Anaesthesia for left thoracoscopic sympathectomy for refractory long QT syndrome: three case reports

Congenital long QT syndrome (LQTS) is a rare genetic disorder that has been associated with various genetic mutations including life-threatening cardiac arrhythmias and sudden death. Left thoracoscopic sympathectomy is an effective treatment for patients who are refractory to medical therapy or who need frequent epicardial internal cardio defibrillator intervention. The authors report three cases, one adult and two children, who underwent successful left thoracoscopic sympathectomy. All three patients remained clinically stable without arrhythmias through 3 months of follow-up. It is suggested in the literature that 77% of patients experienced immediate relief of symptoms. The results of this case report suggest that left thoracoscopic sympathectomy is a safe and effective approach for treating patients with LQTS.Keywords: congenital condition, left cardiac sympathetic denervation, left thoracic sympathectomy, prolonged QT syndrome, video-assisted thoracoscopic surger

Emergence agitation in paediatric patients using sevoflurane and isoflurane anaesthesia: a randomised controlled study

Background: Emergence agitation (EA) is a well-recognised phenomenon often observed in children following general anaesthesia. The aim of this study was to compare the incidence and severity of EA in the paediatric age group under sevoflurane or isoflurane anaesthesia using the PAED Scale (Pediatric Anaesthesia Emergence Delirium Scale) (the primary outcome) and its correlation with preinduction agitation as well as its association with pain using the FLACC (Face Legs Activity Cry Consolability) score (the secondary outcome).Method: In this randomised controlled trial, 60 children aged between 2 and 6 years were enrolled and randomly divided into two groups. All patients were induced with sevoflurane, relaxed with atracurium and the airway secured with an appropriate device. Anaesthesia was maintained with O2, N2O and sevoflurane or isoflurane. Adequate analgesia was ensured. Post-procedure, they were observed in the post-anaesthesia care unit (PACU) for development of EA. The statistical package SPSS® version 17 was used and data were analysed using Student’s unpaired t-test and a chi-square test. Statistical significance was accepted at p < 0.05.Results: The mean PAED scale was 12.9 in the sevoflurane group and 9.4 in the isoflurane group (p < 0.001). The incidence of EA was significantly related to preinduction agitation (p = 0.00). Higher FLACC scores were observed only within the initial 10 min in the sevoflurane group (p = 0.009).Conclusions: An increased incidence of EA was observed with sevoflurane maintenance anaesthesia, particularly during the initial 10–20 min of the postoperative period. EA was strongly associated with preinduction agitation, but it was poorly correlated to pain, i.e. not all patients who developed EA had a high FLACC score.Keywords: sevoflurane anaesthesia, emergence agitation, preinduction anxiety, paed scale, preschool childre

Review Article - Anesthesia for dermatological surgery

Knowledge of local anesthesia is critically important to perform dermatological surgery. Local anesthetics when used judiciously are extremely safe and allow dermatologists to perform a variety of procedures. This article aims to provide an updated review of local anesthesia and local anesthetic drugs. Side effects of local anesthetics and techniques of regional anesthesia are discussed and some commonly used nerve blocks are explained. A detailed knowledge of the pharmacology of local anesthetics aids in optimal therapeutic use, and in prevention, early diagnosis and management of their toxicities by the clinician

Hypertensive disorders in pregnancy

Hypertensive disorders of pregnancy (HDP) remain among the most significant and intriguing unsolved problems in obstetrics. In India, the prevalence of HDP was 7.8% with pre-eclampsia in 5.4% of the study population. The anaesthetic problems in HDP may be due to the effects on the cardiovascular, respiratory, neurologic, renal, haematologic, hepatic and uteroplacental systems. The basic management objectives should be facilitating the birth of an infant who subsequently thrives and completes restoration of health to the mother, or the termination of pregnancy with the least possible trauma to mother and foetus in severe pre-eclampsia. This comprises obstetric management, adequate foetal surveillance, antihypertensive management, anticonvulsant therapy, safe analgesia for labour and management of anaesthesia for delivery

Low-flow anaesthesia – underused mode towards “sustainable anaesthesia”

Any technique that employs a fresh gas flow that is less than the alveolar ventilation can be classified as low-flow anaesthesia. The complexities involved in the calculation of uptake of anaesthetic agents during the closed-circuit anaesthesia made this technique less popular. However, the awareness of the dangers of theatre pollution with trace amounts of the anaesthetic agents and the prohibitively high cost of the new inhalational agents, have helped in the rediscovery of low-flow anaesthesia. Moreover, the time has arrived for each of us, the practicing anaesthesiologists, to move towards the practice of low-flow anaesthesia, to achieve lesser theatre and environmental pollution and also to make anaesthesia more economical. The article also reviews low-flow anaesthesia (LFA) in paediatrics, recent advances such as automated LFA and updates on currently undergoing research to retrieve and reuse anaesthetic agents

Comparison of the use of McCoy and TruView EVO2 laryngoscopes in patients with cervical spine immobilization

Context: The cervical spine has to be stabilized in patients with suspected cervical spine injury during laryngoscopy and intubation by manual in-line axial stabilization. This has the propensity to increase the difficulty of intubation. An attempt has been made to compare TruView EVO2 and McCoy with cervical spine immobilization, which will aid the clinician in choosing an appropriate device for securing the airway with an endotracheal tube (ETT) in the clinical scenario of trauma. Aims: To compare the effectiveness of TruView EVO2 and McCoy laryngoscopes when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. Settings and design: K. M. C. Hospital, Mangalore, This was a randomized control clinical trial. Methods: Sixty adult patients of either sex of ASA physical status 1 and 2 who were scheduled to undergo general anesthesia with endotracheal intubation were studied. Comparison of intubation difficulty score (IDS), hemodynamic response, Cormack and Lehane grade, duration of the tracheal intubation and rate of successful placement of the ETT in the trachea between TruView EVO2 and McCoy laryngoscopes was performed. Results: The results demonstrated that TruView has a statistically significant less IDS of 0.33 compared with an IDS of 1.2 for McCoy. TruView also had a better Cormack and Lehane glottic view (CL 1 of 77% versus 40%) and less hemodynamic response. Conclusions: The TruView blade is a useful option for tracheal intubation in patients with suspected cervical spine injury

Submental intubation in patients with panfacial fractures: A prospective study

Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma

A randomized controlled study comparing intrathecal hyperbaric bupivacaine-fentanyl mixture and isobaric bupivacaine-fentanyl mixture in common urological procedures

Background and Aims: Bupivacaine is available in isobaric and hyperbaric forms for intrathecal use and opioids are used as additives to modify their effects. The aim of this study was to compare the efficacy and haemodynamic effect of intrathecal isobaric bupivacaine-fentanyl mixture and hyperbaric bupivacaine-fentanyl mixture in common urological procedures. Methods: One hundred American Society of Anesthesiologists physical status 1 and 2 patients undergoing urological procedures were randomized into two groups. Group 1 received 3 ml of 0.5% isobaric bupivacaine with 25 μg fentanyl while Group 2 received 3 ml of 0.5% hyperbaric bupivacaine with 25 μg fentanyl. The parameters measured include heart rate, blood pressure, respiratory rate, onset and duration of motor and sensory blockade. Student's unpaired t-test and the χ2 test were used to analyse the results, using the SPSS version 11.5 software. Results: The haemodynamic stability was better with isobaric bupivacaine fentanyl mixture (Group 1) than with hyperbaric bupivacaine fentanyl mixture (Group 2).The mean onset time in Group 1 for both sensory block (4 min) and motor block (5 min) was longer compared with Group 2. The duration of sensory block (127.8 ± 38.64 min) and motor block (170.4 ± 27.8 min) was less with isobaric bupivacaine group compared with hyperbaric bupivacaine group (sensory blockade 185.4 ± 16.08 min and motor blockade 201.6 ± 14.28 min). Seventy percent of patients in Group 2 had maximum sensory block level of T6whereas it was 53% in Group 1. More patients in Group 1 required sedation compared to Group 2. Conclusion: Isobaric bupivacaine fentanyl mixture was found to provide adequate anaesthesia with minimal incidence of haemodynamic instability