Often conventional Inhalational agents are used for maintenance of anaesthesia in spine surgery. This study was undertaken to compare propofol with isoflurane anaesthesia with regard to haemodynamic stability, early emergence, postoperative nausea and vomiting (PONV) and early assessment of neurological functions.
Patients & Methods:
Eighty ASA grade I &II adult patients were randomly allocated into two groups. Patients in study group received inj propofol for induction as well as for maintenance along with N2O+O2 and the control group patients received inj thiopentone for induction and N2O+O2+isoflurane for maintenance. BIS monitoring was used for titrating the anaesthetic dose adjustments in all patients. All patients received fentanyl boluses for intraoperative analgesia and atracurium as muscle relaxant. Statistical data containing haemodynamic parameters, PONV, emergence time, dose of drug consumed & quality of surgical field were recorded and compared using student t' test and Chi square test.
The haemodynamic stability was coparable in both the groups. The quality of surgical field were better in study group. Though there was no significant difference in the recovery profile (8.3% Vs 9.02%) between both the groups, the postoperative nausea and vomiting was less in propofol group than isoflurane group (25%Vs60%). The anaesthesia cost was nearly double for propofol than isoflurane anaesthesia.
Haemodynamic stability was comparable in both the groups. There was no significant difference in the recovery time between intravenous and inhalational group. Patients in propofol group were clear headed at awakening and were better oriented to place than inhalational group.
Propofol; Isoflurane anaesthesia; spine surgery
To review the anaesthetic management and outcome for emergency laparotomy for paediatric intestinal obstruction in the University of Nigeria Teaching Hospital, Enugu, Nigeria.
The anaesthetic charts and folders of pediatric patients that had emergency laparotomy for intestinal obstruction in the general operating theatre of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, from October 2007 – September 2008 were reviewed. The records were examined for anaesthetic technique, patient primary diagnosis, intra-operative events, blood and fluid therapy and patient outcome. Patients above thirteen years were excluded.
Forty-four out of 285 (15.7%) paediatric patients underwent emergency laparotomy for intestinal obstruction in the general operating theatre. There were 29 males and 15 females. The average age of the patients was 3.75 years. There were a total of 1674 anesthetics in the general operating theatre during the study. The leading causes of intestinal obstruction in this study were typhoid peritonitis (14 or 31.8%), intussusceptions (14 or 31.8%) and congenital anomalies (11 or 25%). Six patients (13%) had a preoperative packed cell volume of less than 30%, while ten patients received intra-operative blood transfusion (21.7%). There was one anesthetic death to give a case mortality rate of 2.2%.
The mortality rate in this study shows the importance and relevance of trained providers of anaesthesia managing paediatric patients in the developing world. Early presentation of patients allowed time for resuscitation and fewer complications before surgery.
Introduction. Suxamethonium, a deepolarizing muscle relaxant, increases intraocular pressure. It is therefore advised to be avoided in open globe surgery, for fear of extruding ocular contents. Several anecdotal reports support this fear. Some workers however, dispute this claim. There is as yet no formal case report in the literature on the subject. Case Presentation. A 34-year old Nigerian male, was involved in a road traffic accident. He presented at the Accident & Emergency Unit of our hospital about 2 hours after the accident. Clinical examination revealed right corneal laceration (with intact ocular contents) and intra-abdominal visceral injury. Emergency laparotomy was scheduled, to be followed with corneal repair. Anaesthesia was induced with 10 mg midazolam, 100 mg ketamine, and 100 mg suxamethonium given intravenously in sequence. After laparotomy, the ophthalmologists reported for the corneal repair, only to find that the vitreous humour has been extruded. Conclusion. The fear about the use of suxamethonium in open globe situations is real. It will be good clinical judgment to use alternative drugs and techniques to effect rapid muscle relaxation, in the anaesthetic management of the open globe patient. This would be of interest to anaesthetists, ophthalmologists and clinical pharmacologists among others.
Emergence from general anaesthesia has been a process characterized by large individual variability. Delayed emergence from anaesthesia remains a major cause of concern both for anaesthesiologist and surgeon. The principal factor for delayed awakening from anaesthesia is assumed to be the medications and anaesthetic agents used in the perioperative period. However, sometimes certain non-anaesthetic events may lead to delayed awakening or even non-awakening from general anaesthesia. We report the non-anaesthetic cause (acute intracerebral haemorrhage) for non-awakening following ventriculo-peritoneal shunt surgery.
Intracerebral haemorrhage; non-awakening from anaesthesia; ventriculo-peritoneal shunt
Both sevoflurane and desflurane have shorter emergence times compared to isoflurane based anaesthesia. Because of its pharmacological properties, desflurane appears to yield a rapid early and intermediate recovery compared with sevoflurane. The aim of this study was to assess the maintenance and emergence characteristics after anaesthesia with sevoflurane or desflurane. One hundred female patients scheduled to undergo daycare laparoscopic gynaecological surgery were enrolled for this prospective study. Patients were randomised into two groups to receive either desflurane [group I (D); n = 50] or sevoflurane [group II (S); n = 50] for maintenance of anaesthesia. The demographic data and the duration of procedure were comparable in both the groups. The early recovery time was shorter after maintenance of anaesthesia with desflurane compared with sevoflurane. However, this faster early recovery failed to lead to early readiness for home discharge. The intraoperative haemodynamic characteristics were comparable with both sevoflurane and desflurane. Both sevoflurane and desflurane provide a similar time to home readiness despite a faster early recovery with desflurane. The intraoperative haemodynamics are similar with both the agents.
Desflurane; outpatient; recovery; sevoflurane
Eclampsia remains a problem in the developing countries despite improvements in antenatal care and emergency obstetric facilities. It is an important cause of maternal morbidity and mortality in Nigeria. A 26-year-old primipara, residing in an urban city in Nigeria with antenatal care facilities, booked for antenatal care at 36 weeks of gestation and was then diagnosed with severe pre-eclampsia. She initially refused therapy and was later booked for an emergency cesarean section. She had eclamptic fits during cesarean section under spinal anesthesia, and the seizure was aborted with intravenous diazepam. The postoperative period was uneventful. Progression of pre-eclampsia to eclampsia during cesarean section under spinal anesthesia is rare, but it can occur. Early booking for antenatal care to enable an early diagnosis and treatment are necessary to prevent the progression of pre-eclampsia to eclampsia. There is need to educate the populace on the importance of ante natal care so as to improve its utilization.
Antenatal care; cesarean section; eclampsia; spinal anesthesia
This paper provides a detailed overview and discussion of anaesthesia in patients with mucopolysaccharidosis (MPS), the evaluation of risk factors in these patients and their anaesthetic management, including emergency airway issues. MPS represents a group of rare lysosomal storage disorders associated with an array of clinical manifestations. The high prevalence of airway obstruction and restrictive pulmonary disease in combination with cardiovascular manifestations poses a high anaesthetic risk to these patients. Typical anaesthetic problems include airway obstruction after induction or extubation, intubation difficulties or failure [can’t intubate, can’t ventilate (CICV)], possible emergency tracheostomy and cardiovascular and cervical spine issues. Because of the high anaesthetic risk, the benefits of a procedure in patients with MPS should always be balanced against the associated risks. Therefore, careful evaluation of anaesthetic risk factors should be made before the procedure, involving evaluation of airways and cardiorespiratory and cervical spine problems. In addition, information on the specific type of MPS, prior history of anaesthesia, presence of cervical instability and range of motion of the temporomandibular joint are important and may be pivotal to prevent complications during anaesthesia. Knowledge of these risk factors allows the anaesthetist to anticipate potential problems that may arise during or after the procedure. Anaesthesia in MPS patients should be preferably done by an experienced (paediatric) anaesthetist, supported by a multidisciplinary team (ear, nose, throat surgeon and intensive care team), with access to all necessary equipment and support.
Electronic supplementary material
The online version of this article (doi:10.1007/s10545-012-9563-1) contains supplementary material, which is available to authorized users.
Eight patients with ruptured aneurysms during induction anaesthesia and endotracheal intubation underwent an emergency "rescue clipping" of their lesion. Three patients died. Of the five survivors three made a good final recovery, one patient was moderately disabled and one remained in coma. Conservative management of this crisis is doomed to failure but the comparatively good outcome of the operative cases supports emergency "rescue clipping".
A total of 300 consecutive anaesthetic axillary blocks was performed over a period of 18 months in 291 patients. These blocks were carried out for emergency and elective hand surgery. Patients did not require any preparation or starving; 20-30 ml of 1% prilocaine according to the size of the patient is used for the block. A minimum induction time of 45 min is needed and patients are able to leave the hospital 20 min-2 h after operation, depending on the nature of the operation. No operation had to be abandoned due to failure of the block. Eleven patients required further injection of local anaesthetic during the operation. The duration of operations ranged from 10 to 130 min. Only 20% needed postoperative analgesia. The technique is easy to perform, it is safe and has long-lasting analgesic effect. It is an efficient, economical method of treatment, well tolerated and often preferred by patients. We think axillary block anaesthesia should be more generally used in hand and orthopaedic units.
Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery.
We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively.
A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.
Pulmonary hypertension is a rare condition and in combination with pregnancy, it can result in high maternal mortality. Mitral stenosis is one of the complicated cardiac diseases that may occur during pregnancy. In this report, we describe our management of such a case, which was even more difficult in combination with pulmonary hypertension, mitral stenosis, and aortic and tricuspid valve insufficiency requiring emergency caesarean section under general anaesthesia.
A 29-year-old primiparae was presented to the anaesthetic department for an urgent caesarean section with a diagnosis of severe pulmonary hypertension in combination with mitral stenosis. The patient was hospitalized prepartum and received oxygen therapy and anticoagulation with heparin. The patient was monitored during labour and delivery with oximetry and arterial and central venous pressure line. Pulmonary arterial lines were not used due to an increased risk and questionable usefulness. Echocardiography revealed a systolic pulmonary arterial pressure of 75 mmHg, and mitral stenosis, aortic and tricuspid valve insufficiency.
We decided to proceed under general anaesthesia. Anaesthesia was induced with etomidate, and succinylcholine. Dopamine and nitroglycerin infusion was preoperatively started and infusion was also preoperatively continued. Hemodynamic parameters were stable during delivery. Neonatal weight and apgar score were satisfactory. After the delivery of a healthy baby, oxytocin was administered. Surgery was completed uneventfully. During the postoperative period, the patient received furosemide and morphine. As the arterial blood gas analyses were stable and the chest-ray was normal, the patient was extubated postoperatively in the second hour in ICU.
Patients with significant multivalvular heart disease require careful preoperative, multidisciplinary assessment and anesthetic planning before delivery in order to optimize cardiac function during the peripartum period and make informed decisions regarding the mode of delivery and anaesthetic technique.
Use of the laryngoscope and tracheal tube during general anaesthesia results in many complications such as sore throat, cough, vocal cord paralysis, compulsory injection of muscle relaxants for tube insertion and risky emergence of anaesthesia. This study investigated the use of laryngeal mask airway (LMA) as a safe and complication-free device in patients undergoing ear surgery. This is a retrospective cross-sectional study on a population comprising patients from 3 to 70 years of age who have undergone major ear surgery, in Amir Alam Hospital, from 1999 to 2006. Laryngeal mask airway replaced the tracheal tube in all patients. Of the 2000 patients who underwent major ear surgery with general anaesthesia using LMA, 246 (12.3%) developed haemodynamic instability. A significant relationship was observed between age and haemodynamic instability (p value = 0.03); 14.9% of these patients were aged between 16 and 40 years and 20% were aged > 60 years. No relationship was observed between the occurrence of this complication and duration of surgery (p value = 0.2). Furthermore, no significant relationship was observed between sex and haemodynamic instability. In conclusion, considering the low rate of complications with laryngeal mask airway, replacing tracheal tube with this device in major ear surgery will lead to a noticeable decrease in associated complications.
Major ear surgery; General anaesthesia; Laryngeal mask airway
Following the notification of several errors of the paper by Lockey and Porter (Emerg Med J 2007;24:437–438) the article has been corrected and is printed below. The online pdf has also been replaced. The journal apologises for these errors.
Prehospital anaesthesia is carried out regularly by a small number of prehospital care practitioners in the UK. Although mostly predictable, prehospital procedures can be more difficult than those in hospital, and, in addition, peer and skilled anaesthetic assistance is usually not available. Patient safety is of paramount importance, and systems need to be in place to ensure that the highest standards are achieved.
Thirteen total hip replacements in 8 patients with ankylosing spondylitis are reviewed. Complications of the disease which can lead to anaesthetic difficulties are discussed, and the importance of a preoperative visit and the value of indirect laryngoscopy emphasized. As intubation problems may occur, especially in undiagnosed cases, equipment for emergency intubation should always be readily available. The results fully justify the operation.
Peripheral nerve block (PNB) in anticoagulated patients is controversial and guidelines are not defined. We report two patients with severe cardiac valvular lesions, who underwent emergency surgeries for lower limb. Both the patients were on anticoagulants, warfarin and heparin in one and aspirin and clopidogrel in the other, with abnormal coagulation profile in the former. Combined femoral and sciatic nerve blocks were used as a sole anaesthetic technique. Postoperatively, the patients were evaluated for bleeding complications at the injection site using high-frequency ultrasound probe. Both had uneventful surgery and recovery. A close postoperative monitoring following PNBs in anticoagulated patients is necessary.
Anticoagulation; lower limb anaesthesia; peripheral nerve blocks
Anterior mediastinal mass is an uncommon pathology that presents significant anaesthetic challenges because of cardiopulmonary compromise. We present a case that presented in the third trimester of pregnancy with severe breathlessness, orthopnoea, and symptoms of superior vena cava obstruction. The patient had emergency Caesarean section under epidural anaesthesia with a good outcome. The paper discusses the relevant perioperative considerations for this complex scenario and reviews reports of similar conditions.
In the present study, we compared isoflurane with sevoflurane in day care surgeries in order to determine the suitability of each agent for anaesthesia with Classical laryngeal mask airway (LMA).
The aim of this study has been to compare isoflurane and sevoflurane as maintenance anaesthetic agents in day care surgeries with respect to intraoperative haemodynamics, recovery profile, time of first postoperative analgesia and pain score, adverse effects when used with classical LMA.
Settings and Design:
This open - level, prospective randomized study was carried out on 60 patients who were admitted on a day care basis for elective short surgical procedures.
The patients were randomly assigned to one of the two study groups of 30 patients each. First group was maintained on isoflurane and second on sevoflurane as inhalational agent.
The observations obtained in both the groups were recorded and tabulated. Statistical analysis was carried out using the Student t test, Chi-square test, Mann-Whitney test.
Emergence from Sevoflurane was significantly quicker as compared to isoflurane. Sevoflurane group also showed earlier discharge time from the post anaesthesia care unit (PACU)-1 as compared to isoflurane group, but discharge time was same from the PACU-1. Isoflurane has more incidences of mild airway hyper reactivity when compared to sevoflurane.
It can be concluded that both isoflurane and sevoflurane are suitable for day care anaesthesia. Sevoflurane has little advantages of less airway hyper reactivity and quicker emergence and discharge from PACU-1.
Anaesthesia; classical laryngeal mask airway; day care surgery; isoflurane; sevoflurane
A 14-year-old boy underwent emergency debridement surgery of right foot under spinal anaesthesia. Four hours after the surgery, the patient developed symptoms of cauda equina syndrome (CES). Postoperative magnetic resonance imaging of the patient's spine suggested underlying tubercular arachnoiditis. The boy was started on intravenous methylprednisolone and antitubercular therapy. He responded to the therapy and recovered completely in 2 weeks without any residual neurological deficits. We suggest that underlying pathological changes in the subarachnoid space due to tubercular arachnoiditis contributed to maldistribution of the local anaesthetic drug leading to CES.
Cauda equina syndrome; spinal anaesthesia; tubercular arachnoiditis
Cardiac transplantation has become the standard therapy for idiopathic dilated cardiomyopathy and end-stage ischaemic heart disease. With the introduction of newer immunosuppressants, together with better patient selection, improved perioperative monitoring and care, the overall survival of recipients has improved. An increasing number of patients who received a transplant present for either elective or emergency non-cardiac surgery. We hereby discuss the perioperative management of such a patient who came to our set-up for bipolar haemiarthroplasty.
Anaesthesia; cardiac transplant; graft function; immunosuppressants; non-cardiac surgery
The prevalence and nature of arrhythmias in horses following general anaesthesia and surgery is poorly documented. It has been proposed that horses undergoing emergency surgery for gastrointestinal disorders may be at particular risk of developing arrhythmias. Our primary objective was to determine the prevalence and nature of arrhythmias in horses following anaesthesia in a clinical setting and to establish if there was a difference in the prevalence of arrhythmias between horses with and without gastrointestinal disease undergoing surgery. Our secondary objective was to assess selected available risk factors for association with the development of arrhythmias following anaesthesia and surgery.
Horses with evidence of gastrointestinal disease undergoing an exploratory laparotomy and horses with no evidence of gastrointestinal disease undergoing orthopaedic surgery between September 2009 and January 2011 were recruited prospectively. A telemetric electrocardiogram (ECG) was fitted to each horse following recovery from anaesthesia and left in place for 24 hours. Selected electrolytes were measured before, during and after surgery and data was extracted from clinical records for analysis. Recorded ECGs were analysed and the arrhythmias characterised. Multivariable logistic regression was used to identify risk factors associated with the development of arrhythmias.
Sixty-seven horses with gastrointestinal disease and 37 without gastrointestinal disease were recruited. Arrhythmias were very common during the post-operative period in both groups of horses. Supra-ventricular and bradyarrhythmias predominated in both groups. There were no significant differences in prevalence of any type of arrhythmias between the horses with or without gastrointestinal disease. Post-operative tachycardia and sodium derangements were associated with the development of any type of arrhythmia.
This is the first study to report the prevalence of arrhythmias in horses during the post-operative period in a clinical setting. This study shows that arrhythmias are very common in horses following surgery. It showed no differences between those horses with or without gastrointestinal disease. Arrhythmias occurring in horses during the post-anaesthetic period require further investigation.
equine; post-anaesthetic; electrocardiography; arrhythmia
Emergence agitation (EA), although well documented in the clinical literature, still has uncertainties and confusion abound on this subject because of the absence of a clear definition and lack of reliable and valid assessment tools.
To compare the incidence and severity of EA and recovery characteristics in paediatric patients under isoflurane, sevoflurane or desflurane anaesthesia and evaluate the effect of age and duration of anaesthesia on the incidence of EA.
Settings and Design:
Randomized prospective double-blinded study.
Seventy-five American Society of Anaesthesiologists I and II patients, aged between 4 months and 7 years, were included in the study. Patients were induced with sevoflurane and oxygen. Anaesthesia was maintained with O2 + N2O and isoflurane, sevoflurane or desflurane according to randomization. Caudal block and paracetamol suppository was administered before the surgical incision. In the Post-Anesthesia Care Unit (PACU), degree of agitation was assessed using the Paediatric Anaesthesia Emergence Delirium Scale. Aldrette score, Face, Legs, Activity, Cry, Consolability score and any adverse events were noted.
Chi-square/Fischer exact test was applied for categorical variables; for continuous variables, the analysis of variance/non-parametric Kruskall–Wallis test was applied. Two-sample t-test/non-parametric Wisconsin Mann–Whitney test was applied between the two groups. Statistical significance was determined at P<0.05.
Incidence and intensity of EA were comparable in all three groups. Age and duration of anaesthesia do not appear to have any bearing on the incidence of EA. Rapid emergence with sevoflurane and desflurane did not translate into early discharge from PACU.
EA is a multifactorial syndrome. More well-conducted studies using validated scales and standardized protocols should be carried out to better understand this phenomenon.
Emergence agitation; desflurane; isoflurane; paediatrics; sevoflurane
Background. Morbid obesity in a pregnancy is a great challenge to medical practice especially when the patient requires caesarean section. Case Summary. A 38-year-old unbooked gravida 3 Para 2+0 weight 195 kg, height 1.7 m with a blood pressure of 210/160 mmhg had spinal anaesthesia for emergency caesarean section which was technically difficult for severe preeclampsia at 32-week gestation. She had poor wound healing and spent 18 days postoperatively on hospital admission. Conclusion. Morbid obesity is a challenge to both obstetric and anaesthetic practice. Antenatal care is necessary in reducing both maternal morbidity and mortality.
There is an increasing demand for intensive care in hospitals, which can lead to capacity limitations in the intensive care unit (ICU). Due to postponement of elective surgery or delayed admission of emergency patients, outcome may be negatively influenced. To optimize the admission process to intensive care, the post-anaesthesia care unit (PACU) was staffed with intensivist coverage around the clock. The aim of this study is to demonstrate the impact of the PACU on the structure of ICU-patients and the contribution to overall hospital profit in terms of changes in the case mix index for all surgical patients.
The administrative data of all surgical patients (n = 51,040) 20 months prior and 20 months after the introduction of a round-the-clock intensivist staffing of the PACU were evaluated and compared.
The relative number of patients with longer length of stay (LOS) (more than seven days) in the ICU increased after the introduction of the PACU. The average monthly number of treatment days of patients staying less than 24 hours in the ICU decreased by about 50% (138.95 vs. 68.19 treatment days, P <0.005). The mean LOS in the PACU was 0.45 (± 0.41) days, compared to 0.27 (± 0.2) days prior to the implementation. The preoperative times in the hospital decreased significantly for all patients. The case mix index (CMI) per hospital day for all surgical patients was significantly higher after the introduction of a PACU: 0.286 (± 0.234) vs. 0.309 (± 0.272) P <0.001 CMI/hospital day.
The introduction of a PACU and the staffing with intensive care staff might shorten the hospital LOS for surgical patients. The revenues for the hospital, as determined by the case mix index of the patients per hospital day, increased after the implementation of a PACU and more patients can be treated in the same time, due to a better use of resources.
An approach which promotes a rapid return to spontaneous respiration after tracheobronchial stent (TBS) insertion is considered the optimal one and is a belief shared by anaesthetists, respiratory physicians, and surgeons alike (Calvey and William (2008)). The value of the laryngeal mask airway (LMA), followed by use of the Monsoon 111 Acutronic jet ventilator pressure limiting system of ventilation, for the deployment of stents in the three individual cases that of tracheoesophageal fistula, a bronchoesophageal fistula, and tracheal compression from an invading oesophageal malignant tumour are reported. The roles of target controlled anaesthesia, high-frequency jet ventilation (HFJV), and the laryngeal mask airway in optimising the surgical field and reducing the risk of bronchospasm at emergence are advantages of this technique.
There has been an exponential growth in the volume of shoulder surgery in the last 2 decades and a very wide variety of anaesthetic techniques have emerged to provide anaesthesia and post-operative analgesia. In this article we examine current opinion, risks, benefits and practicalities of anaesthetic practice and the provision of post-operative analgesia for shoulder surgery.
interscalene block; local anaesthetics; regional anaesthesia; shoulder surgery.