Wandering paravertebral catheter detected during thoracoscopy.

We report a case of intrapleural migration of paravertebral catheter inserted under ultrasound guidance, detected during video assisted thoracoscopic surgery.

Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases.

Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.

A randomised trial to compare the increase in intracranial pressure as correlated with the optic nerve sheath diameter during propofol versus sevoflurane-maintained anesthesia in robot-assisted laparoscopic pelvic surgery.

Robot-assisted surgery can cause raised intracranial pressures (ICP) due to steep trendelenburg position and pneumoperitoneum. The choice of anesthetic agents can influence the ICP, which can be measured indirectly by correlating it with the sonographically measured optic nerve sheath diameter (ONSD). In this study, our primary aim was to compare the change from baseline of the ONSD during propofol versus sevoflurane-maintained anesthesia in patients undergoing robotic pelvic surgery. In this prospective, interventional, double-blinded study, we randomised 50 patients into two groups P and S. Subjects in group P received intravenous propofol infusion while those in group S received inhalation sevoflurane for maintenance of anesthesia. The ONSD at fixed intervals was noted as the mean of four values measured using ultrasound in both eyes by two independent anesthesiologists who were blinded to the group allocation. The patient demographics and baseline parameters were similar. The mean maximum rise in ONSD from baseline was 0.01 ± 0.01 cm in group P while it was 0.03 ± 0.01 cm in group S (p = 0.001). Percentage change from baseline in group P was 3.41 ± 1.81% and 8.00 ± 2.95% in group S (p = 0.001). We found a positive correlation between the duration of surgery and the maximum rise in ONSD in group S (p = 0.003), but not in group P. Propofol-based total intravenous anesthesia is more effective than inhalation sevoflurane in attenuating the increase in ICP as correlated with the ONSD during robotic pelvic surgery.Clinical trial registration: Yes; Principal investigator: Nambiath Sujata; Trial number: REF/2016/11/012713 (registered); Trial registry: CTRI- http://ctri.nic.in .

Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases.

Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.

Randomized controlled trial of tranexamic acid among parturients at increased risk for postpartum hemorrhage undergoing cesarean delivery.

OBJECTIVE: To assess the effects of tranexamic acid among patients undergoing cesarean delivery who were at high risk of postpartum hemorrhage. METHODS: Between August 1, 2012, and April 30, 2013, a randomized controlled trial was performed at a tertiary care center in India. Women undergoing an elective or emergency cesarean delivery who were at high risk for postpartum hemorrhage were enrolled. They were randomly assigned using sealed, opaque envelopes to receive 10mg/kg tranexamic acid or normal saline 10min before skin incision. Anesthesiologists were not masked to group assignment, but patients and obstetricians were. The primary outcome was need for additional uterotonic drugs within 24h after delivery. Analyses were by intention to treat. RESULTS: Thirty patients were assigned to each group. Additional uterotonic drugs were required in 7 (23%) patients assigned to tranexamic acid and 25 (83%) patients in the control group (P<0.001). CONCLUSION: Intravenous tranexamic acid, administered before skin incision, significantly reduced the requirement for additional uterotonics among women at increased risk for postpartum hemorrhage. Clinical Trials Registry India: CTRI/2015/05/005752.