ASSESSMENT OF EFFICACY OF MIDAZOLAM

AS AN ADJUVANT TO INTRATHECAL
BUPIVACAINE FOR LOWER ABDOMINAL
SURGERIES
DR MIR AHMEDUDDIN ALI KHAN. P.G
SHADAN INSTITUTE OF MEDICAL SCIENCES HYDERABAD

A prospective randomised double blind study was carried out on 60

adult ASA gr 1 and 2 pts,to compare the efficacy of intrathecal
bupivacaine with midazolam and bupivacaine alone for post operative
pain relief. Pts were randomly divided into 2 groups. Group B {n=30}
received 3ml of 0.5% bupivacaine with 0.2 ml of 0.9% normal saline.
Group BM{n=30} received 3ml of 0.5% bupivacaine with 0.2 ml of
preservative free midazolam.
• DEMOGRAPHIC PROFILE CHART SUMMARY RESULTS

Both groups did not differ significantly as regard to time of onset of sensory block,
duration of action, time for regression of sensory block to T12. There was significant
duration of post operative analgesia observed in group BM . There were no episodes
of bradycardia, hypotension, sedation, intraoperatively or postoperatively and no
vomiting , pruritis and urinary retention in post operative period.
Discussion : Our study shows that the addition of midazolam to intrathecal
bupivacaine significantly prolongs the duration of postoperative analgesia. The time
to first rescue analgesic was more than 16 hrs in BM group as compared to 3.5 hrs in
B group. Antinociceptive action are mediated via BZD/GABA-A receptor complex
which are present in lamina 2 of dorsal horn ganglia of spinal cord
Intrathecal midazolam probably causes release of an endogenous
opioid acting at spinal delta receptors as naltrindole.Intrathecal
midazolam besides causing analgesia has also been found to be
effective in supressing reflex response to visceral distention and its
pain.Intrathecal midazolam has been shown to be free of any
neurotoxicity and other side effects with dose up to 2mg
Conclusion : Intrathecal midazolam added to bupivacaine prolongs
duration of post op analgesia without prolonging the duration of
dermatomal sensory block with no side effects.
REFERENCES : 1.valentine MJ ,lyons G bellemy MC.the effect of intrathecal
midazolam on post op pain . j of anaesthesia 1996 13:589-593
2.Edwards m,serrao.mechanism by which midazolam causes spinally mediated
analgesia.anaesthesiology 1990-73,273,77.
3.Indian j,anaesthesia 2005 ;49(1);37-39 effect of intrathecal midazolam
bupivacaine combination on post op analgesia.
 ANAESTHETIC MANAGEMENT OF A 2YR OLD
WILMS TUMOUR KID FOR NEPHRECTOMY
PRESENTER MODERATOR
Dr ANIL KUMAR B Dr SHILPASHRI A M
JJMMC, DAVANGERE Asst Prof, JJMMC, DAVANGERE

Wilms tumour is the most common renal cancer in pediatric population,

represents 6% of all pediatric neoplasms. Anaesthetic challenges include fluid
balance, potential for major haemorrhage and in addition consequences of para
neoplastic phenomenon viz hypertension and coagulopathy.
We present a case of a 2yr old female weighing 10kgs, with mass per
abdomen and hypertension, diagnosed as Wilms tumour of left kidney and was
posted for surgical resection. The patient blood pressure was 100/70 and was on
Tab Labetalol 20mg for control of hypertension. The baby had no other associated
congenital anomalies. Pre op investigations including CBC, RFT, LFT, Coagulation
profile, were in normal limits. CT scan revealed tumour confined to left kidney
with no evidence of metastasis (Stage I) and the right kidney was un involved. A
combined GA + Epidural anesthesia was planned. Labetalol was continued on the
day of surgery.
 The patient was taken to the operating room and
3 peripheral 20 G IV cannulas were secured. Premedicated
with Inj Fentanyl 20mcg + Inj Glycopyrrolate 0.1mg + Inj
Clonidine IV 15mcg. Patient was induced with Inj
Propofol 20mg, intubating conditions was achieved with
Inj Vecuronium 1mg and intubated using 4.5 mm ETT.
Then put in lateral position, under asepsis, epidural was
done in L3-4 interspace using 19G epidural tuohy needle,
space identified by LOR technique at 1.5cms depth, 21G
Epidural catheter was passed into the space and 3cms was
left in situ. Epidural 0.25% Bupivacaine 5ml was given for
analgesia.
Anaesthesia maintained on Oxygen, Nitrous,
IPPV and Inj Vecuronium. Intra operatively Inj
Nitroglycerine infusion was titrated to maintain BP of
systolic < 100mm Hg during tumour manipulation.
Tumour was completely resected. Intra op Blood loss was
replaced and vitals were maintained. Total duration of
surgery was 130 mins. Patient was reversed and extubated
after adequate respiratory efforts.
 Patient was shifted to PICU for further management. Post op analgesia
was achieved with Inj Bupivacaine 0.125% 5ml + Inj Fentanyl 10 mcg 6th hrly
for 1st and 2nd day and 12 hrly for the 3rd day and catheter was removed on 4th
post operative day. Labetalol was continued post op for control of hypertension.
Post op events were uneventful. Patient was discharged on 8th post op day.

References:
• Anesthetic considerations in the management of Wilm‘s Tumor- Simon D
Whyte, Pediatric Anesthesia 2006, 16:504-513
• Clinical guidelines for the management of children with Wilm‘s tumor in a
low income, Trijn Israels; Pediatr Blood Cancer
• Resection of Wilms tumor with extension into Right Atrium using Deep
Hypothermic Arrest: A case report, Nguyen V, Henry M
• Principles of Wilms tumor biology, Coppes M J, Urol Clin North Am 2000;
27; 423-433
• Anesthetic management of renin secreting nephroblastoma. Br J An 1992;
69:206-209
• Smith‘s Anaesthesia for Infants and Children, 7th Edition
 Masquerading Giant Bulla and its Anesthetic
Management
Dr. Anitha Sunny, Dr. Ganesan C
Following blunt injury to chest, patient developed
symptoms & signs suspected pneumothorax – CXR
showed right radiolucent field
ICD was inserted- non functioning (no air leak)
Check X-ray – collapsed right lung- no re-expansion of
lung
CT-scan – revealed an incidental giant bulla in right
lung with ICD lateral to the bulla – masquerading as
pneumothorax
 • A giant bulla may mislead as pneumothorax
• After ICD insertion, if no regression of pneumothorax/
persistant air leak CT-scan is advised
• This patient was planned for bullectomy
• Left DLT 37Fr size was inserted and position confirmed
with bronchoscope.
• The right lung was isolated and the left lung was
ventilated- by one lung ventilation technique.
• Oxygenation and hemodynamics maintained
intraoperatively.
• End of surgery, full re-expansion of right lung; patient
was extubated on table

References- 1.
References=
1. Jr.Frederick A Hensley, Donald E. Martin, Glenn P Gravlee- A Practical Approach to Cardiac
Anesthesia 5th ed. Philadelphia,PA:Lippincott Willams & Wilkins 2013
3.
Anesthetic Management
• Preoperative assessment-
respiratory function
assessment i.e. respiratory
mechanics, gas exchange and
cardiopulmonary reserve &
stratify risk.
• Chest x-ray and CT-scan.
• Optimization improves
outcome- stop smoking,
bronchodilators,
physiotherapy
Postoperative- Preoperative respiratory status, intraop hemodynamics
and ABG will help to decide extubation & outcome
Intraoperative- appropriate size
DLT & check position with
fiberoptic bronchoscope.
Problems- malposition, airway
resistance, hypoxemia due to
V/Q mismatch, hypotension,
arrhythmias, bronchospasm,
hemorrhage, hypothermia,
Monitors- ECG,Spo₂, Etco₂,
ABG, Ventilator parameters
Maintain optimal acid-base
status; adjust TV, Fio₂, PEEP, RR,
volume or pressure control.
Restrict blood flow to non
ventilating lung. Avoid
vasodilators and nitrous oxide.
Use CPAP.
 A RARE CASE OF NITROBENZENE
POISONING
Dr.Anshu S.L, Dr. Ravi .R ,Dr Gangadhar , JJMMC Davengere

 Nitrobenzene is a nitrite compound used in polishes or solvents.

 An acute poisoning with nitrobenzene presenting as

methemoglobinemia is an uncommon medical emergency.

 Clinically presents with symptoms & signs of tissue hypoxia &

Concentrations around 80% are life-threatening.

 Here we report a case of suicidal poisoning of nitrobenzene

successfully treated with Intravenous methylene blue & with
mechanical ventilator support.
40 yr old farmer with alleged history of consumption of unknown liquid. There was a
delay of approximately 4hours in seeking medical attention.

Patient was in altered sensorium & was Blood was noted to be dark brown, raising the
gasping for air .He was cyanotic with poor suspicion of methemoglobinemia & this was
respiratory effort, responding only to deep confirmed by serum MetHb levels.
painful stimuli.

PR - 120/min, B.P-90/60 mmHg. Pupils

were bilaterally dilated with sluggish
reaction. ABG analysis, on admission
showed metabolic acidosis ; Spo2 70%.

Patient was immediately intubated & put on MetHb level was 55% & I.V methylene blue
mechanical ventilator. A thorough stomach 120 mg (2mg/kg) was administered and a
wash was given. repeat ABG at 1 hour showed a fall in MetHb
level to 27%.

Methylene blue was continued at dose of 2mg/kg 12th hourly till his conscious level
improved.
Patient conscious level & vitals normalised over few hours . Repeat MetHb level -
5% with oxygen saturation of 90%, pH 7.36, PaO2 88%, PaCO2 34% .Patient
gradually weaned off the mechanical ventilator and was discharged after 3days
CONCLUSION
• Nitrobenzene poisoning should be suspected with low oxygen
saturation on pulse oximetry and the presence of chocolate
colored blood.
• Though it‘s a rare poisoning clinician should have high clinical
suspicion, as early diagnosis & timely intervention goes a long way
in saving patient.
• These cases can be managed successfully with intravenous
methylene blue & with aggressive haemodynamic &
cardiopulmonary support.

References:
1. Schimelman MA, Soler JM, Muller HA. Methaemoglobinem:
Nitrobenzene ingestion. J Am Coll Emerg Phys 1978; 7:406-408.
2. Chongtham DS, Phurailatpam J, Singh MM, et al.
Methaemoglobinemia in nitrobenzene poisoning. J Postgrad Med
1997;43:73–4.
 ANAESTHETIC MANAGEMENT OF AN
ADULT WITH HUGE PAROTID
SWELLING FOR EXCISION - A
DIFFICULT AIRWAY
PRESENTER MODERATOR
DR ARAVIND R M DR PABHU B G
PG,JJMMC,DAVANGERE Prof,JJMMC,DAVANGERE

Huge head and neck swellings present challenges to the anaesthesiologists

due to difficulty in mask ventilation , difficulty in intubation due to changes
in the anatomy of the airway due to compression or extension by the
neoplasm. Any flaw in airway management may lead to grave morbidity
and mortality.
We present a case of 62 year old male patient,weighing 70 kg
with a parotid swelling of 15*10 cm on the right side of face extending
from right side of ear to 2 cm above hyoid bone in the neck posted for
surgery for excision. On medical history there were no other comorbidities.
Systemic examination and Pre operative investigations were within normal
limits.
Airway examination revealed MP grade 3,mouth
opening was 2 fingers,thyro-mental distance was
<6 cm, neck movements were adequate .A
difficult airway was anticipated and the equipment
necessary for difficult airway were kept ready
before the start of the case.
Patient was shifted to operating
room, 18G I.V cannula was secured. All basic
monitors including pulse oximetry , ECG, NIBP
were attached. Patient was premedicated with Inj
Glycopyrrolate 0.2mg, Inj Pentazocine 30 mg, Inj
Midazolam 3.5mg i.v & preoxygenated with bag
and mask ventilation using both hands with the
help of an assistant. Patient was induced with Inj
Propofol 140 mg and after confirming of the
ability to mask ventilate Inj Succinyl choline 125
mg i.v was given for muscle relaxation.
Laryngoscopy was done using Mc coy 3 sized
blade ,vocal cords were visualised and intubated
with Armoured ET tube 7.5 sized cuffed using a
stylet
 Position of ET tube was confirmed and secured. Anesthesia was maintained
with O2 + N2O + IPPV + Inj Vecuronium. Intraoperative blood loss was
replaced. Intraoperative course was smooth &vitals were maintained. Following
surgery patient was reversed with Inj Neostigmine 3mg and Inj gylcopyrrolate
0.4mg i.v and extubated when fully awake and with adequate muscle power.
Post operative analgesia provided with Diclofenac 1mg/kg IM 20 min before
extubation. Patient was observed for any signs of stridor or respiratory
obstruction and shifted to post operative recovery ward for observation. Post
operative course was uneventful and Patient was discharged on 5th post op day

REFERENCES
Airway Management in a Patient with Huge Neck Mass:Anwarul Huda,JPMA
Airway management in Submandibular abscess patient :Chetan B. Raval
American society of Anesthesiologists:Task Force on Management of the
Difficult Airway. Anesthesiology; 2003; 98:1269-1277
Strategies for airway management:Berkow LC,Best Pract Res Clin
Anaesthesiol. 2004 Dec;18(4):531-48.
Airway management in adult patients with deep Neck infections: a case series
and review of the literature. Anesth Analg; 2005
https://www.anesthesiologyboards.com/pdfs/airway.pdf
 Dr.Arish.B.T, M.D Post Graduate, second year – Department Of
Anesthesiology, Sri Manakula Vinayagar medical college and
hospital, Puducherry.
Dr. K .Suresh kumar, M.D
Fat embolism – a case

Associate Professor
Dr. Mohamud Iqbal, M.D, D.A, Professor
 Introduction
• Fat embolism syndrome is a rare clinical diagnosis with
report

nonspecific/ insensitive diagnostic tests and is an often overlooked

cause of breathlessness in trauma patients.

• So a high index of suspicion is always important to ensure

diagnosis. The classic triad of respiratory changes, neurological
abnormalities, and petechial rash is not always present

• It is most commonly associated with fractures of long bones (0.5 to

2% incidence) and pelvis, and is more frequent in closed, rather
than open fractures.
 • In this case, we report a 25yrs male patient posted for IM
nailing for right leg both bone fracture, on pre-operative
evaluation he was asymptomatic, initially assessed as ASA 1
status but when reexamined on the day of surgery in the pre-
op holding area, patient was found to be tachypneic.
• Base line monitoring shows the picture of heart rate of
Case report

122/min, NIBP 118/80mmHg and SPO2 79% only (room

air) and EtCO2 showed 30mmHg with RR of 44/min.
• With this clear picture of hypoxemia, hypocapnia,
tachypnea with tachycardia diagnosed as FES, so surgery
was postponed and patient was successfully managed in
RICU with LMWH(Enoxaparin 40mg BD s/c) and
rescheduled after 1 week with uneventful surgery.
 • The mortality for FES is 5-15% and treatment of FES is supportive
with early resuscitation and stabilization to minimize the stress
response to hypoxemia, hypotension, and diminished end-organ
perfusion.

• Although 10% of patients with FES may require mechanical

Discussion

ventilation, in most of these patients the symptoms resolve

within 3 to 7 days.

• We stress in this case report the high index of suspicion of FES

in perioperative period for trauma and high risk patients and
emphasize on ETERNAL VIGILANCE not only in
intraoperative and postoperative period but also in preoperative
period for our safe day to day anesthesia practice.

 References
• Jacob George, Reeba George1, R. Dixit, R. C. Gupta, N. Gupta. Fat embolism syndrome. Lung India; 2013 Jan – Mar; Vol
30 : Issue 1
• Pal CP, Kumar H, Dinkar KS, Agrawal A, ::Fat Embolism Syndrome in Fracture Tibia Treated by Unreamed Interlocking
Nail. Journal of Orthopaedic Case Reports 2013 Jan-March;3(1): 32-33
• Amandeep Gupta, Charles S. Reilly. Fat Embolism. Continuing Education in Anaesthesia, Critical Care & Pain | Vol 7: (5)
2007
 EVALUATION OF THE IMPACT OF
MAGNESIUM SULPHATE ON
NEUROMUSCULAR BLOCKADE BY NON
DEPOLARISING MUSCLE RELAXANT-A
QUANTITATIVE ANALYSIS

• Presentor : Dr.A.Asha M.D. Postgraduate

• Co-Authors: 1.Dr.N.Jothi 2.Dr.R.Selvakumar 3. Dr.M.Suresh
Professor of Anaesthesiology
• K.A.P.Viswanatham Govt. Medical College, Trichy. Tamilnadu
Aim: To find out quantitatively the impact of magnesium on
neuromuscular conduction and correlation between the
serum level of magnesium and onset & depth of
neuromuscular blockade.
Methodology: 50 patients are randomly assigned into 2
groups. Group NS received 100ml of NS & Group Mg
received 50mg/kg of MgSO4 before induction for a period
of 10 minutes & induced with IV Thiopentone 5mg/kg,
vecuronium 0.1mg/kg. A single twitch test is performed
with peripheral nerve stimulator on ulnar nerve until STR
disappears at which, patients are intubated, time from
muscle relaxant administration and STR fade noted &
blood sample for serum Mg1 drawn. Depth of block is
monitored with PTC. Time from intubation to PTC4 is
noted, at which second blood sample for Sr.Mg2 is drawn
Results: Time to disappearance
variable Group Group Mg P of STR
NS value
Age (yrs) 41.4±9.7 40.8±8.8 0.67
Gender(M/F) 11/14 14/11 0.36
ASA PS(1/2) 19/6 17/8 0.526
Weight(kg) 54.4±6.4 52.5±7.7 0.367
HR(bpm) 84.7±7.5 83.04±4.4 0.342
MAP(mmHg) 93.7±5.1 97.08±4.04 0.01
Time to 184.2±5. 123±11 0.001
disappearanc 4
e of STR(sec)
Sr Mg 1 1.89±.09 2.08±0.18 0.001
(meq/L)
Time to 42±4 54±4 0.001
reach
PTC4(min)
Sr Mg 2 1.93±0.0 2.02±0.15 0.01
(meq/L) 8
 Thus MgSO4 shortens the onset and increases the intensity of block
by vecuronium,a positive correlation exist between Sr.Mg and NMB.
Discussion: Fuchs buder et al found pretreatment with MgSO4
40mg/kg,shortened the onset time and prolonged the clinical
duration of vecuronium. Ghodraty et al showed that the speed of
onset and intensity of muscle relaxation increased as higher
doses of magnesium were used(Mg 25mg/kg vs 50mg/kg) in
evaluating its effect on neuromuscular blockade by
cisatracurium.
References:
1.Miller´s Anaesthesia seventh edition.pg:859-912,1515-1532.
2.T.Fuchs-Buder,O.H.G.Wilder-Smith,A.Borgeat,E.Tassonyi.
Interaction of magnesium sulphate with vecuronium-induced
neuromuscular block.British journal of anaesthesia.1995;74:405-
409.
3.Mohammad R.Ghodraty,Amir a.Saif,Ali R.Kholdebarin. The
effects of magnesium sulfate on neuromuscular blockade by
cisatracurium during induction of anaesthesia. Japanese society
of anaesthesiologist 2012.
PULMONARY ARTERY CATHETER
KNOTTING AND ITS RETRIEVAL.
Dr Ayaskant Sahoo
Final Year Postgraduate
Yenepoya University,
Mangalore.
Indications of PAC1: INTRA
CASE HISTORY: Complications
OPERATIVE of PACPOSTThe OPERATIVE:
various
1. Severe
60 yr old
left MONITORS:
use has been  Pttechniques
extubatedthat samehas
female with  Patient
ventricular  reported
Routine was then
to be shifted
about day
beento
after
described
6hours are
dysfunction
triple vessel cath-lab
24% 2 in
monitors  Xusually
Ray wasclassified
taken asas
2. Severe
ds waspulmonary  interventional
 1.
Invasive
Pulmonary cardiologist.
Arterial
artery routine
surgicalinvestigation.
or non
dysfunction
posted for  The orPAC
lines Right was
atriumapproached
 PAC
surgical.
could not be
CABG.pulmonary through
3. Severe  Pulmonary the femoral vein
rupture •and
pulled
Viaout during 5,
cardiotomy
hypertension
LV the2. catheter
artery
Venouscatheterwas cutremoval
access • just
Interventional
of lines.
4. Septic
dysfunction
shock above
 TEE the knot. like Repeat
complications radiological
trial was done
5. Cardiogenic shock  The upperartery
 Temperature
carotid cut part bywas passing
techniquesa guide
6. Pulmonary edema removed probe
punctureby simply pulling• 0.038
wire to straighten
inch movable
the
7. Severe toxaemia out through the
3. Entrapment in internal
catheter
core-guided
but failed
wire
of pregnancy jugular vein.during  X-raythrough
sutures was revisited
the lumen
8. Assessment of  The lower cardiaccut part was pulled
surgery and ofonthe
closer
catheter
looking
to
respiratory and
4. brought upto the femoral
Dysrhythmias a knot
untie
wasthenoticed
knot in
distress vein following
and with PAC a small incision
the RA.
under fluoroscopic
9. Assessment of on insertion
the femoral most vein the guidance
therapy knotted part was removed
commonly • removal using snare
References:
[1]. Lopes MC, de Cleva R, Zilberstein B, Gama-Rodrigues JJ. Pulmonary artery catheter
complications: Pulmonary
report on acase of artery
a knot accident and literature
catheters provide review. Rev HospClinFac Med
Sao Paulo. 2004;59(2):77-85.
[2]. Boyd KD, Thomas essential hemodynamic
SJ, Gold measurements
J, Boyd AD. A prospective both
study of complications of
pulmonary artery in operation intheatres
catheterizations as well
500 consecutive as inChest.
patients. ICU 1983;84(3):245-
set up 249.
[3]. Huang L, Elsharydah
but many A, Nawabi
a timesA, Cork RC. Entrapment
debated aboutofthepulmonary artery catheter in
a suture at the inferior vena cava
cannulation site. Jassociated morbidity and mortality,
ClinAnesth. 2004;16:557-559.
[4]. EshkevariVarious studies claim
L, Baker BM. Occurrence various
and removal of a percentages
knotted pulmonaryofartery catheter
a case report. AANA J. 2007;75:423–8.
problems but its application or importance
[5]. Kao MC, Lin SM, Yu YS, Huang YC, Ting CK, Tsai SK. Knotted continuous cardiac output
cannot becatheter
cardiac output thermodilution undermined.
diagnosed by intraoperative transesophageal
The
echocardiography. clinician
Br J Anaesth. should always keep in mind the
2003;91:451-452
[6]. England MR,associated
Murphy HI, Yakirevich V, Vidne B. A
complications knotty
and tryproblem.
to avoidJ Cardiothoracic
VascAnesth. 1997;11:682-683 *7+. Colbert S, O’Hanlon DM, Quill DS, Keane P. Swan Ganz
them
catheter- all in a knot. Eurby utilizing the
J Anaesthesiol. available information
1997;14:518-520
[8]. Tan C, Bristolregarding the
PJ, Segal P, Bell RJ:successful
A technique toapplication.
remove knotted pulmonary artery
catheters. Anaesth Interns Care. 1997;25:160-
162.
PHEOCHROMOCYTOMA- A CHALLENGE
TO
ANAESTHESIOLOGISTS

BALA KUSUMA KUMARI Ch

2nd year RESIDENT
NRI MEDICAL COLLEGE, AP
 INTRODUCTION
Highly vascular catecholamine producing neoplasms arising from
the Adrenal Medulla.
CASE REPORT
• 24 year male, known hypertensive (on amlodipine 5mg).
• Recurrent episodes of triad of headache, palpitations & sweating.
• 24 hour urinary metanephrines – 7.2 µmol/24hrs (<5).
• On prazosin 5mg & metoprolol 50mg BD

• BP : 160/120 mm Hg HR : 120/min.
• Prazosin 10mg & metoprolol 100mg BD.

• BP : 130/90 mm Hg HR : 82/min.

• Posted for left open adrenalectomy.

 BP : 140/90 mm Hg HR : 82 / min

GA (O2:N2O, Sevoflurane, Dexmedetomidine, C/V) + EA

Tumor manipulation After Tumor resection

BP : 220/150 mm Hg
HR : 70-80 / min
Titrated NTG infusion for HTN.
BP: 70/40 mm Hg
Fluid resuscitation with
crystalloids, colloids &
vasopressors.
Noradrenaline infusion.

Extubated in the OR & shifted to SICU with pressor support & stable
haemodynamic parameters.
Discussion
• Potentially dangerous circumstances.
• Pre-op α & ß blockade.
• Care during tumour manipulation and following tumour removal.
• Invasive haemodynamic monitoring & hypertensive and hypotensive
crises.
• Post-op persistent arterial hypotension may be refractory to
intravascular volume replacement and adrenoceptor agonists.

References
1. Lentschener C, Gaujoux S, Tesniere A, Dousset B (2011) Point of
controversy: perioperative care of patients undergoing
pheochromocytoma removal-time for a reappraisal? Eur J Endocrinol
165: 365-373.
2. Pierre-Francois Plouin & Anne-Paule Gimenez-Roqueplo :
Pheochromocytoma & secreting paragangliomas. Orphanet Journal of
rare diseases 2006,1:49.
 ANESTHETIC MANAGEMENT OF A CHILD WITH
CLEFT LIP AND PALATE FOR CYSTIC HYGROMA
EXCISION - A DIFFICULT AIRWAY
PRESENTER MODERATOR
Dr BARGHAVI R, POST GRADUATE Dr PRABHU B.G
JJM MEDICAL COLLEGE PROFESSOR

Cystic hygroma is a benign tumour composed of large lymph-

containing cysts. They present challenges to the anesthesiologists due to
extension in the neck, airway and thorax, haemorrhage, involvement of
pretracheal region, post operative respiratory obstruction . Associated
cleft lip and palate carries a high risk of associated congenital
anomalies and a difficult airway
Here is a case report of anesthetic management of a 20 day male
child weighing 2.5kg with cleft lip and palate with swelling in right side
of neck 10 ×10 cm diagnosed as Cystic hygroma and posted for excision.
CT head and neck revealed multiple fluid-filled loculi with mild
deviation of the trachea to the left
 Preoperative examination and investigations
were within normal limits and no other congenital
anomalies associated
A difficult airway anticipated and the equipment
necessary kept ready. I.V cannula secured in both
the hands with 24G cannula. All basic monitors like
pulse oximetry, ECG, precordial stethoscope and
temperature probe attached. Intubation was planned
without the use of muscle relaxant.

Child was preoxygenated and induced with Inj

atropine 0.05mg i.v, Inj Fentanyl 5mcg i.v and
Halothane. The larynx could not be visualized in the
first attempt. Laryngoscopy was tried again and this
time the glottis could be seen, a 3 mm uncuffed
endotracheal tube with stylet was introduced and the
stylet withdrawn. After confirmation of the tube in
place Inj Atracurium 1.5mg was given.
 Child maintained on O2+N20+IPPV+Inj Atracurium+ halothane.
Intraoperative blood loss of 80cc was replaced. Intraoperative course
smooth and tumour completely resected.

Following surgery reversed with Inj Neostigmine 0.125mg and Inj

Glycopyrrolate 0.02mg i.v and extubated when fully awake and adequate
muscle power. The child was observed for any signs of stridor or
respiratory obstruction and was shifted to NICU for observation.

REFERENCES:
1. Sharma S et al: anaesthetic considerations and review. Singapore Med
J. 1994;35(5):529–31.
2. Gurulingappa, et alCystic hygroma: A difficult airway and its
anaesthetic implications; Indian J Anaesth. 2011 Nov-Dec;55(6): 624–26
3. Mohammad Reza Haji Esmaeili, et al Cystic hygroma: anesthetic
considerations and review; J Res Med Sci 2009 May-Jun: 14(3) 191-95
4. Kim H, et l. Anesthetic management for neonate with giant cystic
hygroma involved upper airway: A case report. Korean J
Anesthesiol. 2011;60:209–13
 CASE REPORT

Rare neurological complication

due to air embolism facilitated
by prone position during PCNL
surgery and its successful
management
Dr. Bhavya Krishna,
Prof. Akhilandeswari,
Prof Aruna Parameswari,
Prof. Mahesh Vakamudi
Sri Ramachandra Medical College,
Chennai
Preoperative assessment: 30 year old female with no Postoperative events: Two hours after
co-morbidities posted for percutaneous lithotripsy was extubation, patient was drowsy with a GCS
accepted as ASA PS I with General Anaesthesia and of 10/15 associated with right hemiparesis
controlled mechanical ventilation in prone position as and extensor plantar reflex but was
the plan hemodynamically stable with a saturation
of 100%. ABG,CBG and 2D Echo were
Intraoperative events: After routine induction normal. Tracheal intubation was done and
of anaesthesia, patient was turned to prone patient electively ventilated .
position and surgery started using
Sevoflurane/Nitrous oxide/Oxygen. During
pelvicalyceal dilatation, there was a sudden MRI revealed multiple
drop of EtCO2 from 35 to 14mm Hg in a span of restricted diffusion defects
3-4 minutes. B/L air entry was checked, airway in both cortex suggestive
pressures and exhaled tidal volume were of recent infarcts
normal, and the patient was hemodynamically
stable. Following this, the heart rate dropped
from 78 to 42 bpm, and blood pressure fell from
98/64 to 78/46 mm Hg with a saturation of
100% throughout. In view of hypotension and Elective ventilation continued for 48 hours. Treated
bradycardia, 100% oxygen given and patient with anti platelets, mannitol and heparin. She was
treated with intravenous fluids, anticholinergics extubated after two days and had residual weakness
and vasopressors restoring the hemodynamic in the right upper limb and was sent back to the
stability and EtCO2 level to 30mm Hg. Surgery ward.
was abandoned. Patient was then positioned After two weeks the patient was reviewed on an out
back to supine position, extubated and shifted patient basis. She had a power of 4/5 in the right
to the PACU. upper limb with no other focal neurological deficit.

Mechanism of air embolism
Conclusion: Air Embolism was the diagnosis made
retrospectively.
•Air pyelogram has the potential risk of an air embolism .
•The possible source was the high pressure of the irrigating
fluid containing potential air bubbles
•The prone position of the patient in this case could have
produced a significant gravitational gradient between the right
side of the heart and the renal pelvis, possibly resulting in air
being drawn into open veins by the negative pressure.
•Decreased caval pressure due to the position of the lower
limbs could have facilitated the embolism
•The site of eventual lodgement of air emboli in brain depends
on the position of patient at the time of incidence
• The delayed manifestation of symptoms in this patient a few
hours after extubation could be explained by the fact that air
emboli may have taken time to pass through the pulmonary
vasculature, delaying the onset of systemic embolic
manifestations.

1. Pyron CL, Segal AJ. Air‐embolism: a potential complication of retrograde pyelography. J Urol 1983; 130: 125–6
2. Hobin FP. Air embolism complicating percutaneous lithotripsy. J Forensic Sci 1985; 30: 1284–6
3. Usha N., Droghetti L. Air embolism—a complication of percutaneous nephrolithotripsy. Br. J. Anaesth. 2003; 91: 760-761
 CASE REPORT

Rare neurological complication

due to air embolism facilitated
by prone position during PCNL
surgery and its successful
management
Dr. Bhavya Krishna,
Post Gradute,
Sri Ramachandra Medical College,
Chennai
Preoperative assessment:
30 year old female posted for percutaneous
lithotripsy was accepted as ASA PS I with
General Anaesthesia and controlled mechanical
ventilation in prone position as the plan
Postoperative events: Two hours after
extubation, patient was drowsy with a GCS
of 10/15 associated with right hemiparesis
and extensor plantar reflex.

Intraoperative events: After routine induction

of anaesthesia, patient was turned in prone MRI revealed multiple
position and surgery started. During restricted diffusion defects
in both cortex suggestive
pelvicalyceal dilatation, there was a sudden
of recent infarcts
drop of EtCO2 from 35->14mm Hg in a span of
3-4 minutes. B/L air entry was checked, airway
pressures were normal and the patient was
hemodynamicaaly stable. Following this, the
heart rate dropped from 78-> 42 bpm, and
Hemodynamic instability, hypoglycemia were ruled
blood pressure fell from 98/64->78/46 mm
out.
Hg. This was treated with intravenous fluids,
2D Echo was normal. Tracheal intubation was done
anticholinergics and vasopressors restoring
and patient electively ventilated for 48 hours.
the hemodynamic stability and EtCO2 level to
Treated with anti platelets, mannitol and heparin.
30mm Hg. Patient was then positioned back to
She was extubated after two days and had residual
supine position. After fulfilling all the
weakness in the right upper limb and was sent
extubation criteria the patient was extubated.
back to the ward.
There was no focal neurological deficit and
After two weeks the patient was reviewed as out
patient was shifted to the PACU.
patient basis and had power of 4/5 in the right
upper limb with no other focal neurological deficit.

Mechanism of air embolism
Conclusion: Air pyelogram has the potential risk of an air
embolism .
•The prone position of the patient in this case produced a
significant gravitational gradient between the right side of the
heart and the renal pelvis, possibly resulting in air being drawn
into open veins by the negative pressure.
• gravitational gradient
• decreased caval pressure due to the position of the lower
limbs
•The site of eventual lodgement of air emboli in brain depends
on position of patient at the time of incidence
• Possible high pressure of the irrigating fluid containing
potential air bubbles .
• Air emboli may have taken time to pass through the
pulmonary vasculature and hence time taken for
manifestation

1. Pyron CL, Segal AJ. Air‐embolism: a potential complication of retrograde pyelography. J Urol 1983; 130: 125–6
2. Hobin FP. Air embolism complicating percutaneous lithotripsy. J Forensic Sci 1985; 30: 1284–6
3. N. Usha, L. Droghetti. Air embolism—a complication of percutaneous nephrolithotripsy
4. Br. J. Anaesth. (2003) 91 (5): 760-761. doi: 10.1093/bja/aeg630
AUTHOR: Co-Author:
Dr.Krishna Chaitanya.B Dr. Rakesh Chintalapudi MD,DA
PG in Anaesthesiology Assistant Professor
Andhra Medical College Dept. of Anaesthesiology
Andhra Medical College
Visakhapatnam.
BACKGROUND:
Lateral position is commonly used for spinal anaesthesia. The sitting position is used for spinal
anaesthesia especially when low lumbar and sacral anaesthesia are needed for the surgical
procedure, such as perineal and urologic procedures, or when obesity or scoliosis makes
identification of midline anatomy difficult in the lateral position or prone position, or when
patients are unable to assume lateral decubitus position because of pain.

CASE REPORT:
A 48 year old male obese patient presented to the operation theatre, with thrombosed pile mass
with excruciating pain in the perianal area. We faced difficulty in providing a comfortable
position, for him to undergo sub arachnoid block since the perianal condition was not allowing
him to sit properly on the operating table. Then we planned a new position in view of the
patient’s presenting condition. The patient was made to sit with knees flexed completely with
buttocks on patient’s feet. Thus perineum was free and was not touching the operation table.
Pressure on the buttocks was reduced.
INDICATIONS:
1) Thrombosed
hemorrhoids
2)Perianal abscess
3) Large pilonidal sinus
4) Acute painful fissure
5) Trauma in perianal
area
CONTRAINDICATIONS:
1) Osteoarthritis of knee joint
2) Osteoarthritis of ankle joint
3) Senile geriatric patients

DISCUSSION: This new position for spinal anaesthesia is comfortable for both patient

and attending anesthesiologist. After assuming the position on the table, patient is made stable
with some pillow support if necessary. Once the intrathecal injection is complete, patient is
positioned according to the surgery. In this position , the hip joint adopts the same position as
that found in sitting posture and only joint that undergoes flexion is the knee joint , which
warrants an extra care in patients with osteoarthritic changes in the knee joint. We certainly
not recommend this posture for patients with lower limb fractures, or those having
osteoarthritis of knee or ankle joints.
REFERENCES:
1) Mohammad T. Baig Mohammadi, MD
2) Zahid Hussain Khan MD,
(Department of anaesthesiology, Imam Khomeini Hospital, Tehran University of Medical Sciences- Tehran,Iran)
 ANAESTHETIC MANAGEMTN T OF CARDIAC PATIENT POSTED FOR NON CARDIAC SURGERY

DR. CHANDANA BHARDWAJ .P DR.R.PRADEEP

Post graduate students in Anaesthesiology, PESIMSR, Kuppam, Andhra Pradesh

INTRODUCTION CASE REPORT

Introduction; Incidence of IHD in elderly is high and compounded by multiple Patient was extubated after giving Reversal of Inj.Neostigmine – REVISED CARDIAC RISK INDEX
risk factors.
Induction:-Thiopentone in graded doses (250mg) Inj Vec 4mg 0.05mg/kg + Inj.Glyco 0.02mg/kg.
In patients with CAD,OCD disease the information regarding myocardial
and ventricular function,ischemic threshold and given and intubated with 7.5.mm ET Tube , B/l air entry checked No other acute cardiac eopervents occurred during intraoperative Predicts Cardiac complications in major non emergent, non
Optimisation should be known during PAE and fixed tube 19 cm. period. Surgical & Anaesthetic outcomes are satisfactory cardiac surgeries in patients more than 50 years, more accurately
IHD is one of the most common problem faced by Anaesthesiologist in Maintaince with Inj Fentanyl 100mcg in divided doses N2o : o2 After extubation patient was monitered for 1 hr in recovery room than GOLDMAN/ DETSKY.
perioperative period in view of anticipated and unanticipated acute cardiac – 66 : 33 %, sevoflurane,- 0.8 to 1 % Inj. Vecuronium – 2+ 1 mg & later shifted to postoperative room. Factors- MI, Pulmonary edema, Cardiac arrest or complete heart
events.. ( 0.05mg/kg ) Inj.NTG was continued in the postoperative period for 3 hrs, block.
since lapcholecystectomy is the preferred surgery, due precautions has to be
taken regarding anaesthetic and surgical complications and the same has to be Intraoperatively hypertention managed with Inj.NTG 5-20mcg titrated according to blood pressure & stopped.
effectively treated. titrated according to BP .ECG remained same as that in pre op Patient was discharged on 3rd postoperative day.
period . CONCLUSION
IHD being one of the common cause of perioperative cardiac complications
CASE REPORT adequate PAE to know the cardiac status was done, due precations with
DISCUSSION
By following AHA/ ACC guidelines one can asess & gain knowledge about regard to triggering events(Tachycardia, Hypo/Hypertention) was taken.
cardio vascular risk asessment for noncardiac surgery.
A 52yr female patient presesnted with cholelithiasis, posted for It helps in identifying clinical markers of risks & demonstrates methods for
laproscopic cholecystectomy. clinical asessment of risk with selective testing & cardiac catheterisation to
asess the presence of Coronary artery disease and therefore risk of
during preoperative evaluation she has been categorised as ASA periopertaive cardiac events.
II having h/o exertional dyspnoea G-III(NYHA)found to have Scoring systems to estimate cardiac risk – 1. GOLDMAN INDEX REFERENCES
LBBB on ECG ,Echo-showing sclerotic Aortic 2. EAGLES CRITERIA
valve,trivialAR,mild TR,PASP 31mmhg mild PAH LBBB 3.REVISED CARDIAC INDEX
during study.
GOLDMANS INDEX – 1.Millers Text book of Anaesthesiology.
2.Morgans clinical Anaesthesiology
MI with in 6mths - 10
Age > 70 yrs – 5
S3 or JVD – 11
Significant aortic stenosis – 3
INTRA OPERATIVE PERIOD Rhythm other than SR or SR with APCs on last ECG – 7
5 PVC /mt at anytime before surgery – 7
Poor general medical status – 3
Intra peritoneal/ Intra thorasic/ Aortic operation – 3
Emergency operation - 4. ACKNOWLEDGEMENTS

CLASS POINT Complications

I 0-5 0.7%

II 6- 12 5%

III 13- 25 11%

IV >25 22 Our sincere thanks to our HOD Dr.(Col) K.V. Srinivasan for
their support and advice during the management of this case and
preparation of this poster.
EAGLES CRITERIA-

1.Eagles factors - >70years, H/O Angina, Significant Q’s , CHF, DM needing

treatment - A.Low risk – if 0 factors , 3.1 % complications
B.Intermediate risk- 1 to 2 factors , 15% complications – Need
Investigations – CBC, LFT, RFT, S.Electrolytes , CXR – noninvasive testing with Angio if inducible Angina
Normal C.High risk – If more than 2 factors, 50 % complications- Go
straight to Angio
D.If Angio shows 1 main vessel disease consider – angioplasty or
O/E - Airway shortneck ,bucked teeth, CABG.
Thyromental distance - 6 cm
Mallampati class III
Goals desired to be achieved
1)avoidtachycardia
2)Hypo/Hypertenstion
3) Normocarbia
Premedication: Inj.Fentanyl 150mcg i.v,
Glyopyrolate0.2mg,Midozolam 1mg, Inj.Xylocard 3cc
 ANAESTHETIC MANAGEMENT OF A
PREGNANT PATIENT WITH OBSTRUCTIVE
HYDROCEPHALUS DUE TO ACOUSTIC
NEUROMA POSTED FOR EMERGENCY
CAESAREAN SECTION AND V-P SHUNT

AUTHOR-
DR. DHANVEER.J.SHETTY
 INTRODUCTION
 The first published report of brain tumor in a pregnant patient was by Bernard in 1898.
 Brain tumors in pregnant patients impose a unique risk to both fetus and mother .
 Case reports and small studies remain an important source of knowledge and experience .
 Though brain tumors in pregnancy are a rare entity, pregnancy itself may hasten the growth
of a previously existing intracranial tumor and can even unmask a previously undiscovered
tumor.
 Immunological tolerance and steroid mediated tumor growth are the widely accepted school
of thoughts ,though the exact cause for this still remains a mystery.
 In this case report the anaesthetic management of a primipara with acoustic neuroma with
severe obstructive hydrocephalus who was posted for emergency caesarean section and V-P
shunt has been discussed.

MATERIAL AND METHODS

 A 23 year old female G2P1L1 presented at 41 weeks of gestation with history of undergoing
previous caesarean section 2 years back for non-reassuring FHR under uncomplicated spinal
anaesthesia .
 She gives h/o having severe headache associated with projectile vomiting since 1 year, for
which MRI head was performed 6 months back and the diagnosis of right sided acoustic
neuroma(AN) was made.
 Patient was also found to be pregnant of 12 weeks, 4 days after the diagnosis of brain tumor
by a positive UPT and USG abdomen
 There is also h/o right sided facial palsy with bilateral profound hearing loss and blurring of
vision since the past 3 months with exaggerated headache.
 Patient also gives h/o having similar features of facial palsy 2 years back which coincided
with the 2nd trimester of her first pregnancy and she wasn’t properly evaluated and her
symptoms had subsided after taking steroid medication for 15 days.
 On PAE she was 150cm tall, 54 kgs, alert, and well oriented;Pulse rate- 96bpm, Blood
pressure- 142/64mmHg, o2 saturation was 98% at room air. She had a normal airway and
normal spine.
 CNS examination revealed decreased field of vision in right eye, nystagmus on horizontal
movements to the right side in right eye, decreased corneal reflex in right eye, deviated
angle of the mouth to the left and decreased eye closure on right side. Her motor, sensory
and cerebellar functions were normal. Cardiovascular and respiratory system examination
showed no derangements.
 Her audiography revealed profound bilateral hearing loss .Fundoscopic examination revealed
bilateral severe papilloedema. All her other investigations were within acceptable limits and
she was classified as ASA class III.
 An informed consent was obtained from the patient and she was shifted to pre-op
room in left lateral position.
 Two IV lines were secured with 18G IV cannulas in the upper limb and an infusion of
ringers lactate started.Patient was premedicated with 50mg ranitidine and 10mg
metoclopramide iv.
 She was then shifted to the Neurosurgery OR with a wedge underneath her right
buttock. She was put in a reverse trendelenberg position on a tiltable OR table.
 Multiparameter monitor consisting of pulse oximetry, NIBP and ECG was connected.
The initial BP was 150/68mmHg with a heart rate of 90bpm and oxygen saturation on
room air was 98%.
 Paient premedicated with 50ug of inj.fentanyl , ondansetron 4 mg and
dexamethasone 8mg iv and dexmedetomidine infusion started at 0.5ug/kg/min.
 Inj lidocaine 1.5mg/kg was administered 30 secs before induction.
 A rapid sequence induction with 250mg thiopentone and 60 mg of rocuronium was
performed and endotracheal intubation with 7.5mm cuffed ET tube was done.
 Patient was maintained with 50:50 mixture of oxygen and nitrous
oxide and 1% isoflurane while constantly monitoring her MAP. Ventilation was
maintained keeping the ETCO2 range between 32-36mmHg.
 After 5 minutes of induction a live female baby was extracted which weighed 2.6kgs
and had an APGAR score of 8 and 9 respectively at 1 and 5 mins.
Oxytocin 10U infusion started in ringers lactate and another 10U administered
intramuscularly. Fentanyl 50µg iv was then repeated for analgesia.
 After completion of caesarean section patient was positioned for left sided V-P
shunting in the reverse trendelenberg position with slight neck flexion towards right
side .
 Adequate brain relaxation was provided with 100ml mannitol 20% infusion and 20mg
frusemide before neurosurgeon inserted the V-P shunt catheter through the burr
hole.
 ETCO2 was maintained between 26-30mmHg.
 Reversal was uneventful with 2.5mg neostigmine and 0.5mg glycopyrrolate.
Postoperatively her pulse was 86bpm, BP-126/70mmHg and 97% saturation at room
air.
 Neonate was handed over to her in PACU and she was shifted to post-partum ward
after 6hrs.
DISCUSSION
 Primary CNS tumors occur in approximately 6 in 1,00,000 females of reproductive age.
 Simon postulated that there are about 90 pregnant women who harbour a brain tumor every year in USA
based on his probability based calculation.
 Pregnancy is found to aggravate the growth of intracranial tumor which has been attributed to hormonal
milieu of pregnancy that may influence the growth of some tumors due to increased blood volume ,
redistribution of total body water between intracellular and extracellular fluid compartments and the
influence of steroid hormones.
 Idiopathic facial nerve palsy occurs in 17 per 1,00,000 women of reproductive age and 38-45 per 1,00,000
during pregnancy and post partum period. During pregnancy 75% of the cases are seen in the third
trimester and post partal period. Recurrence during successive pregnancies and bilateral facial nerve palsy
in pregnant women have also been described.
 The diagnosis of brain tumor requires imaging and in pregnancy MRI is the preferred imaging modality
because of its greater resolution, increased sensitivity and lack of ionizing radiation.MRI scanning without iv
contrast has been found safe for both mother and the fetus.
 There are no preformed guidelines for anesthetic management of pregnant women with intracranial tumor
coming for emergency C-section. Epidural anesthesia was ruled out as there is always a possibility of
sudden increase in intracranial pressures .We decided to go ahead with general anesthesia with rapid
sequence induction.
CONCLUSION
 Management of brain tumors in pregnant ladies is challenging because of a combination of factors including
their diagnosis, nuances of maternal physiology, fetal viability and complexity of surgical and anesthetic
interventions.
 Maintenance of hemodynamic stability and control of ICP are the major goals in managing these cases and
hence well defined management goals should be outlined and anesthetic technique tailored to meet these
goals.
REFERENCES

1. Estilita,Joana M et al. goal oriented C-section in a patient with a VP shunt. Revista SPA vol 18’ n 6’ 2009
2. Alaa A Abd-Elsayed et al. A case series discussing the anaesthetic management of pregnant patients with
brain tumours . Latest Published: 11 Dec 2013, 2:92 (doi: 10.12688/f1000research.2-92.v2)
3. Christopher M. Bonfield, MD, Johnathan A. Engh, MD. Pregnancy and Brain Tumors. Neurol Clin 30 (2012)
937–946
4. WK To, RTF Cheung. Neurological disorders in pregnancy. HKMJ 1997;3:400-8
 ANAESTHETIC MANAGEMENT
A CASE OF COLLODION BABY SYNDROME FOR
TARSORRHAPHY
PRESENTER: MODERATOR:
Dr KAVYASHREE N G Dr GANGADHAR GOWDA
JJMMC,DAVANGERE Asst Prof, JJMMC,DAVANGERE

Ichthyosis is an infrequent clinical entity worldwide (1:300,000 birth). It is

characterised by thick and hard skin with deep splits. Clinically at high risk for
dehydration, electrolyte imbalance, temperature malfunctioning and sepsis.

Anaesthetic implications - There is no definite recommendation for either

GA or Regional. Possibility of difficult airway must be kept in mind because of
severe involvement of tissues which may lead to restriction of mouth opening and
mobility. Venous cannulation could be difficult. Fixation of the intravenous cannula
and ECG electrodes may be difficult. ET Tube to be secured using tube holder.
 We report a case of collodion baby syndrome aged
6months female weighing 5kgs with exposure keratitis due to
ectropion posted for bilateral tarsorrhaphy.

Pre-operative investigations with in normal limits and

no other congenital abnormalities were associated. A difficult
airway was anticipated and adequate preparation done.

Child put on table. Essential monitors connected,

induced with Halothane and IV line secured with 24g cannula
and fixed with micropore plaster. Child premedicated with
Inj Glyco pyrrolate (0.05mg) + Inj Fentanyl (5mic) , relaxed
with Inj Scoline (10mg), intubated orally with ETT 3
uncuffed, after confirming airway, tube fixed with tube
holder.
 Maintained with Halothane + Nitrous oxide + Oxygen + IPPV + Inj
Atracurium (0.25+0.25mg). Intra-operative course were uneventful. Following
surgery child reversed and extubated, after fully awake and adequate muscle power.
Post operative period was uneventful.

References:
• Hegde HV, Annigeri VM,Pai VV: Anestetic challenges in lamellar icthyosis.
Paediatr Anaesth 2012;22:492-4.
• Vahlquist A. Pleomorphic ichthyosis: proposed name for a heterogenous group of
congenital ichthyoses with phenotypic shifting and mild residual scarring. Acta
Derm Venerol 2010;90:454-460
• Kubota R,Miyake N,Nakayama H,et al: anesthetic management of a patient with
non-bullous congenital ichthyosiform erythroderma. Masui2011;60:258-261
• Oji V,Traupe H.Ichthyoses: differential diagnosis and molecular genetics. Eur J
Dermatol 2006;16:349-359
 Anaesthetic challenges and post operative
pulmonary complications in a patient with
myotonic dystrophy for gynaecological surgery

Dr. Prabha Udayakumar

Dr.Vinodhadevi Vijayakumar

PSG IMS & R

Coimbatore
 Myotonic Dystrophy

• 36 y / F, Myotonic dystrophy
• Poor cough efforts (non
modifiable risk factor )
Pre-op
• Posted for TAH with BSO
• Plan : Combined spinal
epidural
• Intra - op : Hemodynamically
stable / no respiratory
problem Hatchet
• 1st POD: breathlessness, Facies
1st POD
desaturated, poor cough effort
 Myotonic Dystrophy

• With NIV, patient improved

transiently

• Intubated for tracheal toilette. 2nd POD

Bronchoscopy done

• 4th POD - weaned and extubated .

Reintubated.

• Multiple episodes of collapse

involving different segments of both
lungs causing weaning difficulty 2nd POD
 Myotonic Dystrophy

• 6th POD - tracheostomy was done

•12th POD weaned off ventilator and
discharged with Shiley tracheostomy Post
tube
intubation
• Follow up left lower lobe collapse
References
1. Mathieu J, Allard P, Gobeil G, Girard M, De Breakeleer M,
Begin P. Anesthetic and surgical complications in 219 cases
of myotonic dystrophy. Neurology 1997; 49: 1646–50.
2. 3. Russell SH, Hirsch NP. Anaesthesia and myotonia. Br J
Anaesth 1994; 72: 210–6.
Follow up
 Tight Corners
Role of Proseal LMA in the management of
High tracheal stenosis

ET TUBE
Dr. Faiza,
Post graduate, MD Anesthesia PROSEAL LMA
SRMC, Chennai
Background
Airway management for
high tracheal resection is
complex and challenging.
Common approach- Initial
orotracheal intubation with
cuff placed near the
stenotic area and
subsequent placement of
second tracheal tube below
the stenotic area through
surgical incision.
Main concern-
• Less space for ET tube
cuff below the vocal
cords
• violent emergence
jeopardizing
anastamosis
• ETT cuff in the surgical
field.
• ETT cuff impeding
transmucosal blood
flow.
History & Investigation
A 30 year old female with
alleged history of hanging
and prolonged intubation 3
months ago , presented with
history of stridor and
dyspnoea on exertion but
comfortable at rest.
PLAIN CT SCAN OF HEAD AND NECK
SAGGITAL SECTION SHOWING TRACHEAL
STENOSIS AT C6-T1 LEVEL
CT SCAN HEAD AND NECK 3D Plan: GA with ProSeal
RECONSTRUCTION SHOWING
TRACHEAL STENOSIS OF 8X5mm LMA insertion under CMV
(APxtrans)and 2.2cm LENGTH
Alternate plan: Rigid
bronchoscopy/
tracheostomy
IMAGE OF FLEXIBLE BRONCHOSCOPY
SHOWING SUBGLOTTIC STENOSIS
 Management
Discussion
• ProSealTMLMA offers several advantages in rigid
subglottic stenosis and high tracheal resection.
• Advantage
 positive pressure ventilation under high pressure
 option between spontaneous/ controlled
 smooth emergence
 conduit for insertion of fibreoptic bronchoscope
 better surgical work space
 less compromise of tracheal mucosal blood flow
<30 cm H2O
Other approaches
Cephalad • Awake tracheostomy (LA)
• LMA & Jet ventillation
• ProSeal LMA spontaneous vent
• Ventillating Rigid Bronchoscopy
• Tracheal Catheters & Jet
ventillation.
Caudad

5.0mm flexometalic tube(MALLINCKDROT) Conclusion

We conclude that the
Reference ProSealTMLMA can be
• Adelsmayr.E1 , Keller C, Erd G, Brimacombe J. The laryngeal mask and high-frequency jet ventilation for used as a dedicated
resection of high tracheal stenosis. Anesth Analg . 1998 Apr;86(4):907-8. airway in High tracheal
• stenosis.
• Brain AIJ, Verghese C, Strube PJ. The LMA ProSeal-A laryngeal mask with an oesophageal vent.
Br J Anaesth 2000; 84: 650–4.
 A CASE OF A DIFFICULT AIRWAY DUE TO MULTIPLE FACIAL FRACTURES IN A RURAL MEDICAL COLLEGE
Department of Anesthesia, PES IMSR, Kuppam, AP
Introduction
 Multiple facial fractures are not
uncommon in road traffic accidents and
pose a great difficulty for an anesthetist
to maintain airway. We report a case
posted for open reduction and internal
fixation of zygomatic and orbital fracture.
Case Report
 27 years old, involved in road traffic accident
and got admitted to the hospital with
polytrauma to the face. Patient complained
about pain over the left side of face and
difficulty in mouth opening.
 On examination of the face and oral cavity,
swelling and tenderness is noted over the left
side of the face, and redness of left eye
conjunctiva present. Neck movements were
normal.
 Preoperative indirect laryngoscopy was
attempted by the otolaryngologist but glottic
structures were not visualized. Rule of 1-2-3
revealed limited Temporomandibular joint
movement, interincisor gap less than 1 finger
Dr. Giridhar Janampet Bekkam, Dr. Mahesh T
N.T.R University of Health Sciences.
Investigations
 On radiographic examination of head and
neck revealed fracture of left zygomatic
arch of left temporal bone, fracture of the
left ramus of the mandible, and fracture of
the left lateral wall of the orbit present
Discussion
 Management of the airway is a major concern
in patients with maxillofacial trauma because
of a compromised airway can lead to death.
Various airway management strategies have
been suggested like blind nasotracheal
intubation, fiberoptic endoscope guided
intubation and preliminary tracheostomy.
 Nasal fiberoptic intubation was chosen as it
was not possible to pass both scope and tube
in the highly limited oral cavity. As the patient
refused bronchoscope placement while
awake, awake fiberoptic intubation was ruled
out. Hence general anesthesia using volatile
anaesthetic agents was chosen as it maintains
spontaneous ventilation. The changes in depth
of anesthesia, associated respiratory and
cardiovascular effects occur gradually and can
be easily reversed.
 Fiberoptic nasotracheal intubation while
maintaining spontaneous breathing under
inhaled anesthesia is one of the recommended
methods of securing airway in patients with
maxillofacial and mandibular fractures.
References
1.Gruen RL, Jurkovich GJ,
McIntyre LK, Foy HM,
Maier RV. Patterns of
errors contributing to
trauma mortality: lessons
learned from 2,594
ACCIDENTAL INJECTION OF INTRATHECAL LARGE DOSE MAGNESIUM
SULPHATE
AUTHOR : DR.GOUSIA BEGUM
RESIDENT,DEPT OF ANAESTHESIA,PES MEDICAL COLLEGE,KUPPAM

INTRODUCTION
1.USED AS INTRAVENOUS DRUG AND WAS PREVIOUSLY USED AS
ADJUVANT DRUG IN SPINAL ANAESTHESIA
2.IN A RAT MODEL,INTRATHECAL INJECTION OF MAGNESIUM SULPHATE
IN AN ISOMOLAR CONCENTRATION OF 6.3% PRODUCED A STATE OF
SPINAL ANAESTHESIA AND GENERAL SEDATION WITHOUT ANY
EVIDENCE OF NEUROTOXICITY AND 13% RESULTED IN
NEURODEGENERATIVE CHANGES IN SPINAL CORD
3.MG2+ BLOCKS THE CALCIUM CHANNEL IN THE N-METHYL ASPARTATE
RECEPTOR
4. IT IS A NON-COMPETITIVE BLOCKER THAT BLOCKS THE ION
CHANNELS IN A VOLTAGE DEPENDANT FASHION
5.THE CURRENT CASE REPORT FOCUSES ON A MISTAKENLY
SUBARACHNOID LARGE DOSE MAGNESIUM SULPHATE INJECTION
INSTEAD OF LIGNOCAINE WHICH PROGRESSES TO A TOTAL SPINAL
BLOCK
 1. 40 YEAR OLD FEMALE BOUGHT TO EMERGENCY DEPT WITH HISTORY OF
HYSTERECTOMY FOR MULTIPLE HUGE FIBROIDS 2 HOURS BACK IN A PRIVATE HO
OUTSIDE.
2.PATIENT WAS IN A STATE OF RESPIRATORY DISTRESS,BRADYCARDIA,HYPOTEN
AND UNCONSCIOUSNESS.
3.PATIENT WAS IMMEDIATELY INTUBATED AND SIMULTANEOUS 1MG IV ATRO
GIVEN,CRYSTALLOID INFUSION AND NORADRENALINE DRIP
4.HISTORY REVEALED THAT 2ML OF MAGNESIUM SULFATE(50%) WAS INJEC
MISTAKENLY INSTEAD OF LIGNOCAINE

CASE 5.PATIENT SHIFTED TO ICU.ABOUT 2 HOURS LATER HER HAEMODYNAMIC STA

BECAME MORE STABLE
REPORT
6.AFTER 24 HOURS PT BECAME FULLY CONSCIOUS BUT BECAUSE OF RESIDUAL M
PARESIS,PT COULDN’T BE WEANED OF FROM MECHANICAL VENTILATION
7.ON THE THIRD DAY,MUSCLE POWER BECAME BETTER AND THE PT WAS SUCCE
EXTUBATED.
8.AFTER TAKING MRI OF BRAIN WHICH WAS NORMAL,PT WAS DISCHARGED O
FIFTH DAY.
9.THREE WEEKS LATER,AN ELECTROMYOGRAPHY AND A NERVE CONDUCTION VE
STUDY WERE PERFORMED THAT SHOWED A NORMAL RESULT.
10.THE PATIENT FOLLOWED UP FOR 3 MONTHS AND FORTUNATELY SHE DINT S
ANY OBVIOUS COMPLICATION DURING THAT PERIOD
 DISCUSSION
1. RARE CASE REPORT OF ACCIDENTAL
INTRATHECAL INJECTION OF MGSO4+
2. LEIJUSTE MJ REPORTED THE FIRST CASE OF
ACCIDENTAL SUBARACHNOID INJECTION OF
MGSO4+
3.IN THAT REPORT PT COMPLAINED OF
INTENSE BACKACHE WITH LEG PARALYSIS
4. THE MAIN DIFFERENCE BETWEEN THE
PREVIOUS CASE AND OUR CASE WAS THAT THE
POSITION OF THE PT WAS TILTED TO HEAD
DOWN TO ACHIEVE HIGHER SENSORY BLOCK
5.MGSO4+ IS A HYPERTONIC SOLUTION AND ITS
SPREAD IS MORE DEPENDANT ON GRAVITY
6.INTRATHECAL SPREAD OF HYPERBARIC
SOLUTIONS CAUSES INCREASED INCIDENCE OF
CARDIORESPIRATORY SIDE EFFECTS
7.NOTEWORTHY THAT DURATION OF MUSCLE
WEAKNESS INDUCED BY MGSO4+ LASTED FOR
A LONG TIME
CONCLUSION
- WE MUST EMPHASIZE ON SOME
FACTORS HERE
1.SIMILAR SHAPE OF DRUG
CONTAINERS
2.CARELESNESS OF THE DOCTOR
3.PROPER AND COMPLETE CARE
ON PART OF ANAESTHETIST IN
LOADING AND INJECTING DRUG IS
NECESSARY FOR SAFETY OF THE
PATIENT.
-THUS,IT IS SUGGESTED THAT
METICULOUS STEPS SHOUL BE
TAKEN TO PREVENT OCCURRENCE
OF SUCH DISASTROUS EVENT
REFERENCES
 PULMONARY EMBOLISM IN A CASE OF BILATERAL SIMULTANEOUS
TOTAL KNEE REPLACEMENT-A CASE REPORT
Dr Jithumol Thankam Thomas, Dr P.I Lohita, Dr.Radhika Dhanpal
St.John‘s Hospital,Bangalore

Introduction: Surgical options available to patients with bilateral end stage degenerative disease of the
knee joints include:
• Staged procedure-with a certain time interval between the two procedures
• Simultaneous bilateral arthroplasty with a single anaesthetic exposure.

ADVANTAGES DISADVANTAGES
Simultaneous bilateral Total knee arthroplasty-Pros & Cons
•Limits invasive surgical procedure and anaesthetic •Cardiovascular Complications(22%)- CCF, Myocardial
exposure to a single event Infarction, Arrythmias

•Symmetrical rehabilitation of both knees potentially •Pulmonary - Embolism(80%), Pneumonia

reducing length of hospital stay
•Neurological- Confusion, CVA
•Reduced hospital costs
•Post haemorrhagic Anaemia
•Reduced requirement and duration of pain medication
and early recovery •ICU admission rates-Double that in unilateral or staged
procedures
•Patient satisfaction rates and pain scores are comparable
to a unilateral procedure •Higher 30- day mortality rate
 CASE REPORT
PREOPERATIVE
• 64 yr old lady posted for simultaneous bilateral Total
knee replacement
• Known Hypertensive on T.Amlodipine for 3 years-
controlled blood pressure recordings
• Systemic examination-Normal
• Preop investigations-Normal
• ECG-Flat T waves in V1-3
• ECHO- EF-70%,no RWMA,LVDD, PASP-26mmHg
INTRAOPERATIVE
• Combined Spinal Epidural anaesthesia
• SAB-3.2cc of 0.5%(H)Bupivacaine
at L3-4 space
• Epidural catheter at L2-3 space
• Level of sensory block T10
• Intraoperatively vitals were normal
• Surgery lasted for 7 hours
• Tourniquet time -3 hours on right lower limb and 3
hrs 20 min in left lower limb
• Intraoperative blood loss was 400ml-1 unit PC was
transfused
POSTOPERATIVE
• Immediate postoperative period was uneventful
• On POD1-patient develped burning chest pain and
sweating
• Vitals at that time were recorded as
BP- 60/40 mmHg,HR-130 bpm,SpO2-77%
• Bilateral air entry was equal
• Blood collected in the drain was 1000ml
• Chest Xray -Normal
• ECG-S wave in lead 1 ,Q wave in lead III,inverted T wave in
lead III(S1Q3T3)
• B.P improved to 94/60 with 750 ml crystalloids
• Saturation however did not improve with O2
• Patient shifted to ICU
• Working diagnosis of pulmonary embolism was made and started
on NIV and LMWH(Enoxaparin 40 mg s.c BD)
• Patient started improving after 24 hours and was slowly weaned
from NIV
• Serial ABGs showed improved oxygenation
Patient discharged from ICU after 3 days.
FINDINGS
• D-Dimer assay was positive
• Echo- EF 65%,no RWMA,PASP-46 mmHg, moderate
Tricuspid Regurgitation, no right ventricular dysfunction
• ECG-S1Q3T3
• Venous doppler of lower limb did not show any thrombus
• Coronary angiogram –normal coronaries
• Compression USG of Bilateral Lower limbs –did not show any
thrombus(USG cannot detect thrombosis of deep veins of pelvis)
• CT angiogram not done as patient was too unstable in first 24
hours
 DISCUSSION
Pulmonary embolism in our patient may have been due to
• Increased operative time (7 hours)
• Prolonged tourniquet time
Mortality rates are twice as high after Bilateral TKR
than after unilateral. Cardiovascular, Respiratory and
CNS complications are twice as frequent in bilateral
simultaneous TKR as compared to unilateral total knee
arthroplasty
No difference between simultaneous and staged
procedures however.
Venous thrombosis and pulmonary embolism occurs
more frequently in simultaneous Bilateral recipients as
compared to staged procedure.
Optimal timing of the second TKR is still controversial .
Decision to perform a simultaneous procedure is based
on patient‘s needs & recommendation of the surgeon .
Recipients of simultaneous bilateral total knee
arthroplasty should be monitored in high dependency
Unit postop for early detection of complications
Higher incidence of complications can be reduced by:
• Appropriate patient selection(Age less than 70,
ASA I /II)
• 2 surgical teams
• Uncemented total knee arthroplasty
• Shorter tourniquet time
• Use of short fluted intramedullary femoral rod
• Intraop monitoring of pulmonary vascular resistance
with pulmonary artery catheter-
Abandon procedure on second knee if PVR >200
dynes/sec/cm
• Postoperative use of TEDS/SCD devices, early
mobilisation and optimal use of Anticoagulants
REFERENCES
1)CamilloRestrepo,Javad Parvizi,Thomas Dietrich, Thomas A
Einhorn. Safety of bilateral simultaneous total knee arthroplasty
Bone Joint Surg Am.2007;89:1220-6
2).Memtsuoids Stavros.G,Ma Yan, Gonzales Della Valle et al
Perioperative outcomes after bilateral and unilateral total
knee arthroplasty. Anesthesiology 2009;111Suppl 6:1206-1216.
3)JRM Hutchison,EN Parish,MJ Cross.Simultaneous or staged? A
Comparison of bilateral uncemented Total Knee Arthroplasty
Bone Joint Surg British 2006;88B:40-43.
4)Jane Barret,John.A.Baron,Elena Losina ,John Wright,Nizar.N.Mahomed
and Jeffery N.Katz
Bilateral total knee replacement: Staging and pulmonary
embolism. The Journal of Bone and Joint
Surgery(American).2006;88:2146-2151
5)Mantilla CB,Horlocker TT,Schroeder DR, Berry DJ, Brown DL
Frequency of Myocardial infarction, pulmonary embolism, deep
venous thrombosis and death following primary hip or knee
arthroplasty.Anesthesiology.2002;96 Suppl 5 :1140-6.
6)K.Kellie Leith,Dustin Dalgorf,Cornelia .M.Borkhoff,Hans .J.Kreeder
.Bilateral knee arthroplasty-staged or simultaneous. Can J
Surg.2005; 48 Suppl 4:273-276
7) Lynch NM,Trousdale RT,IlstrupDM, Complications after concomitant
bilateral knee arthroplasty in elderly patients. Mayo Clinic
Proc.1997;72:799-805
 “ANAESTHETIC MANAGEMENT OF A PATIENT WITH
DILATED CARDIOMYOPATHY POSTED FOR EMERGENCY
NON-CARDIAC SURGERY”- A CASE REPORT.
Dr.K.Aditya(M.D/J.R), Dr. Madhusudan(Asst Prof), Dr.M.H.Rao(Sr.Prof &
H.O.D) Dept. of Anaesthesiology and Critical Care, Sri Venkateswara
Institute of Medical Sciences (SVIMS), TIRUPATI
 A 77 year old woman suffering from dilated cardiomyopathy(DCM) and
severe left ventricular dysfunction was diagnosed to have irreducible
umbilical hernia and was posted for emergency laparotomy and hernia
repair.
 She was on medical management (tablet digoxin, torsemide, carvedilol,
aspirin and clopidogrel) since 2008.
 Blood investigations were normal and chest X ray revealed cardiomegaly.
 ECG - Normal sinus rhythm with infrequent premature ventricular
complex (PVCs) (<6 /min) without any ischemic changes.
 Echocardiography demonstrated, global hypokinesia of left ventricle,
poor systolic function, ejection fraction of 25% and moderate aortic
regurgitation.
 After thorough preoperative evaluation and optimization patient was
posted for surgery.
 Monitoring : 2 lead ECG (LII and V5), IBP , CVP , SPO2, ETCO2,
temperature & urine output.
 Induction : Etomidate 0.2mg/kg, Fentanyl 2mcg/kg , Xylocord
1.5mg/kg (to treat the PVCs) and paralysed with Atracurium 0.5mg/kg.
 Intubation was done with Size 3 Laryngeal mask airway (LMA) 1,2 and
secured after proper positioning.
 Maintainance : Oxygen, air, isoflurane up to 2%, top up dose of
atracurium 5mg and intermittent positive pressure ventilation(IPPV).
CVP was monitored to optimize the preload.
 Patient was maintained on dopamine infusion 5μg/kg/min to avoid
sudden fall in blood pressure due to anaesthetic drugs and was tapered
slowly at the end of surgery.
 Hernial content (omentum)was reduced and defect was closed with
mesh. Procedure lasted for 90 minutes.
 At the end of surgery, residual neuromuscular blockade was reversed
and LMA was removed after return of protective airway reflexes and
patient had good spontaneous respirations.
• Patient had stable haemodynamics throughout the procedure. All the
intra operative monitoring except ETCO2 were continued post
operatively.
• All her preoperative medications including aspirin and clopidogrel
were continued as per the recommended dosing and timing. Further
course was uneventful.
 Preferred General anaesthesia over Regional Anaesthesia:
Patient was on antiplatelets ; poor LV function; may cause sudden drop
in blood pressure with Regional anaesthesia.
 Preferred LMA over ETI (endotracheal intubation):
No risk of gastric aspiration(hernial content is omentum), Pressor
response of ETI can be avoided.3,4 , ETI requires more depth of
anaesthesia.5
 Preferred IPPV over Spontaneous ventilation:
Adequate muscle relaxation can be provided.
References:
1) Prashan HT, Thiagarajah S, Elizabeth AMF. Anaesthetic considerations in patients with cardiomyopathies. MEJ Anaesth
2009; 20: 347-54.
2) Hase K, Yoshioka H, Wachi Y. Anaesthetic management of 6 cases with dilated cardiomyopathy for non cardiac surgery.
Masui 1996; 45:741-5.
3) Girish P. Joshi, Yoshimi Inagaki, Paul F. White, Lisa Taylor-Kennedy, Linda I. Wat, Clifford Gevirtz et al: Use of the
laryngeal mask airway as an alternative to the tracheal tube during ambulatory anesthesia. Anesth Analg 1997; 85:573-7.
4) Swarm DG, Spens H, Edwards SA, Chestnut RJ. Anaesthesia for gynaecological laparoscopy: a comparison between the
laryngealmask airway and tracheal intubation. Anaesthesia 1993;48:43-4.
5) Fuji Y, Tanaka H, Toyooka H. Circulatory responses to laryngealmask airway insertion or tracheal intubation in
normotensive and hypertensive patients. Can J Anaesth 1995;42:32-6.
 BARTTER SYNDROME COMPLICATING Pregnancy- A CASE REPORT
Dr K.Sruthi , Dr Shriram VaidyA
Department of Anaesthesiology, Kasturba Medical College ,Manipal
• Bartter Syndrome- a rare inherited anomaly with defect in• Hb-10.6g/L, Platelet count-3,59,000cell/cumm, WBC- 15,300
thick ascending limb of loop of Henle with reduced cells/cm3, RBS-108mg/dl, S.Urea-14mg/dl, S.Cr 1mg/dl,
reabsorption of potassium. S.Na+-127mEq/L, S.K+ 1.7mEq/L, S.Mg++-1.4mEq/L, S.Ca++
• We present a case of Bartter syndrome complicating pregnancy 7.3mg/dl,ABG- pH - 7.5,PaCO2-31mmHg, HCO3-30.5mmol/L, ABE-
presented with presumed cardiac arrest at 37 weeks of 7mmol/L , PO2 – 515mmHg.LFT- Normal, ECG- HR-92/min, s/o
gestation. atrial fibrillation. Echo-Normal
CASE REPORT: • Emergency LSCS under general anesthesia.
• 28 year old primigravida at 37 week gestation presented with• Potassium correction with i.v. KCl started in ICU, continued
complaint of weakness since two days and difficulty in intraoperatively. Patient shifted back to ICU
breathing since one day to local hospital • Mechanical ventilation with SIMV VC PS mode in ICU.
• Sustained witnessed collapse and LOC associated with tonic• Potassium correction with i.v. KCl infusion 20 mEq/hr to a total
posturing of limbs in hospital of 100 mEq/day. Magnesium correction with 1g of magnesium
sulfate. i.v. calcium gluconate infusion under ECG monitoring
• EEG and MRI- no evidence of HIE, Trop-T.CK-MB normal.
• Urine analysis s/o renal loss of potassium, calcium and chloride.
24 hr urinary calcium excretion elevated. Hence diagnosis of
Bartter syndrome was arrived at.
• On day 2 patient became oriented and conscious, sedated with
iv morphine infusion. 12 lead ECG- Normal rhythm.
• Presumed cardiac arrest, chest compression delivered, referred
to our hospital after intubation. • Day 3, serum potassium improved to 2.8mEq/l with continued
i.v. correction, power improved to 4/5 in all four limbs.
• On presentation- GCS E4M3Vt, BP-140/80mmHg, PR-90/min
Potassium correction tapered to 80 mEq/day.
irregular, pedal edema present, Power in all limbs was 1/5,
Fetal heart sounds present, dropping to 90bpm. • Day 5, serum potassium 3.7 mEq/l, Ca and power 5/5 in all four
limbs, iv KCl reduced to 40 mEq/day with oral syrup potassium
chloride 60 mEq thrice daily.
• Day 6, patient tolerated spontaneous breathing trial with T-piece
well after a trial of CPAP and was extubated
• Discharged from ICU on day 7 with advice for life long
potassium, magnesium and calcium replacement therapy
DISCUSSION:
• Bartter syndrome- autosomal recessive disease with incidence of
1.2 per million
• Defective ion transport in thick ascending segment of loop of
Henle and distal convoluted tubule
• Urinary loss of K+, Na+ and Cl- stimulates renin angiotensin
aldosterone axis leading to increased secretion of potassium and
hydrogen precipitating hypokalemia and alkalosis
K+; renal K+ wasting
Metabolic alkalosis
Normal blood pressure
Renin and aldosterone
Urine Ca2+ excretion or Ca2+ /
creatinine
• Metabolic alkalosis contributes to decreased ionic calcium
and seizures
• Bartter syndrome- presentation in pregnancy: diarrhoea,
hyperemesis, polyuria, polydipsia, muscle cramps,
paralysis, polyhydramnios, premature delivery or
abortion.
• Correction of hypokalemia: potassium rich diet and 10
% KCl supplement -safe for long term use at doses from
1-5 mmol/kg/day up to 200 mmol/day.
• For acute improvement: iv KCl infusion at a rate upto
40mEq/hr by two separate peripheral veins or upto 20
mEq/hr through central venous line for patients with severe
deficit.
• Life long Ca++, Mg++ and K+ correction needed . Other
treatment options include prostaglandin synthetase
inhibitors and NaCl
• Differential diagnosis of Bartter syndrome:
 Gitelmann syndrome
 Chronic use of diuretics
 Chronic vomiting

High Low  Laxative abuse

 Chronic diarrhoea
Serum Mg2+ Serum Mg2+

Normal Low

Bartter’s Syndrome Gietelman’s Syndrome

• CONCLUSION:
• Bartter syndrome- extremely rare in pregnancy
• Significant maternal and neonatal implications
• Needs prompt recognition and careful management
• Understanding the pathological basis can minimize maternal and fetal morbidity and mortality

REFERENCES:

1) Chinnery PF. Muscle diseases. In: Goldman L, Schafer AI,eds. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa: Elsevier
Saunders; 2011: chap 429.
2) Mount DB, Zandi-Nejad K. Disorders of potassium balance. In Taal MW, Chertow GM, Marsden PA, et al., eds. Brenner and
Rector’s The Kidney. 9th ed. Philadelphia, Pa: Elsevier Saunders; 2011: chap 17.
3) Bartter FC, Pronove P, Gill JR Jr, MacCardle RC. Hyperplasia of juxtaglomerular complex with hyperaldosteronism and
hypokalemic alkalosis. Am J Med. 1962; 33:811-828
4) Simon DB, Karet FE, Rodriguez-Soriano J, Hamdan JH, DiPietro A, et al. Genetic heterogeneity of Bartter's syndrome
revealed by mutations in the K+ channel, ROMK. Nat Genet. Oct 1996; 14:152-6.
5) Assadi F. Diagnosis of hypokalemia: a problem-solving approach to clinical cases. Iran J Kidney Dis. Jul 2008; 2:115-22.
6) Lin SH, Yang SS, Chau T. A practical approach to genetic hypokalemia. Electrolyte Blood Press. Jun 2010; 8:38-50.
Anaesthetic Management Of Post Abortal
Profuse Bleeding Following Incomplete
Abortion

Dr. M. Kalirathinam
Dr. P. Jeyakrishnan
Department of Anaesthesiology
PSG IMS & R
Coimbatore
• 32/F P2 L2 with h/o LSCS twice, admitted with persistent
bleeding P/V for 4 days after a D&C.

• She was 7 weeks pregnant inspite of her prior sterilization.

• On admission she was pale, Pulse - 98/min , BP - 80/60 mm

of Hg and tender lower abdomen.

• USG showed retained products of conception.

• Preoperatively her Hb was 6.7 gms/dl, Platelets- 1.72 lakh

cells / cubic mm.
• Suction evacuation was done under G.A.

• Blood loss was around 900ml.

• Profuse uterine bleeding persisted.

• Hence Uterine artery embolization was planned in Cath lab

• Bilateral Uterine artery embolization was done by

interventional cardiologist.

• 3 packed cells, 4 FFPs, and a Liter of Crystalloid was given

during these procedures.
• Her clinical condition became stable after embolization.

• Immediate Post op D-dimer was 0.8 µgm /ml FEU

• Quick clinical decision and multidisciplinary team effort

prevented further worsening of haemorrhagic shock, DIC
and saved her life.

References
1. Steinauer JE, Diedrich JT, Wilson MW, Darney PD, Vargas JE,
Drey EA. Uterine artery embolization in postabortion
hemorrhage. Obstet Gynecol 2008;111(4):881-9.
 ANAESTHETIC MANAGEMENT OF A 1YR OLD
WITH KLIPPEL FEIL SYNDROME POSTED FOR
PUSHBACK PALATOPLASTY
PRESENTER MODERATOR:Dr MANJUNATH
Dr KAVYA.K.G JAJOOR ,PROFESSOR JJMMC,
JJMMC, DAVANGERE DAVANGERE
INTRODUCTION: Klippel feil syndrome is an inherited condition that was first
described in 1912 by Maurice klippel and Andre feil. It is characterized by triad of
shortness of neck,limitation of neck movements resulting from fusion of several
cervical vertebrae and low posterior hairline.

CASE REPORT: Here is a case report of anaesthetic management of 1 yr old

,7.5kg female child who presented for correction of cleft palate –pushback
palatoplasty. On examination of this child following were noted – short neck, low
posterior hairline ,restricted neck movements and a dermoid cyst at the nape of the
neck. Mouth opening was restricted and child had grade 4 cleft palate. Cervical
spine x ray- AP and lateral veiw showed closed spinal dysraphism of
cervicothoracic region . There was no other associated congenital anamolies.
Routine preoperative blood investigations were within normal limits. Anticipating
a difficult airway fiberoptic intubation was planned.
 The chid was kept nill orally from 5am on the day of
surgery. Child was brought to the operating room and on
table ,an IV line was secured and IV fluids started. Pulse
oximeter, ECG, NIBP,precordial stethescope were
attached.
Inj glycopyrrolate 0.05mg and Inj fentanyl
2microgram/kg were given intravenously. child was
induced with O2:N2O:Halothane, when sufficient depth of
anaesthesia was reached ,a check laryngoscopy was done
and it was found that there was difficulty in visualization
of the vocal cords. The ability to ventilate the lungs by
mask was confirmed and a muscle relaxant –inj
succinylcholine 15mg was given intravenously.
A 3.5mm ETT was threaded over the fiberoptic
bronchoscope ,the scope was carefully maneuvered
through the vocal cords and was slowly advanced till the
bifurcation of the trachea was seen.fiberscope was then
removed and ETT secured in position . The position of the
ETT was confirmed by bilateral equal chest movements on
inspection and equal airentry on ascultation.
The child was then maintained on O2+N2O+
Intermittent positive pressure ventilation, halothane and
inj Atracurium ( 0.5mg/kg)
Surgery proceeded uneventfully and residual neuromuscular blockade was reversed
With inj glycopyrrolate 0.01 mg /kg and inj neostigmine 0.05mg/kg. After return of
good muscle tone and resumption of spontaneous breathing the ETT was removed
Postoperatively child was monitored in recovery room and the course was uneventfull.
CONCLUSION: Difficult intubation is anticipated in patients with klippel feil
syndrome due to limited neck mobility and short neck.Therefore endotracheal
intubation with fibreoptic bronchoscope or awake intubation is preferred.

REFERENCES:
• Daum REO, Jones DJ. Fiberoptic intubation in klippel feil syndrome .A naesthesia
1988; 43
• Naguib M, Farag H , Ibrahim AEW.Anaesthetic considerations in klippel feil
syndrome , Can Anaesth Soc J 1986; 33
• William C,Warner Jr , Paediatric cervical spine S.T Canale Ed.Cambell ‗s
operative orthopaedics vol2, 10th edition.Mosby, 2003: 1737-40
• Elliot J.Krane, Bridget M.Philip, Kelly K. yeh, Karen B.Domino, Smith‘s
anaesthesia for infants and children , 7th edition : mosby: 2005.
A Rare Presentation Of Perioperative Myocardial
Infarction

• The incidence of myocardial infarction in the perioperative period (PMI)

varies from 1.1% to 3.1 % and commonly occurs in patients with chronic
coronary artery disease (CAD) (1,2,3).
• PMI causes significant immediate and long term morbidity and mortality.(4)
• A 50 yr/M ASA 1, nonsmoker posted for tibial non union after previous
surgery. Six hours postoperatively, the patient complained of sudden onset
of retrosternal pain.
• On examination, the patient was fully conscious with HR-110/min and BP-
160/90 mm Hg.
• A 12 lead ECG revealed normal sinus rhythm with ST segment elevation in
leads II, III, aVf, V3,V4 and V6.
 A Rare Presentation Of Perioperative
Myocardial Infarction
• 2D ECHO showed RWMA in the apex, inferior and lateral walls with mild left
ventricular dysfunction (EF- 45%).
• CAG revealed distal thrombotic occlusion of multiple vessels including distal LAD,
2nd diagonal and 2nd obtuse marginal arteries.
• Angioplasty and stenting was not done as multiple distal arteries were occluded
with thrombi.
• Plan for thrombolysis was abandoned in view of major surgery few hours back and
the relatively small area of myocardium at risk. 2D ECHO, Venous doppler of lower
limbs normal
• The fasting homocysteine levels, protein C and S activities were normal. He was
negative for anticardiolipin antibodies.
A Rare Presentation Of Perioperative Myocardial
Infarction-DISCUSSION
• Two distinct mechanisms leading to PMI on a background of chronic CAD have
been proposed :
– Type I: an acute coronary syndrome due to atherosclerotic plaque rupture and
thrombosis.
– Type II: due to oxygen demand and supply mismatch (5).
• The majority of PMIs are non Q wave type with ST segment depression rather than
elevation (6,7,8).
• The PMI in this case was STEMI with no h/o CAD and is suspected to be coronary
embolism.
• The source of embolism may be either
a) distal migration of thrombus in the left main coronary artery ,
b) embolism of thrombus in the left sided chambers of the heart or
c) paradoxical embolism of deep vein thrombosis of the lower limbs.
 A Rare Presentation Of Perioperative Myocardial
Infarction-DISCUSSION

• Prolonged immobilization, failure to reinitiate DVT prophylaxis in the present

admission, the prothrombotic milieu of perioperative period and manipulation of the
lower limb during the procedure all point to DVT of lower limb as the source of
embolism.

• The presence of an extracardiac right to left shunt which could not be demonstrated
may have served as a conduit for coronary embolization.

• The mechanism is different from the two well described mechanisms of PMI and has
occurred in a patient with no prior history of CAD or the risk factors for it and resulted
in ST elevation MI.
 REFERENCES
1.Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johnston N et al. Predicting cardiac
complications in patients undergoing non-cardiac surgery. J Gen Intern Med 1996; 1: 211-9.
2.Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau FJ, Tateo IM. Association of
perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac
surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med 1990; 323: 1781-8.
3.Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF et al. Derivation and
prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
Circulation 1999; 100: 1043-9.
4.Mangano DT, Browner WS, Hollenberg M, Li J,Tateo IM. Long-term cardiac prognosis following
noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA 1992; 268: 233-9.
5.Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative Myocardial Infarction.
Circulation 2009; 119: 2936-44.
6.Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and perspectives. J
Cardiothorac Vasc Anesth 2003; 17: 90–100.
7.Landesberg G, Luria MH, Cotev S, et al. Importance of long-duration postoperative ST-segment
depression in cardiac morbidity after vascular surgery. Lancet 341:715–719, 1993.
8.Landesberg G, Mosseri M, Wolf Y, Vesselov Y, Weissman C. Perioperative myocardial ischemia and
infarction. Identification by continuous 12-lead electrocardiogram with online ST-segment monitoring.
Anesthesiology 2002; 96: 262–70.
 ANAESTHETIC MANAGEMENT OF
LSCS IN CORRECTD TOF ANAESTHETIC MANAGEMENT OF LSCS IN A PATIENT WITH TOF

By Dr Lakshmi Bhavana,Dr Pawan Nanangund

INTRODUCTION CASE
• Most common incidence of 5% in children • 34 year female shanthi mathias;primigravida
and 15% in adults with 37 weeks of gestation a corrected TOF
• TOF is Characterised by in 1999 admitted in view of safe
confinement ,patient is adjusted to normal
1.VSD
life except for
2. Aortic overriding C/O breathlessness on moderate exertion and
3.RVH occasional palpitations.
4.Pulmonary artery outflow obstruction CVS- Ejection systolic murmur in
pulmonary area was heard, baseline
haemogram,RFT, Coagulation profile is
normal
ECG - Right bundle branch block ,rt
ventricular hypertrophy
ECHO- EF of 60% with tiny residual VSD
,Left to right shunt, RT atrial ,ventricular
dilatation , Moderate Pulmonary
regurgitation
 TECHNIQUE ADVANTAGES DISADVANTAGES

1.Airway 1. SVR
protection 2. VR
GA 2. Work of 3.Hypoxemia
breathing 4.Hypercarbia
Intra op RT IJV secured and arterial 3. Oxygen 5.Acidemia
line ,and monitored IBP and CVP consumption
through out , episodes of
1.Good postop 1. SVR
hypotension were managed with analgesia 2.Abrupt
boluses of fluid and phenyephrine 2.Sympathetic hypotension
TECHNIQUE AMOUNT OF LEVEL SAB blockade
DRUG 3.Spontaneous
respiration
SPINAL at I.6 ml of 0.5% T8
1.Graded 1.Less motor
L3-L4 heavy
hypotension blockade
bupivacaine
2.Continuous 2.Time
EPIDURAL at 3ml of T4 EPIDURAL titrated consuming
L3-L4 lignocaine with analgesia
15µg
adrenaline
 DISCUSSION CONCLUSION
• Considering the advantages • Choice of anaesthesia depends
and disadvantages of the on procedure and thorough
anaesthetic techniques , we 1.understanding of these cases ,
opted CSE as technique of 2.anticipation of problems
choice providing us with 3.careful selection of drugs
better control of 4.attention to haemodynamic
haemodynamic parameters parameters is most important
and analgesia for satisfactory outcome
REFERENCES
1.Stoeltings Robert K.congenital heart disease,Anaesthesia and coexisting disese
Churchill livingstone 3rd edition 42-45
2.Chestnuts obstetric anaesthesia principles and practice David H.Chestnut.Cynthia
A.wong 5th ed 974
3.Cunningham FG,Grant NF, Leveno Jk,medical and surgical complications in
pregnancy, Williams obstetrics,21st edition 2001, Mc graw Hill,1193
4.Roberts SL,Chestnut DH,Anaesthesia for the obstetric patient with cardiac
disease,Clin obst Gyn 1987,30,601
.
CASE REPORT
INTRODUCTION
Each and every anaesthesiologist in his / her professional career
faces a challenging airway anticipated or unanticipated.
Ludwigs angina is a challenge to anaesthesiogist, as it is assosciated
with upper airway obstruction , limited mouth opening, which will
interfere with traditional direct laryngoscopy & orotracheal
intubation.
CASE REPORT
A 35 yr male patient of height 170cm , of weight 72kg, working as a farmer
presented to Emergency department with complaints of fever for 5 days,
difficulty in mouth opening with lower jaw swelling for 4 days. History is
not suggestive of comorbidities & drug allergies. Diagnosed as a case of
Ludwigs angina, posted for emergency Incision & drianage.
As the surgical field is near the airway, so airway is shared for the
anaesthesiologist & surgeon we planned for General anaesthesia.
Investigations- CBC- WBC- 28,000 ,.
RFT, HB- Normal
CXR - Normal
O/E – Patient had restricted mouth opening with inter incisor gap of 1.5cm.et
Temporomandibular joint – not able to admit the tip of finger .
Mallampati class- cannot be assessed , Thyromental distance 7cm, Hyomental
distance – 3 fingers.
Upper lip bite test – class III
-Because of anticipated difficult laryngoscopy & orotracheal intubation ,
planned of AWAKE BLIND NASOTRACHEAL intubation.
AIRWAY ASESSMENT
MANAGEMENT OF CHALLENGING AIRWAY USING NOVEL AGE OLD TECHNIQUE IN RURAL SETUP
Dr.LAKSHMI TULASI.DUGGISETTY & DR.KRANTHI KUMAR.GTS
Post graduate in Dept.of ANAESTHESIOLOGY, PESIMSR, KUPPAM.
CONCLUSION
CASE REPORT
BLIND AWAKE NASAL Intubation has been gold standered in securing
airway from ages and still comes handy even in this modern era of Fibre
optic intubation.
Patient shifted to operating room, connected to all moniters, IV canula secured. Nasal cavities
examined, big patent nostril is selected. Before 30 minutes of procedure 4 drops of
Xylometazoline instilled in nostril, anaesthetised with 4 %xylocaine soaked nasal pack .Airway
is anaesthetised with bilateral superior & recurrent laryngeal nerve blocks.
BLIND AWAKE NASOTRACHEAL intubation done by pathfinder technique ,guided by breath
sounds using 7.5 size Nasal Endotracheal tube is gently passed through the nose, towards the
larynx. The tube is guided in the direction of loudest breath sounds by moving the patients REFERENCES
head until the larynx is entered.
Premedication – Inj. Glycopyrolate – 0.01mg/kg , Inj. Fentanyl – 3mcg/kg, Inj.Midazolam-
0.05mg/kg. 1.Millers text book of Anaesthesiology – 7th edition
Induction – Inj.Propofol- 2mg/kg. 2.Review article of Nasotracheal intubation for Head & neck
Muscle relaxant – Inj.vecuronium 0.1mg/kg at induction. surgeries- CEJ Hall & L.E Shutt- Anaesthesia 2003, pages 249-
Maintainance with N2O : O2 – 66 : 33 % , sevoflurane – 1 to 3 %. & Inj.Vecuronium 0.05mg/kg 256.
After surgery is completed , 3.Rashid Khan- text book of airway management.
Reversal of muscle realxants is given with Inj. Neostigmine – 0.04mg/kg + Inj. Glyco –
0.01mg/kg smooth extubation done .
Surgical & Anaesthetic outcomes are satisfactory .
Patient is observed for one hour in recovery room , later shifted to Postoperative room.
ACKNOWLEDGEMENTS
DISCUSSION
My sincere thanks to our professor Dr. Kranthi kumar GTS
and our HOD Dr.(Col) K.V. Srinivasan for their support
and advice during the management of this case and
preparation of this poster.
• Naso tracheal intubation offers the Head & Neck surgeon more scope for surgical manoeuvre in operations of mouth, pharynx, larynx, neck.
• KUHN (1902) was first to describe the technique of Nasotracheal intubation, which he felt was a more physiological approach to tracheal intubation.
• The technique was further populerised in the 1920 by MAGILL.
• The success of the procedure depends on the skill of Anaesthetist & cooperation from the patient.
• Alternative modes of Intubation apparatus should be kept ready ( ex- Fibreoptic intubation equipment ) or Invasive methods of intubation shoulb be kept in mind.
Advantages - It can be rapidly achieved whilst avoiding the stimulation of rigid instrumentation.
Pressor response can be minimised as there is no laryngoscopy procedure.
The risk of dental trauma can be avoided.
Can be used for prolonged intubation in ICU patients.
Disadvantages -
The procedure was deferred nowadays because of complications like – Epistaxis, Traumatic avulsion of structures with in the nasal fossa & Nasopharynx especially
Inferior turbinate , Bacteremia, edema around the maxillary ostium & eustachian duct, maxillary sinusitis, esophageal perforation if multiple attempts of esohageal
intubation was done.
 Reference No: ISA/2014/ABS/31

Anaesthetic Management of a Patient with Wilson’s

Disease posted for Emergency LSCS: A case report
B. Lavanya PG, Kousalya C, R R murthy, Niolufer Hospital, Hyderabad
Introduction • Wilson‘s disease is a rare AR disorder
• Prevalence 1:50,000-1:100,000 live births
• Hepatic & neurological features, Kayser-Fleischer rings
• Both GA /RA techniques a challenge to the anaesthesiologist

Case Report • 19 yr /un booked /primi / 37 wks/ k/c/o WD, in early

PAC labour/ severe oligo / fetal compromise/ LSCS Cat 2
• Neurological symptoms 3yrs back, progressive difficulty in walking ,
proximal muscle weakness, polyarthralgia, contractures right elbow..
• WD was Confirmed by :
• Copper in the urine -325μg/day (normal <60 μg/day)
• Low serum ceruloplasmin - 0.1 g/l ;( normal range 0.25-0.63 g/l)
 Ophthalmic Stabilized with
MRI /2011 consultation 2011
• Methyldopa
• Trientene &
zinc
• Discontinued medications from 20wks gestation. No neurological
follow up. Asymptomatic . Ref to Niloufer Hospital in early labour
• Vitals stable, sensory & motor power normal No S/S of pre eclampsia.
• CBC, LFT, KFT, APTT/PT/INR –WNL. USS: Placenta fundal
• NBM 6hrs / Antiemetic prophylaxis given
• Co hydrated with 500ml RL
• Monitoring : SpO2, NIBP, ECG, Urine output
• SAB : 26G Q, 10mg Bupivacaine + 20ug Fentanyl. Level up to T4,
Wedge kept. 2.9 Kg Mch / APGAR 8,9,9 / Oxytocin 10 U infusion
• Blood loss – 300ml / intraop fluids 2L / intra op urine – 100ml clear
• Post op : Regression of block noted in 2hrs , Ambulated after 8hrs.
• Post op uneventful. Discharged on 5th POD. Ref to neuro physician.
 Effect of WD on pregnancy Effect of pregnancy on WD
• Coombs -ve haemolytic • ↑ serum-ceruloplasmin & ↑ need
anaemia (10–15%) by fetus es maternal S.copper
• Risk of PIH /HELLP/abruption • ↑ Risk of hepatorenal
• ↑ Copper causes IUGR / involvement & neuro-psychiatric
Neurological sequelae illness
• ↑ Risk of post partum • ↑ Risk of ascitis, Gl bleeding &
depression (PPD) Varicial rupture
Effect of Anaesthesia on Wilson’s disease
• Risk with GA : Altered hepatic metabolism,  renal excretion, altered
neuromuscular transmission,  muscle power - ↑es sensitivity to
NMBDs adding to airway difficulty in pregnancy
• Hypnotic & sedatives – aggravate neuro psychological problems
• Caution with RA :Pre existing neurological deficiency, HELLP....
: 1. A. B. De Souza Hobaika, ―Anesthesia for a patient with
Conclusion: Meticulous PAC, RefWilson's disease—a case report,‖ Middle East Journal of
proper planning of anaesthesia Anesthesiology, vol. 19, 905–908, 2008
et al. Wilson‘s disease in pregnancy: case series and review
leads to good outcome in WD. 2. A Malik,
of literature BMC Research Notes 2013, 6:421
BLUNT INJURY ABDOMEN WITH
MAJOR VASCULAR INJURY-
ANESTHETIC MANAGEMENT
Dr M.Kiran, PG, Osmania Medical College, Hyderabad, Telangana
Dr A.Muralidhar, MD, Asst. Professor, Niloufer Hospital/OMC
Dr Radha Ramana Murthy, MD, Professor
Dr C.G.Raghuram, MD, Head of Department
• Vascular injuries involving major vessels in abdomen are associated
with high mortality. With modern imaging technologies, prompt
resuscitative measures and advanced critical care support, the
outcome is promising.
• A 4 yr. old 19 Kg male child presented to the ER with a history of
blunt injury abdomen at around 6 PM on 16th April 2014 due to
accidental fall of 28 inch television over his back.
• On examination, his GCS was 15/15, peripheries are cold, feeble
peripheral pulses, BP-64/40(50) mm Hg, HR-200/min, RR-30/min,
H/L- NAD, SPO2-87% in RA, 100% with O2 4 lit/min, ABG showed
severe metabolic acidosis(pH-7.1), Hb- 6gm%.
• CECT scan- showed large Retroperitoneal Hematoma extending from
Gastro Oesophageal junction to Aortic bifurcation, unenhanced Right
kidney due to rupture of Right renal artery.
• Patient resuscitated in PICU, intubated and
ventilated to maintain paO2; nor-adrenaline
to maintain BP, 50 ml Sodium Bicarbonate,
transfused 5 PRBC, 3 units FFP.
• Urine output was nil from admission time till morning 4 am next day
when the child was posted for emergency laparotomy.
• Monitors– ECG, SPO2, IBP, EtCO2, Temperature, CVP.
• IV Lines- 5.5 Fr Triple lumen Central Venous Cannula- Right IJV, 2
peripheral venous lines 20 G on Right and Left upper limbs.
• Premedication: Glycopyrrolate, Fentanyl and Midazolam, induced
with TPS 50 mg, intubated and maintained with Atracurium.
• Intra-operative diagnosis- Hemorrhagic Biliary peritonitis, Duodeno
Jejunal Junction transection, abdominal aortic tear, IVC tear, Right
renal artery tear.
• During surgical manipulation, massive hemorrhage occurred and
around 4 units of PRBC pushed rapidly. Other fluids infused - 1500ml
RL and Calcium Chloride, 250ml DNS, 500ml FFP, SDP 250ml.
• At the end of surgery Furosemide challenge of 5mg was given; U/O of
300 ml seen & child was shifted to PICU for elective ventilation
during which renal parameters are maintained in normal limits;
extubated after 24 hrs. uneventfully.
• Aggressive volume replacement, correction of acid base abnormalities
and elective ventilation hold the key for success in such cases.
• Ref:1. Verma A, Hemlata D Blood component therapy. Indian J Pediatr. 2008;75:717–22.
• 2. Uppal P, Lodha R, Kabra S. Transfusion of blood and components in critically ill children. Indian J
 Dr.G.Madhavi [P.G],ISA
No.G0742,
Dr.Srinivas Reddy [Asst.prof],
Dr.Radharamana Murthy
[Professor]
NILOUFER HOSPITAL,
OMC,HYD
Introduction: Airway management in neonates is always quite
challenging for anaesthesiologists when associated with intrinsic
causes. Tumors occupying oral cavity pose problems at all levels of
airway management (maintaining patent airway, difficult mask
ventilation, laryngoscopy and intubation). Oral tumors also impede
feeding resulting in poor nutritional state and metabolic
derangement.
B/o Anuradha full term newborn delivered by Em.LSCS referred to ED,
Niloufer Hosp.with swelling floor of mouth-bluish colored cystic
swelling arising from the floor of mouth under the tongue extending into
submandibular region, after work-up ,was posted for elective surgery on
8th day.
Obs H/o mother nil significant.
Preop assessment: Activity &cry good, stridor+, no cyanosis, H/R -
130/min, RR- 35/min, Heart-S1 S2, Lungs-BAE+,Spo2 - 97% . Wt;3kgs
Invgns: Hb %-15gm%,usg,cect
Standard NPO guidelines, Shifted to OT,IV access secured 24 G on rt.
hand dorsum. Airway Assessment: 2% xylocaine jelly applied in oral
cavity ,direct laryngoscopy done, glottis visualized,
planned for NT intubation .
Pre-medication: Atropine ,Ondansetron &Fentanyl.
Pre oxygenation: 100% oxygen J R Ayre‘s T-piece.
Inhalation induction (Sevoflurane) & spontaneous
ventilation .
After 3 attempts, Nasotracheal intubation with 3 no. uncuffed ETT
Maintenance: Atracurium 1.5mg,N2O:O2::2:2,
Sevoflurane Intra op: Vitals monitored &
maintained, Sub total excision of lymphangioma up to
anterior wall of pharynx done, Stay suture
taken on tip of tongue.
Recovery : Reflexes, tone regained, Breathing regular, Vt adequate.
2 P.M.: Baby shifted to NICU with ET tube connected to ventilator
CPAP with 12cm of H2O.-airway edema, neonates more prone for
apnoeic episodes. 3 P.M.: Desaturating, Spo2 74% suction done, tube
block noticed - ?? Peritubal blood seepage. Reintubated with micro cuff
tube. baby warm,pink,Spo2 96%, I POD: Baby extubated, advised to
nurse in prone position, vitals monitored and maintained. II POD: Stay
suture on tongue removed , vitals monitored and maintained.
Discussion: Anaesthetic considerations are in view of neonatal age,
difficult airway-extension into pharynx or thorax, haemorrhage during
Resection postop respiratory obstruction and concurrent congenital
abnormalities.
Options: 1.Awake intubation
2.Fibreoptic intubation
3.Tracheostomy
4.Retrograde intubation
References: Motoyama E,Davis P.Smith‘s
th
 CASE OF CHRONIC MESENTERIC ISCHEMIA
POSTED FOR SURGICAL REVASCULARISATION
Author:Dr K.Mahender (PG),
Dr R.Raghu&Dr Bhaskar Rao(Asst.prof’s), Dr Baby Rani(Assoc.prof),
Dr C.G.Raghuram (Prof&HOD.). OGH / OMC, HYDERABAD`

46 yrs /F c/o pain abdomen diagnosed as Chronic Mesentric

Mesenteric Ischaemia,planned for surgical Revascularisation.
Medical history : Hypothyroid (Rx-Thyroxine100mcg
OD)since 25 years, no significant surgical history.
G/E:Pallor +++, H/L-NAD , HR-108/min , Hb-10gm%,
Bl.U:46 mg/dl, Sr.Cr.:1.2 mg/dl ; APPT:46secs ;
PT:18 sec ; INR : 1.46
2D-ECHO :Gr I Diastolic Dysfunction.
CT ANGIO : SMA Thrombus
ABG : pH-7.204,pCO2-43.7mm,pO2-78.6mm, HCO3-16.1
mmol/L,BE: -9.9mmom/L , pH correction with NaHCO3
150meqs
 ANESTHESIA MANAGEMENT
Lt. Radial Ar.,Rt,subclavian v. cannulation for IBP,
ABG & CVP;.GA(Morphine+ Muscle relaxant ) +
Epidural ( T6-7 Space),Standard monitoring done .
Maintainance : O2@4ltrs,Desflurane 2%.
SMA Embolectomy End-arterectomy,
CHA embolectomy
IVCclamp(45min) , Hemodynamics maintained
with Nor-epi :2.5µ/min , Dobutamine:5mcg/kg,
Pre-IVC clamp
crystalloids , colloids , packed RBC‘s .
Renal protection &Reperfusion injury prevention :
meropenem,Clindamycin,I.V hydration , NaHCO3,
Dextrose,NAC i.v, Mannitol ,Maintaining BP above
100mm of Hg.At end of surgery good flow across SMA
During IVC clamp restoration of bowel perfusion noticed
Hemodynamics stabilised with Dobutamine
2.5µg/kg , Nor-epi: 2.5µ/min, HR-90/min ; BP-
120/70mm of Hg. Shifted to RICU for Elective
ventilation.
 Post op analgesia: Epidural 0.125% bupivacaine +
300mcg Buprenorphine - 3ml/hr (with multirate
infusor). Post-op ventilated for 72 hrs.(Enoxaparin s/c;
Rosuvastatin ; i.vglutamine; nutrition through feeding
jejunostomy instituted).Extubated on 4th POD . Patient
was discharged on 14th POD in hemodynamically stable
condition .
POST-OP CT Angio
Follow up CT angio showed good result.

DISCUSSION: Conducting anesthesia for

vascular surgeries is challenging for
anaesthesiologist.
Multidisciplinary approach is crucial in recovery of patient . In absence
of Veno-Venous Bypass maintaing organ perfusion , preventing AKI,
treating cosequences of I-R Injury(MODS) requires comprehensive
understanding of pathophysiology.Aim of revascularisation:To give
patients a better chance of survival with a functioningGIT.Mortality rates
are 70% - 90%.References:KaleyaRN,Boley SJ Mesenteric ischemic
disorders;Collard CD,Gelman S Pathophysiology,clinical manifestations & prevention
 CASE REPORT OF 102 YRS FEMALE WITH
HYPERTROPHIC OBSTRUCTIVE
CARDIOMYOPATHY POSTED FOR PFN FOR LEFT
INTERTROCHANTRIC FRACTURE.
DR.MANJUNATH BN, DR.RAVI M, DR.KIRAN.
SDUMC,KOLAR.
• Hypertrophic cardiomyopathy is a commonly inherited cardiovascular
disease present in 1:500 of the general population.
• It is caused by more than 1400 mutation in 11 or more genes in coding
protiens of cardiac sarcomere. It is the most frequent cause of sudden
death in young patients. It can lead to functional disability from heart
failure to stroke. Majority of the affected individuals probably remain
undiagnosed.
• An elderly female of 102 years posted for left IT fracture. On routine
ECG, there was deep T inversion in lead I and aVL and further ECHO
revealed HOCM with left ventricular mid cavity obstruction, with an
ejection fraction of 60%.
 Anaesthetic technique: Sub Arachnoid Block.
Dose: Inj. Bupivacaine (0.5%) 2.5 cc + Inj. Fentanyl 0.5 cc (25 ug)
Block Height: Complete motor and sensory blockade achieved till T6 level.
Duration of surgery: 3 hours 30 minutes.
Conclusions: Intertrochanteric fracture of left femur requires a prolonged
surgery with anaesthesia with a considerable loss of blood which is not well
tolerated by an elderly woman, and hence such surgeries are contra indicated.
But since, conservative management is not acceptable, surgery was undertaken.
In comparison to general anaesthesia, spinal anaesthesia is associated with
significantly reduced mortality, reduced incidence of DVT, post-operative
confusion, Pneumonia, Myocardial Infarction, Pulmonary Embolism and Post-
operative Hypoxia. Due to the aforementioned reasons, Spinal Arachnoid block
was chosen based on the patient‘s preference, co-morbidities and potential post-
operative complications.
Result: Perioperatively, the patient was stable. The level of the blockade
receded till T10 towards the end of surgery and patient was shifted to the ward.
REFERENCES:
Miller‘s anaesthesia 7th edition chapter 71.
Neuraxial v/s GA in geriatric patients for hip fracture surgery:does it matter-
Luger,TJ etal vol 21 issue suppl 4 December 2010
 Upsurge of Laryngeal Mask Airway

Presenter : Dr Mukka Manasa,Resident

Authors : Dr Mukka Manasa,Resident

Dr Sumalatha R
Shetty,Professor
Dr. Ananda Bangera,Professor and Head

Department of Anaesthesia
K.S. Hegde Medical Academy
Nitte University
Mangalore
Karnataka
 Upsurge Of Laryngeal Mask Airway
Dr.Mukka Manasa, Resident; Dr Sumalatha R Shetty, Professor; Dr Ananda Bangera, Professor & Head
Department of Anaesthesiology, K. S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka
Archie Ian Jeremy Brain
•Born in Kobe, Japan, on 2 July 1942
•Young Archie Brain was an athlete, poet, designed an
electric motor and built his own guitar at age of 14
•Preclinical studies in Radcliffe Infirmary in Oxford
•Clinical training in St Bartholomew‘s Hospital, London and graduated in
1970
• Anaesthetic career at the Royal East Sussex Hospital in November 1971
•Diploma in Anaesthetics within 6 months
Birth of Laryngeal mask airway
1980‘s : Airway management limited to
•Nasal or oral tracheal tube
•Facemask with airway requiring anaesthetist to hold the mask
Brain’s objective : To make a “hands free system” to manage airway
with most logical approach of forming a direct end-to-end junction between
the tracheal tube and an artificial tube for supplying gas.1
1981, experimented with Goldman mask and its cuff,cut plastic tube and
made prototypes from cadaveric casts
•Modified the shape of Goldman mask to fit the space in the pharynx
•Coined the term ―Laryngeal Mask Airway‖
Goldman mask
Technique of insertion :
Brain found that LMA insertion was easily
done if it was placed in the mouth with
the bowl facing backwards and rotated
through 180°, as it passed downwards into position behind the larynx
Pitfalls during manufacture of LMA and its evolution were airway
obstruction due to LMA malposition or epiglottic down-folding.
Brain overcame these problems by conventional plastic-covered aluminium
stylet, special introducer tool and later by aperture bars
Progress of LMA
AIJ Brain. The Laryngeal Mask- A new concept in Airway Management.
Br. J. Anaesth.(1983),55,801-805. Brain used LMA in 23 patientsand
found that insertion and ventilation was successful in all patients with an
average insertion time of 7.3s and an airtight seal of >20cmH2O achieved
in all patients. Emergence was uneventful with 3 had mild sore throat.
This study raised the possibility that
•LMA might be useful for head, neck and ear, nose and throat surgery.
•Could the LMA possibly have a role in the difficult airway??!!
Various
First airway rescue: types
Brain usedofLMA
Prototypes of LMA obese patient with
in a morbidly
large bowel obstruction who had adequate facemask ventilation but
unsuccessful intubation. LMA copuld be easily inserted and ventilation was
successfull but Brain was unhappy about protection against aspiration.
LMA found inclusion in the emergency non-surgical limb of the 1993
ASA difficult airway algorithm partly due to Jonathan Benumof2
Alexander CA et al. Use your Brain! Anaesthesia 1988; 43: 893-4. First
clinical use of commercially prepared LMA by Dr Colin Alexander in 1988.
Evolution of materials used for LMA
• Initially made from vulcanised black rubber cuff modified from the
original Goldman dental nasal mask, attached in most cases to a modified
polyvinylchloride tracheal tube using acrylic adhesives
•1984, Brain first considered silicone as a construction material as it
provides smooth surface and ability to deflate cuff into a thin ellipse but
the Dunlop Company could not form a bowl shape to his satisfaction.
•1986, 60 different designs of latex prototype tested clinically aiming for
easy atraumatic insertion and to achieve the highest possible seal pressure
against laryngeal inlet, avoiding malposition, epiglottic down folding
and obstruction.
Support of LMA
•Andranik Ovassapian: Inventor of Ovassapian airway was first to
acknowledge the utility of the LMA and admitted that it had distinct
advantages over his Ovassapian airway.
•Jonathan Benumof: Pioneer of difficult airway management , was partly
responsible for inclusion of the LMA in the emergency non-surgical limb of
the 1993 ASA difficult airway algorithm.2
•Paul White: Promoted its use for ambulatory surgery.3
•Stephen Dierdorf: Recognised its potential for use in children
Special LMA
•Flexible LMA: In 1990,following two reports of LMA tube
kinking, Brain designed flexible version by wire-reinforcing
and used it successfully in 20 patients.4
•Intubating LMA: Realising the difficulty in using Classic
LMA for intubation, Brain developed a new prototype of split LMA.5,6
Later he developed ILMA prototype with a short,
wide stainless steel airway tube with single epiglottic
elevating bar that could accommodate a normal
sized tracheal tube and an integral handle that allowed
manipulation of the cuff within the pharynx.
ILMA was released in 1997
•ProSeal LMA : Early prototype design incorporated a second mask to
isolate the upper oesophagus and a second cuff to increase the seal against
the glottis.7 Second tube was located behind the airway tube that ran
posterior to the cuff.
In 1998-99 the changes in prototype ProSeal LMA were a change in the
shape of the proximal end of the cuff, drain tube alongside rather than
behind, distal drain tube within the bowl, anatomic shaping of the drain
tube‘s distal orifice and the addition of an introducer tool. In June 2000, the
first LMA ProSeal available.
LMA Unique & LMA
Supreme: Single use
Conclusion
The LMA,a simple but
Brilliant idea, has made the life
of the anaesthetist much easier, and the life of our
patients for whom we care that much safer1. LMA
is so much part and parcel of our teaching and
practice that CAN WE IMAGINE A WORLD OF
ANAESTHESIOLOGIST WITHOUT LMA?
References

1.Van Zundert et al.Archie Brain : Celebrating 30 years of development in laryngeal mask

airways.Anaesthesia 2012,67,1375-1885.

2. Caplan RA, Benumof JL, Berry FA, et al. Practice guidelines for management of the difficult airway –
a report by the American Society of Anesthesiologists Task Force on Management of the Difficult
Airway. Anesthesiology1993; 78:597–602.

3.Smith I, White PF. Use of the laryngeal mask airway as an alternative to a face mask during outpatient
arthroscopy.Anesthesiology1992; 77: 850–5.

4.Alexander CA. A modified Intavent laryngeal mask for ENT and dental
anaesthesia. Anaesthesia1990; 45: 892–3.

5.Brimacombe J, Johns K. Modified Intavent LMA. Anaesthesia and Intensive Care1991; 19: 607.

6.Maroof M, Khan RM, Khan H, Stewart J, Mroze C. Evaluation of a modified laryngeal mask airway as
an aid to fibreoptic intubation (FOI). Anesthesiology1992; 77: A1062..

7.Brain AIJ, Verghese C, Strube P, Brimacombe J. A new laryngeal mask prototype – preliminary
evaluation of seal pressures and glottic isolation. Anaesthesia1995; 50: 42–8.
• Defective collagen production
• CLINICAL FEATURES:
Blue sclera
Fractures after minor trauma
Bowing of femur and tibia
Kyphoscoliosis
Otosclerosis and deafness.
• Decreased range of cervical spine-anticipated difficult
intubation
• Kyphoscoliosis and pectus excavatum-makes regional
anaesthesia technically difficult
• 8yr female child posted for corrective
osteotomy and intramedullary nailing.

GENERAL ANAESTHESIA:
• Nebulised with lignocaine 4%
in ward.
• Difficult intubation cart kept ready
• Premedication and induction done
• Intubation uneventful

CAUDAL EPIDURAL BLOCK:

• Attempted , failed due to bony deformity
• USG used to locate the caudal space

Intraop uneventful except for blood loss of 350ml;

replaced with whole blood.
Post op analgesia with paracetamol suppositories.
ULTRASOUND FOR PAEDIATRIC CAUDAL BLOCK

•COCCYX SEEN LIKE A EVIL EYE.

•SACRAL HIATUS SEEN LIKE MICKEY

MOUSE EAR ON MOVING CEPHALAD.
 OF PULMONARY ARTERY
HYPERTENSION PATIENT
POSTED FOR ORTHOPAEDIC
• Dr. Nachiketha Rao K,SURGERY
Dr. Sujatha M.P., Dr. Ravi M. SDUMC, Kolar,
Karnataka

• Abnormal elevation in PAH may be the result of Left Heart Failure,

Pulmonary Parenchymal or Vascular Disease, Thromboembolism, or a
combination of these factors.
• Case: 60 year old male met with an RTA and presented with Polytrauma
and was posted for ORIF for BB Fracture of Left Upper limb and
wound debridement.
• On Pre Anaesthetic Evaluation, and Investigations, Patient was found to
have Severe Pulmonary Arterial Hypertension. Patient was a known
smoker with 30 pack years.
• Pre Operative SpO2 was 72% on room air.
• Anaesthetic Technique: Left Supra Clavicular Brachial Plexus Block.
• Pain due to other injuries like Chest Abrasions, Pelvic Fracture were
managed with adequate analgesics.
• Conclusion: Regional Anaesthesia was preferred in order to
avoid circumstances which exacerbate pulmonary arterial
hypertension like hypoxemia, hypercapnia, acidosis with
adequate pain relief for other injuries.
• Peri-operative Management of patient with PAH Presents a
challenge that requires adequate involvement of anesthetists,
surgeons, pulmonologists and cardiologists.
• References:
• Stoelting‘s anesthesia and co-existing disease, 5th ed-chapter 5
• Fleisher:Anesthesia and Uncommon Diseases, 5th ed-chapter 4
• Harrison‘s Principle of Internal Medicine,18th ed-chapter 250
• Perioperative Anesthesiological Management of Patients with
Pulmonary Hypertension-Jochen Gille, Hans-Jürgen Seyfarth,
[...], and Armin Sablotzki-Anesthesiol Res
Pract.2012;2012:356982
 Missed traumatic haemopneumothorax under
general anaesthesia
Dr Nemani N , MBBS, Post graduate in Anaesthesiology
Dr Shenoy L, MD, Assistant Professor of Anaesthesiology
Kasturba Medical College, Manipal
Introduction:
Case
Rib fractures are the commonest injury
presentation:
following blunt thoracic trauma. Thorough
12 year old child
clinical examination and a chest X-ray is a must
with history of
in trauma victims to rule out rib fractures and
road traffic
associated complications. Immediate diagnosis
accident- Soft
of hemopneumothorax will facilitate urgent
tissue injury. No
thoracocentesis and re expansion of the
history of chest
collapsed lung. We are presenting a case of a
trauma.
hemodynamically stable trauma victim with an
Unremarkable
undetected hemopneumothorax preoperatively,
systemic & airway
who was administered general anaesthesia with
examination.
 Posted for emergency wound
debridement and suturing. Chest
X ray could not be viewed
preoperatively because of
technical issues with the Syngo
imaging system.
General endotracheal anaesthesia was Post extubation - blood
administered with IV Fentanyl, IV noticed on the inner aspect of
Propofol, IV Atracurium. Intubated with ET tube. Immediate post
size 5.5 mm ID Portex COETT (single operative period- decreased
shot, atraumatic), fixed at 16cm after chest rise noted on left side,
confirming bilateral equal air entry. dull note on percussion and
Volume controlled ventilation used. shift in apical impulse noted.
Vt – 200ml, RR- 18 to 20 cycles/minute, Vital signs- Unremarkable.
Peak airway pressure-21 to 23 cm H2O,
EtCO2- 38 to 48 mm Hg, SpO2-100%.
No hypotension or unexplained
tachycardia. Uneventful intraoperative
period.
 Discussion:
Chest X-ray evaluation is a very important initial
step in all poly trauma victims. In children, the
elasticity of the osseous structure of the chest can
lead to an underestimation of parenchymatous
injuries. In our case, since the chest X-ray could not
• Khan MLZ, Haider J, Alam SN,
be viewed preoperatively and given the negative Jawaid M, Malik KA. Chest Trauma
Management:Good
history we did not suspect chest trauma. Nitrous outcomes possible in a general
surgical unit. Pak J Med Sci
oxide is contraindicated in cases of chest trauma as it 2009;25(2):217-221.
• Locicerco J, Mattox KL.
Epidemiology of chest trauma. Surg
has the propensity to expand in closed spaces. With Clin North Am 1989;69:15-6.
• Blyth, Andrew. Thoracic Trauma.
IPPV, a simple rib fracture could cause a tension ABC of Major Trauma 246 (2013):
18-26
pneumothorax leading to major cardiorespiratory • Torsten Ritcher , Maxmillan Ragela
.Ventilation in chest trauma .Journal
embarrassment. The only signs under general of emergency Trauma and shock
.2011.April –june 4(2):251-259.
• E S Munson. Transfer of nitrous
anaesthesia could be hypotension, hypoxemia and oxide into body air cavities. Br J
Anaesth 1974;46:202
rise in peak airway pressures which were not • Paramasivam E, Bodenham A. Air
leaks, pneumothorax and chest
observed in our patient despite using nitrous oxide. drains. Br J Anaesth Contin Educ
Anaesth Crit Care Pain (2008) 8 (6):
Conclusion: Missing a simple case of hemopneumothorax 204-209.
• Barton, Erik D. et al.The
could have devastating complications after the administration of pathophysiology of tension
pneumothorax in ventilated swine. J
general anesthesia with the use of nitrous oxide Emerg Med. 1996; 15 (2):147 – 153
 TOTAL ABDOMINAL
HYSTERECTOMY IN A POST
RENAL TRANSPLANT PATIENT

PRESENTOR: Dr Nidhin

YENEPOYA UNIVERSITY

MANGALORE
•38 Year old •Type of Anesthesia: Discussion:
female posted for GA. •Anesthetic
total abdominal •Disposable bains implications on the
hysterectomy circuit to ensure surgery as well as the
with BSO and sterility. renal allograft.
lymph node •Propofol and •Anticipation of
dissection Atracurium using difficult airway and
•Past h/o: Post priming technique. following extra
renal transplant. •Controlled ventilation aseptic precautions.
with ET and HME •Meticulous fluid
FILTER. management to avoid
renal insult.
 REFERENCES.
1.Hirsche BL, woods JE. Experience with elective surgery in renal allograft recipients. Am JSurg
1974;127:730-2.Raff gj, kasper km, hollinger ef jr, goggins

2.Wc. Laparoscopic hysterectomy in patients with prior renal transplantation. J minim invasive
Gynecol 2008;15:223-6.

3. Gohh RY, warren G. The preoperative evaluation of the transplanted patient for nontransplant
Surgery. Surg clin north am 2006;86:1147-66.

4. Nezhat F, Nezhat C, Gordans S, Wilkins F. Laparoscopicversus abdominal hysterectomy. J Reprod

Med 1992;37:247–50.

5. Kostopanagitou G, Smyrniotis V, Arkadopoulos N, et al. Anesthetic and perioperative management

of adult renal transplant recipients in nontransplant surgery, Anesth Aanal 1999; 89(5):613-22.

6. Csete M, Sipher MJ. Management of the transplant patients for non-transplant

procedures. Adv Anesth 1994; 11:407-11.

7.Fellstrom B, Larsson E, Tufreson G. Strategies in chronic rejection of transplanted organs: a current

view on pathogenesis, diagnosis andtreatment. Transplant Proc 1989; 21(11):1435-9.
“Anesthetic Implications 0f A Patient With Permanent
Cardiac Pacemaker Posted For Non Cardiac Surgery.”
- DR.P.NISHITHA , ESI PGIMSR, CHENNAI.
ANESTHETIC CONSIDERATIONS :
• Rule out other co morbid conditions.
• Device assessment.
• Patient with pacemaker may be unable to react to situation
requiring increased cardiac output by increasing heart rate, so
vigilant monitoring is required during intra-operative period1.
• Pacemaker functions can be affected by electromagnetic
interference from diathermy. The proximity of the pacing wire
makes it possible to get a microshock in case of faulty electrical
equipment1.
• Bipolar may be safely used since hip is away from pacemaker site1.
• Pacemaker function must be rechecked after surgery2.
• Isoproteronol is medical pacemaker and must be available.
 INDEX CASE
• 65 years old hypertensive female diagnosed as fracture neck of
femur was posted for elective total hip replacement.
• Patient was on permanent pace maker since 3 years which was
inserted for complete heart block.
• Patient pacemaker Mode –VVI was changed to VOO before surgery.
• The surgery was done under combined spinal and epidural , level
upto T10.
• Duration of surgery was 3 hours.
• Intra-operative monitoring done with pulse, BP, Ecg and pulse
oximetry .
• 2 units of crystalloids and 2 units of packed cell given. Blood loss
was around 700 ml.
• Pacemaker mode was changed to VVI after the completion of
surgery and its function was rechecked.
 CONCLUSION
• This case highlights the fact that patients with implanted pacemakers
can be managed safely for surgery and other non-surgical procedures.
• Safe and efficient clinical management of these patients depends upon
our understanding of implantable systems, indications for their use,
and the peri-operative needs that they create.

REFERENCES:
1. Anesthetic implications of implanted pacemaker : A case study mark
R.Baller .
2. Pacemakers and defebrillators: anaesthetic implications. T. V. Salukhe,
D. Dob and R. Sutton. Br J Anaesth 2004; 93: 95,104
• 65 years old female with alleged history of
accidental fall diagnosed as fracture neck of
femur Rt planned for elective total hip
replacemknown case of hent.
Congenitally corrected Transposition of great
arteries for Non Cardiac Surgery

Case Report

Presenter : Dr.Pavan Kumar Dammalapati M.B.B.S., D.A.,

DNB Final year Post graduate

Under
Dr. Bala Balaji M.B.B.S., D.A., D.N.B.,
Consultant Anaesthesiologist

Department of Anaesthesiology and Critical care

Kauvery Hospitals
Trichy
 Present complaints
• 32 year/ Male
• K/C/O CCHD, S/P BT shunt @1yr age
• Thrombocytopenia (2 y), giddiness (4 m), SOB II to IV (2m)
• CAG Hematoma  platelet transfusion Seizure Fall
• IT # L Femur/ Desaturated  Intubated  Worsened with IPPV 
Weaned off  Extubated  Surgery

• O/E : Thin/ Ill built, Petichiae , Cyanosis, Clubbing

• SpO2 : 76% in room Air, Basal Crepts

• Hb : 21.3, Plat : 63000

• ECHO : Single vent LV morph/ Hypo Global / PAH Mod / PS
• Change in morph of heart with age & intervention
• Reported to have ASD till 12 y & TOF
• Bidirectional VSD & ↓ BT shunt flow
 Anaesthetic Goals
• Maintain or rise in SVR
• Maintain or decrease PVR
• Adequate preload
• Maintain or increase in Heart Rate
• Regional contraindicated (SVR & Thrombo)
• GA (IPPV) contraindicated (Bidirectional VSD)
• USG Femoral, Obturator and Lumbar plexus blocks

• Inference : Understanding the pathophysiology/

Team approach/ Using Latest technological
developments/ Preparedness
 Four point para cervical block for minor
gynaecological procedures
author – dr. ponbavithra devi ,co author – prof. dr.selvamani and dr. santhi
• INTRODUCTION -The paracervical block relieves pain arises from the
uterus and cervix by blocking nerve .
• AIM - To determine analgesic effects during minor gynaecological
procedure by paracervical block in four point at 2, 4 , 8 , 10 ‗o clock
positions. Safety and simplicity of the procedure.
• MATERIALS – 60 patients included in this case series. All patients
received same % of drug & dosage , four point technique for all
patients. Parameters are – VAS score and HR variability,BP
• observed.
• Inclusion criteria -35 to 60 yrs , fractional curettage and cervical biopsy
in a case of AUB , cervical polyp & infertility .ASA -1 ,11 ,AND 111
• Exclusion criteria – allergic to LA drug ,local infection ,
• malignancy, Patient not willing for the procedure.
• TECHNIQUE - After Preanaesthetic evaluation, LA test
dose , informed consent, routine check list carried out
,pt shifted to the OT. IV line secured , monitors
connected - ECG, NIBP,SPO2
PROCEDURE - under aseptic technique , the patient
was placed in a modified lithotomy position. A sterile
bivalve speculum was introduced, cervix was visualised &
anterior lip of cervix hold with vulsellem.
• Paracervical block was performed with 10 ml 1%
ligocaine solution. Local anaesthetic solution was
injected by sterile hypodermic 21 G needle, length -
11/2 inch at 0.5-1 cm depth of the cervico -vaginal
junction at the four points and 2 ,4 ,8, 10 o'clock
positions ,each site 2.5 ml ,after aspiration and without
application of tenaculum to the cervix We waited for 5
• DISCUSSION -Endometrial biopsy is one of the minor but painful procedure of
gynecology. Procedural pain appears to arise from two separate anatomical structures, the
cervix and the uterus. The cervix and uterus are richly innervated and pain perception from
the cervix and the corpus of the uterus appears to pass through two distinct neural
pathways; Frankenhäuser plexus (parasympathetic S2-4) supplying the cervix and lower
uterus, and sympathetic nerves via the infundibulopelvic ligament from the ovarian plexus
supplying the uterine fundus . Procedural pain may occur during dilatation of the cervix for
insertion of the catheter and during endometrial biopsy, which further aggravates pain by
inducing uterine contraction.
• RESULTS- 59 patients comfortable without any pain VAS- 0 , 1 patient- anxious and un-co
operative , supplemented with I.V sedation.
• ADVANTAGES –1.In this four point technique least chances of vascular injury& avoid
local anesthetic toxicity when compared to traditional TWO POINT (3,9 ) technique.
• 2. DAY CARE procedure
• 3 Can be used safely in high risk patients, they can
resume regular drug &
• diet within 30 mins of observation.
• 4. Avoid poly pharmacy , problem related to I.V
sedation,
• CONCLUSION: total analgesia, patient‗s and surgeons
satisfaction, safe
References : Miller‘s Anaesthesia 7th edition, PCB
Dep.anaesthesia Newton welles Wellesley
hospital, Medical journal of the Islamic republic of IR
Iran.
 Dexmedetomidine premedication as an
adjuvant to fentanyl in patients undergoing
laparoscopic surgery under general
anaesthesia.
Author: Dr. Prathibha K T
Post gradutae in
Anaesthesiology

Co-author: Dr. Manjunath

Jajoor
Professor.

JJM Medical college,

Davangere.
 Introduction
• Demedetomidine is a highly selective alpha 2
agonist with properties of sedation, analgesia
and anxiolysis.
• As a result, it is being increasingly used as
adjuvant in general ansesthesia.
 AIMS AND OBJECTIVES

The present study was carried out to evaluate the

effect of IV Dexmedetomidine as
premedication on,

• The dose of anaesthetics required

• The dose of opioids required
• Intra operative haemodynamic stability
• Recovery time
 STUDY DESIGN
• 20 patients scheduled for laparoscopic surgery
were randomized into 2 groups

Group F (n=10)-received Fentanyl 2mcg/kg

bolus.

Group D (n=10)-received Dexmed 1mcg/kg +

Fentanyl 2mcg/kg bolus and maintenance infusion
of dexmed 0.5 mcg/kg/hr.
• Inclusion criteria:
 ASA grade1and 2
 Age 20 to 50 years

• Exclusion criteria:
 Patient refusal
 ASA grade 3 and 4
 Patients with Liver, Renal and CVS disorders
 Epilepsy
 COPD patients
 Pregnancy
 H/o any drug allergy
 METHODS
• After premedication, Thiopentone sodium was given until eyelash reflex
disappeared.
Induction & • Relaxation with Sch 2mg/kg to facilitate intubation.
Relaxation

• Anaesthesia was maintained by balanced anaesthesia technique of 70% N2O +

30% O2 + intermittent vecuronium.
• Inhalational anaesthetic adjusted to maintain systolic BP within 20% of preop
Maintenance value.

• Reversal - Inj Neostigmine 0.05mg/kg + Glycopyrolate 0.02mg i.v

• Haemodynamic parameters were recorded at regular intervals of time.
Extubation • Time needed for recovery noted
&Recovery
 Patient Monitoring:

• Pulse oximetry
• Heart rate
• Non invasive blood pressure
• End tidal CO2
• Sedation score
 Observation – Demographic Data
Group F Group D
Age (yrs) Mean+ SD 33.4±7.8 36.8±6.7

Gender Male 6 8

Female 4 2

Weight (Kg) Mean + SD 56.4±5.8 53.2±7.2

n=10, p>0.05
 Observation – Heart Rate
Time interval Group Group
F D
Base line 76 75
After 76 70*
infusion
Induction 72 66**
Intubation 80 70**
1’ 78 68*
3’ 77 67*
5’ 76 66*
10’ 74 66
15’ 72 68
Reversal 76 72
*significant(p<0.05);
Extubation 76 74
** highly significant(p<0.001).
5’ Extu..n 74 72
 Observation- Mean Arterial pressure
*significant(p<0.05); Time interval Group Group
** highly significant(p<0.001). F D
Base line 90 92
After 88 82*
infusion
Induction 86 76**
Intubation 100 82**
1’ 96 80*
3’ 94 80*
5’ 92 80*
10’ 86 80
15’ 86 82
Reversal 84 84
Extubation 90 86
5’ Extu..n 86 84
Observation – O2 saturation
Time Group F Group
interval D
Base line 98 98
After 98 94
infusion
Induction 98 95
Intubation 99 98
1’ 99 99
3’ 100 99
5’ 100 100
10’ 100 100
15’ 99 99
Reversal 99 100

 n=10, Extubation 99 99
5’ Extu..n 99 99
 Observation:
6.6 Group F Group D
62 mg/kg
58 min
min
51.2
48 4.8**
min
min mg/kg 8.9
min

6.3*
min
2.6
mcg/kg

1.3**
0.7
0.4**

duration of duration of Thiopentone Isoflurane Fentanyl recovery time

surgery anaesthesia *significant(p<0.05);
** highly significant(p<0.001).
 Observation :

* Significant P < 0.05

** Highly significant P<0.001
Observation – Post op sedation score(
Ramsay Sedation Score)
Sedation score Group F Group D p
1 2 3 0.011*
2 3 5 0.036*
3 4 2 <0.001**
4 1 0 <0.001**
5 0 0 -

* Significant p<0.05
** Highly significant p<0.001
 Results:
HEART RATE & MEAN ARTERIAL PRESSURE
 The mean Heart rate & MAP were significantly low in
group D after infusion compared to group F (p=0.02).
 The laryngoscopy and intubation was assosiated with a
significant rise of heart rate & MAP in group F compared to
group D (p<0.001).
 Therafter , till complition of surgery, no significant difference
noted in these parameters (p>0.05)
O2 SATURATION:
• Immediately after complition of dexmedetomidine
infision fall in O2 saturation observed (SpO2=94-95%)

INHALATIONAL ANAESTHETIC:
• The end tidal concentration of isoflurane was observed to
be almost 30% less with group D compared to group F
(p<0.001)
ANALGESIA:
• The mean total requirement of fentanyl in entire intraop period
was reduced significantly in group D compared to group F
(p<0.001).

THIOPENTONE:
• The mean dose of thiopentone required for induction was
reduced significantly in group D compared to group F
(p<0.001)
 DISCUSSION:

• Dexmed has very good patient outcome

• Less anaesthetics requirements
• Less analgesic requirement
• Haemodynamic stability
• Less recovery time
• Dexmed attenuates pressor response during laryngoscopy,
surgery and pneumoperitoneum
• The dosage of general anaesthetics for induction decreases
significantly.
• Requirments of inhalational anaesthetics markedly reduced
• Analgesia, sedation,anxiolysis produced by dexmed were
excellent via alpha 2recepptor agonistic activity
• Clear concsious and alert state of mind in dexmed group
makes recovery earliar than group F.
 CONCLUSION:

• DEXMEDETOMIDINE is an excellent drug as it not

only decreases the magnitude of haemodynamic
responses to laryngoscopy, surgery and
pneumoperitoneum but also decreases the dose of
opioids and anaesthetics in achieving adequate
analgesia and anaesthesia respectively
• Dexmed can be safely used in laparoscopy surgery
without the fear of awareness under anaesthesia
 References:
1. Sukhminder jit singh bajwa et all.. Attenuation of
pressor response and dose sparing of opiods and
anaesthetics with pre-operative dexmedetomine.
2. Poonam S Ghodki et all; dexmedetomidine as an
adjuvant in laparoscopic surgery: An observational
study using entropy monitoring.
3. Dexmedetomidine compare with fentanyl for
postoperative analgesia in outpatient gynecologic
laparoscopy: a randomized controlled trial.
4. Vanda G et all; Perioperative uses of dexmedetomidine
INFLUENCE OF PREOPERATIVE ANXIETY
ON HYPOTENSION AFTER SPINAL
ANAESTHESIA IN WOMEN UNDERGOING
CAESAREAN DELIVERY
Dr. Prathima sharon jayaraj
Co-authors:
Dr. Ganeshprabhu, Dr.Thirunavukkarasu,
Dr.Vairavarajan, Dr. Sivaprasath
Madurai Medical College
Aim: To assess the effect of preoperative anxiety on hypotension
after spinal anaesthesia in women undergoing caesarean delivery
Inclusion criteria: 60 Term parturients of ASA 1 status undergoing
elective caesarean section under spinal anaesthesia.
Exclusion criteria: In active labour, chronic hypertension, PIH,Any
medical or psychiatric illness, Contraindications for spinal
anaesthesia & Refusal of patient
Pre anaesthetic anxiety : Preoperative anxiety was assessed on the day of
surgery using verbal analogue scale {VAS}, anxiety score where 0 was
no anxiety and 10 worst anxiety imaginable. After examination for
normal distribution, data was transformed into ordinal groups
corresponding to low anxiety 0-3,medium 4-6, high anxiety 7-10.
Methodology: Ater securing iv line, preloading was done with 500 ml of
ringer‘s lactate. Subarachnoid block was performed in sitting position
using 1.8 cc of 0.5% bupivacaine in L3- L4 interspace. Immediately after
SAB patient was placed in supine position with a wedge under right hip
and supplemental oxygen delivered using facemask.
Maternal arterial pressure was measured by non invasive method.
Arterial pressure was measured at baseline, immediately before SAB
,after SAB till delivery.
Systolic arterial pressure below 100mm Hg was treated by fluid bolus
and SAP below 90 mm Hg by vasopressors. The effect of low,medium
and high baseline anxiety on baseline SAP, lowest SAP ,maximal
percentage of change in systolic blood pressure,absolute change in
systolic blood pressure were observed
 BASE LINE SYSTOLIC PRESSURE
% CHANGE SYSTOLIC BLOOD PRESSURE
150.0
89.5
140.0 90.0
85.0 80.8
130.0
80.0
120.0
120.0 114.5 116.9
MEAN

75.0
70.2

MEAN
70.0
110.0
65.0
100.0 60.0

90.0 55.0
50.0
80.0 High Medium Low
Low Medium High
ANXIETY LEVEL ANXIETY LEVEL

MINIMUM SYSTOLIC BLOOD PRESSURE The absolute fall of SAP after spinal anaesthesia
115.0
showed a significant difference between low and high
110.0

105.0
anxiety groups. The difference between low and
100.6 medium anxiety and medium and high anxiety groups
MEAN

100.0

95.0
94.5 were not significant.
90.2
90.0
DISCUSSION
85.0
High Medium Low Increased preop anxiety was associated with a
ANXIETY LEVEL

ABSOLUTE CHANGE IN SYSTOLIC BLOOD PRESSURE

greater reduction in SAP after spinal anaesthesia
30.0
29.8
for caesarean delivery. Due to increase in anxiety
25.0

20.0
22.4
mediated increase in baseline sympathetic activation
14.0
the fall in SAP after subarachnoid block is more
MEAN

15.0

10.0

5.0 in high anxiety group.

0.0
High Medium Low
References:
ANXIETY LEVEL
OUT OF THE BLUE-
THYROID STORM

M.PRATHYUSHA
2nd year RESIDENT
NRI MEDICAL COLLEGE, AP
 CASE REPORT
• 37 year male for emergency laparotomy.
• BP:110/70, PR:145/min, SPO2: 93%, febrile (1030F).
• ↓ breathe sounds on rt side of chest.
• Biochemistry – normal.
• ECG:AF with FVR 202/min.
• 2D-Echo:mild LV dysfunction , EF 47%.
• 150 mg bolus of amiodarone followed by continuous infusion.

• BP:110/60 mm Hg HR:195/min with AF.

• Plan : GA with IPPV.
• Metoprolol 1mg aliquot - 4 times to ↓ HR.
• While securing right IJV access -
a thyroid swelling noted.
• Blood sample was sent for thyroid profile
& Trop I.
• AF with FVR persisted throughout.
• Shifted to SICU for elective ventilation.
• Amiodarone discontinued as BP started to decrease
• Started on dobutamine, noradrenaline infusion & hydrocortisone.
• DC cardioversion failed to slow the rate.
• Thyroid profile: TSH:0.037µIU/ml (0.27-4.20) T4:17.64µg/dl (5.13-
14.06) T3:2.60ng/ml (0.846-2.02), Trop I was normal.
• Started on neomercazole 20 mg P/R, digoxin , LMW heparin .
• Free T3 and T4 levels sent on the 2nd POD revealed elevated levels.
• Patient was extubated on 1st POD & inotropes were tapered.
• Rate was controlled to 102/min but irregular.
• 4th POD- HR:88/min with regular rhythm & echo showed fair LV
function with EF of 66%.

DISCUSSION
• Transition from compensated hyperthyroidism to thyroid storm.
• Beta blockade and anti-thyroid drugs.
• No specific cut off levels of T4 or TSH .
• Because definitive biochemical testing for these disorders is not
usually part of the routine pre-op investigations, clinical suspicion of
these disorders is largely based on findings from the history and
physical examination.

REFERENCES
• Catherine M. Grimes, CPT Hector Muniz, William H Montgomery,
Yong S.Goh. Intraoperative thyroid strom: A Case Report. AANA
Journal /February 2004/Vol.72,No.1.
• Dr,Rajeev Sharma, Dr. Raktima Anand, Dr. B.V.R.Shastri, Dr.
Poonam Motiani. An Unusual presentation of intraoperative thyroid
storm- A case report. Indian J. Anaesth. 2003; 47(2): 137-139.
• S.Pugh, K.Lalwani , A. Awal. Thyroid storm as a cause of loss of
consciousness following anaesthesia for emergency caeserean section.
Anaesthesia, 1994,volume 49, page 35-37.
ROLE OF VIDEOLARYNGOSCOPE
AND SITTING POSITION FOR
TRACHEAL INTUBATION IN A
PATIENT WITH ACUTE SUPERIOR
VENA CAVAL SYNDROME

DR. PRIYADHARSHINI, DR. RANJITH

KARTHIKEYAN, DR. ARUNA PARAMESHWARI,
DR. MAHESH VAKAMUDI
PREOPERATIVE ASSESMENT:
A 12 year old boy came to the ER with
h/o breathlessness for 10 days
O/E patient was tachypneic, dyspneic
and unable to lie down supine with
puffines of face, engorged neck veins,
decreased air entry on the right side.
CXR showed massive right pleural
effusion
CT Thorax showed a 12.8x8.4cm
anterior mediastinal mass compressing
on the SVC and right bronchus
ANAESTHETIC MANAGEMENT:
As patient was unable to maintain saturation in a
supine position, difficult airway cart including a C-
MAC videlaryngoscope was kept ready.
Plan: Endotracheal intubation with the help of C-
MAC laryngoscope under topical anaesthesia in
sitting position
Baseline monitors were connected, iv glycopyrollate
0.2 mg given. 2% viscous lignocaine gargle done, 4%
lignocaine sprayed in the larynx.
Awake intubation was done with the D blade of the C
MAC laryngoscope with #6.5mm ID ETT with a
FROVA
 DISCUSSION
• As mouth opening was adequate and positioning patient in supine was
difficult we tried videolaryngoscopy aided awake intubation under topical
anaesthesia in sitting position
• It was successful without any complications
•Compared to the use of fibreoptic aided intubation in sitting position
which requires more expertise, skill and time Videolaryngoscope guided
intubation seems to be a better option in emergency situations

CONCLUSION:
Videolaryngoscope is a novel
modality for management of
difficult airway and has been
recently added to the difficult
airway algorithm and is a useful
alternative to awake fibreoptic
intubation in sitting position

Reference: 1.Shapiro, Sanford. Fibreoptic Stylet Laryngoscope and sitting position for tracheal intubation in acute superior vena caval
syndrome. Anaesth Analg ;1984 ;63:161-2
2. Broke- Utne JG. Tracheal intubation with the patient in a sitting position. Br J Aanesth. 1991 Aug;67(2):225-6
 VSD WITH SUB ACUTE INTESTINAL
OBSTRUCTION- ANESTHETIC
MANAGEMENT.
Dr.Priyanka K J,Dr.Ravi M, Dr.Harish B G, SDUMC
• Imperforate anus ranges from a mild stenosis to a complex
Kolar,congenital
syndrome with other associated Karnataka anomalies. Incidence of
anorectal anomalies is 1:5000 live births. Among the associated
anomalies genitourinary, spinal and vertebral anomalies account for
50%.Imperforate anus is associated with VACTERL association
(Vertebral, anal, cardiovascular, esophageal, renal, limb).The
common cardiac lesions being ASD and PDA. Tetralogy of Fallot
and VSD are the less common anomalies associated with
imperforate anus.
• Case: A 5 year old female child presented with sub-acute intestinal
obstruction and fecal impaction posted for second stage colostomy
closure. The child was a postoperative case of Posterior sagittal
anorectoplasty (PSARP) performed at 2 years of age for a high
anorectal anomaly with ventricular septal defect.
• On PAE:After preanaesthetic evaluation child was found to have
mild dehydration and VSD with a systolic murmur.
• Anaesthetic technique: GA with caudal block for post
operative analgesia.
• Adequate fluid resuscitation(Isolyte-P) was done and appropriate
laboratory investigations were sought.
• After preoxygenation with 100% oxygen and premedication with
inj.midazolam 0.5 mg, inj.atropine 0.4 mg and inj.fentanyl 40 mcg,
the child was induced with IV thiopentone 100 mg. Airway was
secured with an oral 4 sized endotracheal tube under inj atracurium
10 mg. Anaesthesia was maintained with 66% nitrous oxide, 33%
oxygen and isoflurane, with controlled ventilation.
• A caudal block was successfully placed for post-operative analgesia
towards the end of procedure.
• The child was extubated after giving reversal and confirming intact upper
airway reflexes.
• Conclusion: In VSD without pulmonary hypertension, reversal of shunt
to be avoided with taking care of Temperature( Hypothermia), providing
good Analgesia and adequate fluid management.
• References:
• Smith‘s Anesthesia for Infants and Children, 8th edition,chapter 18, page
584
• Stoelting‘s Anaesthesia and Co-existing Disease, 5th edition, chapter 24
• Paesdiatric Anaesthesia- Doyle, 1st edition, chapter 8
• Anesthetic management of high anorectal malformation in a 2 day old
neonate- Research and Reviews-Journal of Medical and Health sciences-
Raghupatruni,Vol 2,No 4(2013)
 A CASE OF SUCCINYL CHOLINE
INDUCED SEVERE MYALGIA ONE
HOUR AFTER RECOVERY FROM
ANAESTHESIA.
NAME:DR.R.MADHU. MD FINAL YEAR PG.(Anesthesiology)
DR .CH.SRINIVAS RAO.MBBS,DA SENIOR RESIDENT
DR.A.SATYANARAYANA MD, PROFESSOR.
DR.T.RAMBABU MD, PROFESSOR
PROFESSOR & HOD:DR.T.ARUNA SUBHASH MD, DA.
MEDICITI INSTITUTE OF MEDICAL SCIENCES,GHANPUR, MEDCHAL
RANGAREDDY DIST, TELANGANA STATE.
A case of 9 year old boy posted for Adenoidectomy under General
anesthesia.
Intraop management:
Premedication: inj. Glycopyrrolate 0.1 mg,inj.Midazolam 0.25 mg,inj. Fentanyl
20 mcg iv.inj.Xylocard 20 mg, inj.Ondansetron 2 mg,inj .Rantac 25 mg iv
INDUCTION: inj.Propofol 40 mg.
INTUBATION: inj.Succinyl choline 50 mg. under direct laryngoscopic vision
intubated with 5.5 sized cuffed oral ET Tube, cuff inflated, bilateral air
entry equal.
MAINTENANCE:02- 3 L/ min, N20- 5 L/ min. sevoflurane 0.8-1% MAC.
EXTUBATION: After thorough oral suction ET Tube removed.
Reflexes regained,respiration regular,Tidal volume adequate, tone normal,
Head lift sustained > 5 sec.
Patient shifted to post operative ward in stable condition.
 POST OPERATIVE MANAGEMENT
• The patient developed severe myalgia one hour after
recovery from anaesthesia in post operative ward.
• The patient was managed using with inj.Paracetamol
IV,
Inj.Fentanyl 20 mcg iv, and Syrup Combiflam (Ibuprofen
and Paracetamol).
Inj.CalciumGluconate 5ml slow iv
Sending ABG ,serum electrolytes and Serum Calcium
blood samples. Reports were with in normal limits.
Patient discharged after 5 days of post operative period.
 REFERENCES:
• Indian journal anesthesia 2005;49 (2) 146-148.
• Bush GH,RothF.Muscle pains after suxamethonium in
children. British journal of anesthesia 1961;33:151.
• FosterCA.Muscle pain that follows the administration
of suxamethonium.British medical journal 1960;2:24-5.
• Burtles R,Tunstall ME.suxamethonium chloride and
muscle pains. British journal of anesthesia 1961;33:24.
• Collier CB.Suxamethonium pains and
fasciculations.Proceedings of the Royal society of
medicine 1975;68:105
 ANAESTHETIC MANAGEMENT
FOR CORRECTION OF EBSTEIN’S
ANOMALY
DR RAJ KUMAR J (PG, FINAL YEAR)
DR SRINIVAS REDDY M.D , PDCC
DR ARUNA SUBHASH M.D , D.A
(PROFESSOR & HOD)
DEPARTMENT OF ANAESTHESIOLOGY
MEDICITI INSTITUTE OF MEDICAL
SCIENCES, MEDCHAL,
R R DISTRICT, TELANGANA STATE
• A 29 yr old female presented to the hospital
with complaints of shortness of breath since 3 yrs
• Shortness of breath was intially of NYHA
Grade 1 which gradually progressed to grade 3
• No H/O cyanosis ,palpitations,chest pain,CVA
• On examination patient was thin built and vitals
were within normal limits . Auscultation of heart
revealed a systolic murmur. Signs of right heart failure absent
• INVESTIGATIONS: Chest Xray: Cardiomegaly
ECG – RBBB pattern
2D Echo: Dilated RA ,Atrialised RV,mod TR
Small RV, moderate PAH
• DIAGNOSIS: Ebstein’s anomaly
• Planned for correction of ebstein‘s anomaly
• SURGERY: DANIELS METHOD OF TV Repair
• Pt shifted to OT . ECG,NIBP,SPO2 monitored
Two 16 G iv line secured. Premedication given
Inj Midazolam 1mg,inj Fentanyl 60mcg,inj zofer4mg
• Invasive monitoring: Rt femoral arterial line, Rt
internal jugular line. Induction: Fentanyl 200mcg+
Midazolam 2mg+Propofol 80mg. Intubation: inj
Pancuronium6mg.Intubated with 7.5mm sized cuffed
ET tube under direct laryngoscopic vision
MAINTAINANCE: O2 + N20+Isoflurane
CPB Time: 1hr 29 min AORTIC CLAMP TIME:45min
Total surgery time: 3 hrs Intraop :uneventful .
Postop : Pt extubated after 9hours in CT ICU.
Postop- Period was uneventful
She was dicharged to home on 6th POD .
 REFERENCES
• Congenital heart disease text book- Rudolph
• Stark J – Surgery for congenital heart disease
• Ebstein’s anomaly- AHA journal -
2007;115:277-285 by Christine H Attenhofer
• Annals of cardiac anaesthesia-2010 vol 13
issue 2 by P K Sinha ,P K Varma,Bhupeesh
Kumar
• British journal of anaesthesia – vol 49 issue 5
by IM Bengtsson
 ANAESTHETIC
MANAGEMNENT OF A
PATIENT WITH SEVERE AR
WITH EMPHYSEMATOUS
BULLAE

DR. RONAKH, DR. RANJAN

 PT DETAILS
44yr male farmer from Neyvelli,
admitted on Feb 26, 2014
Dyspnea on exertion on & off for 10
yrs, severe since 2 months – NYHA -II

No h/o chest pain / palpitations / orthopnea /

PND
syncope / CVA / seizures
fever / cough / haemoptysis

Past history:
TB 10 yrs ago
asthma x 1 yr
 Clinical Features
Gen. Exam : HR- 76/mt, waterhammer pulse ,
regular ,
BP- 160/ 70mmHg, RR- 25/mt, SPO2- 95% (room
air)

thumb sign + wrist sign + arm span greater than

height, archanodactyly, subluxation of lens in the
left eye, hyperextension of wrist joint, high arched
palate

Peripheral signs of AR : demucet‘s sign+,

Corrigan‘s sign, Muller‘s sign, Quinke ‗s sign+,
locomotor brachialis, Hill‘s sign+, Durozeiz‘s
murmur+, Traube sign+

CVS: Hyperdynamic apical beat, S1,S2 Normal,

EDM+
RS : ↓ breath sounds on right side
 Investigations

Blood investigations: within Chest Xray

normal limits
ECG: LVH (+)
CAG: Normal
ECHO: Mod. to severe AR
with dilated aortic root & Asc.
Aorta, LV IDD 6 cm, LVEF =
60%
 CT Chest
- Shows large bulla of 15 x 15 cm involving
superior segment of lower lobe and another
loculated bulla involving apical segment of
upper lobe
- Minimal emphysematous changes in the left
lung
 CT Angio -THORAX
Showing dilated aortic valve, Arch of aorta and arch
aortic root and ascending vessels and descending
aorta with max diameter at
aorta are normal. No
aortic root of 5.5cm
evidence of cardiomegaly
What are treatment options?
BULLECTOMY of the right lung
Bentall’s Procedure ( Replacement of Aortic valve with Asc.
Aorta & reimplantation of main coronary arteries)

Which surgery to be done first or both together?

Final decision : first Bullectomy then Bental‘s procedure

as 2nd stage surgery 4 weeks after the 1st surgery

Reason:
-Access to the lung cyst through midline sternotomy is not
optimal even with the availability of lung staplers which we do
not have.
-Surgery of the lung cyst may require prolnged ICD drainage
and that increases the probality of infection of the prosthesis
 BULLECTOMY
GOALS :
• To prevent the emphymatous cyst from rupture and
prevent tension pneumothorax

• To prevent the worsening of AR

• To maintain SVR, HR within normal range.

• To maintain positive pressure < 20cmH2O.

 ANAESTHETIC MANAGEMENT
PREMEDICATION:
• Tab. Lorazepam 1mg P.O

INDUCTION:
• Rapid-sequence induction with cricoid pressure
• Inj. Thiopentone Sodium 250mg.
• Inj. Scoline 100mg
• Intubate with DLT.
• Consider using DLT with bronchial lumen to side opposite
BPF.
• Adequate cuff inflated.
• central line placed, arterial line placed.
• thoracic epidural placed.
MAINTENANCE :
• O2 + air + sevoflourane 1% + Inj. VEC
• adequate expiratory time (↓ I:E ratio, low RR).
• Caution with applied PEEP was taken.
• reduced ventilatory pressures (low tidal volumes, permissive
hypercapnia and pressure-control ventilation @ < 20cmH2O ).
• Inhala-tional anesthesia supplemented with epidural, local
anesthetics, or iv opioids.
• chest drains placed.

MONITORING:
• #ECG #ABP #SpO2 #etCO2 #CVP #urine output

FLUID MANAGEMENT:
• 4ml/kg/hr was maintained.
• Urine output was replaced.
• Blood loss was replaced.
Through right Postero-lateral
thoracotomy, right lung bullae
excision was done on March 3,
2014

Bullae
Normal
lung
POSITIONING:
• pads at pressure points
• Axillary roll, airplane for fore arm

EMERGENCE:
• Awake . Reversed with Inj neostigmine + Inj glycopylorrate
• Good breathing efforts
• Extubated on table and shifted to post op room
POST OP :

• Proped up position
• NPO for 4hrs
• O2 via face mask
• IVF – maintenance
• PCEA
• On POD 4 all the lines were removed.
• To review for Replacement of Aortic valve with Asc. Aorta &
reimplantation of Main coronary arteries
 BENTALL’S PROCEDURE
GOALS:
• AR → chronic LV volume overload → LV eccentric
hypertrophy →massive cardiomegaly →LV failure (CHF) →↑
LVEDP →↑ PA pressure and pulmonary congestion.

• Possibility of ischemia: ↑ MVO2 and ↓ supply (↓ diastolic

pressure, ↑ HR).

• Sensitivity to rate changes: ↓ HR →↑ AR + ↓ CO.

• Sensitivity to changes in SVR: ↑ SVR →↑ regurgitation + ↓

CO.
 ANAESTHETIC MANAGEMENT
PREMEDICATION:
• Tab. Lorazepam 1 mg P.O

INDUCTION :
• Central line for CVP monitoring. Arterial line for real time BP
monitoring.
• O2 + Inj. fentanyl 50 mcg/kg +Inj. Thiopentone sodium6mg/kg.
+Inj. Vec 0.1mg/kg
• Intubated with 8.5 ETT, cuff inflated .B/L AEE. Tube fixed

MAINTENANCE :
• O2 + air + sevoflourane 1% + Inj. VEC + Inj.Fentanyl 10mcg/kg
Bypass initation and management
• ACT checked q 30mins. And kept >400.heparin was added
when required
• Fows of 1.2–3 L/m2/min are used.
• Pressures of 30–80 mmHg.
• MAP of 50–60 mmHg is probably best for cerebral perfusion.
• ABG done and corrections were done.
• Urine output was maintained 1ml/kg/hr.
• Hb was maintained, transfusion was done.
• Temp maintained at 280 C.

Bypass terminated by rewarming, relaxant, analgesia,

electrolyte correction, Hct, air maneuvers.
weaned from Bypass with NSR, gradual volume load,
reversal of anticoagulant, BP management

Post Bypass : dopamine 5 mcg/kg/min, dobutamine 5

mcg/kg/min

MONITORING:
• #ECG #ABP #SpO2 #etCO2 #CVP #urine output

FLUID MANAGEMENT:
• 4ml/kg/hr was maintained.
• Urine output was replaced.
• Blood loss was replaced.
POSITIONING:
• pads at pressure points

EMERGENCE:
• Shifted to cardiac care unit. Electively ventilated 12hrs
• Awake . Reversed with Inj neostigmine + Inj glycopylorrate
• Good breathing efforts

POST OP :
• Proped up position
• NPO for 4hrs
• O2 via face mask
• IVF – maintanance
• On POD 4 all the lines were removed.
 POST OP ECHO

– Gradient stereo AV – 25/15 mm Hg

– No regional wall motion abnormality

– Normal LV systolic function, EF = 60%

Thank you
 ANAESTHETIC
MANAGEMNENT OF A
PATIENT WITH SEVERE AR
WITH EMPHYSEMATOUS
BULLAE

DR. RONAKH, DR. RANJAN

 PT DETAILS
44yr male farmer from Neyvelli,
admitted on Feb 26, 2014
Dyspnea on exertion on & off for 10
yrs, severe since 2 months – NYHA -II

No h/o chest pain / palpitations / orthopnea /

PND
syncope / CVA / seizures
fever / cough / haemoptysis

Past history:
TB 10 yrs ago
asthma x 1 yr
 Clinical Features
Gen. Exam : HR- 76/mt, waterhammer pulse ,
regular ,
BP- 160/ 70mmHg, RR- 25/mt, SPO2- 95% (room
air)

thumb sign + wrist sign + arm span greater than

height, archanodactyly, subluxation of lens in the
left eye, hyperextension of wrist joint, high arched
palate

Peripheral signs of AR : demucet‘s sign+,

Corrigan‘s sign, Muller‘s sign, Quinke ‗s sign+,
locomotor brachialis, Hill‘s sign+, Durozeiz‘s
murmur+, Traube sign+

CVS: Hyperdynamic apical beat, S1,S2 Normal,

EDM+
RS : ↓ breath sounds on right side
 Investigations

Blood investigations: within Chest Xray

normal limits
ECG: LVH (+)
CAG: Normal
ECHO: Mod. to severe AR
with dilated aortic root & Asc.
Aorta, LV IDD 6 cm, LVEF =
60%
 CT Chest
- Shows large bulla of 15 x 15 cm involving
superior segment of lower lobe and another
loculated bulla involving apical segment of
upper lobe
- Minimal emphysematous changes in the left
lung
 CT Angio -THORAX
Showing dilated aortic valve, Arch of aorta and arch
aortic root and ascending vessels and descending
aorta with max diameter at
aorta are normal. No
aortic root of 5.5cm
evidence of cardiomegaly
What are treatment options?
BULLECTOMY of the right lung
Bentall’s Procedure ( Replacement of Aortic valve with Asc.
Aorta & reimplantation of main coronary arteries)

Which surgery to be done first or both together?

Final decision : first Bullectomy then Bental‘s procedure

as 2nd stage surgery 4 weeks after the 1st surgery

Reason:
-Access to the lung cyst through midline sternotomy is not
optimal even with the availability of lung staplers which we do
not have.
-Surgery of the lung cyst may require prolnged ICD drainage
and that increases the probality of infection of the prosthesis
 BULLECTOMY
GOALS :
• To prevent the emphymatous cyst from rupture and
prevent tension pneumothorax

• To prevent the worsening of AR

• To maintain SVR, HR within normal range.

• To maintain positive pressure < 20cmH2O.

 ANAESTHETIC MANAGEMENT
PREMEDICATION:
• Tab. Lorazepam 1mg P.O

INDUCTION:
• Rapid-sequence induction with cricoid pressure
• Inj. Thiopentone Sodium 250mg.
• Inj. Scoline 100mg
• Intubate with DLT.
• Consider using DLT with bronchial lumen to side opposite
BPF.
• Adequate cuff inflated.
• central line placed, arterial line placed.
• thoracic epidural placed.
MAINTENANCE :
• O2 + air + sevoflourane 1% + Inj. VEC
• adequate expiratory time (↓ I:E ratio, low RR).
• Caution with applied PEEP was taken.
• reduced ventilatory pressures (low tidal volumes, permissive
hypercapnia and pressure-control ventilation @ < 20cmH2O ).
• Inhala-tional anesthesia supplemented with epidural, local
anesthetics, or iv opioids.
• chest drains placed.

MONITORING:
• #ECG #ABP #SpO2 #etCO2 #CVP #urine output

FLUID MANAGEMENT:
• 4ml/kg/hr was maintained.
• Urine output was replaced.
• Blood loss was replaced.
Through right Postero-lateral
thoracotomy, right lung bullae
excision was done on March 3,
2014

Bullae
Normal
lung
POSITIONING:
• pads at pressure points
• Axillary roll, airplane for fore arm

EMERGENCE:
• Awake . Reversed with Inj neostigmine + Inj glycopylorrate
• Good breathing efforts
• Extubated on table and shifted to post op room
POST OP :

• Proped up position
• NPO for 4hrs
• O2 via face mask
• IVF – maintenance
• PCEA
• On POD 4 all the lines were removed.
• To review for Replacement of Aortic valve with Asc. Aorta &
reimplantation of Main coronary arteries
 BENTALL’S PROCEDURE
GOALS:
• AR → chronic LV volume overload → LV eccentric
hypertrophy →massive cardiomegaly →LV failure (CHF) →↑
LVEDP →↑ PA pressure and pulmonary congestion.

• Possibility of ischemia: ↑ MVO2 and ↓ supply (↓ diastolic

pressure, ↑ HR).

• Sensitivity to rate changes: ↓ HR →↑ AR + ↓ CO.

• Sensitivity to changes in SVR: ↑ SVR →↑ regurgitation + ↓

CO.
 ANAESTHETIC MANAGEMENT
PREMEDICATION:
• Tab. Lorazepam 1 mg P.O

INDUCTION :
• Central line for CVP monitoring. Arterial line for real time BP
monitoring.
• O2 + Inj. fentanyl 50 mcg/kg +Inj. Thiopentone sodium6mg/kg.
+Inj. Vec 0.1mg/kg
• Intubated with 8.5 ETT, cuff inflated .B/L AEE. Tube fixed

MAINTENANCE :
• O2 + air + sevoflourane 1% + Inj. VEC + Inj.Fentanyl 10mcg/kg
Bypass initation and management
• ACT checked q 30mins. And kept >400.heparin was added
when required
• Fows of 1.2–3 L/m2/min are used.
• Pressures of 30–80 mmHg.
• MAP of 50–60 mmHg is probably best for cerebral perfusion.
• ABG done and corrections were done.
• Urine output was maintained 1ml/kg/hr.
• Hb was maintained, transfusion was done.
• Temp maintained at 280 C.

Bypass terminated by rewarming, relaxant, analgesia,

electrolyte correction, Hct, air maneuvers.
weaned from Bypass with NSR, gradual volume load,
reversal of anticoagulant, BP management

Post Bypass : dopamine 5 mcg/kg/min, dobutamine 5

mcg/kg/min

MONITORING:
• #ECG #ABP #SpO2 #etCO2 #CVP #urine output

FLUID MANAGEMENT:
• 4ml/kg/hr was maintained.
• Urine output was replaced.
• Blood loss was replaced.
POSITIONING:
• pads at pressure points

EMERGENCE:
• Shifted to cardiac care unit. Electively ventilated 12hrs
• Awake . Reversed with Inj neostigmine + Inj glycopylorrate
• Good breathing efforts

POST OP :
• Proped up position
• NPO for 4hrs
• O2 via face mask
• IVF – maintanance
• On POD 4 all the lines were removed.
 POST OP ECHO

– Gradient stereo AV – 25/15 mm Hg

– No regional wall motion abnormality

– Normal LV systolic function, EF = 60%

Thank you
High concentration sevoflurane induction
with or without Nitrous Oxide?
in
Uncooperative children

Dr .K.V.S. Sailaja
2nd year Postgraduate Anesthesiology
NRI Medical College
 INTRODUCTION
• Inhalation induction with high concentration sevoflurane is a
rapid, needleless technique, and better tolerated by the
uncooperative children.
• The aim of the study is
• To compare the effect of Sevoflurane with or without N2O
on induction time.
• The addition of N2O may speed up induction by its concentration
and second gas effect.

•Group A: without N2O (8% sevoflurane with 100% O2 )

•Group B : with N2O (8% sevoflurane 30% O2 and 70% N2O)
MEASURED PARAMETERS
• Loss of cry
• The loss of eyelash reflex
• Establishment of regular breathing
• Return of conjugate gaze
• SBP, HR,SP02
 RESULTS
Group A Group B P-value
(with out N2O) (with N2O)

Loss of cry 59.7 51.8 0.01

Time to loss of eyelash 61.2 52.4 0.01

reflex
Mean duration(sec)
Time to return of regular 92.7 83.5 Statistically not significant
breathing (sec)
Time to return of 157.5 149.3 Statistically not significant
conjugate gaze
Changes in vital signs such as SAP, HR and SpO2after induction
did not differ significantly between the two groups.

•
CONCLUSION
We found that the high concentration sevoflurane technique is
more pleasant, effective, easy canulation and well-accepted even
in uncooperative children.
 The addition of N2O resulted in less excitation and faster
induction times.
 REFERENCES
 Epstein RH, Stein AL, Marr AT, et al. High concentration vs incremental induction of
anaesthesia with sevoflurane in children: a comparison of induction times, vital signs and
complications.J Clin Anesth 1998; 10: 41–5
 Agnor RC, Sikich N, Lerman J. Single-breath vital capacity rapid inhalation induction in
children: 8% sevoflurane versus 5% halothane. Anesthesiology 1998; 89: 379–84
 Lejus C, Bazin V, Fernandez M, et al. Inhalational induction using sevoflurane in children: the
single-breath vital capacity techniquecompared to the tidal volume technique. Anaesthesia 2006;
61:535–40
 Ghatge S, Lee J, Smith I. Sevoflurane: an ideal agent for adult day-case anesthesia? Acta
Anaesthesiol Scand 2003; 47: 917–31
 Sheraton TE, Gildersleve CD, Hall JE. The use of nitrous oxide in paediatric anaesthetic
practice in the United Kingdom: a questionnaire survey. Anaesthesia 2007; 62: 62–6
 Byhahn C, Strouhal U,Westphal K. Exposure of anesthetists to sevoflurane and nitrous oxide
during inhalation anesthesia induction in pediatric anesthesia. Anaesthesiol Reanim 2000; 25:
12–6
 Goldman LJ. Anesthetic uptake of sevoflurane and nitrous oxide during an inhaled induction in
children. Anesth Analg 2003; 96: 400–6
 Peyton PJ, Fortuin M, Robinson GJ, et al. The rate of alveolarcapillary uptake of sevoflurane
and nitrous oxide following anaesthetic induction. Anaesthesia 2008; 63: 358–63
 O’Shea H, Moultrie S, Drummond GB. Influence of nitrous oxide on induction of anaesthesia
with sevoflurane. Br J Anaesth 2001; 87: 286–8
 Dr. K.Sanmuga Piriya, MD, Post Graduate, Final year,
Department of Anaesthesiology, Sri Manakula Vinayagar
Medical college and Hospital, Puducherry.
Dr.K.Suresh Kumar, MD, Associate Professor
EPIDURAL ANESTHESIA FOR
CAESAREAN SECTION IN A PREGNANT
PATIENT WITH PITUITARY
MACROADENOMA
• Introduction:
Anaesthesia for a pregnant patient with pituitary adenoma is a
challenge, due to a sudden change in intracranial dynamics during
spinal anaesthesia. There is a chance of increase in tumour size
during antenatal period. A careful assessment of pituitary function
and a screening of visual field and fundus examination are essential
to pituitary macroadenoma and oligohydramnios, admitted at 37
weeks of gestation for elective LSCS. Started Carbogolin 0.5mg
twice a week six months before conceiving, till 7th month. MRI
revealed enlarged anterior pituitary with well-defined adenoma
(11x12mm) in Sella. Patient informed about anaesthetic options and
perioperative risks. Anti aspiration prophylaxis given. Epidural
anaesthesia given at L3-L4 ,18G catheter fixed at 9.5cm. 12 ml of 2%
(Plain) lignocaine including test dose given. Wedge placed under right
pelvis to minimize aorto-caval compression. Sensory level of T4
achieved. 3.2kg baby delivered with Apgar score 8. Patient stable,
postoperative analgesia with Fentanyl and Bupivacaine.

• Discussion:
hyposecretion. During pregnancy there is global hyperplasia of the
pituitary gland due to progesterone. Prolactinomas are classified into
micro adenoma (<1cm) and macroadenoma (>1cm). 95% curable with
medical management (dopamine agonist). We avoided GA and spinal
anaesthesia due to the possible risk of increase in ICP during intubation
and laryngoscopy and decrease in ICP respectively. Awake patient
would alert the early event of increase in ICP. So we decided to give
epidural anaesthesia. There are reports of safe use of epidural block for
labour analgesia and caesarean section in pt. with IC tumour

• Reference :
• Goroszeniuk T et al,. The management of labour using continuous
lumbar epidural analgesia in a patient with a malignant cerebral
Spinal cord surgery in left lateral position with a tilt in a pregnant
patient with intradural extramedullary schwannoma

• During pregnancy spinal tumours are rare, surgery at third trimester is challenging,
here we present a case of 22yrs old pregnant lady in 30weeks of gestational age
under going D8 D9 laminectomy with excision of grade ii schwannoma under
general anaesthesia.
• Patient was posted for surgery as she became bedridden past 22 days inspite of
gestation.MRI dorsolumbar spine revealed intradural extramedullary dumbbell
shaped lesion at D8D9 level extending into right D9D10 neural foramina suggestive
of nerve sheath tumour causing adjacent compression and displacement of the
cord, gravid uterus.

Conduct of anaesthesia
• concerns: positioning, fetal hypoxia,
patient full stomach, reduce intubation
response, hemodynamic stability,
ventilation in lateral position
• Patient received ranitidine 150mg orally
premedication.
• Patient induced by RSI fixed dose of
250mg inj thiopentone,100mg inj
succinylcholine, inj fentanyl 50µgs, ETT
7.5 , with sevoflurane 0.5%, with 50%
nitrous and 50% O2, with CMV ,closed
circle system.
• Fetal heart rate for prompt detection of
fetal hypoxia was monitored using a
fetal doppler fixed to mother
abdominal wall.
• Monitoring – ecg, IBP, pulse oximetry,
ETCO2, fetal doppler.
• Inj atracurium used for muscle
relaxation.
• Positioning : intubation with a wedge and
after judicious fluid replacement patient put
in left lateral position without provoking
haemodynamic instability.
• Patient then plastered to the OR Table after
appropriate placements of gel foams and
cotton rolls to avoid nerve compression.
• the fetal heart rate was monitored by
doppler, the whole table was given a
45degree tilt.
• Heart rate and MAP(86-94) mmHg remained
stable during procedure. fetal heart rate and
ABG assessed periodically.
• Surgical procedure completed in 6 hrs
without complications. Patient reversed by
neostigmine and glycopyrrolate , extubated
and sent to neurosurgical icu for continuous
monitoring .
• Subsequent obstetric and ultrasound checks
were normal. Patient discharged on 12th day .
• Caesarean section was performed under
general anaesthesia during 35th gestational
week and child was healthy of 2.5kgs.
 Discussion
• Anaesthetist and surgeons are reluctant to operate on pregnant patients due to fear
of miscarriage and premature births. In case of emergency surgery in pregnancy
should not affect the decision.
• Here spinal tumour leading to paraplegia ,delay in treatment jeopardize the life of
mother and fetus. Our case was distinguished by the rare spinal tumour in
pregnancy, operating position{left lateral with 45degree tilt of table}, third
trimester, signs of nerve compression and long duration of surgery.
• Only few reports in the literature regarding positioning of pregnant patients
for surgery except for delivery .
• Management of spinalcord tumours in pregnancy must be individualized .
The patients physical condition ,gestational weeks, site, size and type of
tumour, neurological signs, in addition to patient wishes must be
considered in decision making process.
• In summary this case demonstrates that anaesthesia and spinalcord
surgeries in third trimester of pregnancy in left lateral position with a tilt of
45degree can be performed uneventfully . continuous attentive monitoring
of mother and fetus is vital.
ANEASTHETIC CHALLENGES IN A
PATIENT WITH SPASTIC
QUADRIPLEGIA AND THORACO
LUMBAR KYPHOSCOLIOSIS FOR
FRACTURE SHAFT OF FEMUR
CORRECTION.

Dr.Shabeel Aboobacker.CP
Second Year Postgraduate
Yenepoya University
Mangalore
INTRODUCTION
Giving anesthesia in a patient with spastic
quadriplegia and thoraco lumbar kyphoscoliosis
is challenging to anesthesiologists because of
problems in administering either general
anesthesia or regional anesthesia .
General anesthesia in this patient would have
been problematic because of restrictive type of
pulmonary dysfunction and quadriplegia but
combined spinal epidural also will be problematic
due to technical difficulties in getting proper
space.
CASE REPORT. A 19 year old female patient
with spastic quadriplegia,seizure disorder and
thoraco lumbar kyphoscoliosis admitted in our
hospital for open reduction and internal fixation
of fracture shaft of femur with k nail.
On examination:- conscious, not oriented and not
cooperative.
She has buck tooth and mouth opening not
adequate.respiratory and cardiovascular system –
normal.
Vitals and investigations are within normal limits.
Under strict aseptic precaution 18 G Touhy
needle inserted into L2-L3 space after
giving adequate local anesthetic. Catheter
inserted and fixed at 6 cm . 2 ml of 2%
Lignocaine with Adrenaline given
epidurally. At L3-L4 space spinal
anesthesia given using 25 G Quinckes
needle. 1.8 ml of 0.5% Bupivacaine
injected in to the space and subarachnoid
block was adequate.
she was on spontaneous ventilation and
mask holding with N2O : O2 4:4.ORIF
with K nail done. the duration of surgery- 2
hours. post operative analgesia with
epidural infusion of 0.125% Ropivacaine
@ 3ml/hour..
CONCLUSION
Considering the risk benefit ratio in a
patient with severe kyphoscoliosis and
spastic quadriplegia , regional anesthesia is
safer than general anesthesia.
• References:-
• Cousins MJ. Neural blockade in clinical anaesthesia and pain
management,3rd Ed. Philadelphia: Lippincott Williams and
Wilkins; 1998.
• Horlocker TT, Wedel DJ. Anesthesia for orthopedic
surgery,Chapter 40, in Clinical Anesthesia by Barash PG, Cullen
BF,Stoelting RK eds.
• Sandler SW. Kyphoscoliosis and Pregnancy. South African
Journal of Obstetrics and Gynaecology. 1969; 13 -15.
• Shah AS, Choudhary ZA: Is caudal epidural anesthesia effective
for anorectal surgery?. Pak J Med Health Sci. 2007, 1:9-10.
• 2. Kita T, Maki N, Song Y S, Arai F and Nakai T: Caudal
epidural anesthesia administered intraoperatively provides for
effective postoperative analgesia after total hip arthroplasty. J
Clin Anesth 2007, 19:204-8.
Anesthetic management of a case of Xeroderma
Pigmentosum with squamous cell carcinoma posted
for wide excision and grafting presenting with a
difficult airway – A Case report

Author : Dr. Shahedha Parveen Asst. Prof

Co. Author : Dr. P. Krishna Prasad Assoc. Prof
Dr. B.Sowbhagyalaxmi Prof & Hod
Rangaraya medical college, Ggh, Kakinada.
Introduction Xeroderma Pigmentosum (XP) 1 is a rare autosommal
recessive disorder characterized by hypersensitivity of the skin to UV
radiation. These patients show a failure to repair UV induced DNA
lesions caused by Nucleotide Excision Repair mechanism. They
develop neoplasms at an early age and require repeated surgeries.
Methodology We report an 18 year old female patient,40kgs, with XP
who presented with squamous cell carcinoma over parotidectomy site
and was scheduled for wide excision and skin grafting.
PAC-H/o since 8 months, different complication (dermal, occular,
neurological and neoplastic of present surgery ).
• O/e-generalized b/l distributed freckles, hypopigmented nodules over
the lips, left conjunctiva was congested, cornea was hazy and
watering+.
• Airway Assessment: Mallampatti class IV. TMJ mobility- mild
restriction on the normal side, could not be elicited on the surgical side
due to pain. Inter Incisor distance ~1.5 cm. TMD > 6cm.
• Difficult airway was anticipated.
• High risk ,written and informed consent taken.
Observation IV cannula was very carefully secured.
• multipara monitor (ECG,NIBP, SPO2, Et Co2) was attached.
• Difficult airway equipment ie. bougie, styleted endotracheal tubes
7.0,6.5 sizes, LMA classic size 3, Igel size 3 and tracheostomy kits 7.0,
6.5 were kept ready.
• General anesthesia with propofol induction followed by
succinylcholine. i-gel
• Patient had severe restriction of mouth opening when compared to
preoperative period probably due to masseter spasm after scolene.
• I- Gel could be placed successfully with a little difficulty as the tongue
was dropping back obstructing the pathway. We had to lift the tongue
using Magills forceps and then slipped the I-Gel into place with little
force and connected to Bain Circuit, ventilation was adequate
Discussion The major anesthetic concerns are psychological,
sociological impact on patients and relatives due to repeated exposure
to surgery and anesthesia. XP demands eye care and protection of
patient from artificial light, well padding of pressure points and
movements should be gentle to prevent skin injuries.
• T.I.V.A (propofol and fentanyl) is reported by Miyazaki. et.al study2.
• Masseter spasm has been implicated as an early indicator of
suspectability for malignant hyperthermia but isolated masseter spasm
is not pathognomic for MH.
I – gel-Quick, easy, reliable to insert, high seal pressure, reduced
trauma, Incorporates a gastric channel, used for routine anesthesia and
also DAM, as a rescue device. Internal bite block reduced the
possibility for airway channel occlusion, virtually eliminates rotation.
Conclusion Newer supraglottic devices like I–Gel may be considered
as a safer alternative in such difficult situations3, especially useful in
resource limited setting.
Ref: Lehmann AR, McGibbon D, Stefanini M. Xeroderma
pigmentosum. Orphanet J Rare Dis. 2011;6:70
• Miyazaki R, Nagata T, Kai T, Takahashi S. Anesthesia for a patient
with xeroderma pigmentosum. Masui. 2007;56(4):439–41.
• Asai T. Successful use of I-gel in three patients in difficult intubation
and difficult ventilation. Masui 2011 july, 60(7); 850-2.
Anaesthetic Management of
Left Atrial Myxoma
- A Case Report

Dr. Shanmuga Priya. A. L

Dr. C. Ganesan
Department of Anaesthesiology
PSG IMS&R
Coimbatore
 LEFT
LEFTATRIAL
ATRIALMYXOMA
MYXOMA

 33 yr old female presented

with acute onset of grade III
dyspnoea with palpitation

 O/E, PR - 120/min

BP - 90/60mmHg Hb - 8.4 g/dl

 ECG : sinus tachycardia

 CXR : left atrial enlargement

ECHO: large left atrial myxoma,
pulmonary artery hypertension, mild  Prominent pulmonary artery
MR pericardial effusion.
 LEFT ATRIAL MYXOMA

 Anticipating sudden cardiac events, Surgery was done under GA -

cardio pulmonary bypass (routine monitors + TEE )

 Intraop - a large pedunculated mass 6x5 cm

attached to inter atrial septum was excised

 Postoperative echo - adequate LV systolic function with mild TR

DISCUSSION
• Female > male
• Incidence of primary cardiac tumor is 0.001- 0.28%
• Prevalence - 0.5 / million populations / year
• 4.75% of cardiac tumors are benign (50% are myxomas )
 Clinical presentation
Presented To Highlight
• Masquerades as mitral
• Rarity of the disease
valve disease
• Mimics valvular heart
• Embolism - 30-40% disease
• Stroke/visual loss/ Syncope • Excision is the treatment
• Intra cardiac obstruction of choice, though
recurrence is common
• Arrhythmias
• Pre planned safe
• Sudden cardiac death
anaesthesia for surgery
( mitral / tricuspid valve will improve the outcome
outflow tract obstruction)
Shapiro–cardiac tumour diagnosis and management.Heart2001;85:218-22
Reynen k. cardiac myxoma-NEJM1995;333:1610-7
 BLIND NASAL INTUBATION IN A 35 YEAR
OLD MALE WITH INADEQUATE MOUTH
OPENING
• Dr.Sharath Krishnaswami, Dr.Nachiketha, Dr.Harish,
Dr.Ramesh, Dr.Ravi, SDUMC, Kolar, Karnataka.
• Management of a “difficult airway” remains one of the most
relevant and challenging tasks for anesthesiologists and
emergency medicine physicians.
• A 35-year-old male presented with a history of seizures and
post-traumatic limitation of temporo-mandibular joint
extension.
• He was in a post ictal state after Status Epilepticus, treated
with Midazolam in the casualty, semiconscious with a GCS of
3.
We successfully secured the airway using blind nasal intubation
technique with 10% lignocaine spray .
• Patient was admitted in the ICU for 3 days. CT Brain showed
Chronic infarct with Encephalomalaic changes in the left
high parietal and left temporo-parietal lobe and lacunar
infarct in lentiform nucleus.
• He was treated with Syp. Donapezil, T.Phenytoin and Inj.
Diazepam. The patient was stabilized, extubated and
discharged.
• References: 1. Benumof JL. Management of the difficult
adult airway. With special emphasis on awake tracheal
intubation.Anesthesiology. 1991;75(6):1087–1110.
• 2. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to
predict difficult tracheal intubation: a prospective
study. Can Anaesth Soc J. 1985;32(4):429–434.
• 3. Redick LF. The temporomandibular joint and tracheal
intubation. Anesth Analg. 1987;66(7):675–676
 UNDETECTED
HYPOTHYROIDISM
PRESENTING AS
INTRAOPERATIVE CARDIAC
ARREST
Patient Pre-op Intra-op Post-op
• 65 yr male, 40 • Labs normal • Premedication • T3-
kgs except for with fentanyl 0.195ng/ml,
sodium 123 30µgm T4-
• Case of ca of meq/dl 0.42µgm/ml,
larynx, post • Induction by TSH-
laryngectomy • ASA III propofol 50mg 31.8µIU/ml,
and adjuvant FT4-
radiotherapy 0.05ng/ml
• Sudden cardiac
• RBS- 90mg/dl,
arrest with
Na+: 115meq/l,
• Posted for asystole
K+: 2.6meq/l,
feeding
Ca+: 3.8mg/dl,
jejunostomy • Revived random
for progressive
cortisol:763nm
dysphagia
ol/l
 Take Home Message!
• Incidence of hypothyroidism following radiation to neck 3-
44% and the addition of neck surgery increases incidence to
43-66%Hypothyroidism and hypoparathyroidism should be
ruled out in post laryngectomy and post radiotherapy case
• Chronic hypocalcemia secondary to hypoparathyroidism can
lead to cardiomyopathy and congestive cardiac failure
• Pre-operative detection of hypothyroidism and
hypoparathyroidism and its treatment would have averted this
complication.
References
Aich RK, Deb AR, Pal S, Naha BL, Ray A. Iatrogenic hypothyroidism: A consequence of
external beam radiotherapy to the head and neck malignancies. Journal of Cancer
Research and Therapeutics 2005;1(3):142-6.
Miccoli P, Minuto MN, Miccoli MN. Incidence of morbidity following thyroid surgery. In:
Miccoli P, Terris DJ, Minuto MN, Seybt MW editors. Thyroid Surgery: Preventing and
Managing Complications. Oxford, UK: John Wiley& Sons, Ltd; 2012. Pp.6-7.
 JJM Medical College ,Davangere

ANAESTHETIC IMPLICATIONS FOR

PARTURIENT WITH GESTATIONAL
DIABETES MELLITUS, THYROTOXICOSIS,
AND GESTATIONAL HYPERTENSION
Dr. RAGHUNATH.SS.
POSTGRADUATE
CO-AUTHOR:
Dr.RAVISHANKAR.RB.
PROFESSOR

240
 CASE REPORT
A 27 yr old primigravida at 20 wks of gestation
was diagnosed with diabetes, thyrotoxicosis.
FBS: 150mg%, PPBS: 207mg% HbA1C: 8.8%
TSH-0.005 uIU/ml; T3-304.9ng/ml; T418.1ug/ml.
She was started on insulin and propylthiouracil
At 36 weeks of gestation, she was posted for
Em LSCS. She was found to have hypertension
and was started on labetalol.
Pulse-88/min; BP-160/100mmHg
FBS-88mg%; HbA1C-6.74%.
TSH of 5uIU/ml; T3-2.40ng/ml; T4-13.59ug/ml.
OT: Spinal Anaesthesia was given, Live baby
was delivered. Sugars and vitals well controlled.
Surgery was uneventful.
 DISCUSSION
• GDM ->glucose intolerance onset during
pregnancy. (incidence2-14%)
• GDM is similar to type-2 DM: initiating
factors:
1. increased peripheral insulin resistance
2. relative pancreatic insufficiency develops
The high blood sugars predispose to risk of:
first trimester loss, congenital anamolies,
Neonatal macrosomia-> shoulder dystocia
Treatment:
1. excellent glycaemia control
2. avoidance of severe hypoglycaemia,
3. stabilisation and monitoring of
complications
4. fetal surveillance.
 DISCUSSION
Hyperthyroidism (incidence-0.4%; MC-Graves85%)
• Uncontrolled hyperthyroidism causes:
1. severe preeclampsia
2. foetal loss
3. low birth weight
4. Prematurity
5. placental abruption
6. worsens glucose control
7. precipitating severe ketoacidosis
8. hypoglycaemia.
 TREATMENT
• Propylthiouracil is the drug of choice for treatment of
thyrotoxicosis in pregnancy.
• Beta blockers ->the sympathetic manifestations.
• Iodides avoided->neonatal goiter, hypothyroidism.
• Radioactive iodine not used in pregnancy
• Regional anesthesia is safer than GA as responses to
hypoglycemia are blunted in these patients and are
difficult to diagnose under GA whereas during
regional anaesthesia (RA) patient will be able to
convey the things verbally.
• CONCLUSION: Endocrine disorders carry significant
maternal and fetal risks during pregnancy. However,
risks can be reduced by timely diagnosis, optimising
treatment, and involving a multidisciplinary team in
patient care. Communication between obstetrician,
anaesthesiologist, and endocrinologist is of utmost
importance
 REFERENCES
• H. King, “Epidemiology of glucose intolerance and gestational-diabetes in
women of childbearing age,” Diabetes Care, vol. 21, no. 2, pp. B9–B13, 1998.
• Berghout A, Wiersinga W: Thyroid size and thyroid function during
pregnancy: an analysis. Eur J Endocrinol 1998, 138:536–542.
• American Diabetes Association, “Diagnosis and classification of diabetes
mellitus (Position Statement),” Diabetes Care, vol. 34, supplement 1, pp.
S62–S69, 2011.
• Kaaja R, Greer I. Manifestations of chronic disease during pregnancy. JAMA
2005; 294: 2751–2757
• Casey BM, Lucas MJ, Mcintire DD, et al. Pregnancy outcome in women with
gestational diabetes compared with general obstetric population. Obstet
Gynecol. 1997; 90: 869-873. Bajwa SJ, Kalra S. Diabeto-anaesthesia: A
subspecialty needing endocrine introspection. Indian J Anaesth
2012;56:513-7.
• Chestnut: Obstetric Anesthesia: Principles and Practice. 3rd ed. box 41-4. p.
745.
• Hoeldtke RD, Boden G, Shuman CR, Owen OE. Reduced epinephrine
secretion and hypoglycemia unawareness in diabetic autonomic neuropathy.
Ann Intern Med 1982;96:459-62.
• Hogan K, Rusy D, Springman SR. Diffi cult laryngoscopy and diabetes
mellitus. Anesth Analg 1988;67:1162-5.
• Francis S, May A. Pregnant women with significant medical conditions:
anaesthetic implications. Contin Educ Anaesth Crit Care Pain 2004; 4: 957
Thank You
 Airway management of a patient with
Penetrating Neck Injury
Dr.Sravanthi Vakada, Dr.Sagar MS, Dr.Malavika, Dr.Manjunath Prabhu,
Department of Anaesthesiology, Kasturba Medical College, Manipal
Introduction: Penetrating neck trauma is a life threatening emergency because of potential injury
to vital structures of the neck and thorax, including the major blood vessels, nerves, aerodigestive
tract, lungs and spinal cord.1 Successful management depends upon prompt recognition of injury,
appropriate diagnostic evaluation & proper surgical intervention.2 We report an unusual case of
penetrating neck injury associated with pneumothorax and tracheal injury and the successful
management of the same after assessing the extent of airway injury by awake fiberoptic
bronchoscopy through the open neck wound and securing airway through it.
Case: A 22 year old male came to our hospital with history of injury on left side of neck
following assault with a sickle. He presented with difficulty in breathing and aphonia.
• Conscious • Wound : Persistent air • Oxygen administered via open cut wound.
• Pulse : 118/min leak, no bleeding. Large bore iv cannula secured.
• BP : 140/70mmHg • Subcutaneous • Routine blood investigations, grouping
• SpO2 : 88-90% emphysema over neck and crossmatching done.
• RR : 42/min and chest • Immediate chest and cervical spine X-ray
• Unable to lie • Decreased breath was done in view of respiratory distress
supine sounds right side and suspected airway injury.
• Chest X ray showed right side
pneumothorax causing collapse of lung.
• Intercostal drain tube(ICD) was inserted
and the respiratory distress reduced.
• CT scan of neck and thorax showed large
anterior tracheal wall injury.
• Hence he was posted for emergency
neck exploration and repair.
• In the Operating room(OR) ECG, NIBP and pulseoximeter were attached.
• Local examination of wound : 8*5cm obliquely incised wound on left lower aspect of anterior
triangle of neck about 1.5cm above the clavicle. Bilateral carotid pulsations well felt.
• We did an awake fiberoptic bronchoscopy through the open tracheal wound itself under
topical anaesthesia with 10% lignocaine spray, iv fentanyl 50µg and midazolam 1mg.
• Assessed the trachea till carina. Slid a preloaded 7.5mm reinforced tube over the
bronchoscope till tip of the tube lied just above carina. Fixed the tube after confirming with
capnograph trace and chest auscultation.
• General anaesthesia administered using IV Propofol,
IV Atracurium , 1.5% isoflurane in air + O2 (1:1) and
IV Morphine analgesia.
• ENT surgeon found transection of anterior wall of
trachea at 3rd and 4th tracheal rings. One stage end to
end anastomosis was planned which required
orotracheal intubation.
• So we did a direct laryngoscopy and passed a gum elastic bougie, the tip of the bougie
protruded through the tracheal wound and surgeon guided it into distal trachea.
• PVC cuffed 7.5mm orotracheal tube was railroaded over the bougie and simultaneously the
flexometallic tube was removed.
• Surgeons repaired the airway defect. Intraoperatively patient was hemodynamically stable.
• We shifted him to intensive care unit (ICU) and electively ventilated for 7 days to permit
healing of the repaired tracheal wound.
• On POD7 under fiberoptic bronchoscope vision extubated in OR and discharged after 15 days.
• Discussion: Penetrating neck injury (PNI) is a life threatening
emergency demanding immediate management due to proximity of
vital structures in the neck.
• The anatomical region of neck can be divided into three zones for
the purpose of evaluating and treating penetrating injuries.4,5 Zone II
injuries are the most common (50-80%).4-6
• For hemodynamically stable patients investigations has to be carried
out to know the extent of injury like neck X-ray, USG and CT scan.
• Hemodynamically unstable patients require immediate surgical
exploration.
Our patient was hemodynamically stable, hence was evaluated before
shifting to OR.Tracheal injury was known by CT scan. But the extent of
injury was known only on direct examination. Fiberoptic bronchoscopy
was done through the neck wound to know the extent of airway injury.
Distal trachea was found intact without any injury hence reinforced
tube was passed over the fiberoptic bronchoscope.
Conclusion: Securing airway is always a first priority in PNI, but it is advisable to secure airway
by fiberoptic guidance in hemodynamically stable patient to prevent any further airway injury.
References:
1. Brywczynski JJ, Barrett TW, Lyon JA, Cotton BA. Management of penetrating neck injury in the emergency
department: a structured literature review. Emerg Med J 2008; 25: 711-5.
2. Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in
the selective management of penetrating injuries to the neck : a reduction in the need for operative exploration. J
Trauma. 2008 Jun; 64(6): 1466-71.
3. Demetriades D, Theodorou D, Cornwell E, T.V. Berne, et al. Evaluation of penetrating injuries of the neck: prospective
study of 223 patients. World J Surg 1997;21:41–8.
4. Bhattacharya P, Mandal MC, Das S, Mukhopadhyay S, Basu SR. Airway management of two patients with penetrating
neck trauma. Indian J Anaesth 2009; 53: 348-51.
5. Hyub Huh, Jin Hee Han, Jun-Young Chung, Jae-Woo Yi et al. Anesthetic management of penetrating neck injury patient
with embedded knife. Korean J Anesthesiol 2012 February 62(2): 172-174
6. Tao Wang, Yeting Zhou, Jiaohui Shi, Zhichun Wang. Perioperative anaesthetic management of penetrating neck injury
associated with Rh blood type in a young adult. BMJ Case Reports 2013.
.
 Anesthetic management of child with cerebral
palsy with post-operative muscle spasm
Dr. SivaShanmugam, Dr.Prasanna kumar (Asst. Prof)
Introduction:
• Cerebral palsy is a non progressive motor disorder
which occurs due to hypoxic insult to fetus during
perinatal period.
• These children often present for elective surgical
procedures to correct various deformities.
• Perioperative care of a child with cerebral palsy
is a real challenge to the anesthetist because every
system of the body is affected in this disorder.
• Regional anesthesia is usually used as
an adjunct to general anesthesia and not used
alone as they have behavioral abnormality and
difficulty in communication
• The two most important anesthetic concerns in these
patients are hypothermia and post-operative muscle spasm.
Anesthetic management:

• This 15 kg ,eleven year old child with spastic

cerebral palsy planned for hamstring release.

• Preoperative evaluation revealed no significant

abnormality except for the deformity in both legs.

• Under sterile precautions epidural catheter

secured in L3-L4 interspace.
• After inducing with propofol, 2.5 size classic
LMA was inserted and secured.

• Post-operatively child developed severe pain

due to muscle spasm, which was effectively
managed using continuous epidural
ropivacaine (0.125%) with clonidine
(0.25mcg/ml).
Discussion:
• Post-operative muscle spasm is a common cause
for severe pain in the post operative period.
• Surgically exposed nerve endings and muscle stretch
receptors activate local spinal reflexes resulting in spasm.
• Clonidine is a very effective adjuvant to
local anesthetics in relieving muscle spasm.

• Role of clonidine
1. Potentiates local anesthetic action,
2. Has intrinsic local anesthetic property,
3. Acts similar to inhibitory interneuron,
4. No nausea and vomiting

References:
• A Rudra, S Chatterjee et al. The Child with Cerebral Palsy
and Anesthesia. Indian Journal of Anesthesia 2008; Aug; 52(4):397-403
• Dylan Parry Prosser, Neeraj Sharma. Cerebral Palsy and Anesthesia
Continuing Education in Anesthesia, Critical Care & Pain,
Vol 10:(3) 2010
 CHEDIAK HIGASHI SYNDROME POSTED FOR
EM.SPLENECTOMY: A CASE REPORT
DR.B. SRINIVAS NAIK (pg).DR . RAGHU;DR.P.S.KARUNABHARATHI (asst. prof.)
DR C.G.RAGHURAM (prof&H.O.D) Dept.of anaesthesiology, OMC, Hyderabad

INTRODUCTION
• An AR disorder affects predominately phagocytosis and
melanocytes.Manifests as partial occulocutaneous albinism with
translucent irides and photosensitive dermatitis , recurrent pyogenic
infections & respiratory tract infections.
• Diagnosis is by peripheral blood smear - giant granules in leukocytes
& hair analysis.
• Bone marrow biopsy showing mild dyspoesis and neutrophils show
incomplete lobulations and pale grey blue like large cytoplasmic
inclusions – myeloperoxidase positive and provisionally diagnosed
7yr old 14 kg/M presented with c/o progressive distention of abdomen
O/E pale and febrile. There is shiny silvery grey discoloration of hair
and petechiae on all over the body . Eyes are light brown in color. Pedal
edema :Tonsils are large & inflamed
Hb- 6.2g% ; Sr.Total bilirubin-2.1 PLATELET COUNT: <10000 ;
Airway – normal

CT abd- severe hepatosplenomegaly and basal atelectasis.

Adv: repeat CBP, coagulation profile: nebulization on the day of

surgery Transfuse 100ml PRP &150 ml whole blood on the day of
surgery and continue antibiotics

ECG,NIBP, SPO2 Preop –pt. is conscious/ irritable,PR-100/min, regular,

H/L-NAD,SpO2@RA 96

IV access secured on left hand & right EJV. Premedication- glyco

0.2mg+Ondan 0.4mg+Fentanyl15µg+hydrocortisone 100mg/iv
Preoxygenation & RSII(propofol 60mg/iv and suxa30mg/iv
with 4mm OCETT)Maintenance with 02:N20 2:2 lt/ min &
atracurium as muscle relaxant Intraop :vitals stable 250ml
RL,100ml NS,1 unit PRP, 1 unit FFP given, u/o-300ml.

For Post op analgesia Caudal block (inj.

buprenorphine 30µg diluted to 10ml) and local
infiltration ( bupivacaine 0.1% +4mg dexamethasone
Reversal done : Recovery –uneventful pt. is c/c, PR-
98/min, BP- 120/70mmHg, H/L- NAD, Spo2-97% @RA
Conclusion rare with thrombocytopenia and
immunosuppression . few cases are reported for surgical
intervention like splenectomy.All the guidelines in
anaesthetizing patients with thrombocytopenia &
protocols to prevent catheter related blood stream
infections are to be followed strictly.
 DIFFICULT AIRWAY
MANAGEMENT IN A PATIENT
WITH UNILATERAL
TEMPOROMANDIBULAR JOINT
ANKYLOSIS

DR.SUNITHA . B
ISA NO:S4341
GUIDE : Dr S.G.K Murthy(prof&hod)
CO-GUIDE : Dr . S . SAIBABA(Asst prof)
Dr. GREESHMA(Asst prof)
 INTRODUCTION
• Temporo-mandibular joint (TMJ) ankylosis results in inability
to open mouth either partially or completely.
• Incidence: 2 - 60 years of age, no sex predominance.
• Causes: congenital, Trauma and infection commonly.
• Consequences: facial asymmetry, poor oral hygiene, caries and
impacted teeth, malnutrition, respiratory distress, Increased
airway resistance &cor pulmonale.
• Anaesthetic implication: difficulty in ventilation, intubation &
extubation.
 CASE REPORT
• A 23yr old male patient, was diagnosed as left sided traumatic
Temporo Mandibular Joint ankylosis.
• On examination there was facial asymmetry,malnourished,
mouth opening 3mm.
• Surgical plan: bone gap arthroplasty(left), coronoidectomy &
eminectomy(right)
• Anaesthetic plan:general anaesthesia with Awake fibre optic
nasal intubation.
• Anaesthetic management: A 18G i.v cannula secured
• basic monitors were connected.
• Premedication:inj.ondansetron,inj.rantidine, were given ½ hr
before. inj.glycopyrrolate , inj.midazolam, inj.fentanyl was
given.oxygenation maintained by insufflation.
• Upper airway block was givenfibreoptic bronchoscope was
checked, focused and feeded with7.5mm cuffed ET tube.
• fiberoptic intubation was introduced into left nostril and after
the glottis was exposed, the bronchoscope was advanced
between the vocal cords and downward till carina was seen.
ET tube was gently advanced over the bronchoscope into the
trachea & bronchoscope was removed.
• patient induced with inj.thiopentone,paralysed with
inj.vecuronium,maintained with 66% N2O & 33% O2 and
halothane.intraoperative vitals stable.at the end of procedure,
patient reversed with Inj.neostimine & inj glycopyrrolate and
extubated after thorough suctioning.procedure uneventful.
• Post operative mouth opening is 35mm
• CONCLUSION :Awake Fibre optic intubation technique is
one of the best technique in managing TMJ ankylosis cases.
 REFERENCES
• S Mishra, S lata, V kumar, G Mishra, P Ezhilarasu. Difficult
Intubation; Temporomandibular Joint Ankylosis With Limited
Mouth Opening And Hypertrophied Adenoid In A Six Year
Old Child- Case Report And Review. The Internet Journal of
Anesthesiology. 2008 Volume 22 Number 1.
• Sahoo TK, Patil Y, Patel RD, Dewoolkar LV. Anaesthetic
management of a child with temporomandibular joint
ankylosis with extrahepatic portal vein obstruction for
ankylosis release.Internet J Anesthesiol 2008; 16:1.
• Weiss M, Engelhardt T. Proposal for the management of the
unexpected difficult paediatric airway. Pediatric Anesth
2010;20:454-64.
• Xue FS, Luo MP, Xu YC, Lio X. Airway anaesthesia for
awake fiberoptic intubation in management of paediatric
difficult airways. Paediatr Anaesth 2010; 20:1264-5.
 FOOT DROP –A RARE
COMPLICATION
AFTER SUB ARACHNOID BLOCK

SWETHA TIRUMLARAJU
2nd Year PG,ANAESTHESIOLOGY
NRI MC&GH
 CASE REPORT
• 24 year old female with poliomyelitis of RLL and left hand for LSCS
• Preoperative -normal hemodynamic parameters.
• SAB,L3-L4 interspace,right lateral position,23g Quincke needle ,first
pass,clear CSF ,drug deposited.
• No pain or paraesthesia during needle insertion or drug deposition.
• Complained of pain in LLL on turning supine,subsided in 3 minutes.
• Pain reappeared 6hrs following surgery
with inability to move left foot
dorsiflexion 0/5,plantar flexion 3/5
• No urinary symptoms
Postoperative MRI spine-Normal study with no
evidence of syrinx and a spinal cord of normal length
• TREATMENT: Dexamethasone 4mg iv 8th hrly
Pregabalin 75mg orally 12 hrly
Physiotherapy
• Discharged home with reassurance and with partial recovery.
• At 4weeks-partial recovery of motor power(3/5)
• At 8 weeks,complete recovery.
• DISCUSSION:
– Rare complication
– With complaints of pain during or immediately after SAB, watch
for progression and reassure patient.
- H/o of a recent RA does not prove causation
-2/3rds of anaesthesia related neurological complications are associated
with either paraesthesia(direct needle trauma) or pain during
injection(intraneuronal injection
-Auroy et al in a large study concluded that 1/3rd of the pts who
developed deficits without paraesthesia ,did so following spinal
anaesthesia
 REFERENCES
• Nirmala BC, Gowri Kumari.foot drop after spinal anaesthesi ..a rare
complication. Indian Journal of Anaesthesia | Vol. 55| Issue 1.
• Reynold‘s F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001;56:238-47.
• Selander D, Dhuner KG, Lundborg G. Peripheral nerve injury due to
injection needles used for regional anaesthesia. An experimental
study of the acute effects of needle point trauma. Acta Anaesthesiol
Scand 1997;21:182-8.
• Auroy et al, Serious Complications Related to Regional Anesthesia:
Results of a Prospective Survey in France 1997:87:479-86
• Holdcraft et al,Neurological complications associated with
pregnanacy. British journal of anaesthesia 1995:75:522-26.
 DIFFICULT INTUBATION DUE TO UNSUSPECTED
SUPRAGLOTTIC NARROWING– a case report
Dr.Syed Ibrahim Zubair , Dr.Syama Sundara Rao, Dr.Syed Ali Aasim CAIMS, Karimnagar

Supraglottic narrowing of the airway is a complication encountered during tracheal

intubation
Present case report describe a patient in whom supraglottic narrowing of airway was
diagnosed during attempts of intubation.
• A 64yr old male with chronic
abdominal pain posted for
laparoscopic cholecystectomy.
• h/o DM 5 years and APD 3yrs.
• Was on H. Actrapid & proton pump
inhibitors
• Past history-uncomplicated
tonsillectomy 10 yrs back.
• Physical examination of the patient
revealed 174 cm tall, weighing 75 kgs
with Mallampati grade III and with no
apparent airway abnormalities.
• Premedicated and preoxygenated
• Bag and mask ventilation was difficult
but possible.
• Orotracheal intubation was attempted but
there was no visualization of laryngeal
inlet on laryngoscopy.
• So, patient was again ventilated with
utmost difficulty with two hand
technique of bag and mask ventilation.
• again attempted for orotracheal
intubation with some cricoid pressure by
an assistant and bougie was passed
blindly but passage of tube was difficult,
so pt was recovered.
• patient regained spontaneous ventilation
& consciousness
• Follow up: CT Scan and bronchoscopy

• The patient was again posted for the

surgery, ready with difficult airway
techniques and equipment.
• The laryngoscopy : erythema, oedema
of larynx and interarytenoid
hypertrophy3 (signs of LPRD)
• With several attempts & cricoid NARROWED AIRWAY NORMAL AIRWAY
pressure bougie was passed, over
which 6.5 mm well lubricated
uncuffed portex tube was threaded in.
• Confirmed: auscultation and EtCO2
• The 6.5 mm tube was then exchanged
with 7.5 mm uncuffed portex tube.
Patient was maintained on controlled
ventilation and showed normal
capnogram.
BRONCHOSCOPIC VIEW
• In the present case, the difficulty occurred
during intubation because of narrowing of
airway at supraglottic level
• The cause for narrowing of airway suspected is
to be laryngopharyngeal reflux disease (LPRD).
• LPRD has been highlighted in this case because
patient has a history of acid peptic disease and
irregular treatment with proton pump
inhibitors.
• GERD (gastroesophageal reflux disease) is
believed to be an important etiological factor
in the development of many inflammatory and
neoplastic disorders of the upper aero
digestive tract 4.
• Exposure of pH <4 for < 1 min during 24 hrs in
the laryngopharynx is considered pathological.
• Studies have proved that chronic intermittent
laryngopharyngeal reflux can cause or
indefinitely perpetuate laryngeal
inflammation5 .
• The present case report highlights the
importance of history taking and proper
examination of the patient for probable
narrowing of airway not only at infra glottis as
well as supra glottis areas also.
REFERENCES
1. Jyi Lin Wong, SiewTeck Tie, BohariSamril –
successful treatment of tracheal stenosis by
rigid brochoscopy and topical mitomycinC : a
case report – Wong et al. cases journal 2010,
3:2 www.casesjournal.com/content/3/1/2
2. Nimmagadda, Usha Rani MD; Salem, Ramez
M. MD; Freidman, Michael MD; Lenz, Richard
F. MD- acute management of unsuspected
subglottic stenosis by tracheal dilation ,
Anaesthesia& Analgesia april 1995 – vol 80-
issue 4 – pg 841-843
3. H.F.Mahiew – REVIEW ARTICLE : the
laryngological manifestation of reflux disease;
why the scepticism? – Aliment pharmacolTher
26 (supp 2), 17 – 24
4. Koufman JA – the otolaryngologic
manifestations of gastroesophageal reflux
disease (GERD): a clinical investigation of 225
patients using ambulatory 24 hour pH
monitoring and an experimental investigation
of the role of acid and pepsin in development
of laryngeal injury – Laryngoscope 1991
apr;101 (4 pt 2 suupl 53) 1- 78.
5. Review article – clinical manifestation of
laryngopharyngeal reflux – 2002 GALE GROUP.
DIFFICULT INTUBATION DUE TO
UNSUSPECTED SUPRAGLOTTIC
NARROWING– a case report.
Presenter – Dr.Syed Ibrahim Zubair (P.G)
Co Presenters– Dr.Syama Sundara Rao (Prof)
Dr.Syed Ali Aasim ( Prof & HOD)
Chalmeda Anand Rao Institute of Medical Sciences
Karimnagar , Telangana.
 ABSTRACT
 Supraglottic narrowing of the airway is a complication
encountered during tracheal intubation.
 There is very scant information in the literature
regarding anesthetic management of such cases.
 It is difficult to treat and traditional surgical approach is
associated with significant risk and complications.
 Present case report describe a patient in whom
supraglottic narrowing of airway was diagnosed during
attempts of intubation.
 The intubation procedure was done after thorough
investigations, preparation of difficult airway measures
to place an appropriate size tube to maintain adequate
ventilation.
 INTRODUCTION
• MacEwen first reported endotracheal intubation for
anesthesia in 18801.
• Intubation has become the gold standard for maintaining the
airway, Anaesthesiogist is specially trained in the technique.
• There are many methods of airway evaluation to anticipate
difficulty in procedure, they make intubation procedure fail
proof but some airways will prove tough as preoperative tests
available may not anticipate 100%.
• Usually there will be difficulty in finding the glottis and
problems at lower airway.
• Narrowing of airway can be at various levels. There are many
causes for narrowing of airway and trachea in which
prolonged intubation, tracheostomy, LPRD (laryngopharyngeal
reflux disease), inflammatory conditions, ingestion of caustic
substances, trauma are some2.
 INTRODUCTION (contd…)
• LPRD is supposed to be an important cause in patients with
asymptomatic narrowing of the airways and tracheal stenosis.
• There have been more than 250 useful publications
(Pubmed/Ovid search:laryngopharyngeal reflux,
supraoesophageal reflux, extraoesophageal reflux, reflux
laryngitis, GERD and larynx) presenting clinical and
experimental evidence some strong, some feeble collectively
providing more than enough data to substantiate the earlier
observation that a relationship between reflux and laryngeal
pathology exists3.
• LPRD is a disease where there is retrograde reflux of gastric
contents beyond oesophagusupto laryngeal level.
• Appropriate understanding the pathology and planning the
approach with difficult airway management may be more
helpful in managing such cases.
 CASE REPORT
• A 64yr old male with chronic abdominal pain posted for
laparoscopic cholecystectomy.
• The patient gave history of diabetes from 5 years and acid
peptic disease from 3 years.
• The patient was taking H. Actrapid insulin and proton pump
inhibitors as daily medications.
• Surgical history included an uncomplicated tonsillectomy
about 10 years back.
• Physical examination of the patient revealed 174 cm tall,
weighing 75 kgs with Mallampati grade III and with no
apparent airway abnormalities.
• Systemic examination, Vital signs and laboratory
investigations were also within normal limits.
• The patient was shifted to the operation theatre and IV line
was started with a wide bore cannula.
• Patient was premedicated with Ranitidine, Ondansetron,
Glycopyrrolate, Fentanyl, preoxygenated and was induced
with Thiopentone and Succinylcholine.
• Bag and mask ventilation was difficult but possible.
• Orotracheal intubation was attempted but there was no
visualization of laryngeal inlet on laryngoscopy.
• So, patient was again ventilated with utmost difficulty with
two hand technique of bag and mask ventilation along with
the help of an assistant.
• After some time patient regained consciousness and was on
spontaneous ventilation.
• Patient was again attempted for orotracheal intubation, induced
with Propofol and Succinylcholine , and there was no visualization
of larynx.
• So, some cricoid pressure was given by assistant and blindly a
bougie was passed.
• A 8.5 mm cuffed portex tube was tried over the bougie but
resistance was observed. Attempts with 8.0, 7.5, 7.0, 6.5, 6.0, 5.5
mm also were unsuccessful.
• After few attempts the patient was brought back to consciousness
with spontaneous efforts and the case was differed for the next
operative day for a better management and planning.
• The CT Scan revealed narrowed airway at supraglottic level and
Bronchoscopy showed mucosal inflammation and oedema at
supraglottic area. In addition to narrowed supraglottic region
mucosal swelling, vocal cords are congested and margins ill formed.
 CT SCAN view of supraglottic area
NARROWED AIRWAY vs THE NORMAL
AIRWAY

Present Patient Normal Patient for comparision

BRONCHOSCOPY view
BRONCHOSCOPIC view
• The patient was again posted for the surgery, ready with difficult
airway techniques and equipment.
• The patient was premedicated, preoxygenated and induced with
similar medications like the previous setting.
• Difficulty was encountered with bag and mask ventilation.
• Laryngoscopy was attempted but there was no visualization of
laryngeal inlet.
• Cricoid pressure was given by assistant and with several attempts
bougie was passed into the trachea, over which 6.5 mm well
lubricated uncuffed portex tube was threaded in.
• The tube placement was confirmed by auscultation and EtCO2
tracings.
• The 6.5 mm tube was then exchanged with 7.5 mm uncuffed portex
tube with help of a bougie. Patient was maintained on controlled
ventilation and showed normal capnogram.
• Maintainance was done by oxygen and nitrous oxide mixture with
inhalational agent sevoflurane and intermittent doses of vecuronium for
muscle relaxation.
• Ryles tube was to be passed for gastric aspiration which encountered a
problem during the insertion with the classic method through the right
nostril.
• Several attempts were made aided with laryngoscopy and magill forceps
but not successful.
• Then 7.0 portex endotracheal tube was passed through the right nostril to
the oesophagus with the help of laryngoscopy and Magill forceps, through
which 16 F Ryles tube was passed into the stomach.
• The endotracheal tube was removed after confirming the placement of
ryles.
• After sometime air leak was observed around endotrachel tube and was
managed by tight packing with saline soaked gauze.
• After the surgery, the patient was reversed to spontaneous
ventilation.
• Patient was extubated after confirming the consciousness,
ventilation, and vitals.
• After extubation the patient was maintained on oxygen mask
and then monitored under room air.
• Patient was closely monitored in ICU for any signs of airway
obstruction.
• The patient was asymptomatic and sent home on the 7th
postoperative day.
 DISCUSSION
 Difficulty in intubation and ventilation was major concern in this
case.
 The difficulty occurred during intubation because of narrowing of
airway at supraglottic level.
 The cause for narrowing of airway usually may be due to prolonged
intubation, tumours, inflammatory conditions, burns or ingestion of
caustic substances and LPRD.
 Many of these cause narrowing at lower respiratory tract below
glottis and they were ruled out.
 In symptomatic patients with severe narrowed airway at supraglottic
level is always an emergency and may be triggered by trauma.
 Treatment can be provided in situation where patient is
symptomatic and unable to maintain the airway.
 Treatment can be surgical repair, laser resection or tracheostomy,
but In our case there was no stridor or any signs of airway
obstruction.
• The diagnosis of the narrowed airway can be made by radiographs,
xeroradiographs, CT, MRI and bronchoscopy helps in determining
the extent of stenosis2.
• CT Scan and bronchoscopy was aided to diagnose the pathology in
this case.
• LPRD has been highlighted in this case because patient has a
history of acid peptic disease and long term treatment with proton
pump inhibitors.
• GERD (gastroesophageal reflux disease) is believed to be an
important etiological factor in the development of many
inflammatory and neoplastic disorders of the upper aero digestive
tract 4.
• Exposure of pH ≤ 4 for < 1 min during 24 hrs in the laryngopharynx
is considered pathological.
• The injury may be mediated by two mechanisms i.e reaction
originating from an acid-sensitive distal oesophagus and direct acid
injury by the acid gastric content in tissues beyond the oesophagus
such as larynx and pharynx3.
• Studies have proved that chronic intermittent
laryngopharyngeal reflux can cause or indefinitely
perpetuate laryngeal inflammation5.
• The laryngoscopy signs of LPRD include erythema,
oedema of larynx and interarytenoid hypertrophy3.
• In a study by Koufman JA the results of diagnostic pH
monitoring was highly abnormal in the cases of
laryngeal cancer and laryngeal stenosis there by
conveying that LPRD may be an important etiology in
these cases4.
• The treatment of LPRD include long term therapy with
proton pump inhibitors.
• Asymptomatic patients with undiagnosed airway abnormalities
pose a challenge for the anaesthesiologist.
• The difficulty in intubation and ventilation is encountered by the
anaesthesiologist during the repeated attempts of laryngoscopy
and intubation.
• This situation leaves the anaesthesiologist with very few options.
• In a non-urgent situation, we thought that patient can be awakened
and further evaluated. The expertise opinion of otolaryngologist
was taken and investigated with CT Scan and Bronchoscopy.
• The patient was posted for the next setting with all the gears of
ventilation ready such as jet ventilation because various forms of jet
ventilation have been used successfully for patients undergoing
tracheal reconstruction surgery2.
• Other altenatives like fiberoptic bronchoscopy, ventilating bougies
and tracheostomy were ready in case of failed intubation
 In our patient we intubated the case with 6.5 mm uncuffed portex
tube and then exchanged with 7.5 mm uncuffed portex tube
because small tube may cause marked increase in airway resistance.
 The 7.5 mm uncuffed portex tube was replaced with extra pressure
against resistance with some difficulty but this helped in dilating the
intubation tract.
 The surgery was uneventful and the patient was extubated after
thorough examination of consciousness, spontaneous ventilation
and vitals.
 Patient was asymptomatic with no signs of airway obstruction.
 This method of managing a patient with unsuspected narrowing of
airway at supraglottic level is not been reported and we believe that
management of patients with such complication becomes much
easier if planned properly.
• The present case report highlights the
importance of history taking and proper
examination of the patient for probable
narrowing of airway not only at infra glottis as
well as supra glottis areas also.
 REFERENCES
 1. Jyi Lin Wong, SiewTeck Tie, BohariSamril – successful treatment of
tracheal stenosis by rigid brochoscopy and topical mitomycinC : a case
report – Wong et al. cases journal 2010, 3:2
www.casesjournal.com/content/3/1/2
 2. Nimmagadda, Usha Rani MD; Salem, Ramez M. MD; Freidman, Michael
MD; Lenz, Richard F. MD- acute management of unsuspected subglottic
stenosis by tracheal dilation , Anaesthesia& Analgesia april 1995 – vol 80-
issue 4 – pg 841-843
 3. H.F.Mahiew – REVIEW ARTICLE : the laryngological manifestation of
reflux disease; why the scepticism? – Aliment pharmacolTher 26 (supp 2),
17 – 24
 4. Koufman JA – the otolaryngologic manifestations of gastroesophageal
reflux disease (GERD): a clinical investigation of 225 patients using
ambulatory 24 hour pH monitoring and an experimental investigation of
the role of acid and pepsin in development of laryngeal injury –
Laryngoscope 1991 apr;101 (4 pt 2 suupl 53) 1- 78.
 5. Review article – clinical manifestation of laryngopharyngeal reflux –
2002 GALE GROUP.
 Dr T . Tanmayee M.D 2nd yr
Dr J. Madhavi [ Asst prof ]
Dr Pavani kalyanam [Asso prof ]
Dr C G Raghuram [Professor &
HOD]
Department of anaesthesiology ,
Osmania Medical College /
Osmania General Hospital,
Inadvertant subarachnoid injection Hyderabad,
of local
anesthetic during interscalene block – ATelangana

rare complication
• Several reports have described spinal or epidural anaesthesia
resulting from attempted blockade of brachial plexus by
interscalene route. Total spinal anaesthesia though very rare
maybe due to anatomic variations , technical performance or
both
• A 14 yr old patient , ASA grade 1, with fracture humerus
middle1/3rd was posted for ORIF
• Interscalene approach of brachial plexus block was planned
• Under aseptic precautions using peripheral nerve locator 25ml
of 1.5% lignocaine with adrenaline injected at C6 level
• Patient became unconscious and apnoeic immediately after
injection , hypotension [60/40 ] was noted
• Patient became almost totally areflexic
• Patient was intubated immediately without any resistance
whatsoever
• Respiratory efforts returned after 15 min , meanwhile patients
hemodynamics improved , decided to go ahead with surgery
[mutual decision] anaesthesia continued with O2
+N2O+sevoflurane with controlled assisted respiration
• Surgery lasted 1 ½ hr. Course of surgery and anaesthesia
uneventful.
• At the end of surgery patient was given 100% oxygen for 10
mins . Patient regained consciousness and reflexes completely
. Extubated uneventfully . Analgesic effect was evident for
4hrs in the postoperative period.
REFERENCES-
1. Fernandez-mere LA, sopena-zubiria LA , Gil-soria L
,Alvarez-blanco M .Spinal anaesthesia after brachial plexus
block 2008
2. Frasca D , Clevenot D, jeanny A , Laksiri L ,Petitpas
F,Debaene B. Total spinal anaesthesia after interscalene
plexus block 2007
THANK YOU……
 USE OF FLEXOMETALLIC
TUBE NOT ALWAYS SAFE

PRESENTOR- TAMBAKE SHRASTI

Guide: DR HABEEB REHMAN
DR SAMPATHILA PADMANABHA, HOD
YMC, MANGALORE
 INTRODUCTION
• Endotracheal intubation is performed to secure the airway.

• But the tube itself can cause obstruction to secured airway which is life
threatening.

• Use of FMT is very common in head and neck surgeries, neurosurgeries,

maxillofacial surgeries and surgeries in prone position due to its kink
resistant frame work.

• As the FMT are embeded with metallic or nylon spirals in its walls for its
reinforcement and give kink resistant structure. kink and obstruction do
occur due to bite of the tube in lighter plane of anaesthesia or following
ETO sterlisation due to deformation of spirals
• After ETO sterlisation, the spirals may get dislodged or loosened from its
place or due to expansion of bubbles in the walls of FMT on using nitrous
oxide which dissects the tube and its spirals. Therefore always make sure
to check the tube meticulously for its obstruction or kink or dislodgement
of spirals before reusing it.

• I would like to put forward a case report of unnoticed occlusion of lumen

of reused FMT.
 CASE REPORT
• A 19y male weighing50 kg and height of 150cm scheduled for lefort
osteotomy I under general anaesthesia with 8.0mm cuffed reused FMT
(Mallinckrodt Co Contour oral /nasal tracheal tube cuffed) . on routine
checking, reused FMT appeared normal and stylet could easily pass
through it.

• The patient on preanaesthetic evaluvation was of ASA I. Airway

assessment showed MPII, TMJ- normal, TMD- 3finger. Preoperative
routine investigations were within normal limit. Patient was prepared for
surgery with NPO, informed consent and premedicated with inj.
Glycopyrolate 0.2mg IM 45mins befor surgery. Pt shifted to OT

• Monitors connected and baseline parameters recorde within normal

limits. IV line secured with 18G cannula on left dorsum of hand. Patient
was intubated according to our institution standard protocol.
• After intubation, resistance felt on bagging, on auscultation BLAEE equal ,
oxygen saturation 100%, ETCO2 rising, vitals were stable.

• we suspected tube block, tried to pass 16F suction catheter, could not pass
beyond 18cm. suspected obstruction of the tube and planned for exchange of
tube.

• Tube was removed and reintubated with new 7.5mm FMT by direct
larygoscopy. BLAEE, oxygen saturation was100%. Then transmyelohyoid
intubation done . intraoperative and extubation was uneventful.

• On thorough inspection of the extubated tube noticed a mark at the level of

the cuff with the cuff intact. This shows that it was not due to the bite of
patient , it is due to loosening of the spiral coils embedded within the walls of
FMT and obstructing the lumen of the tube
 DISCUSSION
Anaesthesiologists should be very vigilant all the time, especially in cases
where the airway is shared with the surgeon.

Causes of obstruction

Ventilator associated
• Inappropriate settings
• Malfunction

Circuit associated
• Fluid pooling in circuit
• Fluid pooling in filter
• Kinking in circuit
ET tube obstruction
• Sputum, blood clot, bite
• Dissection of internal wall of FMT

Increased airway resistance

• Endobronchial intubation

Patient related
• Bronchospasm
• Decreased respiratory compliance
• Always whenever high airway pressures are encountered after ET
intubation , one should rule out mechanical causes before suspecting pts
pathology.

• Ersa Mercanoglu et al the recommended maneuvers for increased airway

pressure in suspicion of an obstruction is passing a suction catheter
through the tube and performing fibre optic bronchoscopic examination

• Ersa et al reported a case of ET tube obstruction during anaesthesia with

use of nitrous oxide or even without nitrous oxide exposure due to heat,
ethylene oxide, glutaraldehyde solution and stretching of FMT.

• Tose R et al 5 reported a case of obstruction of reinforced ETT during

laryngeal surgery under TIVA. This case shows obstruction complication
that can be seen even without any use of anaesthetic gases.
• Chalkeides et al presented a case where airway compromised due
to bite causing leak in the tube intraoperatively during
neurosurgical operation.

• Rashmi et al In case of block of tube due to bite can be prevented

by use of bite block or Guedel airway.

• Therefore reinforced tubes should not be taken as safe guard

against airway obstruction .

• Paul M et al says as the tube has been used multiple times without
any complication, the dissection was likely caused by reuse and
washing . gradual diffusion of nitrous oxide into space would have
enlarge the size of bubble as reported even during anaesthesia
without nitrous oxide. Cutting costs by reusing ETT which are not
meant to be re autoclaved is likely to be at the expense of patient
safety and therefore cannot be justified.
 CONCLUSION

This case high lights about whenever high airway pressures

encountered after ETT, one should rule out mechanical

causes before suspecting pts pathology. To avoid a

complication, such as dissection of wall of ETT, avoid use of

reused and resterlised ETT which could be the main cause of

obstruction of ETT
 REFERENCES
• Rashmi Jain, Nitin Sethi, Jayshree sood: loss of integrity of reinforced endotracheal tube by
patient bite. IJA; july aug 2013; 57(4):424
• Surya Kumar Dube, Mihir Prakash Pandia,Varun Jain: Kinking of patent FMT due to
dislodgement of reinforcing spirals. Journal of Anaesthesiology clinical pharmacology; july sep
2013;29(3):408-409
• Ersa Mercanoglu, Dreya Topuz, Nurkaya: the dissection of reinforced ETT internal wall causing
intraoperative airway obstruction under GA- Case report. Rev. Bras. Anesthesiolo july aug
2013;vol 63 no 4 campinas
• Rao Gannes, Umamaheswara M, Ali, Zulfiqar, Ramkiran, Seshadri, Chandrasekhar Horkote:
Dissection of reinforced ETT causing near fatal intraoperative airway obstruction.Anaesthesia
and Analgesia Dec 2006;103(6):1624-1625
• Tose R, Kubota T, Hirotak, Saka T, Ishihard, Matsuki A: Obstruction of reinforced endotracheal
tube due to dissection of internal wall during intravenous anaesthesia. Masui 2004 ;
Nov;52(1): 1218- 20

• Paul M, Ducck M, Kampe S, Petzeke F: Failure to detect an unusual obstruction in a

reinforced endotracheal tube with fibre optic examination; Anesth Analg ; 2003; 97: 909-10
• Malhotra D, Rafiq M, Qazi S, Gupta SD: ventilator obstruction with spiral embede tube – Are
they safe? ; IJA; 2007;57: 432-3
ANAESTHETIC MANAGEMENT OF BIL. RAS
AUTHOR :
FOR LEFT SPLENO-RENAL ANASTOMOSIS
AUTHOR:Dr.U.Swathi(PG);Dr.R.Raghu;Dr.R.Bhaskar Rao(Asst.prof‘s)
Dr.BABY RANI(Assoc.) Dr.C.G.RAGHURAM (HOD) OGH ,HYD.
17 yr old male patient a case of accelerated hypertension diagnosed as
bil.Renal artery stenosis(Renal Angio:B/L Ostial St >90%) , after failed
endovascular Rx , referred to OGH and planned for left SPLENO-
RENAL ANASTOMOSIS(left EARBS).
Rx-Nifedipine 20mg tid,Clonidine 100mcg tid, Prazosin
5mg bd,Hydralazine 25mg tid,Carvedilol 3.625 mg bd
General examination:Thin built , AIRWAY–MPG-I
CVS : S1 S2 (+) , A2 loud , systolic murmur (A)area
INVESTIGATIONS:Hb 10.5gm% ,Sr.cr.:1.8mg/dl HYDRALAZINE 25mg
CXR:Cardiomegaly(+),2D-ECHO:EF-40%,global
hypokinesiaof LV,trivial AR,MildLVdysfunction. .
USG KUB & Renal Doppler:(Aorto arteritis
with Bil. proximal renal artery stenosis of >90%)
CT-ANGIO:Diffuse thickening of distal thoracic upper abdominal
aorta,bil.long segment occlusion of renal arteries
Pre-op vitals PR: 86/min;BP:160/110mm Hg;Heart:Systolic
murmur Ar. area ;SpO2:100% with O2 @ 5L/min.
ANAESTHESIA TECHNIQUE :Epidural.A (T10) +
GA : Morphine,Rocuronium,Dexmedetomidine
Desflurane 2-4%, IPPV (ventilator) O2+N20.
Maintainence : NTG & Dobutamine @ 5µg/kg/min;
I.v NAC ; I.v Dextran40 500ml with other I.V fluids
Monitoring: ECG, IBP, SpO2, EtCO2,
CVP(Rt.Subclavian vn.),Urine output. Perioperative
period was uneventful and hemodynamically stable.
Post-op Analgesia:Buprenorphine 300mcg+0.125%
bupivacaine(300ml) multirate infusor @ 3ml/hr
Post-op:patient shifted to ricu for elective ventilation and extubated on
2nd post-op day. Blood pressure stabilised above 120/80mmHg
 Follow-up: Patient blood pressure maintained around 120/80mm Hg
with DepinRetard 10mg tid & Arkamine 100mcg od
& S.creatinine reduced to 1.2mg/dl
DISCUSSION:
Anesthetic management for EARBS is quite
challenging & should take in consideration the
cardiac and cerebrovascular status, the renal
dysfunction,antihypertensive drug therapy, and
control of hemodynamics.The aim should be to CT ANGIO on 10th POD

avoid LV dysfunction to preserve renal blood flow( B.P should be above

80mm Hg to protect kidneys and spinal cord).Adequate I.V hydration
with CVP as guide,optimization of hemodynamic status,correction of
acid-base disturbance, avoidance of sepsis and nephrotoxic drugs.
REFERENCES:Kumar B, Sinha PK, Unnikrishnan M. Anesthetic
management of patients undergoing EARBS for renovascular HTN;
BrestAN, Bower R. Renal arterial Hypertension.
 ANAESTHESIA FOR A PATIENT WITH SITUS
INVERSUS TOTALIS POSTED FOR
EMERGENCY CAESAREAN SECTION

AUTHORS :
Dr S.UMA SOUJANYA (PG STUDENT),
Dr.R.PADMAJA (ASSISTANT PROFESSOR),
Dr.V.HARINATHA BABU (PROFESSOR & HOD),
Dr.A.S.KAMESWARA RAO (PROFESSOR OF ANAESTHESIOLOGY & DEAN),
KONASEEMA INSTITUTE OF MEDICAL SCIENCES & RESEARCH FOUNDATION
AMALAPURAM
 INTRODUCTION
• Situs inversus totalis is a congenital visceral malrotation anomaly that
results from disturbance in establishment of right left asymmetry. It can
exist as a part of Kartagener’s syndrome or Immotile cilia syndrome and
also independent of them.

CASE REPORT
• A 20 yr old female of primi gravida with Situs inversus totalis with history
of Bronchial asthma, recurrent childhood respiratory tract infections
came for emergency caesarean section.
• On examination heart sounds are heard on right side. Her chest x ray &
2D ECHO showed dextrocardia with structurally normal heart.
• Preoperatively she was evaluated for associated congenital deffects like
cardiac disease, spine deformities, respiratory tract & airway
malformations.
• Spinal anaesthesia was given. All the vitals remained stable.
Intraoperatively she developed wheeze for which she has been treated &
got relieved.
A CASE OF SITUS INVERSUS :
1.CHEST X RAY SHOWING DEXTROCARDIA
2.PATIENT WITH LEADS IN REVERSE
MANNER
3.ECG SHOWING DEXTROCARDIA
 CONCLUSION
• In congenital anomalies like situs inversus, careful evaluation
for associated defects and proper planning of anaesthesia
technique can prevent the patient from complications.

REFERENCES
1) Bajwa SJ, Kulshrestha A, Kaur J, Gupta S, Singh A, Parmar SS. The
challenging aspects and successful anaesthetic management in a case of
situs inversus totalis. Indian J Anaesth 2012;56:295-7.
2) J Singh, I Muntyan, Y Fulman. A patient with Situs Inversus without ciliary
dysfunction presenting for urgent Cesarean Section: considerations for a
safe anesthetic. The Internet Journal of Anesthesiology. 2007 Volume 16
Number 2.
3) Reidy J, Sischy S, Barrow V. Anaesthesia for Kartagener’s syndrome. Br J
Anaesth 2000;85:919-21.
4)Mathew PJ, Sadera GS, Sharafuddin S, Pandit B. Anaesthetic considerations
in Kartagener's syndrome -- a case report. Acta Anaesthesiol Scand 2004;
48(4):518-520.
 A comparative study of effects of sitting and lateral
positions on quality of block during induction of
spinal anaesthesia in patients undergoing elective
caesarean section

Dr Varun ; Dr. Chevuri ; Dr J.V.Subba Rao

Department of Anaesthesiology
Deccan college of medical sciences
Hyderabad
 AIM OF STUDY

• To assess effect of posture on quality of spinal block in patients undergoing

caesarean section
• To compare sitting and lateral positions during spinal

MATERIALS AND METHODS

40 parturients
Group I Group II
2.2 ml hyperbaric bupivacaine 2.2ml hyperbaric bupivacaine
SITTING POSITION LATERAL POSITION

EXCLUSION CRITERIA
• Patients of height more than 5.2 feet or less than 5 feet
• Patients with multiple pregnancy
• Patients with polyhydramnios
• Patients other than ASA grade l
 RESULTS , BLOCK AT 1 MINUTE
HAEMODYNAMICS
20 8
15 Hypotensive
T6-T4 6 episodes
10
T7-T10 4 bradycardia
5
Column1
0 2
Column1
l ll 0
RESULTS , BLOCK AT 5 MINUTES l ll
QUALITY OF SENSORY BLOCK
15 20
Good no
15
10 T4-T6 pain
10
5 T7-T10 mild pain
5
Column1 0
0 Column1
l ll l ll
RESULTS BLOCK AT 45 MINUTES QUALITY OF MOTOR BLOCK
20 15
15 10 Excellent
T4-T6
10 good
T7-T10 5
5 Column1
Column1 0
0
I ll
 REFERENCES
• Effect of posture and baricity on the spread of intrathecal
bupivacaine for elective caesarean delivery . Stephen P
hallworth , Roshan fernando et al Anaesth-Analg 2005 ; 100 ;
1159 – 1165
• Maternal position during induction of spinal anaesthesia for
caesarean section. A comparison of right lateral and sitting
positions . A Inglis , M Daniel , E.Mc Grady ;Anaesthesia 1995 ,
volume 50 , pages 363-365
• Comparison of maternal and neonatal effects of combined
spinal epidural anaesthesia either in sitting or lateral
position during elective caesarean section . E ce Dumanlar
Tan , BerrinGunaydin , turk J Anaesth reanim 2014; 42 ; 23-32
• Intrathecal drug spread , G Hocking and J.A.W Wildsmith ,
BJA 2004 , 93(4) 568-578 .
MANAGEMENT OF A CASE OF BLUNT INJURY
THORAX AND ABDOMEN
Dr. Veera Babu – Final Year PG, Dr. R. Pratap – Prof and HOD,
GSL MED. COLLEGE AND GEN. HOSPITAL, RJY.
• A 38 year old male patient presented with crush injury over the chest
and abdomen to the ER.
• Pt was dyspneic, unconscious and disoriented at the time of
presentation.
• Vitals : BP : 76/ 44 mm of Hg; PR : 132/min, regular rhythm, low
volume; spo2 : 90% with O2 @ 15 l/min.
• Initial assessment of the patient was done using injury severity score
(ISS) which is > 25, with 4 rib fractures on the left side, splenic
rupture and hemoperitoneum, suspected traumatic diaphragmatic
rupture.
• Resuscitation was contemplated with primary survey of establishing
airway in the ER and a poor GCS of 7. There was little time for
secondary survey as the patient was taken up for emergency life
saving surgery.
• A 7 Fr central venous catheter was inserted through Rt. IJV and BP
was maintained with colloid throughout the procedure.
• Maintenance of anesthesia was done with O2/ N2O mixture,
minimal inhalation agent, Inj. Vec, narcotic analgesic( fentanyl).
• Rib fractures were sutured, diaphragmatic rupture was repaired and
splenectomy was done.
• Intraoperative period was otherwise uneventful.
• Post operative elective ventilation was planned in view of poor chest
wall compliance. Thoracic epidural was established at T4-T5 level.
0.2% ropivacaine in a volume of 6 to 14 ml/hr was infused for pain
relief.
• After two days of elective ventilation weaning started and extubated
on 3rd POD following weaning protocol.
• Intermittent CPAP therapy was given during periods of hypoxia for
another 2 days.
• Patient recovered well and discharged on 9 th POD.
• References :
• 1) Attar S, Kirby WH. The forces producing certain types of thoracic trauma. In
Daughty D C (ed). Thoracic trauma, Little Brown, Boston 1980;7.
• 2) Trunkey D. Initial treatment of patient with extensive trauma.New Eng J Med
1991;324: 1259-1263.
• 3) Westaby S, Brayley N. Thoracic trauma-1, Brit Med J 1990;300:1639-1643.
 INTRODUCTION
• Surgical (subcutaneous) emphysema is one of the known
complications of laparoscopic (lap) surgery.

• There is presence of gas within the tissue beneath the skin. The
incidence reported in literature is 0.3 to 3% 1.

• The risk is more in elderly patients undergoing laparoscopic

extra peritoneal surgery with more than 5 entry ports, use of
high insufflation pressure (>14mm Hg) and prolonged surgical
time2.

• Here We describe a case of massive surgical emphysema

during laparoscopic inguinal hernia repair which was detected at
the end of surgery
A CASE REPORT OF MASSIVE SURGICAL
EMPHYSEMA DURING LAPAROSCOPIC
HERNIA REPAIR

PRESENTING AUTHOR:DR VENKATESH

CO-AUTHORS:DR PM VELANKAR(PROF)
DR WS THATTE(PROF&HOD)
DR MARY SAMUEL(PROF)
 INTRODUCTION
• Surgical (subcutaneous) emphysema is one of the known
complications of laparoscopic (lap) surgery.

• There is presence of gas within the tissue beneath the skin. The
incidence reported in literature is 0.3 to 3% 1.

• The risk is more in elderly patients undergoing laparoscopic

extra peritoneal surgery with more than 5 entry ports, use of
high insufflation pressure (>14mm Hg) and prolonged surgical
time2.

• Here We describe a case of massive surgical emphysema

during laparoscopic inguinal hernia repair which was detected at
the end of surgery
 CASE REPORT
• A 60 year old male hypertensive patient weighing 60 kg and well controlled on
medication was posted for lap hernia repair under general anaesthesia(GA).

• Pre anaesthetic evaluation including investigations were normal. Conventional

pre anaesthetic medication was administered intravenously on operation table
followed by conventional balanced endotracheal GA and controlled mechanical
ventilation in closed breathing system with soda lime. He was monitored with
pulse oximeter, electro cardiogram(ECG) and end tidal carbon dioxide(Et CO2)
monitor.

• CO2 was used for insufflation under pressure of 10-14 mmHg. After 30 min of
surgery it was noticed that Et CO2 was steadily increasing from base line values
of 30-35mmHg to 50-55mmHg.

• During surgery pulse rate varied between 76 to 95/min and arterial blood
pressure between 134 to 153mmHg systolic/ 78 to 94mmHg. diastolic.
• Efforts were made to look for possible causes of raised Et CO2 such as
kinking or obstruction of tracheal tube(TT), bronchial displacement of TT,
light plane of anaesthesia, bronchospasm and exhausted soda lime. All
these causes were ruled out

• We continued to hyperventilate the patient mechanically by increasing the

tidal volume and respiratory rate without much improvement in Et CO2.

• The surgery lasted for 130 min. At the end of surgery after dressing of
surgical wounds when the surgical drapes were removed, to our surprise
we noticed swelling of face and neck which was extending up to mid
thighs on both sides and there was crepitus on palpation all over chest,
both arms, abdomen and up to middle of both thighs.

• So mechanical ventilation was continued. Arterial blood gas analysis

(ABG) was done which revealed pH 7.28, PaCO2 64mmHg and bicarbonate
28 mmol/L consistent with respiratory acidosis.
 The patient was then managed in surgical intensive care unit (SICU) on ventilator
for 6 hours during which ABG analysis done thrice at 2 hour interval showed
remarkable improvement.

• By the end of 4 hours ABG report was pH 7.36, paCO2 41mmHg and bicarbonate
25 mmol/L. So the patient was weaned off the ventilator in step wise manner.
Subsequent postoperative course was uneventful and he was discharged home
after 10 days

• Our patient developed massive subcutaneous emphysema, grade 3 on 4 point

scale of subcutaneous emphysema3.

• We failed to detect it intra operatively due to surgical drapes. Though we

diagnosed this complication late, we were able to manage it successfully without
any other morbidity.
 CONCLUSION
• However we strongly suggest that during laparoscopic surgery vigilance and
extreme caution must be taken to promptly recognize and treat this condition.

• Frequent examination and palpation of abdomen and chest wall should be done
to detect subcutaneous gas accumulation during surgery.

• REFERENCES:
1 Gutt T, Onin T, Mehrabi A, Schemmer P, Kashfi A, Kraus T et al. Circulatory and
respiratory complications of carbon dioxide insufflation. Dig Surg 2004;21(2) : 95-105

2 Singh K, Singhal A, Saggar VR, Sharma B, Sarangi R. Subcutaneous carbon dioxide

emphysema following endoscopic extra peritoneal hernia repair : possible
mechanism. J laparo endosc Adv Surg Tech A . 2004; 14(5) : 317-320

3 Sumpf E, Crozier A, Ahrens D, Brauer A, NeufnagT, Braun U. Carbon dioxide

absorption during extra peritoneal and trans peritoneal endoscopic hernioplasty.
Anesth Analg 2000;91:589-595
 ENDOTRACHEAL TUBE FIXATION: AN
UNSUAL PROBLEM
• Introduction: Dr. VIJAYAKRISHNA
Dr. AMRUT RAO MD.
• ETT are often plastered and fixed in the operation theaters and
in the Intensive Care Unit (ICU) for ventilation in most of the
hospitals. The ASTM/ISO standard requires that the external
diameter of inflation tube of the ETT does not exceed 2.5 mm
and recommends that it be attached to the tube at a small
angle.[1] The standard also specifies the distance from the tip of
the tube to where inflation tube is attached and requires that
there should be at least 3 cm distance between the machine end
of the inflation tube and the pilot balloon.
• But there hasn‘t been any particular standard guideline for
fixation of the ETT(Endotracheal Tube) with regards to
inclusion or exclusion of the ETT cuff tubing.
• We report one such incidence, where the ETT cuff tubing
snapped from the tube itself while plaster was being changed
to re-adjust the ETT.
• There have been a few case reports of similar problem like ours [2],
but definitive practice guidelines for fixation of ETT is not
available at present.
Case Report:
• 28 year old male patient was
brought into our ICU after a
RTA with an ETT secured in
the casualty. The patient had a
head trauma, with a GCS of 8,
stable vitals but shallow respiration. The patient required mechanical
ventilation and was connected to a ventilator on Synchronised
Intermittent Mandatory Ventilation (SIMV)mode.
• We noticed that the patients breath sounds was lesser on the left
side on auscultation. The plastering of the ETT was also soaked
with secretions. After thorough oral suctioning the plastering was
attempted to be removed, but it resulted in snapping of the ETT cuff
tubing from the exit point on the ETT as a whole unit (Figure-1)
and the cuff was deflated. With careful handling we managed to
change the ETT with the help of a tube exchanger. We secured the
ETT this time with plasters excluding the cuff tubing.
• Like stated earlier, there is no particular guideline (some guidelines
are reported [3] but not standardized) as to whether the cuff tubing is
included along with the ETT while plastering or not. This problem
can be avoided if we use preformed ETT fixators (which some
companies manufacture) or in some ETT where the cuff tubing is
embedded for some length before separating from the tube more
distally from the patient end (like in a Flexo Metallic Tube).
• From our experience and a few other reported articles we feel that
the cuff tubing has to be excluded completely while plastering the
ETT. If included it should not be included for one circle and
avoided the next as the chances of kinking will be higher in such
instances. [3]
• Reference:
• Anaesthetic and respiratory equipment- tracheal tubes and
connectors (ANS/ISO 5361) New York, NY: 1999. American
National Standards Institute/ International Standards Organization.
• Bhandari S, Gupta SP, Gupta K, Kumar A. Accidental
intraoperative avulsion of external inflation tubing of armored
endotracheal tube. J Anaesthesiol Clin Pharmacol. 2012;28:132-3
• Gupta B, Farooque K, Jain D, Kapoor R. Improper tube fixation
causing a leaky cuff. J Emerg Trauma Shock. 2010;3:182–4.
INTRODUCTION –
 The Cormack-Lehane 2 – (in inexperienced hands may prove to
be difficult) - managed by head position, neck tilt changes, usage
of stylets, external laryngeal manouevers (1)
 Various invasive equipment / technique (ex : Flex-It stylet – FIS,
Parker Medical, Highlands Ranch, CO, USA or the Endotrol
tracheal tube or laryngeal lift)
 Tracheal tube manouevres – reflective intubation (2)
 Scissor-like manouevre - helps increase the success rate of the
very first intubation attempt

TRACHEAL TUBE – SCISSOR-LIKE

MANOUEVRE
DR VIJAYALAKSHMI SIVAPURAPU
  PVC tracheal tube with Scissor-like
manouevre using middle and ring
fingers at the holding point of tube
 Bends tube to allow for more
anterior insertion / straightening it
for increasing radius of curvature
 Simple, easy to perform and
expedient approach
 Manual modification of tracheal tube
during ongoing laryngoscopy
 Comparative scientific investigation
with existing methods warranted
(stylets, ELM, introducers, etc.)

THE MANOUEVRE & ITS ADVANTAGES

 Difficult airways, especially with anteriorly placed larynx –
accessed by the scissor-like manouevre, without use of external
laryngeal manouevre
 Bending of tube used commonly than straightening of tube
 Learning was easy for postgraduates and they found it to be a
simple method to access difficult airways
 Comparative research being done to ascertain its utility
 ? Perhaps an intermediate role in airway algorithms
 References –
• Miller RD et al. (editors): Anesthesia 7th Ed,
New York, 2010, Churchill Livingstone
• Biro.P. Reflective Intubation : a simple and effective method to improve
intubating conditions by elevating the tip of the tube without additional
equipment. Br J Anaesth 2013;111:505-6

MY EXPERIENCE WITH THE TECHNIQUE

Anaesthetic Challenges in a Pregnant patient with
Post Mitral Valve Replacement
Complete Heart Block and Coagulopathy
Coming for Emergency Caesarean

Dr. Vinodha devi. V

Dr. Dhanabagyam. G
Dr. Thiruvarul Santhoshini, Dr. Arun Shankar. R
PSG Institute of Medical Sciences and Research
Coimbatore
Post MVR/Complete Heart Block - Caesarean
 24 yr / primi; RHD - post  On assessment, she had
developed cardiac failure
MVR on oral anticoagulants  HR reset to 50/min
 Booked case lost her follow up  Anti - cardiac failure measures
 Echo - good LV function
after 30 weeks, came @ 37
moderate PAH
weeks of gestation with PROM

 On admission; HR- 40/min, BP  Hb - 8.6 gm%

 PT - INR - 2.9
100/60 mmHg, Asymptomatic

 ECG - Complete Heart Block  Indication for LSCS - CPD

 Temporary pacemaker (®IJV)-  IE & Anti -Aspiration
Prophylaxis were given
HR @ 80/min in VVI mode
Post MVR/Complete Heart Block - Caesarean
Anaesthetic challenges Intra operatively
 Post MVR / Warfarin Induced  ASA monitors; USG guided
Coagulopathy CVC Lt IJV for CVP, IBP

 CHB on Temporary Pacemaker  Paced HR was set at 50 /min

 Cardiac Failure  Rapid sequence induction

 Hemodynamically stable
 FFP / PRBC transfusion -
volume Overload  Uterus Well Contracted, No
excessive bleeding
 New CVC for monitoring and
 Electively ventilated &
inotropes - needed
extubated
Optimised over a period of 3h
Post MVR/CHB/Caesarean
 Bridged with LMWH

 On an attempt to remove TPI,

developed pulseless VT & reverted

 Permanent pace maker PPI - VVI

Temp PI, Mechanical valve
mode HR @ 70/min. Recovered well Lt IJV CVC

In patients with asymptomatic CHB,

paced HR should be stepped up
incrementaly

Reference
1. Descarries LM, Leduc L, Khairy P, Mercier LA. Low molecular weight
heparin in pregnant women with prosthetic heart valves. J Heart Valve Dis. Permanent pacemaker, Mechanical
2006;15(5):679-85.
valve
 Expectant management at term
pregnancy in severe coarctation of
aorta and LVOT Obstruction

Dr. Madhavi.Y
2nd year PG, Anaesthesiology
NRI MC & GH
Moderator – Dr.Sk.Masthan Saheb,
Professor & HOD, Anaesthesiology
• 21 year primi, 37 weeks, with
. severe coarctation of aorta &
severe LVOT obstruction for safe confinement.

• 2D Echo & MRI - Severe coarctation (Gradient-120

mmHg), severe LV mid cavity obstruction (Gradient-70
mmHg), concentric LVH with good collaterals.
• Cardiologist & Obstetrician emphasized elective caesarean
section in view of severe CoA and LVOT obstruction to avoid
2nd stage complications and to reduce need for Valsalva
maneouver.

• We agree absolutely with their decision, but we disagree with

their recommendation as the difference between upper &
lower limbs pressures is <20mmHg.

• We have vast experience and worked jointly with

cardiologists and obstetricians for many years caring for
parturients with cardiac disease.
• Unless the mother or fetus is in imminent danger we do not
recommend elective c-section.

• We sited an epidural and provided labour analgesia with

0.125% bupivacaine at the onset of labour and NVD ensued.

• NVD avoids the risks associated with caesarean section.

• Both RA & GA are more likely to induce cardiovascular

instability
• Conclusion :
• In the past, elective caesarean section (usually under general
anaesthesia) was advocated for most women with severe
coarctation.

• Now there is increasing evidence that vaginal delivery with

regional analgesia can produce a good outcome provided
there are good collaterals with minimal pressure gradient as
in this case. .

• References :
1. Dob DP, Yentis SM. UK Registry of High-risk Obstetric Anaesthesia:
report on cardiorespiratory disease. Int J Obstet Anesth 2001;10: 267-72
2. Zwiers WJ. Blodgett TM. Vallejo MC. Finegold H. Successful vaginal
delivery for a parturient with complete aortic coarctation. Journal of
Clinical Anesthesia. 18(4):300-3, 2006 Jun.
3. Singh BM. Kriplani A. Bhatla N. Vaginal delivery in a woman with
uncorrected coarctation of aorta. Journal of Obstetrics & Gynaecology
Research. 30(1):24-6, 2004 Feb.
 Anaesthetic concerns in Mucopolysaccharidosis
Dr. Yogeshwaran . S . M.D Post Graduate,
Department Of Anaesthesiology,
Sri Manakula Vinayagar Medical College And Hospital, Puducherry.
Dr .V. Santhosh M.D Assistant Professor
INTRODUCTION :
•Mucopolysaccharidoses(MPS) is a group of metabolic disorder caused
by the absence or malfunctioning of lyzosomal enzymes needed to break
down glycosaminoglycans (long chains of sugar carbohydrates) that
helps in building bone, cartilage tendons, cornea, skin, and connective
tissue.
•MPS patient most commonly present with ENT problem for surgical
therapy.
•The main anaesthetic concerns in managing patients with MPS are:
• Difficult intubation,
• Chronic pulmonary disease and
• Cervical instability.
• We present a 8 year old child, a case of Type –
I Mucoploysachroidosis posted for
adenotonsillectomy. Clinically child had
abnormal facies of large head, large tongue,
hepatospleenomegaly, and mental retardation.
After a complete pre-op evaluation, patient was
taken for surgery under general anaesthesia
which was uneventfull.

• 12 hours later baby developed nasal bleeding

which was continous, associated with stridor.
So patient was taken for emergency
exploration. On laryngoscopy epiglottis
appeared edematous with Cormack Lehane
class IV and intubated orally with 5 sized
cuffed endotracheal tube.
DISCUSSION :
• The choice of anaesthetic technique is a point of interest in MPS
patient.
• General anaesthesia may be dangerous in MPS patient and when
possible Local anaesthesia with peripheral block should be preferred.
• Generally, oral intubations should be preferred due to adenoid &
tonsil dimensions, besides nasal mucosa weakness.
• The anaesthetic risk can be reduced if anaesthetist anticipates
potential problems that may arise during and after procedure.
This requires a thorough pre operative evaluation of these
patients.
• REFERENCES :
• A. E. P. Jones and T. F. Croley, ―Morquio syndrome and anesthesia,‖ Anesthesiology, vol. 51,
no. 3, pp. 261–262, 1979.
• C. Moores, J. G. Rogers, I. M. Mckenzie, and T. C. K. Brown, ―Anaesthesia for children
withmucopolysaccharidoses,‖ Anaesthesia and Intensive Care, vol. 24, no. 4, pp. 459–463,
1996.
• J. H. Diaz andK.G. Belani, ―Perioperativemanagement of children with
mucopolysaccharidoses,‖ Anesthesia and Analgesia, vol. 77, no. 6, pp. 1261–1270, 1993.
ROLE OF I.V. CALCIUM FOR TREATING
INTRAOPERTIVE REFRACTORY HYPOTENSION
Author: Dr. Kolimi Zeenath Begum (K1811), PG under guidance of
Dr.Abhimanyu Singh, Asso.Professor, Osmania Medical College.
• 25year old male by name Sailu, a k/c/o HTN and CKD (Chronic
Interstitial Nephritis) treated with Clonidine 0.1mg t.i.d, Amlodipine
5mg bd, maintenance HD twice weekly since 6 months posted for Live
donor Renal Transplantation under GA.
•Preop-PR-92/min, BP-144/90 mmHg in supine position .
•Except for renal disease, systemic
examination unremarkable .
•Airway: MPG-I
•Lab reports : Hb-8.5 gm%,
Sr.creatinine -5.6, K+ 5.1, Ca -9.2
ECG-WNL, 2DEcho-EF 70%
no RWMA.
• Right Radial artery cannulation
done under aseptic precautions and local anaesthetic infiltration.
Anaesthetic Management
• GA : Opioid (Fentanyl) muscle relaxation technique – ETT & IPPV.
• Monitoring : ECG, IBP, HR, SPO2, CVP monitoring(rt.subclavian v).
• Maintenance –O2 :N2O, Isoflurane 0.15-1.0%, RL infusion. Prior to
declamping noticed severe hypotension unresponsive to fluid
challenge, NEpi @2mcg/kg/min, Dopamine @5mcg/kg/min, finally
resorted to iv calcium (1gm+1gm 10% Calcium Gluconate), blood
pressure improved and stabilised.
• Surgery resulted in good intraoperative graft perfusion.
• Post operative recovery uneventful & good graft
patency.
• Retrospective review revealed that patient has taken
Tab.Enalapril 5mg preop, possibility of CCB + ACE
Inhibitor has resulted in refractory hypotension.
• Conclusion –A combination of calcium channel blocker and ACE
Inhibitor can result in refractory hypotension in volume depleted CKD
patients and emphasis laid on role of calcium in management of
hypotension.
Discussion:
• Management HTN in CKD patients is often resistant to drug therapy
and patients may be on multiple drugs like CCB‘s,β-blockers , ACE
Inhibitors & vasodilators, ∞-2 adrenergic agonists .In CKD under
anaesthesia interactions with volatile anaesthetics result in
myocardial depression, arrhythmias and hypotension .
• Anaesthesiologist should know about
pharmacology of different classes of
antihypertensives, drug combinations
and anaesthetic interactions
• A combination of CCB &ACE Inhibitor
causing refractory hypotension in CKD
patients, has to be differentiated from
other causes
• I.V. Calcium has a role in treating refractory
hypotension due to CCB‘s
• References: Wylie 7th edition-Pierre Foex