Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal and epidural anaesthesia

Background: Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one. Objectives: We performed a study to compare two popular CSE techniques: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT). Methods: After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared. Results: SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups. Conclusion: SDT is an acceptable alternative to DST and SST

Incidental thrombocytosis: Should it concern the anesthesiologist?

Preoperative thrombocytosis, often detected incidentally in surgical patients and inadvertently overlooked, has important implications for the anesthesiologists. The primary form is a chronic clonal myeloproliferative disorder usually affecting adults while the secondary type is a benign reactive disease commonly found in children. Serious perioperative hemostatic complications are reported in primary thrombocytosis and hence, a detailed preoperative evaluation and initiation of therapy to lower the platelet count (PC) is required before undertaking surgery. Patients with reactive thrombocytosis however, usually have complication-free surgeries, and if there is no prior evidence of hemostatic complications and the reactive cause can be identified, no specific perioperative intervention may be required. A thorough preanesthetic checkup and implementation of basic thrombo-prophylaxis measures in all patients with a raised PC is advocated. We present here our experience with three infants diagnosed with high preoperative PC, presumably due to reactive causes, who underwent uneventful neurosurgeries at our institution

Comparison of the landmark technique and the static ultrasound-guided technique for internal jugular vein cannulation in adult cardiac surgical patients

Background: The use of real time ultrasound (US) for insertion of central venous catheters is limited by various factors such as availability, space constraints, and perceived lack of need according to surveys including cardiovascular anesthesiologists. Methods: After the ethical committee approval and patient consent, 201 adult patients scheduled for elective cardiac surgery were randomized to undergo internal jugular vein (IJV) cannulation by either of the two methods: Landmark technique (control group), static US technique using the transthoracic echocardiography (TTE) probe (US group). The success rate, number of attempts, total cannulation time, and complication rate in the two groups were compared. Results: The overall success rate and the first attempt success rate were significantly higher in the control group than the US group (99% vs. 89.6%, P = 0.003 and 87.6% vs. 70.8%, P = 0.003, respectively). The total number of attempts to locate the IJV with the finder needle as well as the puncture needle was significantly lower in the control group than the US group (2.2 vs. 1.3, P = 0.001and 1.7 vs. 1.2, P = 0.021, respectively). The incidence of arterial puncture was higher in the US group than the control group (9.4% vs. 1.9%, P= 0.020). The total cannulation time was also higher in the US group (430 ± 320 s) than the control group (197 ± 116 s, P= 0.001). Conclusion: The landmark technique has a higher success rate, lower complication rate, and total cannulation time as compared with the static US technique using the TTE probe for IJV cannulation in adult cardiac surgical patients