Intra-operative haemodynamic volatility in a patient undergoing retroperitoneal cyst excision

Excision of a suspected retroperitoneal, duodenal duplication cyst was performed in a pre-operatively normotensive patient under combined epidural and general anaesthesia. Intraoperatively, the cystic tumour was discovered to be a retroperitoneal mass, free from duodenal or adrenal origin. Development of severe arrhythmias, ST segment changes and hypertensive spikes during cyst handling and dissection suggested the possibility of a catecholamine-secreting tumour. These were managed effectively with pharmacological agents. Subsequently, histopathology of the specimen revealed a paraganglioma. Vasoactive tumour has to be suspected in every patient undergoing anaesthesia for retroperitoneal cystic lesion

Penetrating abdominal injury in a polytrauma patient: Anaesthetic challenges faced

Penetrating abdominal injuries are potentially life threatening due to the associated hemorrhagic shock and visceral injury. Through and through penetrating injury with polytrauma is rarely encountered. We report a case presenting with in situ projecting heavy metallic rod in a through and through penetrating abdominal injury along with foreign body in a road traffic accident. Anaesthetic management was difficult due to inability to position in supine, rapidly progressing hemorrhagic shock and hypoxia due hemopneumothorax. Two operating tables were used with adequate intervening space to accommodate the posteriorly projecting metallic rod during intubation in supine position. Intensive monitoring and resuscitation resulted in uneventful successful outcome

Sevoflurane versus isoflurane in shoulder arthroscopy in beach chair position in patients with prior interscalene brachial plexus block: A prospective randomised equivalency-based haemodynamic evaluation trial

Background and Aims: There is a paucity of literature on comparative effects of different inhalational anaesthetics in beach chair position (BCP) for shoulder arthroscopy. We aimed to investigate and compare the haemodynamic effects, anaesthetic and surgical outcomes between two inhalational agents. Methods: In this randomised study, patients of age 18–60 years, were allotted to two groups (29, sevoflurane and 28, isoflurane) and received protocol-based anaesthesia. Intraoperatively, different haemodynamic and other data were recorded. Results: All mean of averages of individual subject's vitals were comparable between the groups [P = 0.681, 0.325, 0.803, and 0.051, respectively for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) and heart rate (HR)]. Higher mean HR was recorded for maximum readings of isoflurane (P = 0.028). Equivalency was observed for SBP, MBP, and DBP (P = 0.000, 002, and 0.027, respectively). Process capability indices indicated that sevoflurane had better values (Pp: 0.55 versus 0.41, Ppk: 0.35 versus 0.22) for SBP as with MBP (Pp: 0.62 versus 0.51, Ppk: 0.36 versus 0.33). For achieving optimal vision, higher pump pressures (PPs) were demanded by surgeon (P = 0.025) and higher differences observed between initial and highest PPs (P = 0.027), in isoflurane subjects. Multivariable analysis revealed that no continuous predictor was able to predict the quality of vision except additional pump flow factor, for both groups. Conclusion: Both inhalational agents demonstrated equivalent haemodynamic effects. Increased arthroscopic PP requirements were observed with isoflurane anaesthesia. Sevoflurane may be superior to isoflurane during BCP arthroscopy

Target-controlled infusion (Propofol) versus inhaled anaesthetic (Sevoflurane) in patients undergoing shoulder arthroscopic surgery

Background: One of the challenges of anaesthesia for shoulder arthroscopic procedures is the need for controlled hypotension to lessen intra-articular haemorrhage and thereby provide adequate visualisation to the surgeon. Achievement of optimal conditions necessitates several interventions and manipulations by the anaesthesiologist and the surgeon, most of which directly or indirectly involve maintaining intra-operative blood pressure (BP) control. Aim: This study aimed to compare the efficacy and convenience of target controlled infusion (TCI) of propofol and inhalational agent sevoflurane in patients undergoing shoulder arthroscopic surgery after preliminary inter-scalene blockade. Methods: Of thirty four patients studied, seventeen received TCI propofol (target plasma concentration of 3 μg/ml) and an equal number, sevoflurane (1.2-1.5 Minimum Alveolar Concentration). N 2 O was used in both groups. Systolic, diastolic, mean blood pressures and heart rate were recorded regularly throughout the procedure. All interventions to control BP by the anaesthesiologist and pump manipulation requested by the surgeon were recorded. The volume of saline irrigant used and the haemoglobin (Hb) content of the return fluid were measured. Results: TCI propofol could achieve lower systolic, mean BP levels and the number of interventions required was also lower as compared to the sevoflurane group. The number of patients with measurable Hb was lower in the TCI propofol group and this translated into better visualisation of the joint space. A higher volume of saline irrigant was required in the sevoflurane group. No immediate peri-operative anaesthetic complications were noted in either category. Conclusion: TCI propofol appears to be superior to and more convenient than sevoflurane anaesthesia in inter-scalene blocked patients undergoing shoulder arthroscopy

Isoflurane versus sevoflurane with interscalene block for shoulder arthroscopic procedures: Value of process capability indices as an additional tool for data analysis

Background and Aims : Hypotensive anaesthesia reduces intra-articular bleed and promotes visualisation during arthroscopy. The haemodynamic effects of inhalational agents isoflurane and sevoflurane were studied extensively, and both were found to reduce mean arterial pressures (MBP) to an equivalent magnitude. We investigated the relative ability of isoflurane vis-a-vis sevoflurane to maintain the target systolic blood pressure (SBP) in patients undergoing shoulder arthroscopic procedures. Methods: In a prospective randomised study, 59 patients in two groups of 30 and 29 patients each received concomitant general anaesthesia (1.2-1.5 MAC of isoflurane and sevoflurane) and interscalene brachial plexus block. Nitrous oxide was used in both groups. Intraoperatively, serial blood pressure recordings of SBP, diastolic blood pressure (DBP), MBP and heart rates were done at every 3 rd min intervals. The manipulations needed to achieve target SBP (T = 90 mmHg) for optimal arthroscopic visualisation and treat unacceptable hypotensive episodes were noted. Conventional statistical tests and process capability index (PCI) evaluation were both deployed for data analysis. Results: Lower mean SBP and DBPs were recorded for isoflurane patients as compared to sevoflurane (P < 0.05, for mean, maximum and minimum recordings). Higher mean heart rates were recorded for isoflurane (P < 0.05). PCIs indicated that isoflurane was superior to sevoflurane in the ease of achieving target SBP of 90 mmHg as well as maintaining blood pressures in the range of 80-100 mmHg. Conclusion: Isoflurane provides better intraoperative haemodynamic status vis-a-vis sevoflurane in patients undergoing shoulder arthroscopic surgery with preliminary interscalene blockade. The PCI can be a useful additional medical data analysis tool