Renal Doppler ultrasonography may have an important role in the detection of acute kidney injury (AKI) in early stages. This study was aimed to determine whether renal Doppler parameters at day 1 can predict the development of AKI at day 5 in acute circulatory failure (ACF). After ethics committee approval and informed written consent from patients or legally acceptable representatives, we recruited n = 80 critically ill adult patients with ACF in this single-center, prospective observational study. Baseline demographic, clinical, and laboratory parameters were noted. Renal resistive index (RRI), power Doppler ultrasound (PDU) score, and their ratio (RRI/PDU) were measured at baseline and three consecutive days. The primary outcome was the development of AKI at day five, and the secondary outcomes were 28-day mortality, length of ICU stay, duration of ventilation, and vasopressor-free days. Out of 80 patients, n = 32 (40

Introduction and aims: Urine output (UO) in response tofurosemide stress test (FST) can predict the progression of acute kidney injury (AKI). This study aimed to assess if changes in UO, urine spot sodium (USS), urine spot sodium creatinine ratio (USSCR) and changes in these parameters over 6 hours could differentiate between progressive and non-progressive AKI. Materials and methods: Fifty critically ill adults with AKI in acute kidney injury network (AKIN) stages Iand II with volume overload were included in this prospective study. The FSTwas performed with 1 mg/kg intravenous bolus. Hourly UO, USS, USSCR, maximum USS difference (USSDMAX), and maximum USSCR difference (USSCRDMAX) were documented. Any progression of AKI was noted till day 3. Results: A total of 50 patients were recruited and n = 10 had progressive AKI (PAKI) and n = 40 had non-progressive AKI (NPAKI). Urine output at 1 and 2 h were significantly less in PAKI group. USS0, USS2, USS6, and USSDMAX were comparable between the groups. USSCR0 and USSCR6 were comparable between the groups whereas USSCR2 and USSCRDMAX were significantly less in PAKI group. USSDMAX did not correlate with UO1 (correlation coefficient 0.2, p = 0.16). However, USSCRDMAX showed a poor but significant correlation with UO1 (correlation coefficient 0.3, p = 0.03). Conclusion: To conclude, hourly UO in the first two hours and maximum change in USSCR within 6 hours following the FST may have an important role in early differentiation of progressive AKI in critically ill patients.

Background: The role of the sympathetic nervous system appears to be central in causing pain in complex regional pain syndrome (CRPS). The stellate ganglion block (SGB) using additives with local anesthetics is an established treatment modality. However, literature is sparse in support of selective benefits of different additives for SGB. Hence, the authors aimed to compare the efficacy and safety of clonidine with methylprednisolone as additives to ropivacaine in the SGB for treatment of CRPS.Methods: A prospective randomized single blinded study (the investigator blinded to the study groups) was conducted among patients with CRPS-I of the upper limb, aged 18-70 years with American Society of Anaesthesiologists physical status I-III. Clonidine (15 mu g) and methylprednisolone (40 mg) were compared as additives to 0.25% ropivacaine (5 mL) for SGB. After medical treatment for two weeks, patients in each of the two groups were given seven ultrasound guided SGBs on alternate days.Results: There was no significant difference between the two groups with respect to visual analogue scale score, edema, or overall patient satisfaction. After 1.5 months follow-up, however, the group that received methylprednisolone had better improvement in range of motion. No significant side effects were seen with either drug. Conclusions: The use of additives, both methylprednisolone and clonidine, is safe and effective for the SGB in CRPS. The significantly better improvement in joint mobility with methylprednisolone suggests that it should be considered promising as an additive to local anaesthetics when joint mobility is the concern.

Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG).

Transmuscular quadratus lumborum block (QLB) may be used as an alternative to psoas compartment block (PCB) for providing analgesia in patients undergoing unilateral, total hip arthroplasty (THA) under general anesthesia (GA). 1-3 Primary objectivesComparison of visual analogue pain scales (VAS) (0-100) at rest & mobilization (walking) at 6hr postoperatively

Sir, Ventricular premature complexes (VPCs) are the premature discharge of ventricular ectopic focus. We report the anaesthetic management of a patient with VPCs who underwent vaginal hysterectomy under single-shot subarachnoid block (SAB). Consent for publication was obtained from the patient. A 45-year-old (52 kg, 165 cm) female, a farmer by occupation, was scheduled for vaginal hysterectomy. She had palpitations for the past 7 years with no relation to routine activity. She was otherwise healthy, active and suffering from no symptoms of breathlessness, chest pain, presyncope, syncope or exercise-induced fatigue. There was no associated comorbidity. Her radial pulse rate was 80 beats/min, which was regularly irregular, and non-invasive blood pressure (NIBP) was 110/78 mmHg. Her systemic examination and investigations were within normal limits. Electrocardiogram (ECG) trace is shown in Figure 1. The 24-h Holter monitoring revealed frequent VPCs of right bundle-branch block morphology with superior axis, left bundle-branch block morphology (4% of total beats) with bigeminy and trigeminy. Two-dimensional echocardiography was suggestive of mild mitral regurgitation, mild tricuspid regurgitation and no regional wall-motion abnormality. with an ejection fraction of 60%. The patient was receiving oral propranolol 40 mg.Figure 1: Electrocardiogram showing multiple ventricular premature complexesWe opted for single-shot SAB given the absence of any structural heart abnormality and short duration of surgery. Emergency resuscitation drugs and a charged defibrillator were kept ready. Preoperatively, oral diazepam 5 mg was used as anxiolytic. In the operation theatre, after placement of standard monitors and five-lead ECG (Lead II and Lead V), the patient was given SAB in sitting position with 10 mg of bupivacaine (heavy) with 25 mcg of fentanyl and a sensory level up to T8 was achieved. The patient was positioned to lithotomy after drug fixation. Following SAB, the rhythm converted into normal sinus rhythm [Figure 2]. After 45 min, sensory level regressed to T10 and the rhythm again became irregular. The NIBP remained stable throughout the surgery. The duration of surgery lasted for 80 min, and the post-operative course was uneventful. Twelve-lead ECG after 24 h was similar to the pre-operative ECG.Figure 2: (a and b) Multiple ectopics before giving subarachnoid block and sinus rhythm for 5 min after giving subarachnoid blockThe goal in the management of this patient was to avoid worsening of VPCs and its haemodynamic implications. Since the patient had no associated haemodynamic disturbances, no antiarrhythmic other than propranolol was suggested. Administering an anxiolytic and providing a calm, quiet environment reduced pre-operative stress and anxiety. Perioperative beta-blocker was continued as it controls symptoms in patients with VPCs from multiple sites.[1] We chose neuraxial anaesthesia as there was no structural or physiological abnormality of cardiovascular system, her effort tolerance was good, and the regurgitant fraction would be reduced by SAB. Neuraxial anaesthesia reduces the stress response and provides effective analgesia compared to general anaesthesia (GA), wherein haemodynamic stress responses have to be blunted during intubation and extubation. In the absence of any pathology, normocarbia, normothermia and analgesia could be well maintained with SAB. The incidence of bradycardia is increased if the sensory block is T5 or higher due to the inhibition of cardiac accelerator fibres, and the incidence is least with a level of T7–T8.[2] We achieved a sensory block height of T8 to avoid severe bradycardia in an already beta-blocked patient. Addition of fentanyl to bupivacaine decreased the dose of bupivacaine needed and ensured a longer SAB without potentially increasing the adverse effects of high local anaesthetics. Studies have shown that sympathetic activity returns to normal after the sensory level has regressed to T10,[3] which might have unmasked the basal stress level in the index patient. Case reports have been published, wherein the neuraxial route has been safely utilised in arrhythmogenic syndromes such as Brugada and congenital sick sinus syndromes.[4] There are case reports of management of patients with benign VPCs using GA. There also are case reports of management of patients with dilated cardiomyopathy with combined spinal–epidural anaesthesia, where giving a small dose of intrathecal local anaesthetic followed by epidural drugs is an effective management strategy.[5] The aim of submitting this case report was to emphasise the fact that after adequate workup to exclude cardiac pathology and electrolyte imbalance and with necessary resuscitative measures as a standby, a patient with VPCs can safely undergo surgery under SAB. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

CONTEXT:Dexmedetomidine, a highly selective alpha-2 agonist has been used as an adjuvant analgesic in vascular, bariatric, and thoracic surgery. We assessed the efficacy of intravenous dexmedetomidine as an analgesic adjunct to local anesthetic infiltration for control of postoperative pain in arthroscopic knee surgery.SETTINGS AND DESIGN:This was a randomized control study performed in a Tertiary Care Hospital.MATERIALS AND METHODS:Forty-five adult patients scheduled for anterior/posterior cruciate ligament reconstruction were randomized into three groups. Group B (bupivacaine group) received bupivacaine intraarticularly and normal saline by the intravenous route. Group D (dexmedetomidine group) received Intravenous dexmedetomidine and normal saline intraarticularly. Group BD (bupivacaine + dexmedetomidine group) received a combination of intravenous dexmedetomidine and intraarticular bupivacaine. Patient's cardiorespiratory parameters, time to first rescue, total rescue analgesic consumption in first 24 h, visual analog scale for pain were assessed.STATISTICAL ANALYSIS:The data were analyzed using analysis of variance and Chi-square test.RESULTS:The time to first request for rescue analgesia was significantly prolonged in Group D and Group BD patients (P < 0.05) compared to Group B. Total rescue analgesic consumption was least in Group BD. Group D and Group BD patients had lower heart rate and systolic and diastolic blood pressure values.CONCLUSION:Intravenous dexmedetomidine in combination with intraarticular bupivacaine decreased perioperative analgesic requirement in patients undergoing arthroscopic knee surgery. However, monitoring and vigilance are essential if dexmedetomidine is used as part of a multimodal analgesic regimen in view of its hemodynamic side effects.

Effective airway management includes anticipating and planning for problems. Difficulties frequently occur as the result of patient characteristics that interfere with spontaneous breathing, bag mask ventilation, laryngoscopy or intubation of the trachea. We are presenting here a case report of a 5 year old child with large sublingual dermoid with bilateral adenoid hypertrophy where successful intubation was done with the use of GlideScope (R).

Pediatric AnesthesiaVolume 23, Issue 10 p. 968-969 Correspondence Unanticipated subglottic stenosis complicating airway management of a child with Langer–Giedion syndrome Kanil R. Kumar, Kanil R. Kumar [email protected] Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this authorMaya Dehran, Maya Dehran Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this authorValluvan Rangasamy, Valluvan Rangasamy Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this authorSrinivasa R. Govindarajan, Srinivasa R. Govindarajan Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this author Kanil R. Kumar, Kanil R. Kumar [email protected] Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this authorMaya Dehran, Maya Dehran Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this authorValluvan Rangasamy, Valluvan Rangasamy Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this authorSrinivasa R. Govindarajan, Srinivasa R. Govindarajan Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiaSearch for more papers by this author First published: 04 September 2013 https://doi.org/10.1111/pan.12249Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Baum VC, O'Flaherty JE. Anesthesia for Genetic, Metabolic and Dysmorphic Syndromes of Childhood, 1st edn. Philadelphia: Lippincot Williams and Wilkins, 1999: 169. Google Scholar 2Graybeal LS, Baum VC, Durieux ME. Anaesthetic management of a patient with tricho-rhino-phalangeal syndrome. Eur J Anaesthesiol 2005; 22: 400–402. 10.1017/S0265021505270679 CASPubMedWeb of Science®Google Scholar 3Michalek P, Doherty JT, Vesela MM. Anesthetic management of a child with Langer-Giedion (TRPS II) syndrome. J Anesth 2009; 23: 456–459. 10.1007/s00540-009-0779-7 PubMedWeb of Science®Google Scholar Citing Literature Volume23, Issue10October 2013Pages 968-969 ReferencesRelatedInformation

OBJECTIVE:The aim of this study is to compare medical therapy alone and medical therapy with add on extraoral glossopharyngeal nerve block in terms of analgesic efficacy and hemodynamic safety in patients with glossopharyngeal neuralgia (GPN). As GPN is a rare disease, our secondary targets were to review the demographic profile of the disease, clinical profile, and any associations with the disease. DESIGN:This was a randomized, prospective, active-controlled, parallel group study conducted from 2007 to 2009 to determine the safety and efficacy of extraoral glossopharyngeal nerve block in GPN and compare it with pharmacological intervention. After institutional ethics committee approval and patient's consent, GPN patients were randomly allocated into two groups. Group A (N = 15) received standard medical therapy (gabapentin 300 mg, tramadol 50 mg TDS, methylcobalamin 500 μgm PO) and group B (N = 15) patients received extraoral glossopharyngeal nerve block together with standard medical therapy. Patients were analyzed for analgesic outcome using numerical pain scale (NPS) and brief pain inventory (BPI) assessing both analgesic effect and degree of interference in quality of life (QOL) during 3-month follow-up. They were also evaluated for any significant hemodynamic alterations. RESULTS:Over the follow-up of 90 days, the mean NPS in group A decreased from 6 ± 2 to 3 ± 2 and in group B from 5 ± 1 to 2 ± 2. From the mean NPS scores, it can be interpreted that both the modalities were effective clinically in treating GPN. However, NPS scores were statistically similar by the end of 90 days. Improvement from baseline in BPI measurement of QOL (mood, interpersonal relationship, and emotion) was earlier in group B (1, 2, and 1 months, respectively) compared with group A (2, 3, and 2 months, respectively). However, there were no significant hemodynamic adverse outcomes after administration of the block. CONCLUSION:This study found that patients in both the groups had significantly lower pain intensities, improved pain relief, and reduced pain interference with QOL, which was especially evident on fourth visit (2 months) after the initiation of treatment regimen. Both were safe and well tolerated. The study advocates rational polypharmacy approach (oral and block) in difficult to treat painful conditions. Further controlled trials are warranted to further define the impact of such a combination therapy.

Tetralogy of fallot (TOF) is the most commonly encountered congenital cyanotic heart disease in pregnant females and maternal mortality approaches 10% in unrepaired TOF. General anesthesia is classically considered the technique of choice for incidental surgery in TOF and neuraxial anesthesia is considered relatively contraindicated. However, general anesthesia for caesarean section can increase maternal morbidity. We report two cases of caesarean section performed under combined spinal epidural (CSE) anesthesia and epidural anesthesia respectively in patients with uncorrected TOF. Adequate preloading to maintain hydration, continuous invasive monitoring, gradual extension of neuraxial blockade by epidural/CSE technique, and judicious use of phenylephrine infusion enabled us to successfully manage both the cases without any complication.

Backgrounds and Objectives: Lumbar-to-thoracic advancement of epidural catheter is a safe alternative to direct thoracic placement in children. In this prospective randomized study, success rate of advancement of two different types and gauges of catheter from lumbar-to-thoracic space were studied. Materials and Methods: Forty ASA I and II children (up to 6 years) undergoing thoracic or upper-abdominal surgery were allocated to either Group I (18G catheter) or Group II (23G catheter). After induction of general anesthesia a pre-determined length of catheter was inserted. Successful catheter placement was defined as the catheter tip within two segment of surgical incision in radio-contrast study. Intra-operative analgesia was provided by epidural bupivacaine and intravenous morphine. Post-operative analgesia was provided with epidural infusion of 0.1% bupivacaine+1mcg/ml fentanyl. Observations and Results: Catheter advancement was successful in 3 cases in Group I and 2 cases in Group II. Five different types of catheter positions were found on X-ray. Negative correlation was found between age and catheter advancement [significance (2-tailed) =0.03]. However, satisfactory post-operative analgesia was obtained in 35 cases. Positive correlation was found between infusion rate, the number of segment of gap between desired level and the level reached [significance (2-tailed) =0.00]. 23G catheter use was associated with more technical complications. Conclusion: Advancement of epidural catheter from lumbar to thoracic level was successful in only 10-15% cases but satisfactory analgesia could be provided by increasing the infusion rates.

The coexistence of hyperthyroidism with gestational trophoblastic disease is a known albeit rare clinical condition. We herein report the successful anesthetic management of such a case in our institute. There are only few case reports in literature of this association. Often, the diagnosis of hyperthyroid state is retrospective one, as it can be missed in the emergency scenario of patient requiring molar evacuation. This case report highlights the perioperative management and optimization of hyperthyroid state prior to surgical evacuation of the invasive hydatidiform mole.

Cochlear implant surgery is commonly performed in small children with impaired communication abilities. In the pre-operative assessment, anaesthesiologist should build up good rapport with the patients and familiarise them with in-the-OT procedures and identify various associated syndromes which have their individual anaesthetic considerations. Intraoperative goals are to maintain stable haemodynamics to provide immobile bloodless field, modulation of anaesthetic technique to allow facial nerve monitoring and to reduce interference with stapedius reflex testing. Average duration of surgery is three hours and blood loss is not much as to warrant transfusion. Reversal and extubation should be smooth to prevent coughing and bulking on the tube to avoid dislodgement on implant. Measures should be taken to prevent post-operative nausea-vomiting and adequate analgesia should be provided. Involvement of primary care providers during pre-operative assessment and their presence in the post-operative period improves communication and ensures comfort to the child.

Purpose A prospective, randomized, double blind, placebo-controlled study was undertaken to evaluate the efficacy of a single preoperative dose of dexamethasone, in different dosages, in providing postoperative analgesia in patients undergoing total laparoscopic hysterectomy (TLH). Method The study included 55 patients randomly divided into three groups. Patients in Groups P, D4, and D8 received saline, 4, and 8 mg dexamethasone, respectively, intravenously, 2 h before induction. Results The time to first analgesic requirement was significantly delayed in patients in the D8 group compared with the D4 group ( P = 0.01) and placebo ( P = 0.01). Total postoperative fentanyl consumption was significantly less in patients in the D8 group compared with the D4 group ( P = 0.01) and placebo ( P = 0.01). Use of 8 mg dexamethasone resulted in a 99.3 mcg decrease in total 24-h fentanyl consumption. Postoperative nausea and vomiting (PONV) was significantly less in the D8 group with a complete response rate (no emetic episodes and no rescue medication for 24 h) of 36.8% compared with the placebo group in which all the patients had PONV. No adverse effects were observed in any group. Conclusion Dexamethasone at a dose of 8 mg given intravenously 2 h before induction, delays patient request for analgesia and reduces total fentanyl consumption and PONV in patients undergoing TLH.