Anatomic Variation of Subclavian Artery Visualized on Ultrasound-Guided Supraclavicular Brachial Plexus Block

Use of ultrasonography for performance of nerve and plexus blocks has made the process simpler and safer. However, at times, variant anatomy of the visualized structures can lead to failure of blocks or complications such as intravascular injections. This is especially true in case of novice operators. We report a case of a variant branch of subclavian artery, possibly the dorsal scapular artery passing through the brachial plexus nerve bundles in the supraclavicular area. Since this variation in anatomy was visualized in the scout scan prior to the performance of the block, it was possible to avoid any accidental puncture. Hence, a thorough knowledge of the ultrasound anatomy is important in order to identify various aberrations and variations. It is also prudent to perform a preliminary scan, prior to performance of the block to localize the target area and avoid any inadvertent complications

Brachial plexus block: Comparison of two different doses of clonidine added to bupivacaine

Background: The role of clonidine as an adjuvant to local anesthetic agents in brachial plexus block (BPB) has been extensively studied. However, till date there has been no consensus about the ideal dose of clonidine for this purpose. This study was carried out to evaluate two doses of clonidine-1 and 2 g/kg, added to 0.5% bupivacaine, with regard to onset and duration of sensorimotor blockade, hemodynamic effects, postoperative analgesia, and adverse effects. Materials and Methods: Sixty adult patients undergoing upper limb surgeries were randomly allocated into two groups. Thirty patients received 1 g/kg clonidine (group I) and the rest received 2 g/kg clonidine (group II) added to 30 mL of 0.5% bupivacaine through nerve stimulator-guided supraclavicular BPB. The onset and duration of sensorimotor blockade, hemodynamic variables, duration of analgesia, level of sedation, and adverse effects was assessed. Results: The onset of sensorimotor block was earlier in group II (9.9 ± 4.1 min for sensory block and 13.2 ± 6.7 min for motor block) than in group I (15.9 ± 6.8 min for sensory block and 18.5 ± 7.8 min for motor block). The duration of analgesia was also prolonged in patients receiving the higher dose (21.0 ± 2.96 h vs. 14.9 ± 3.0 h). Although hemodynamics remained comparable in both the groups, incidence of hypotension and bradycardia was higher in group II as compared to group I. The sedation was clinically and statistically more in group II patients (43% vs. 17%). Conclusion: Higher dose of clonidine in BPB hastens the onset, prolongs the duration of sensorimotor blockade and postoperative analgesia without significant hemodynamic alterations. It also causes more sedation, which although ensures patient comfort in most cases, but might be undesirable in certain situations

Pneumothorax during laparoscopic repair of giant paraesophageal hernia

Giant paraesophageal hernia is an uncommon morbid disorder which may present a risk of catastrophic complications and should be repaired electively as soon as possible. Laparoscopic fundoplication is the mainstay of surgical management of this disorder due to several advantages such as lower post-operative morbidity and pain. We report a case of a 70-year-old patient with a giant paraesophageal hernia, who developed subcutaneous emphysema with pneumothorax during laparoscopic fundoplication. Early diagnosis was possible by close clinical evaluation and simultaneous monitoring of end-tidal carbon dioxide levels and airway pressures. Although positive end-expiratory pressure application is an effective way of managing pneumothorax secondary to the passage of gas into the interpleural space, insertion of an intercostal drain may be used in an emergent situation

Perioperative hemodynamic management in surgery for phaeochromocytoma: A narrative review

Pheochromocytomas are rare adrenal tumors that produce excessive catecholamines and their surgical removal poses significant risks of intraoperative hemodynamic instability (HI) due to catecholamine release. This review article discusses the perioperative factors that impact hemodynamic lability and its management in patients undergoing surgical removal. A literature review was conducted by searching the electronic databases - Ovid MEDLINE, Embase, and Cochrane Library using appropriate Medical Subject Heading terms and keywords such as phaeochromocytoma, HI, and perioperative hemodynamic monitoring. The advancements in surgical and anesthetic techniques and appropriate preoperative medical optimization have contributed to a significant decrease in mortality rates. However, perioperative HI remains the biggest surgical and anesthetic challenge in treating pheochromocytomas. Patients with larger and more hormonally active tumors are at higher risk for extreme hypertensive episodes during surgery. Preoperative α-blockade, higher phenoxybenzamine doses, and laparoscopic approach improve the outcomes in phaeochromocytoma removal. Anesthetic techniques and drugs used during surgery may help prevent HI, but careful intraoperative management is essential. Perioperative HI can lead to increased surgical blood loss, patient morbidity, and prolonged intensive care unit (ICU) and hospital stay. Therefore, a multidisciplinary approach involving the surgeon, anesthesiologist, and ICU team is essential to ensure optimal perioperative management of patients with pheochromocytoma. Intensive hemodynamic monitoring may be required in the postoperative period to manage hypotension seen after tumor removal. In conclusion, perioperative HI is a significant risk during the surgical removal of pheochromocytomas, even with preoperative pharmacological treatment. Therefore, the use of appropriate preoperative medical optimization, surgical and anesthetic techniques, and careful intraoperative management can significantly improve the outcomes

Anesthetic management of a case of pulmonary alveolar proteinosis for whole lung lavage

Pulmonary Alveolar Proteinosis (PAP) is a rare disease of the lungs characterized by deposition of lipo-proteinaceous material in the alveoli. This leads to reduced lung compliance and V/Q mismatch, causing respiratory failure. Patients with PAP may be posted for Whole Lung Lavage (WLL) under anesthesia, which is a challenging case for anesthetists. Preexisting respiratory failure is complicated by requirement of single lung ventilation with the help of double lumen tube during the procedure. Intraoperative ventilation is difficult and is managed with blood gas and airway pressure monitoring. Some degree of hypoxemia and hypercapnia may have to be tolerated. Large volumes of fluid are instilled into the lung which may cause hypothermia, hypervolemia, and electrolyte disturbances. These patients frequently require elective ventilation and intensive care admission in the postoperative period. We report the case of a young woman with PAP, posted for unilateral WLL under anesthesia. We wish to highlight the possible challenges posed by this case and how to conduct a safe anesthesia for this patient

Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer

Overview: Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks. Materials and Methods: A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted. Results: The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L. Conclusion: Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate