion of the bowel is controversial. Once symptoms of bowel obstruction or peritonitis appear, antitubercular drugs are of little use and surgery is inevitable. We report a case of abdominal TB in a patient under antitubercular treatment who later developed multiple intestinal strictures and a perforation. KEYWORDS: perforation; stricture; tuberculosis.

Heart rate variability: Response to graded head up tilt in healthy men.

BACKGROUND: Heart rate variability is actually a misnomer for R to R variability in cardiac cycle. Variation in successive cycle length is called the heart rate variability (HRV). Head-up tilt is a model of studying cardiovascular haemodynamics, which reflects in heart rate variability (HRV). OBJECTIVES: To study the effect of 10 degrees and 70 degrees head-up tilt on HRV. MATERIALS AND METHODS: The study was done in the Department of Physiology using graded head up tilt (passive orthostatism). HRV measurement was done at 10 degrees and 70 degrees tilt and compared with supine using standardised methods on 30 consenting healthy males (age 25.37+/-3.89 years). The HRV variables across postures were compared by ANOVA and Bonferroni test. RESULTS: The heart rate increased at 70 degrees compared to 10 degrees and supine (70.48+/-8.17 Vs 70.22+/-8.67 and 88.51+/-12.84 bpm, p<0.001). The 70 degrees tilt decreased vagal HRV indicators compared to 10 degrees and supine: SDNN (31.13+/-8.12 Vs 38.07+/-11.29 and 38.13+/-10.89 ms, p<0.05), RMSSD (20.06 +/-8.47 Vs 34.23+/-14.22 and 36.16+/-12.22 ms, p<0.001), NN50 count (13.03+/-20.58 Vs 45.07+/-44.44 and 55.27+/-44.10, p<0.01), pNN50 (3.28+/-6.08 Vs 14.06+/-15.65 and 16.65+/-14.23, p<0.01), HF power (197.20+/-143.76 Vs 218.17+/-155.85 and 216.87+/-150.98 Hz, p<0.05), HFnu unit (24.28+/-14.16 Vs 45.48+/-16.34 and 47.67+/-19.89, p<0.001). The 70 degrees tilt increased LF power% (197.20+/-143.76 Vs 218.17+/-155.85 and 216.87+/-150.98, p<0.001). LFnu unit (75.72+/-14.76 Vs 54.52+/-16.34 and 52.32+/-19.89, p<0.001), LF: HF (4.96+/-4.08 Vs 1.53+/-1.138 and 1.69+/-1.67, p<0.001) compared to 10 degrees and supine. CONCLUSION: At 70 degrees tilt, HRV measures, reflecting vagal contribution to cardiac-cycle length, decreased with reciprocal increase in sympathetic activity compared to 10 degrees or supine leading to increase in sympathetic predominance. A 10 degrees tilt, which is almost equivalent to lying down with pillow, did not change HRV from supine. activity.