[Show abstract][Hide abstract] ABSTRACT: Pain following craniotomy has frequently been neglected because of the notion that postcraniotomy patients do not experience severe pain. However a gradual change in this outlook is observed because of increased sensitivity of neuroanaesthesiologists and neurosurgeons toward acute postcraniotomy pain. Multiple modalities exist for treating this variety of pain each with its own share of advantages and disadvantages. However, individually none of these modalities has been proclaimed as the best and applicable universally. A considerable amount of dispute remains to ascertain the appropriate therapeutic regimen for treating postcraniotomy pain in spite of numerous trials using different drugs and their combinations. This review aims to highlight the genesis, characteristics, and different strategies that are undertaken for management of acute postcraniotomy pain. Chronic postcraniotomy pain which can be debilitating sequelae is also discussed concisely.
[Show abstract][Hide abstract] ABSTRACT: Exposure of the lateral and inferior surface of the heart during off-pump coronary artery bypass grafting is associated with some degree of cardiac instability during recovery with completion of grafting. Exposure of lateral and posterior surfaces by currently available equipment is difficult in minimally invasive coronary artery bypass grafting (MICABG) owing to limited exposure. We describe an effective variation of often-used technique of pericardial stitch in exposure of cardiac surfaces during MICABG. This technique was used in 24 patients undergoing multivessel MICABG. Deep pericardial sutures were used to manipulate the exposure of cardiac surfaces. Left anterior descending artery was grafted in all 24 cases. Obtuse marginal artery was grafted in 20 cases and posterior descending artery in 12 cases. Average grafts were 2.3 per patient. There was no conversion to median sternotomy. Use of deep pericardial suture is simple technique for exposure of lateral and inferior surface during multivessel MICABG. This offers adequate exposure and operating space for easy maneuverability.
Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 01/2015; 10(1). DOI:10.1097/IMI.0000000000000116
[Show abstract][Hide abstract] ABSTRACT: Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique.
We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months-4 years) is available.
Median age was 58.5 years (41-77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up.
MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting.
Indian Heart Journal 03/2014; 66(2):193-6. DOI:10.1016/j.ihj.2014.02.010 · 0.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Unanticipated difficult tracheal intubation is a significant source of morbidity and mortality in anesthetized patients. A number of modules have been developed to predict difficult airways, but they are often complex in nature. We combined the modified Mallampati score (M), thyromental distance (T), anatomical abnormality (A), and cervical mobility (C) into a single scoring system with the acronym M-TAC, and evaluated it against Mallampati scoring.
We prospectively analyzed 500 adult patients of the American Society of Anesthesiologists (ASA) class I or II, scheduled for elective surgery under general anesthesia. Preoperative airway assessments using M-TAC were performed, all of which were given a score. Anesthesiologists, blinded to the pre-anesthetic airway assessment, performed laryngoscopy and graded the laryngoscopic view as per Cormack and Lehane's classification. For the study purpose, difficult laryngoscopy was defined as Cormack and Lehane Grade 3 or 4 of laryngoscopic view.
An M-TAC score ≥ 4 had a significantly higher sensitivity (96% vs. 72%) and specificity (86% vs. 78%) with a high positive predictive value (44% vs. 28%) and a very low false negative value (2% vs. 15%) in comparison with Mallampati scoring (p < 0.05). Analysis of the receiver operating characteristic (ROC) curve for predicting difficult laryngoscopy revealed an area under the curve of 0.83 (95% CI = 0.78-0.88) for Mallampati scoring and 0.94 (95% CI = 0.92-0.96) for M-TAC scoring system.
The M-TAC scoring system has provided a higher sensitivity and specificity in predicting difficult laryngoscopy in comparison with Mallampati classification.
[Show abstract][Hide abstract] ABSTRACT: Encephalocele is a form of neural tube defect, characterized by protrusion out of the meninges and brain tissue through a bony skull defect. As per the site of origin, these encephaloceles have been classified into different types, out of which the frontoethmoidal one is exclusively common in Southeast Asia with a reported incidence of 1 in 5,000. Neurological outcome of such malformations depends on the size of the sac, neural tissue content, hydrocephalus, associated infection, and other pathologies that accompany this condition. Here we describe the anaesthetic concerns and perioperative management of a giant occipital encephalocele.
[Show abstract][Hide abstract] ABSTRACT: Topical capsaicin and eutectic mixture of local anesthetics (EMLA) have been found to be equally effective in minimizing the pain of venipuncture. After the injection of capsaicin, both tertiary amine local anesthetics and their quaternary ammonium derivatives can elicit a prolonged and predominantly sensory/nociceptor selective block. We hypothesized that the combined application of capsaicin and ELMA will be more effective than their individual effect, and lower concentrations of individual drugs in this mixture may also be associated with reduced side effects.
One hundred twenty patients were randomized into 4 equal groups. The control group received plain lubricant cream; the EMLA group received EMLA cream; the capsaicin group received Myolaxin ointment (containing oleoresin capsaicin equivalent to capsaicin 0.075% w/w, methylsalicylate IP 20% w/w, menthol IP 10% w/w, camphor USP 5% w/w, and eucalyptus oil IP 5% w/w); and the EMLA + capsaicin group received EMLA cream and Myolaxin ointment mixed in equal amounts. An anesthesiologist applied the cream to a 10-cm(2) area (site of venous cannulation) on the dorsum of the nondominant hand of the patient 1 hour before venipuncture and covered the area with an occlusive transparent dressing. Venipuncture was performed with an 18-gauge cannula after removing the dressing. Venipuncture pain was graded by the patient on a 0 to 10 visual analog scale, where 0 means no pain and 10 means worst imaginable pain. P values (after correction for multiple comparisons) of <0.05 were considered significant.
The incidence of no pain on venous cannulation (primary end point) was 0% in the control group (0/30). The incidence of no pain were significantly higher in the EMLA group (32%, 9/28, 95% corrected confidence interval for the difference 12%-57%, P = 0.0025), capsaicin group (30%, 9/30, 10%-53%, P = 0.0031), and EMLA + capsaicin groups (47%, 14/30, 25%-69%, P < 0.0001). Severity of venipuncture pain as assessed by visual analog scale median (interquartile range) was lower in the EMLA + capsaicin group 1 (2) compared with other groups 3 (1), 1.5 (3), and 1.5 (3) for control, EMLA, and capsaicin, respectively (P < 0.001, P = 0.04, and P = 0.04, respectively).
We observed that the combination of capsaicin and EMLA in a low concentration is as effective in managing venous cannulation as when applied as an individual drug alone. Larger studies with varying concentration of capsaicin and EMLA are recommended to more fully evaluate the potential advantages.
Anesthesia and analgesia 03/2013; 116(3):568-71. DOI:10.1213/ANE.0b013e3182788376 · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Etoricoxib, a selective Cox-2 inhibitor has been found to be effective in the management of acute pain. This study evaluates the effect of preoperative use of oral Etoricoxib on post operative pain relief and sleep in patients undergoing single level diskectomy.
In this prospective, randomized, controlled study, forty four patient (ASA 1 & 2, age 18-60 years) scheduled to undergo single level lumber diskectomy were given either placebo (control group) or Etoricoxib 120 mg orally one hour before surgery. Post operatively fentanyl intravenous (IV) PCA pump was started. Visual analog score (VAS) was assessed at 0, 6, 12, 18 and 24 hours at rest and movement. Primary end point was total pain relief over 24 hours. Sleep overnight, total fentanyl consumption, incidence of nausea and vomiting, intra-operative blood loss and patient satisfaction were noted.
Forty three patients completed the study. Reductions in VAS at rest and on movement were observed in the Etoricoxib group when compared with the Control group at all the intervals till 24 hours postoperatively, except on movement at 24 hours postoperative (P < 0.05). Total fentanyl consumption (microg/kg/hr) was higher in Control group (P = 0.007). More patients in Etoricoxib group had a contented facial expression (p = 0.003), relaxed body language (p = 0.00) and better sleep at night than control group (p = 0.0004).
Single preoperative oral dose (120 mg) of Etoricoxib, given one hour before surgery, has significantly reduced the post operative pain at rest and movement and improved sleep in patients undergoing single level diskectomy without any side effects and with good patient satisfaction.
Middle East journal of anaesthesiology 06/2012; 21(5):725-30.
[Show abstract][Hide abstract] ABSTRACT: We have designed a technique of tracheostomy in pediatric patients with S-shaped incision on the tracheal wall which we think, provides a larger cross-sectional area of stoma and facilitates easier insertion of tracheostomy tube and thus helped in reducing early and late complications associated with it in our series.
The trachea was exposed in midline by a vertical skin incision. In order to make S-shaped tracheostoma, second tracheal ring was identified. The conventional vertical incision was made in second tracheal ring and then extended at both its ends laterally in the inter-cartilaginous space parallel to the tracheal cartilage in the opposite direction to make the incision S-shaped. The trachea was dilated with tracheal dilator and appropriate size of tracheostomy tube was then placed into the trachea.
S-shaped tracheostomy was performed in 40 children with mean age of 6.36 years (age range is 2-12) required for airway maintenance or prolonged ventilatory support. The incidence of early complications was quite less in our patients (ranged from 0 to 5%). There was no incidence of excessive intra-operative bleeding or injury to surrounding structures causing subcutaneous emphysema or vocal cord palsy. One patient developing pneumothorax after the procedure was managed conservatively. There was no incidence of tracheo-esophageal fistula, suprastomal collapse or difficulty in decannulation on 9 months of follow up related to our technique. However, one of the patients developed early trachietis and cutaneous peristomal granulomas and 2 patients developed late trachietis which was treated conservatively.
S-shaped tracheoplasty, a new pediatric tracheotomy technique has resulted in a quantifiable reduction in the risk of the early and late complications in our series. Hence, we feel that this new technique is a better alternative to existing methods but larger randomized controlled studies are required before universal adoption of this technique.
International journal of pediatric otorhinolaryngology 05/2012; 76(8):1132-5. DOI:10.1016/j.ijporl.2012.04.016 · 1.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Severe cardiovascular responses in the form of tachycardia and hypertension following nasal speculum insertion occur during sublabial rhinoseptal trans-sphenoid approach for resection of small pituitary tumours. We compare the effects of preoperative administration of clonidine (α-2 agonist) and atenolol (α-blocker) over haemodynamic response, caused by speculum insertion during trans-sphenoid pituitary resection. We enrolled 66 patients in age range 18-65 years, of ASA I-II, and of either sex undergoing elective sublabial rhinoseptal trans-sphenoidal hypophysectomy. Group I (control) received placebo, group II (clonidine) received tablet clonidine 5 µg/kg, and group III (atenolol) received tablet atenolol 0.5 mg/kg. The heart rate increased on speculum insertion and 5 and 10 minutes following speculum insertion as compared to the pre-speculum values in the control group, while no change in the heart rate was observed in other groups (P<0.05). There was a rise in the mean arterial pressure during and 5, 10, and 15 minutes after nasal speculum insertion in the control group, whereas it was not seen in other groups (P<0.05). We therefore suggest that oral clonidine and oral atenolol (given 2 hours prior to surgery) is an equally effective and safe method of attenuating haemodynamic response caused by nasal speculum insertion during trans-sphenoid pituitary resection.
Indian journal of anaesthesia 03/2011; 55(2):135-40. DOI:10.4103/0019-5049.79893
[Show abstract][Hide abstract] ABSTRACT: Anomalous connections between an extracranial venous sac and intracranial dural sinuses through dilated diploic and emissary veins of the skull result in sinus pericranii (SP). In this study, two patients with the rare presentation of multiple, congenital SP with associated dural venous lakes and venous anomalies are described. In one patient, multiple SPs were located in the frontal, parasagittal region with an associated subcortical venous angioma; and, in the other, peritorcular and juxta-transverse-sigmoid sinus junction SP coexisted. The venous anomalies drained into venous lakes in close proximity to major sinuses. They also communicated with extracranial tributaries via interosseous veins leading to the development of venous hypertension that presumably caused pressure erosion of the skull. This may have been responsible for the pathogenesis of multiple subgaleal venous sacs of SP and may also lead to profuse hemorrhage, cortical venous thrombosis, or air embolism. Multiplicity, associated venous lakes, venous angioma, and a lateral location are unique presentations of SP. Sac excision, transcranial venous anastomotic channel blockage, and reinforcement/replacement of the underlying bone are the recommended modalities of treatment.
[Show abstract][Hide abstract] ABSTRACT: Intracranial meningioma during pregnancy challenges the skill of obstetricians, neurosurgeons and neuroanesthesiologists in resection of the tumor and to secure delivery of the baby. Advances in fetal and maternal monitoring, neuroanesthesia, and microsurgical techniques allow safe neurosurgical management of these patients. Urgent neurosurgical intervention is reserved for the management of malignancies, active hydrocephalus, and benign brain tumors associated with signs of impending herniation or progressive neurological deficit. Particular attention is given to maintain stable maternal hemodynamics to avoid uterine hypo perfusion and fetal hypoxia intraoperatively. Therefore, the major challenge of neuroanesthesia during pregnancy is to provide an appropriate balance between competing, and even contradictory, clinical goals of neuroanesthesiology and obstetric practice.
Journal of Neurosciences in Rural Practice 04/2010; 1(1):35-7. DOI:10.4103/0976-3147.63101
[Show abstract][Hide abstract] ABSTRACT: Preinduction i.v. fentanyl bolus is associated with coughing in 28-65% of patients. Fentanyl-induced coughing (FIC) is not always benign and can be remarkably troublesome at the most critical moment of induction of anaesthesia when airway reflex is lost. We postulated that the huffing manoeuvre, a forced expiration against open glottis, just before i.v. fentanyl, may suppress this undesirable spasmodic cough.
Three hundred patients of ASA I and II, aged 18-60 yr, undergoing elective surgical procedures were randomly allocated into two groups consisting of 150 patients. Both groups received i.v. fentanyl (2.5 microg kg(-1)). Group 1 patients breathed normally whereas Group 2 patients were asked to perform huffing manoeuvre just before the fentanyl injection. The incidence of cough was recorded for 1 min before the induction of anaesthesia, and graded as mild (1-2 cough), moderate (3-5 cough), and severe (>5 cough). The incidence of FIC was analysed with Fisher's exact test and severity was analysed with the Mann-Whitney U-test. A P-value of <0.05 was considered significant.
The incidence of cough was 32% in the control group and 4% in the huffing manoeuvre group (P<0.00). In the control group, 12% of FIC cases were moderate to severe in nature whereas no patient suffered severe coughing in the huffing manoeuvre group (P=0.049).
A huffing manoeuvre performed just before i.v. fentanyl (2.5 microg kg(-1)) significantly reduces the incidence and severity of FIC in the majority of the patients.
BJA British Journal of Anaesthesia 11/2009; 104(1):40-3. DOI:10.1093/bja/aep333 · 4.85 Impact Factor