The perioperative concerns of emergency neurosurgery in elderly patients: A series of three cases

Owing to many advances in anesthetic techniques, perioperative sophisticated monitoring as well as surgical techniques, there has been an exponential increase in the geriatric patients presenting for elective as well as emergency surgeries. Perioperative period in the elderly is more prone to adverse outcomes due to factors such as advanced age group, limited functional capacity, multiple comorbid conditions, impaired cognition as well as limited support at the home front. The severity of illness is a better predictor of outcomes if compared with the age. The perioperative risk of mortality and morbidity in elderly patients increases all the more if the surgery has to be performed in an emergency. We present a series of three cases, highlighting perioperative concerns and management of elderly patients undergoing emergency neurosurgeries at our institution

Cardiac arrest despite optimal preloading of patient using ultrasonography-guided inferior vena cava indices under subarachnoid neuraxial blockade: A report of two cases

Spinal anesthesia (SA) is utilized as an effective means of anesthesia and has an impressive safety record but it is not devoid of complications, and sometimes, the complications are as fatal as cardiac arrest. Although many factors are involved in etiology of cardiac arrest under SA, the vagal responses to the decreased preload are the most common culprits. We report two cases of cardiac arrest under SA; which happened despite our patient being adequately preloaded utilizing the ultrasonography-guided targeted volume therapy. The patients were successfully resuscitated with no neurological deficit

Anesthetic management of a patient of multinodular goiter with retrosternal extension presenting with obstructive sleep apnea for total thyroidectomy

Multinodular goiter (MNG), one of the disorders of the thyroid gland, is often detected as a mass in the neck, but sometimes produces pressure symptoms. We present successful anesthetic management of a case of an obese woman having MNG with retrosternal extension, in the setting of severe OSA, planned for total thyroidectomy. The complicated presentation of the disorder, with challenging airway management during the peri-operative period and a positive outcome is a reason for sharing this experience

Anesthetic management of excision of recurrent C2 chordoma with extension into posterior pharyngeal wall

Tumors from remnants of the embryonic notochord are called as Chordomas. These are slow growing, yet aggressive tumors. Despite treatment, these, low grade, malignant tumors are very prone to recurrence and 6 years is approximately the median survival time. Though commonly located in the sacrococcygeal or sphenooccipital regions, their incidence in the cervical spine is around 7.5%. Treatment approaches vary from surgical excision to radiotherapy and chemotherapy. Outcome of these tumors depends on the size and location of tumour and the course of treatment delivered. Surgery is the treatment of choice with the goal to remove maximum tumor as possible and thereafter, patients are offered radiotherapy or chemotherapy. Due to the proximity of these tumors to various vital structures such as brain and spinal cord, the management requires the involvement of various subspecialties working in cohesion. We present the anesthetic management of a 32-year-old male patient who presented with recurrence of C2 chordoma postradiotherapy and was a challenge for airway management

Evaluation of two different dosages of local anesthetic solution used for ultrasound-guided femoral nerve block for pain relief and positioning for central neuraxial block in patients of fracture neck of the femur

Introduction: Surgical management of the fracture femur is preferred so as to prevent complications associated with prolonged immobilization. Central neuraxial blockade (CNB) is an attractive option for these patients, and an optimal positioning of the patient is a definite requirement. Owing to the pain associated with movement of the fractured limb, it becomes difficult for the patients to give suitable positioning. Femoral nerve block (FNB) features as a rescue analgesia so as to provide adequate analgesia for facilitation of satisfactory positioning. Aim: This study aims to compare analgesic effect of two different dosages of local anesthetic (LA) solution administered for ultrasonography (USG)-guided FNB given to facilitate optimal positioning for conduct of CNB. Materials and Methods: After taking permission from the institutional review board, eighty patients were enrolled in the study to find out the efficacy of dosage of LA solution for FNB in providing pain relief caused by movement of fractured limb during conduct of regional anesthesia. Informed consent was taken. All patients were given USG-guided FNB. Patients were randomized using a computer-generated random number table, into two groups of forty patients each. Group A patients received USG-guided 12 ml of LA solution containing 10 ml lignocaine solution without preservative (2%) plus 2 ml normal saline (NS), while Group B patients received USG-guided 15 ml of LA solution containing 13 ml lignocaine solution without preservative (2%) plus 2 ml NS for positioning before combined spinal epidural. Results: A total of eighty patients, divided randomly into two groups, were enrolled in the study. Demographics (age, sex, weight, and American Society of Anesthesiologists grades) were similar in both groups. No statistical significance was found in the numeric rating scale scores at baseline, zero minutes, 5, and 15 min in both the groups. Conclusion: USG-guided FNB with 12 ml of LA solution was as effective as 15 ml of LA solution for achieving adequate pain relief so as to give optimal positioning for CNB in patients of fracture neck of femur

Cardiopulmonary Resuscitation: Unusual Techniques for Unusual Situations

Background: The cardiopulmonary resuscitation (CPR) in prone position has been dealt with in 2010 American Heart Association (AHA) guidelines but have not been reviewed in 2015 guidelines. The guidelines for patients presenting with cardiac arrest under general anesthesia in lateral decubitus position and regarding resuscitation in confined spaces like airplanes are also not available in AHA guidelines. This article is an attempt to highlight the techniques adopted for resuscitation in these unusual situations. Aims: This study aims to find out the methodology and efficacy in nonconventional CPR approaches such as CPR in prone, CPR in lateral position, and CPR in confined spaces. Methods: We conducted a literature search using MeSH search strings such as CPR + Prone position, CPR + lateral Position, and CPR + confined spaces. Results: No randomized controlled trials are available. The literature search gives a handful of case reports, some simulation- and manikin-based studies but none can qualify for class I evidence. The successful outcome of CPR performed in prone position has shown compressions delivered on the thoracic spine with the same rate and force as they were delivered during supine position. A hard surface is required under the patient to provide uniform force and sternal counter pressure. Two rescuer technique for providing successful chest compression in lateral position has been documented in the few case reports published. Over the head CPR and straddle (STR), CPR has been utilized for CPR in confined spaces. Ventilation in operating rooms was taken care by an advanced airway in situ. Conclusion: A large number of studies of high quality are required to be conducted to determine the efficacy of CPR in such positions