Definitions and pathophysiology of vasoplegic shock.

Vasoplegia is the syndrome of pathological low systemic vascular resistance, the dominant clinical feature of which is reduced blood pressure in the presence of a normal or raised cardiac output. The vasoplegic syndrome is encountered in many clinical scenarios, including septic shock, post-cardiac bypass and after surgery, burns and trauma, but despite this, uniform clinical definitions are lacking, which renders translational research in this area challenging. We discuss the role of vasoplegia in these contexts and the criteria that are used to describe it are discussed. Intrinsic processes which may drive vasoplegia, such as nitric oxide, prostanoids, endothelin-1, hydrogen sulphide and reactive oxygen species production, are reviewed and potential for therapeutic intervention explored. Extrinsic drivers, including those mediated by glucocorticoid, catecholamine and vasopressin responsiveness of the blood vessels, are also discussed. The optimum balance between maintaining adequate systemic vascular resistance against the potentially deleterious effects of treatment with catecholamines is as yet unclear, but development of novel vasoactive agents may facilitate greater understanding of the role of the differing pathways in the development of vasoplegia. In turn, this may provide insights into the best way to care for patients with this common, multifactorial condition

A comparative study of landmark-based topographic method versus the formula method for estimating depth of insertion of right subclavian central venous catheters

Background and Aims: Subclavian central venous catheterisation (CVC) is employed in critically ill patients requiring long-term central venous access. There is no gold standard for estimating their depth of insertion. In this study, we compared the landmark topographic method with the formula technique for estimating depth of insertion of right subclavian CVCs. Methods: Two hundred and sixty patients admitted to Intensive Care Unit requiring subclavian CVC were randomly assigned to either topographic method or formula method (130 in each group). Catheter tip position in relation to the carina was measured on a post-procedure chest X-ray. The primary endpoint was the need for catheter repositioning. Mann–Whitney test and Chi-square test was performed for statistical analysis using SPSS for windows version 18.0 (Armonk, NY: IBM Corp). Results: Nearly, half the catheters positioned by both the methods were situated >1 cm below the carina and required repositioning. Conclusion: Both the techniques were not effective in estimating the approximate depth of insertion of right subclavian CVCs

Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia

Background: Both epidural analgesia and combined spinal epidural analgesia (CSEA) are employed for pain relief during labor because they provide reliable analgesia compared to other modalities. Studies are equivocal with respect to their effect on the rate of cervical dilatation, duration of labor, and labor outcome. The primary outcome of the present study was to compare the effect of epidural analgesia alone with CSEA with respect to the rate of cervical dilatation. Materials and Methods: One hundred and twenty parturients with an initial cervical dilatation of <4 cm were randomized to receive CSEA or epidural analgesia alone for pain relief during labor. The rate of cervical dilatation, onset of effective analgesia, number of epidural top-ups requested, labor outcome, and the quality of analgesia was assessed in both the study groups. Statistical Analysis: Mann–Whitney and Chi-square tests were performed where applicable to compare the data between the two groups. Results: The results of the study showed that the rate of cervical dilatation was rapid with CSEA compared to epidural analgesia alone [median (interquartile range) 2 (1.2,3) v/s 1.16 (1,2)]. The onset of analgesia was earlier with combined spinal epidural (CSE v/s EA, 3.7 ± 1.3 min v/s 23.8 ± 5.8 min). Labor outcome and quality of analgesia was similar between the two groups. The incidence of pruritus was higher with CSEA than with epidural analgesia alone. Conclusion: CSEA is associated with more rapid cervical dilatation and shorter duration of first stage of labor when compared with epidural analgesia alone

Efficacy of dexmedetomidine with ropivacaine in supraclavicular brachial plexus block for upper limb surgeries

Background and Aims: The primary aim of this study was to evaluate the effect of addition of dexmedetomidine on the duration of analgesia in patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Material and Methods: Sixty patients of American Society of Anesthesiologists physical status I/II/III undergoing elective upper limb surgeries under supraclavicular brachial plexus block using nerve stimulator were randomized into two groups. Group A (n = 30) received 30 mL 0.5% ropivacaine and 1 mL normal saline, and Group B (n = 30) received 30 mL 0.5% ropivacaine and 1 μg/kg of dexmedetomidine. The primary outcome was the duration of analgesia. Secondary outcomes included time to onset and duration of sensory/motor blockade. Statistical Analysis: Results on continuous measurements are presented as mean ± standard deviation and compared using Student's unpaired t-test. Results on categorical measurements are presented in number (%) and compared using Chi-square test. Results: Onset of sensory and motor block in Group A (13.0 ± 4.1 and 23.5 ± 5.6 min) was slower than those in Group B (9.5 ± 5.8 and 15.6 ± 6.3 min; P = 0.009 for sensory and P < 0.001 for the motor block). Duration of sensory and motor block in Group A (400.8 ± 86.6 and 346.9 ± 76.9 min) was shorter than those in Group B (630.6 ± 208.2 and 545.9 ± 224.0 min; (P < 0.001). The duration of analgesia in Group A (411.0 ± 91.2 min) was shorter than that in Group B (805.7 ± 205.9 min; P < 0.001). The incidence of bradycardia and hypotension was higher in Group B than in Group A (P < 0.001). Conclusion: Perineural dexmedetomidine with ropivacaine provides prolonged postoperative analgesia, hastens the onset of sensory and motor block and prolongs the duration of the supraclavicular brachial plexus block

The effect of addition of low dose fentanyl to epidural bupivacaine (0.5%) in patients undergoing elective caesarean section: A randomized, parallel group, double blind, placebo controlled study

Background: Opioids have synergistic action with local anesthetics which may alter characteristics of epidural block. Giving opioids to mother before delivery of baby is still fully not accepted with some fearing risk of neonatal depression. Aims: Our primary aim was to evaluate the analgesic effect of addition of 50 μg fentanyl to epidural 0.5% bupivacaine in patients undergoing elective caesarean section using visual analog scale. The secondary aim was to assess onset of analgesia, volume of drug required to achieve T6 level, grade and duration of motor block and Apgar score. Materials and Methods: In this prospective, randomized, double blind, placebo controlled study 64 patients scheduled for elective caesarean section under epidural anesthesia were randomly divided into two groups of 32 each. The fentanyl group received 1ml of 50 μg fentanyl and the saline group received 1ml of normal saline mixed with 10ml of 0.5% bupivacaine for epidural anesthesia. VAS score, time to achieve T6 level, dose of bupivacaine, intraoperative analgesic consumption and duration of analgesia, grade and duration of motor block and any adverse maternal and neonatal effects were noted. Statistical Analysis: Data was analyzed using Students t test, chi-square test and Mann-Whitney U-test. The values of P < 0.05 were considered statistically significant. Results: Fentanyl improved the VAS score significantly (1.6 ± 1.32) compared to the saline group (3.77 ± 1.0, P < 0.0001). It also reduced the intraoperaitve analgesic supplementation compared to the saline group. (P = 0.031). The postoperative duration of analgesia was prolonged in the fentanyl group (275.80 ± 13.61 min) compared to the saline group (191.47 ± 12.16 min, P < 0.0001). The other characteristics of epidural block were unaltered. Conclusion: Addition of 50 μg fentanyl to epidural 0.5% bupivacaine significantly reduces the VAS score. It also reduces intra-operative analgesia supplementation and prolongs the duration of postoperative analgesia without altering the other characteristics of block. The neonatal outcome is not affected with addition of fentanyl before delivery of baby

Is intraoperative endoscopy safe in a child with Kasai procedure?

We report a case of venous air embolism which occurred during intraoperative endoscopy in a five-year-old boy who had undergone Kasai procedure in his infancy. The child had a cardiac arrest during the procedure from which he could not be resuscitated. The awareness about this complication would allow rapid diagnosis, which is vital to provide specific treatment and prevent fatal outcome

Transient brachial monoparesis following epidural anesthesia for cesarean section

Monoparesis following lumbar epidural block is a rare occurrence, with few cases reported in the literature. We report development of transient brachial monoparesis following epidural anesthesia in a parturient for cesarean section. The patient received a mixture of 15 mL of 2% lignocaine with 50 mcg fentanyl epidurally to achieve a blockade up to T6 level. She remained hemodynamically stable throughout the procedure, with no respiratory distress or desaturation. However, near the end of surgery, she developed weakness in the right upper limb. The weakness lasted for 90 min, followed by complete neurological recovery. Subsequent hospital stay was uneventful

Anesthesia management in a child with laryngeal papilloma causing near complete airway obstruction

Recurrent respiratory papillomatosis (RRP) is a rare, chronic disease of viral etiology affecting most commonly larynx. A 5-year-old child with stridor was posted for microlaryngoscopic excision of laryngeal papilloma. We discuss the perioperative management of case with the various ventilation strategies. In child with stridor intubation remains the safest option. It is suggested to maintain spontaneous ventilation until intubation as mask ventilation could be difficult