A large cirsoid aneurysm of the scalp with multiple arterial supply: illustrative case

BACKGROUND

Cirsoid aneurysm of the scalp is a rare arteriovenous fistula having a traumatic, congenital, iatrogenic, or idiopathic etiology. Its presentation can range from a small swelling to a large pulsatile mass with tinnitus, headache, and scalp necrosis.

OBSERVATIONS

A 67-year-old female presented with a gradually increasing swelling on her forehead and head since childhood and no history of trauma. Examination revealed 12 × 5 cm tortuous midline swelling. Computed tomography angiography revealed a mass of tortuous vessels in the right frontoparietal region of the scalp with no bony defect or intracranial extension. Contrast-enhanced computed tomography of the head showed no intracranial pathology. The diagnosis of cirsoid aneurysm was made, and surgery was planned. A bicoronal incision was made. The feeding arteries were dissected and ligated. The nidus was carefully separated, cauterized, and excised in toto. Inadvertently, a buttonhole in the skin was created while dissecting the nidus, which was sutured. The patient developed a small area of scalp necrosis on the 10th postoperative day, which was debrided and sutured. At the 6-month follow-up, no signs of recurrence were present.

LESSONS

A large cirsoid aneurysm of the scalp with multiple arterial supplies can be treated successfully with surgery. Meticulous dissection and hemostasis are warranted to avoid perioperative complications.

POS1154 OUTCOMES AND RESOURCE UTILIZATION AFTER TOTAL HIP ARTHROPLASTY IN PATIENTS WITH CALCIUM PYROPHOSPHATE DEPOSITION DISEASE

Background

Total hip arthroplasty (THA) is a safe and effective treatment option in patients with advanced degenerative joint disease who have failed conservative management. Calcium pyrophosphate deposition disease (CPPD) is a common crystal-induced arthritis in older adults characterized by the deposition of calcium pyrophosphate crystals in the articular and periarticular tissues1. CPPD might manifested with acute and chronic arthritis that can lead to joint damage and the need for joint replacement. To our knowledge, no previous studies investigated the outcomes of CPPD patients who underwent THA.

Objectives

We aim to examine the mortality, in-hospital complications, and resource utilization following THA in patients with and without CPPD.

Methods

We queried the US National Inpatient Sample (NIS) database to identify patients who underwent THA between 2006 and 2014. The ICD-9 code 81.51 was used to identify the patients who underwent THA and of those, we classified 2 groups of patients: (i) those with ICD-9 codes defining CPPD (275.49 and 712.1–712.39) and (ii) those without any CPPD code. Data collection included patient demographics and comorbidities. Outcomes post-THA were in-hospital mortality, hospital length of stay, hospital charges, and discharge disposition. Associations between CPPD and specific morbidity were evaluated with chi-square tests. T tests were used for continuous variables.

Results

Among the 4,111,808 (adjusted for sampling weight) patients who underwent THA between 2006 and 2014, 6198 (0.15%) had CPPD, with a mean age of 77 years and 65.2% were females (Table 1). CPPD patients were more likely to be older (mean age 77 vs 72.7; p<0.001) than non-CPPD patients. Comorbidities more frequently observed among CPPD patients included chronic kidney disease, osteoarthritis, rheumatoid arthritis, gout, hyperparathyroidism and hypomagnesemia. Further, Charlson Comorbidity Index scores ≥ 2 was more frequent seen in CPPD (96.1% vs 89.1%, p <0.001). The in-hospital mortality post-THA was lower in the CPPD patients (0.76% vs 1.72%, p <0.001). THA in CPPD patients was associated with a longer mean length of stay than those without CPPD (6 vs 5.1 days; p <0.001) while mean total charges were not statistically different between the 2 groups (p=0.344). CPPD patients were more likely to be discharged to rehabilitation or other nursing facilities (p<0.001).

Table 1.

Demographics, clinical characteristics, outcomes and resource utilization of patients with and without CPPD who underwent hip arthroplasty between 2006-2014.

No CPDD, n (%) (N=4105610)CPPD, n (%) (N=6198)P-value*Age in years at admission, median (mean ± SD)75 (72.7 ± 31.5)80 (77.0 ± 24.2)<0.001†Female2507971 (61.1)3979 (64.2)<0.001Chronic kidney disease516688 (12.5)1154 (18.6)<0.001Osteoarthritis684171 (16.6)1280(20.6)< 0.001Gout139648 (3.4)330 (5.3)<0.001Rheumatoid arthritis199175 (4.8)478(7.7)<0.001Hyperparathyroidism7959 (0.1)24(0.3)<0.001Hypomagnesemia100390 (2.45)239 (3.86)<0.001Charlson Comorbidity Index score ≥ 23659906 (89.1)5961(96.1)<0.001Outcomes/Resource utilizationLength of stay, (mean ± SD)5.15 ± 11.726.04 ± 13.91<0.001†Total hospital charges, (mean ± SD)$ 41284 ± 108238($ 42757 ± 124894)0.344†Death during hospitalization70706 (1.7)47 (0.7)<0.001†Discharge DispositionHome (including home health care)2653860 (64.7)3558 (57.4)<0.001All others§1447312 (35.3)2635 (42.5)<0.001

*Chi-square P except †t-test

§All others include transfer to nursing or rehabilitation facility.

Conclusion

CPPD patients who underwent THA were more likely to be older, with a higher comorbidity burden, longer length of stay, and discharged to a non-home setting, than non-CPPD patients.

References

[1]Rosenthal AK, Ryan LM. Calcium Pyrophosphate Deposition Disease. N Engl J Med. 2016;d 374(26):2575-84.

Disclosure of Interests

None declared

Machine learning approaches for the prediction of bone mineral density by using genomic and phenotypic data of 5130 older men

The study aimed to utilize machine learning (ML) approaches and genomic data to develop a prediction model for bone mineral density (BMD) and identify the best modeling approach for BMD prediction. The genomic and phenotypic data of Osteoporotic Fractures in Men Study (n = 5130) was analyzed. Genetic risk score (GRS) was calculated from 1103 associated SNPs for each participant after a comprehensive genotype imputation. Data were normalized and divided into a training set (80%) and a validation set (20%) for analysis. Random forest, gradient boosting, neural network, and linear regression were used to develop BMD prediction models separately. Ten-fold cross-validation was used for hyper-parameters optimization. Mean square error and mean absolute error were used to assess model performance. When using GRS and phenotypic covariates as the predictors, all ML models' performance and linear regression in BMD prediction were similar. However, when replacing GRS with the 1103 individual SNPs in the model, ML models performed significantly better than linear regression (with lasso regularization), and the gradient boosting model performed the best. Our study suggested that ML models, especially gradient boosting, can improve BMD prediction in genomic data.

Machine Learning Approaches for Fracture Risk Assessment: A Comparative Analysis of Genomic and Phenotypic Data in 5130 Older Men

The study aims were to develop fracture prediction models by using machine learning approaches and genomic data, as well as to identify the best modeling approach for fracture prediction. The genomic data of Osteoporotic Fractures in Men, cohort Study (n = 5130), were analyzed. After a comprehensive genotype imputation, genetic risk score (GRS) was calculated from 1103 associated Single Nucleotide Polymorphisms for each participant. Data were normalized and split into a training set (80%) and a validation set (20%) for analysis. Random forest, gradient boosting, neural network, and logistic regression were used to develop prediction models for major osteoporotic fractures separately, with GRS, bone density, and other risk factors as predictors. In model training, the synthetic minority oversampling technique was used to account for low fracture rate, and tenfold cross-validation was employed for hyperparameters optimization. In the testing, the area under curve (AUC) and accuracy were used to assess the model performance. The McNemar test was employed to examine the accuracy difference between models. The results showed that the prediction performance of gradient boosting was the best, with AUC of 0.71 and an accuracy of 0.88, and the GRS ranked as the 7th most important variable in the model. The performance of random forest and neural network were also significantly better than that of logistic regression. This study suggested that improving fracture prediction in older men can be achieved by incorporating genetic profiling and by utilizing the gradient boosting approach. This result should not be extrapolated to women or young individuals.

AB1224 MAJOR DEPRESSIVE DISORDER AMONG CYPRIOT PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND CORRELATION WITH CLINICAL CHARACTERISTICS AND DISEASE-SPECIFIC HEALTH-RELATED QUALITY OF LIFE

Background:

Major depressive disorder (MDD) is a common comorbidity in patients with chronic rheumatic conditions, and patients with systemic lupus erythematous (SLE) have an increased risk of developing depression. The coexistence of SLE and MDD might lead to impaired health-related quality of life (HRQOL). Gaining a deeper understanding of the factors associated with MDD in SLE will allow us to develop strategies in order to prevent depression and achieve an early diagnosis and management.

Objectives:

The aim of this study is to determine the contributing factors associated with MDD in Cypriot SLE patients and examine the correlation between disease-specific HRQOL domains and depression.

Methods:

We conducted a cross-sectional study of SLE patients who fulfilled the SLICC-2012 criteria. The patients were recruited from August 2019 to January 2020. Baseline demographic data, clinical features, and therapeutic regimens were captured. Depression was assessed by the patient health questionnaire (PHQ)-9, a validated tool to screen and diagnosed the condition. Scores above ≥10 are indicating MDD. HRQOL was evaluated by a disease-specific validated questionnaire, LupusQoL-Greek. LupusQol scores ranged between 0-100, with higher scores reflecting better QoL. The self-rated health status was examined, and the response was separate to poor/fair vs excellent/good. Demographic data, LupusQoL domains, clinical and other features of the SLE patients were described and compared between MDD (PHQ-9 ≥ 10) and non-MDD (PHQ-9<10) groups using Wilcoxon ranksum tests for continuous variables and chi-square tests for categorical variables.

Results:

A total of 88 SLE patients were included in the study, with a mean age of 48.6 (19-80), 71(80%) were women, and mean disease duration of 13.2 years (0-44). Compared to the non-MDD group, patients with MDD (n=32, 36%) were significantly older (mean age 53.5 vs 46.9; p=0.03) and more likely to have the following SLE manifestations: mucocutaneous, vascular, pulmonary and musculoskeletal involvement. Furthermore, patients with MDD were less likely to be clinical quiescent (34.3%) compared with the non-MDD group (57.1%) (P<0.05). Self-rated health described as poor/fair was markedly associated with MDD (p<0.001). The LupusQoL domains’ scores were notably lower in patients with MDD (PHQ ≥ 10), with a statistically significant reduction in all LupusQoL domains, indicating that depression was associated with worse HRQOL (Table 1).

Table 1.

Differences in 8 LupusQoL domain scores among SLE patients with and without major MDD (PHQ-9 .10)

LupusQoL Domains (0-100)PHQ-9 <10(non-MDD)PHQ-9 ≥10(MDD)P-valuePhysical Health72.87 (81.2, 9.3-100)40.01 (32.75, 0-90.6)<0.0001Pain75.27 (75, 16.6-100)43.2 (41.6, 0-100)<0.0001Planning81.08 (91.6, 0-100)44.51 (50, 0-100)<0.0001Intimate relationship68.38 (75, 0-100)46.25 (50, 0-100)0.0382Burden to others79.73 (83.3, 16-100)51.97 (50, 0-100)0.0003Emotional health81.76 (85.4, 25-100)50.14 (50, 0-91.6)<0.0001Body image84.09 (90.8, 5-100)58.45 (66.6, 0-100)0.0004Fatigue72.08 (75, 18.7-100)41.2 (40.6, 6.2-81.2)<0.0001

Conclusion:

To our knowledge, this is the first study demonstrating significantly lower scores among MDD relative non-MDD (based on PHQ-9) patients across all the 8 domains of LupusQoL; therefore, it adds to the current evidence that depression significantly impacts the quality of life of SLE. Predictors of MDD include older age, and involvement of the vascular, mucocutaneous, pulmonary, and musculoskeletal system. Additionally,a poor or fair description of self-rated health was a predictor of depression.

Disclosure of Interests:

None declared

Effect of Positive Airway Pressure During Preoxygenation on Safe Apnea Period: a comparison of the supine and 25° head up position

Background Preoxygenation is performed before induction of anaesthesia which increases oxygen reserve and provides delayed onset of hypoxia during period of apnea. Several techniques such as positive airway pressure and head-up tilt during preoxygenation have shown to prolong safe apnea period compared to conventional technique. However, uniform recommendations have not yet been made. Objective To find out the effect of combination of 5 cmH2 O continuous positive airway pressure (CPAP) and 25° head up position during preoxygenation on safe apnea period. Method In this comparative study 60 non-obese adult patients were divided into three equal groups; Group C receiving preoxygenation in conventional technique, Group S receiving preoxygenation with 5 cmH2 O continuous positive airway pressure in supine position and Group H receiving preoxygenation in 25° head-up position with 5 cmH2 O continuous positive airway pressure. After 3 min of preoxygenation, intubation was performed after induction of anaesthesia with propofol, fentanyl and succinylcholine. After confirming the tracheal intubation by direct visualization, all patients were administered vecuronium to maintain neuromuscular blockade. Postintubation, patients in all groups were left in same position with the tracheal tube exposed to atmosphere and without being ventilated till the SpO2 dropped to 92%. The primary outcome compared between the groups was the safe apnea period (time from loss of consciousness to fall of SpO2 to 92%). Result The duration of safe apnea period was longer (p < 0.05) in Group H patients (405.9 ± 106.69 s) as compared to the Group C (296.9 ± 99.01s) and Group S (319.65 ± 71.54s). Although the duration of safe apnea period was longer in the Group S as compared to Group C the difference was not statistically significant. Conclusion Preoxygenation in 25° head-up position with 5 cm H2O continuous positive airway pressure significantly prolongs safe apnea period in non-obese adults compared to supine position, with or without 5 cmH2O continuous positive airway pressure.

Implications of Subarchnoid Block in Senile Kyphosis

Since the literature related to safety or efficacy of placing spinal blocks in patients with kyphosis is lacking, we aim to discuss about the anaesthesia implications of spinal anaesthesia in senile kyphosis. We successfully administered spinal anesthesia in three elderly patients with predominant kyphotic deformity with absent or mild scoliosis. The needle insertion attempts did not exceed two and a smaller dose of anesthetic was sufficient. While choosing spinal anaesthesia in patients with kyphosis, a risk benefit analysis needs to be performed based on the co-presence of scoliosis and its severity, desired level of anesthesia, and associated or coexisting systemic illness.

The Analgesic Effectiveness of Ipsilateral Transversus Abdominis Plane Block in Adult Patients Undergoing Appendectomy: A Prospective Randomized Controlled Trial

Transversus abdominis plane block (TAP) has been shown to produce effective pain relief following lower abdominal surgeries but is yet to be routinized in different type of surgeries including appendectomy. The main risk of visceral injury can be logically avoided when the block is performed with the abdomen open using landmark technique in the absence of ultrasound guidance. Objective To assess the effectiveness of TAP block with bupivacaine for postoperative analgesia using landmark technique (performed with the abdomen open) in adult patients undergoing appendectomy. Method Forty patients undergoing appendectomy were randomized to undergo ipsilateral TAP block with bupivacaine (n=20) versus control (n=20) in addition to standard postoperative analgesia. All patients received standard general anaesthesia. The block was performed using the landmark technique with 20 ml of 0.5% bupivacaine or isotonic saline on ipsilateral side just before abdominal closure. Pain severity was measured using Visual Analogue Scale (VAS). Tramadol 50 mg was administered as rescue analgesic intravenously when VAS was four or more postoperatively. The duration of analgesia and the requirement of tramadol in 24 hours postoperatively were recorded. Result Mean duration of analgesia in the TAP block with bupivacaine was longer as compared with placebo (724.00±299.07 min vs 168.25±55.18 min; p< 0.01). The TAP block with bupivacaine compared with saline significantly reduced postoperative VAS pain scores. Mean tramadol requirement in the first 24 hours was also reduced (42.50±37.25 mg vs 120.00±55.18 mg; p<0.01). There were no significant complications attributable to the TAP block. Conclusion Ipsilateral TAP block with bupivacaine using landmark technique with the abdomen open in appendectomy provides effective postoperative analgesia and opioids sparing effect.

Postoperative Analgesic Effect of Morphine Added to Bupivacaine for Transversus Abdominis Plane (TAP) Block in Appendectomy

Background Transversus abdominis plane (TAP) block with local anaesthetics produces effective pain relief following lower abdominal surgeries. Although opioids have been found to have effects through peripheral receptors also, reports on their effect when used as additive to local anaesthetics for TAP block are lacking. Objective To assess the analgesic effect of peripherally administered morphine with bupivacaine for ipsilateral TAP block in patients undergoing emergency appendectomy under general anaesthesia. Method Sixty patients undergoing appendectomy were randomized to undergo ipsilateral TAP with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 ml of intravenous (IV) saline (Group TB) or with 20ml of 0.5% bupivacaine plus 2 mg (2 ml) of morphine (total 22 ml) and 2 ml of NS IV (Group TBM) or with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 mg (2 ml) IV morphine (Group TB-IVM). Pain severity was measured using Visual Analogue Scale (VAS) preoperatively (Baseline) and at 30 min, 6h, 12 h and 24 h postoperatively. Inj. tramadol 50 mg IV was used as rescue analgesic when postoperative VAS was 4 or more. The duration of analgesia (time to first analgesic) and the postoperative 24 h tramadol requirement was recorded. Result The mean duration of analgesia in Group TBM was significantly longer (801.50 ± 74.92 min, p=0.002) than in Group TB (720.00 ± 42.17 min) and Group TB-IVM (712.70 ± 40.94 min). The mean postoperative 24 h tramadol requirement was also less in Group TBM (69.23 ± 25.31mg) than in Groups TB (100.00 ± 38.34 mg) and TB-IVM (95.00 ± 39.40 mg) but did not reach the level of statistical significance (p=0.057). Significantly less ondansetron was required in Group TBM (3.80 ± 2.04 mg) than in Group TB (6.80 ± 2.93 mg) and TB-IVM (6.00 ± 2.75 mg) (p=0.002). Conclusion Morphine added to bupivacaine effectively prolongs the analgesic duration of TAP block in appendectomy.

Efficacy of Prophylactic use of Ciprofloxacin and Metronidazole in Mild and Moderately Severe Acute Pancreatitis

INTRODUCTION

There are new concepts and developments in the diagnosis and management of acute pancreatitis. Current evidence suggests that there is no role of prophylactic antibiotics use in acute pancreatitis. However, it is still a common practice to administer prophylactic antibiotics in a country like Nepal. So, we have conducted a study in mild and moderately severe acute pancreatitis to study the efficacy of prophylactic antibiotics.

METHODS

A case control study was conducted among 76 patients comparing efficacy of prophylactic antibiotics versus no antibiotics in patients with mild and moderately severe acute pancreatitis.

RESULTS

The two most common etiology of acute pancreatitis in AG and NAG were alcohol 21 (55.2%) vs. 24 (63.1%) and biliary 10 (26.3%) vs. 4 (10.5%) respectively. Pancreatic necrosis was seen in five (13.1 %) in AG and four (10.5%) in NAG. Four (10.5%) developed extra pancreatic complications in AG and five (13.1%) in NAG. There was one (2.6%) death in AG and no death in NAG. Abdominal pain improvement seen in AG vs. NAG was 3.2 days vs. 2.4 days (P=0.002). The hospital stay was 7.7±2.23 days in AG and 7.5±1.85 days in NAG (P=0.65).

CONCLUSIONS

The routine use of prophylactic antibiotics for mild and moderately severe acute pancreatitis is not associated with improvement in meaningful clinical outcomes.

Analgesia before Performing Subarachnoid Block in the Sitting Position in Patients with Proximal Femoral Fracture: A Comparison between Fascia Iliaca Block and Femoral Nerve Block

BACKGROUND

Positioning for subarachnoid block (SAB) in patients with femoral fracture is painful and may remain suboptimal requiring use of large doses of opioids. These patients generally being elderly with multiple comorbidities and frailty are likely to have many undesirable effects of opioids including respiratory depression and confusion.

OBJECTIVE

The objective was to compare the feasibility and effectiveness of fascia iliaca compartment block (FICB) and femoral nerve block (FNB) in reducing pain associated with positioning for subarachnoid block in patients undergoing proximal femoral fracture fixation procedures.

METHOD

Group FICB patients (n=15) received fascia iliaca block with 30 ml of 1.5% lignocaine with adrenaline and group FNB patients (n=15) received femoral nerve block with 15 ml of 1.5% lignocaine with adrenaline. After the study blocks, patients were kept on supine position for at least 20 minutes before shifting them to the operation theatre. Pain was assessed by using visual analog scale values before the block and during the position for subarachnoid block. Time to perform subarachnoid block, quality of positioning and acceptance was recorded.

RESULT

Visual analog scale values during positioning for SAB were lower in FIB group than in FNB (1.0±1.1 versus 2.1±0.8; P< 0.05). Time to perform SAB was shorter in FIB than in FNB (109.6±28.2 seconds versus 134.8±31.9 seconds; P< 0.05). Quality of patient positioning for SAB was comparable between the groups. Patient acceptance was less in group FNB (P< 0.05).

CONCLUSION

Fascia iliaca compartment block provides better analgesia than femoral nerve block in terms of facilitating optimal positioning for subarachnoid block in patients undergoing proximal femoral fracture fixation procedure.

Adverse Events in Children Receiving General Anaesthesia with Laryngeal Mask Airway Insertion

INTRODUCTION

Perioperative adverse events are more common in children compared to adult population. Reporting an adverse event proves effective in identifying problems and helps in prevention and early management. Our objective was to identify the types, incidence, and the time of occurrence of perioperative adverse event. We also aimed to find out whether the occurrence of the types of adverse events differ in children below and above five years.

METHODS

This was a prospective study in 242, ASA Physical Status I and II children aged day one to 14 years, receiving general anesthesia with laryngeal mask airway for various elective surgeries. Adverse events observed in the perioperative period were recorded.

RESULTS

Adverse events related to respiratory system (n=26, 55%) were the most common followed by cardiovascular system (n= 14, 30%). Adverse events were observed in 24(10%) children in the operating room and in 20 (8%) children in the post anaesthesia care unit. In the operating room, majority (14 of 27, 52%) of the events occurred immediately after removal of laryngeal mask airway. Respiratory events were more common in children below five years (p=0.007), whereas cardiac events were more common in children above five years (p=0.02).

CONCLUSIONS

The commonest adverse event in children is related to respiratory system. Adverse events occur more frequently in the operating room, mostly immediately after removal of laryngeal mask airway. Respiratory events are more frequent in children below five years whereas cardiac events are more frequent in children above five years.

Clinico-epidemiological characteristics of central retinal vein occlusion in a tertiary level eye care center of Nepal

BACKGROUND

Central retinal vein occlusion (CRVO) is one of the common retinal disorders causing severe visual impairment.

OBJECTIVE

To study the clinical profile, risk factors and visual outcome in central retinal vein occlusion.

MATERIALS AND METHODS

Seventy-four eyes of 74 patients with central retinal vein occlusion were retrospectively enrolled during the period of one year. All the patients in the study were classified with regard to their ischemic status into two groups, ischemic CRVO and non-ischemic CRVO. The demographic pattern of the patients was recorded. The other parameters studied were visual acuity, history of glaucoma, hypertension, diabetes mellitus and hyperlipidemia. The patients were followed up at 1 month, 3 months and 6 months after treatment.

RESULTS

The majority of the patients (n = 49, 66.2 %) had the ischemic type of CRVO, whereas, 25 (33.8 %) of them had the non-ischemic type. The CRVO was more commonly observed in males in both the groups. Hypertension was the most common risk factor associated with CRVO. The visual improvement was significantly better in non-ischemic CRVO (RR = 0.04, 95% CI = 0.01 - 0.31, p = 0.000).

CONCLUSION

The CRVO was more common in males than in females. It was associated with systemic hypertension. The ischemic type of the CRVO was more prevalent than the non-ischemic one in this study. Visual outcome was better in the non-ischemic CRVO.

Comparison of Phacotrabeculectomy and Phacotrabeculectomy with Subconjunctival 5-Fluorouracil

INTRODUCTION

Glaucoma is the second leading cause of blindness worldwide. Phacotrabeculectomy is a technique in which glaucoma and cataract surgery performed.

METHODS

Prospective study was carried out in the department of glaucoma at Lumbini Eye Institute, Bhairahawa.100 patients who underwent phacotrabeculectomy within a period of two years. Patients were divided into two groups those who received 5FU (n=47) and no antifibrotic agent (n= 53) RESULTS: The age range was from 38 to 80 years; mean age of 62.97±9.14 SD. 55% were male and 45% were female.The postoperative IOP reduction in last follow- up group A was mean=13.08±1.57SD and mean=13.23±1.73SD in group B. This was statically significant with P <0.001. Bleb survival was almost similar in two groups 3.17(78.31%) in group A and 3.20 (78.93%) in group B. 85% visual acuity was improved in both groups.

CONCLUSIONS

Phacotrabeculectomy and phacotrabeculectomy with inj. 5FU, both were equally effective surgical techniques in terms of visual acuity, IOP control and bleb survival.There was no significant statistical difference vis-à-vis the success of Phacotrabeculectomy using of either these two techniques.

Preemptive use of small dose fentanyl suppresses fentanyl induced cough

BACKGROUND

Fentanyl, a synthetic opioid, is a popular choice amongst anaesthesiologists in the operating room. Pre induction intravenous fentanyl bolus is associated with coughing in 28-65% of patients. Fentanyl induced cough is not always benign and can be remarkably troublesome at the most critical moment of anaesthesia when airway reflex is lost.

OBJECTIVES

To study the effect of pre emptive use of minimal dose fentanyl through the peripheral venous cannulae on the incidence of cough by a larger bolus of intravenous fentanyl.

METHODS

One hundred and fifty patients aged 18-75 years undergoing elective surgical procedures were randomized into three groups of 50 each. The first group received 0.5 ml saline 0.9% intravenously one minute prior to the administration of fentanyl 150 μg (3 ml); the second group received pre emptive fentanyl 25 μg (0.5 ml) prior to the administration of fentanyl 125 μg (2.5 ml); and the third group received preemptive fentanyl 25 μg (0.5 ml), followed by the administration of fentanyl 150 μg (3 ml). Based on the number of coughs observed, cough severity was graded as mild (1-2), moderate (3-5), or severe (>5).

RESULTS

The incidence of fentanyl induced cough was significantly lower in both pre emptive group 4 (8%) for 125 μg fentanyl and 7 (14%) for 150 μg than in the saline group 15 (30%).

CONCLUSION

Pre-emptive use of minimal dose fentanyl 25 μg administered one minute before a larger bolus dose of fentanyl (125 or 150 μg) can effectively suppress cough.

Comparative study of hyperbaric bupivacaine plus ketamine vs bupivacaine plus fentanyl for spinal anaesthesia during caeserean section

BACKGROUND

Spinal anesthesia is widely used for caesarean section due to its rapid onset, low failure rate, complete analgesia. Addition of intrathecal ketamine and opioids to local anaesthetics seems to improve the quality of block and prolong the duration of analgesia.

OBJECTIVES

The purpose of this study was to compare the effect of intrathecal ketamine mixed with hyperbaric bupivacaine to intrathecal fentanyl mixed with hyperbaric bupivacaine.

METHODS

One hundred parturients ASA Grade I scheduled for elective or semiurgent caesarean section under spinal anaesthesia were randomly divided into two groups. Group A received 2ml (10 mg) hyperbaric bupivacaine 0.5% plus 25 mg preservative free ketamine. Group B received 2ml (10mg) hyperbaric bupivacaine 0.5% plus 25μg fentanyl. The patients were observed intraoperatively for the onset of sensory block, degree of motor block and total duration of analgesia.

RESULTS

The time to achieve Bromage scale 3 motor blockade was shorter in Group A than in Group B.(p= 0.445) whereas time to achieve highest dermatomal level of sensory block was shorter in Group A than in Group B (p= 0.143). The duration of spinal analgesia was longer in Group B than in Group A (p= 0.730). The frequency of side effect such as sedation score was higher in Group A compared to Group B (p= 0.048). The incidence of pruritus was significantly higher in Group B compared to Group A (p = 0.000).

CONCLUSION

Addition of preservative free ketamine lead to faster onset of sensory and motor blockade, although it did not prolong the duration of spinal analgesia compared to addition of fentanyl in parturients undergoing caesarean section with spinal anaesthesia.

Smear technique for intraoperative diagnosis of central nervous system neoplasms

Background: Smear cytology has become increasily popular as an alternative to frozen section for the rapid diagnosis of most of central nervous system lesions. The aim of this study was to assess the utility of smear technique for the rapid diagnosis in the neurosurgical biopsies and to compare the smear cytological features with the final histopathological examination. Materials and Methods: This was a prospective study conducted in the Department of Pathology of BP Koirala Memorial cancer Hospital for a period of one year. Sixty cases of clinically suspected CNS tumors were sent for intraoperative smear cytological examination and histological examination. Both techniques were then compared for their ability to diagnose as well as grade the tumors. Results: Gliomas (51.6%) were the most frequently occurring tumors in the total cases. Diagnostic accuracy of squash/smear technique achieved was 88 %( 53/60) when compared with histopathological diagnoses. In two cases, smears comprised of blood clots and no opinion was possible in cytology. Complete discrepancy was seen in five cases that included two cases of atypical meningioma, a one case each of germinoma, glioblastoma and metastatic tumor. Conclusion: Smear technique is a fairly accurate, rapid, easily reproducible and cost effective tool to diagnose brain tumours. Smear cytology is of great value in Intraoperative consultation of central nervous system lesions. DOI: http://dx.doi.org/10.3126/jpn.v4i7.10296 Journal of Pathology of Nepal (2014) Vol. 4, 544-547 

Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

INTRODUCTION

Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms.

METHODS

Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h(-1)) than group 2 (n=5) (1.5 to 2 g.h(-1)).

RESULTS

The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d(-1)) than group 2 (n=3) (106±9 mg.d(-1)) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO(4) for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d(-1)) of infusion in group 2 (n=4) but not in group 1 patients (n=4).

CONCLUSIONS

The larger dose of MgSO(4) infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.

Successful intubation with McCoy laryngoscope in a patient with ankylosing spondylitis

Involvement of cervical spine in ankylosing spondylitis limits neck movement resulting in difficult intubation. We report a case of 45-yr-old lady of ankylosing spondylitis with restricted neck movement planned for emergency laparotomy. Grade 3 Cormack and Lehane laryngoscopic view was observed with Macintosh laryngoscope and gum elastic bougie could not be negotiated. At second attempt with McCoy blade, the posterior commissure of the vocal cord could be visualized and intubation was successful. Thus, in absence of flexible laryngoscopes and when awake intubation is not feasible, McCoy blade should be considered an alternative than Macintosh blade to attempt intubation in patients of ankylosing spondylitis with restricted neck movement.

Perception about the role of anesthesia and anesthesiologist among the paramedical staffs: perspective from a medical college in Nepal

BACKGROUND

Anesthesiologists and anesthesia has been considered behind the scene. The image and status of anesthesiologist in the eyes of the medical and lay communities has always been a problem.

OBJECTIVES

This study was designed to assess the knowledge about the role of anesthesiologist among the paramedical staffs at Kathmandu University Hospital.

METHODS

This prospective questionnaire based study was done at Kathmandu University School of Medical Science, Dhulikhel Hospital for 2nd January 2011 to 30th Jan 2011 among the paramedical staffs working in different department of the hospital.

RESULTS

There were 150 questionnaire distributed out of which 120 responded. Mean Age was 23.33 and most of the respondents were female with majority having education qualification equivalent to intermediate level. Only 49.20 said it to be a different specialty and 72.5% said anaesthesiologist work differently in the theatre where as 70% knew anaesthesiologist did something in the post-operative period too.

CONCLUSION

Anesthesiologists have duty to visit patients pre operatively and post operatively. The role inside the theatre and expanding role outside the theatre is poorly known. The awareness about the role of anesthesiologist in operation theatre, in intensive care unit, acute and chronic pain management and emergency care areas should be highlighted to all the staffs.

Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block: a randomized study of dexamethasone prophylaxis

BACKGROUND

Postoperative nausea and vomiting is a common distressing problem in patients undergoing gynaecological surgery under anaesthesia including central neuraxial blockade, which requires frequent medical interventions.

OBJECTIVES

We aimed to find out the antiemetic effect of prophylactic dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block. Influences of dexamethasone on patient satisfaction and postoperative analgesia were also observed as secondary objectives.

METHODS

This was a prospective, randomized, double blind, placebo controlled study conducted in BPKIHS, from January 2009 to April 2009. This study involved 80 American Society of Anaesthesiologist Physical Status I and II patients undergoing total abdominal hysterectomy under subarachnoid block. Patients were divided into two groups of 40 each to receive either 4 mg of dexamethasone (group D) or normal saline (group N) in volume of 2 ml intravenously 1 hour prior to subarachnoid block. Surgery was allowed to start with block height of at least T8 dermatome. Intraoperative and postoperative nausea and vomiting was observed using nausea and vomiting scale every 4 hour for 24 hours.

RESULTS

Seven (17.4%) patients in group D and 11 (27.5%) patients in group N had nausea and vomiting in the intraoperative period (P=0.284). Sixteen (40%) patients in group D experienced nausea and vomiting in the postoperative period as compared to 27 (67.5%) in group N (P =0.0136). Accordingly, the mean requirement of rescue antiemetic was less in group D compared to Group N (P=0.042). Further, only 15 (37.5%) patients in group D required postoperative supplemental analgesic as compared to 23 (57.5%) in group N (P=0.058). After 24 hrs of surgery, 26 (65%) patients expressed satisfaction in group D as compared to 16 (40.0%) in group N (P =0.025).

CONCLUSIONS

Use of dexamethasone prior to subarachnoid block in patients undergoing total abdominal hysterectomy significantly reduces the incidence of nausea and vomiting and the requirement of antiemetic in the postoperative period, with better patient satisfaction.

Propofol sedation during spinal anaesthesia- a dose finding study

BACKGROUND

It is important to be able to measure and maintain a specific sedation level to compare outcomes of different levels of sedation during anesthesia and the aims include general patient comfort, freedom from specific discomfort, and some amnesia for both the block procedure and the surgical operation, in order to meet the patient preference and safety. In this prospective randomized clinical study, we compared the three different infusion doses of propofol.

OBJECTIVE

To find out the appropriate infusion dose of propofol for optimal sedation without causing undue side effects in patients undergoing spinal anaesthesia.

METHOD

One hundred twenty patients ASA PS I-II were randomly allocated to three groups 1, 2 and 3 receiving propofol infusion at the rate of 25, 50 and 75 microgram/kg/min with concentration of (0.5%), (1%) and (1.5%) respectively. They were observed for sedation score, hemodynamic parameters and satisfaction level. The adverse effects like respiratory depression, nausea and vomiting score were assessed.

RESULT

Median sedation score increased in a dose dependent manner, with significantly higher scores in group 2 and 3 compared with group 1. Hemodynamic parameters were better in group 1 and 2 as judged by mephentermine requirement. The awakening time after stoppage of infusion was significantly delayed in group 3 (p < 0.001). Respiratory depression, nausea and vomiting were comparable clinically. Almost three fourth of the patients were satisfied with the techniques used.

CONCLUSION

Propofol infusion at the rate of 50 mcg/kg/min for sedation in spinal anaesthesia provides optimal sedation, early awakening and excellent satisfaction level in the postoperative period.

Incidence of hypertension in patients undergoing surgery at Dhulikhel Hospital-Kathmandu University Hospital

BACKGROUND

Hypertension is an important public health challenge worldwide and is most important modifiable risk factor for cardiovascular, cerebrovascular and renal disease. Blood pressure determination forms an integral part of anaesthesiologist evaluation of his patient condition prior to and during surgery. Data are not available which indicate changes in blood pressure occurring preanaesthetically in hospitalized patients. There are several risks from untreated preoperative hypertension in perioperative and postoperative phase.

OBJECTIVE

To know the incidence of hypertension in preoperative patients undergoing major surgery.

METHODS

This retrospective observational study was based on the data collected from preanaesthetic checkup record book from January 2010 to December 2010.

RESULTS

A total of 955 patients were studied and analyzed in terms of hypertension and demographic characteristics. The total incidence of hypertension in preoperative phase was 10.16%. Among them 64.9% being male and 35.1% female. Maximum incidence was found in age group 50-59 years i.e. 26.6%. Among the case detected maximum patients i.e. 52% were patients with newly diagnosed hypertension and among those under medications 61.1% were using calcium channel blockers.

CONCLUSION

Knowing the incidence will help in proper preoperative optimization of the hypertensive patients and also help in decreasing the incidence of postoperative complications.

Negative pressure pulmonary edema--case series and review of literature

Post obstructive pulmonary edema (POPE) also known as negative pressure pulmonary edema (NPPE) is potentially life threatening complication. It occurs in about 0.1% of anesthetics and is related to upper airway obstruction. Two types have been described in literature. Different etiology has been attributed to development of Negative pressure pulmonary edema. Early identification and treatment of predisposing factor along with proper monitoring of this complication early treatment should be instituted because resolution is also fast and in most cases without residual effects.

Comparison of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy

Background The ability of good glottis visualization during direct laryngoscopy is major determinant of easy tracheal intubation. Sniffing position for laryngoscopy is considered as gold standard and ideal position. Several studies have questioned the validation of sniffing potion. Objectives This study aims to compare relative efficacy of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy. Methods Four hundred patients undergoing elective surgery under general anesthesia requiring endotracheal intubation were randomized into two groups and study was concluded. Glottic visualization was assessed using modified Cormack and Lehane classification. After laryngoscopy, tracheal intubation was performed and intubation difficulty scale was noted. Results Both the groups were comparable regarding glottis visualization. Both the groups were comparable in demographic profiles. All the intubation difficulty scale variables were comparable in both the groups except N3. Total Intubation Difficulty Score was better in sniffing position than in simple head extension group. Conclusion Glottic visualization and intubation difficulty score was better in sniffing position as compared to simple head extension.http://dx.doi.org/10.3126/kumj.v9i1.6265 Kathmandu Univ Med J 2011;9(1):58-63

Surgical site fire: a case of evil spirit or lapsed communication?

Electrocautery has become an indispensable tool in the operating room mainly to achieve bloodless surgical field. However, it does carry several risks including fire burn. Abundant fuels and oxidizer in operation theatre in the presence of electrocautery can easily get ignited, imposing serious risk to the patient and health professionals. This report of a case of surgical site burn injury due to unintentional reuse of a spirit soaked gauze piece intends to create awareness among health professionals and staff regarding such serious complication.

Topical anaesthesia of the vocal cords by nebulized lignocaine inhalation to facilitate fi breoptic nasotracheal intubation in a head-size parotid tumour patient

This case report describes a successful fi breoptic naso-tracheal intubation in a patient with difficult airway due to a nearly head-size right parotid swelling. Nasal fi breoptic intubation was performed by maintaining spontaneous breathing under propofol infusion at a dose of 25 mcg/kg/hour and topical anaesthesia of vocal cords by using oxygen (6 l/min) fl ow to nebulize 4 % lignocaine from the side port of the fi breoptic bronchoscope. The topical anaesthesia was achieved by keeping the scope in close proximity of the vocal cords and in the centre of view of the scope. This case emphasizes the possibility of fi breoptic intubation in a sedated yet spontaneously breathing patient by allowing inhalation of nebulized lignocaine during fi breoptic intubation.  Keywords: fibreoptic intubation, naso-tracheal intubation, nebulized lignocaine, spontaneous breathing, topical anaesthesia.

Incidence and risk factor for ventilator-associated pneumonia in Kathmandu University Hospital

BACKGROUND

Ventilator associated pneumonia is a major cause of morbidity in the intensive care unit. Difficulties in identification of the risk factors, in diagnosing and in prevention, have intensified the problem.

OBJECTIVES

To measure the incidence of ventilator associated pneumonia in intensive care unit and to identify the risk factors associated.

METHODS

A prospective observational cohort study was done in which we evaluated 69 patients who were mechanically ventilated for more than 48 hours to find out the development of nosocomial pneumonia and presence or absence of risk factors. Data were subjected to univariate analysis using chi-square and t-test. Level of significance was set at 0.05.

RESULTS

Twenty two (31.88%) out of 69 patients developed ventilator associated pneumonia, majority of them between four days to 14 days. Reintubation, invasive lines, H2 blockers and low PaO2/FiO2 were identified as major risk factors in our study. Enteral feeding via nasogastric tube and use of steroids was not associated with development of ventilator associated pneumonia. The patients with ventilator associated pneumonia had significantly longer duration of mechanical ventilation (18.88+/-7.7 days vs 7.36+/-4.19 days) and stay (29+/-17.8 days vs 9.22+/-5.14 days). The morality was similar for both the groups with or without ventilator associated pneumonia.

CONCLUSION

The incidence of ventilator pneumonia is high. Patients requiring prolonged ventilation, re-intubation, more invasive lines and H2 blockers, are at high risk and need special attention towards prevention.

Topical anaesthesia of the vocal cords by nebulized lignocaine inhalation to facilitate fibreoptic nasotracheal intubation in a head-size parotid tumour patient

This case report describes a successful fibreoptic naso-tracheal intubation in a patient with difficult airway due to a nearly head-size right parotid swelling. Nasal fibreoptic intubation was performed by maintaining spontaneous breathing under propofol infusion at a dose of 25 mcg/kg/hour and topical anaesthesia of vocal cords by using oxygen (6 l/min) flow to nebulize 4% lignocaine from the side port of the fibreoptic bronchoscope. The topical anaesthesia was achieved by keeping the scope in close proximity of the vocal cords and in the centre of view of the scope. This case emphasizes the possibility of fibreoptic intubation in a sedated yet spontaneously breathing patient by allowing inhalation of nebulized lignocaine during fibreoptic intubation.

Ketamine gargling and postoperative sore throat

INTRODUCTION: Tracheal intubation is a foremost cause of trauma to the airway mucosa, resulting in postoperative sorethroat (POST). The aim of the study was to compare the effectiveness of ketamine gargle with placebo in preventing POST after endotracheal intubation. METHODS: Forty patients scheduled for elective surgery under general anaesthesia were enrolled in this randomized, control trial. Patients were randomly allocated into two groups of 20 patients each: Group C, gargling with drinking water 30 ml; Group K, gargling with ketamine 50 mg in drinking water 30 ml for 30 s, 5 min before induction of anaesthesia. POST was graded at 4, 8, and 24 hours respectively after operation on a four- point scale (0-3). RESULTS: POST occurred more frequently in Group C, when compared with Group K at 4, 8, and 24 hours. CONCLUSIONS: Ketamine gargle reduces the incidence of POST after endotracheal intubation.

Curved knife "Khukuri" injury in the back and anaesthesia induction in lateral position for thoracotomy

Penetrating injury in the back with knife (Khukri) demands induction of anaesthesia and intubation in lateral position. In thoracic injury a double lumen tube placement is required to facilitate one lung ventilation during thoracotomy. In emerging situation, we could successfully execute induction of patient in right lateral position using right sided DLT for left thoracotomy. Its correct placement was confirmed by fiberoptic bronchoscopy. In conclusion right-DLT intubation can be performed without difficulty by conventional direct laryngoscopy using Macintosh blade in lateral position. Keywords: khukuri knife, lateral position, one lung ventilation, thoracic injury.

Ketamine gargling and postoperative sore throat

INTRODUCTION

Tracheal intubation is a foremost cause of trauma to the airway mucosa, resulting in postoperative sorethroat (POST). The aim of the study was to compare the effectiveness of ketamine gargle with placebo in preventing POST after endotracheal intubation.

METHODS

Forty patients scheduled for elective surgery under general anaesthesia were enrolled in this randomized, control trial. Patients were randomly allocated into two groups of 20 patients each: Group C, gargling with drinking water 30 ml; Group K, gargling with ketamine 50 mg in drinking water 30 ml for 30 s, 5 min before induction of anaesthesia. POST was graded at 4, 8, and 24 hours respectively after operation on a four- point scale (0-3).

RESULTS

POST occurred more frequently in Group C, when compared with Group K at 4, 8, and 24 hours.

CONCLUSIONS

Ketamine gargle reduces the incidence of POST after endotracheal intubation.

Caudal bupivacaine vs bupivacaine plus tramadol in post-operative analgesia in children

BACKGROUND

Caudal analgesia with bupivacaine is used commonly for pain relief in children and extradural administration of tramadol seemed to be a safe method of analgesia. The aim of the study is to compare the analgesic efficacy of caudal bupivacaine and bupivacaine and tramadol mixture for postoperative analgesia and to observe for side effects.

METHODS

Forty children, aged between 1- 6 years undergoing infra umbilical surgeries were selected for this randomized, control trial. They were randomly divided into two groups. Group A (n = 20) received 0.5 ml/kg of 0.25 % bupivacaine and Group B (n = 20) received 0.5 ml/kg of 0.25 % bupivacaine with 1 mg/kg of tramadol as a single shot caudal block. In the postoperative period heart rate, respiratory rate, pain score, recovery to first analgesic time, total number of analgesics required in 24 hours and side effects were noted and analyzed.

RESULTS

It was observed that the mean duration of pain relief was significantly longer in Group B (8.8 hrs Vs 7 hrs). Nausea and vomiting was observed in 25% of the patients in group B and 20 % of the patients in group A. None of the patients in both the groups had complication like motor weakness, urinary retention in the postoperative period.

CONCLUSIONS

The addition of tramadol to bupivacaine in the caudal analgesic technique provides longer analgesia and lesser need for rescue analgesic in the postoperative period compared to bupivacaine.

Curved knife "Khukuri" injury in the back and anaesthesia induction in lateral position for thoracotomy

Penetrating injury in the back with knife (Khukri) demands induction of anaesthesia and intubation in lateral position. In thoracic injury a double lumen tube placement is required to facilitate one lung ventilation during thoracotomy. In emerging situation, we could successfully execute induction of patient in right lateral position using right sided DLT for left thoracotomy. Its correct placement was confirmed by fiberoptic bronchoscopy. In conclusion right-DLT intubation can be performed without difficulty by conventional direct laryngoscopy using Macintosh blade in lateral position.

Anaesthesia and perioperative care in remote health camps: patients' concerns

INTRODUCTION

Identifying patients' concerns and expectations regarding anaesthesia and perioperative care in mobile surgical camps is relevant for the camp workers. This prospective observational study was conducted to assess knowledge, concerns, and expectations about anaesthesia and perioperative care in patients undergoing surgery in mobile surgical camps in remote mountainous districts of Eastern Nepal.

METHODS

A questionnaire with seven items related to anaesthesia and perioperative care was used for interviewing 80 individuals of age > or = 12 years, 20 from each camp at Solukhumbu, Sankhuwasabha, Khotang and Bhojpur districts.

RESULTS

Data of two patients were lost leaving only 78 individuals for analysis. The mean age of the subjects was 30.5 (+/- 14.6) years with the male: female ratio of 43: 35. Fifty-eight (74.4%) patients had some gross idea about the modality of administration of anaesthetics. Twenty-six (33.3%) individuals preferred GA over local anaesthesia, whereas 22 (28.2%) were happy either way if there was no pain. Pain was the main concern for 73.1% of the patients. Of the 25 patients expressing fear of GA, death or not being able to wake up anymore was the main concern for 60.0%. Increasing age was associated with lower fear of GA (p < 0.05). Surgical experience was distressing for 17 (21.8%) patients. The overall experience of the anaesthesia and surgery was worse than expected for 25.6% of the patients.

CONCLUSIONS

Patients presenting to these health camps have limited knowledge regarding anaesthesia and perioperative care but have valid concerns and expectations in respect of their safety, comfort and outcome.

Comparison of Bolus Phenylephrine, Ephedrine and Mephentermine for Maintenance of Arterial Pressure during Spinal Anesth

INTRODUCTION: Hypotension is common following spinal anesthesia. Various vasopressors have been indicated to prevent it. The study compares three such agents namely phenylephrine, ephedrine and mephentermine. METHODS: The study included 90 patients undergoing elective and emergency cesarean section who developed hypotension following subarachnoid blockade. Parturient were randomly divided into three groups each group had 30 patients. Group P received bolus of Phenylephrine 25 microgram, where as group E received Ephedrine 5mg and Group M received Mephentermine 6mg. RESULTS: It was found that rise of blood pressure was significantly higher in case of phenylephrine group in first six minutes, after the bolus, there was significant reduction in the heart rate in phenylephrine group, but there was tachycardia following administration of bolus ephedrine and mephenteramine. Neonatal APGAR score were similar in all three groups. CONCLUSIONS: All three drugs maintained hemodynamics within 20 percent of the baseline values on intravenous administration. Keywords: APGAR, ephedrine, hypotension, mephentermine, phenylephrine, spinal anesthesia.

Comparison of bolus phenylephrine, ephedrine and mephentermine for maintenance of arterial pressure during spinal anesthesia in cesarean section

INTRODUCTION

Hypotension is common following spinal anesthesia. Various vasopressors have been indicated to prevent it. The study compares three such agents namely phenylephrine, ephedrine and mephentermine.

METHODS

The study included 90 patients undergoing elective and emergency cesarean section who developed hypotension following subarachnoid blockade. Parturient were randomly divided into three groups each group had 30 patients. Group P received bolus of Phenylephrine 25 microgram, where as group E received Ephedrine 5mg and Group M received Mephentermine 6mg.

RESULTS

It was found that rise of blood pressure was significantly higher in case of phenylephrine group in first six minutes, after the bolus, there was significant reduction in the heart rate in phenylephrine group, but there was tachycardia following administration of bolus ephedrine and mephenteramine. Neonatal APGAR score were similar in all three groups.

CONCLUSIONS

All three drugs maintained hemodynamics within 20 percent of the baseline values on intravenous administration.

Anesthetic management of a child with Down's syndrome having atlanto axial instability

Down's syndrome is the most commonly encountered congenital anomaly in medical practice. These patients are of special concern to medical practice because of their associated problems with regard to respiratory, cardiovascular and other systemic problems. As these patients present for repeated surgeries like dental extraction, facial reconstruction and fixation of cervical spine, these patients pose challenges to the anesthesiologist because of their unique set of problems, namely atlantoaxial instability, small trachea, congenital heart disease and repeated chest infections due to lowered immunity. Their reactivity to inhalational anesthetics and atropine is variable. Here we present an interesting case report of a child with Down's syndrome who presented with atlantoaxial instability for MRI of cervical spine under general anesthesia.

Complex regional pain syndrome (CRPS) type-1 following snake bite: a case report

The pathophysiological mechanism and clinical course of complex regional pain syndrome (CRPS) type-I still remain ill defined. Both the treatment and the prediction of the outcome of the treatment are difficult. Abnormal neurohumoral and inflammatory mechanisms have been implicated in its causation usually following trivial noxious event in an extremity. However, to the best of our knowledge CRPS type-1 following snakebite has not been reported yet in the literature. We here report a case of an aggressive CRPS type-1 following a mountain pit viper bite, locally known as Gurube (Ovophis monticola monticola) in a 55-year-old lady. The clinical condition responded well to the therapy with serial sympathetic blockade of the limb with local anaesthetics, non-steroidal antiinflammatory analgesic, antiepileptic, antidepressant and physiotherapy. Our experience in managing this patient and associated pathophysiology in development of CRPS type-1 are discussed.

Erythema nodosum leprosum in Nepal: a retrospective study of clinical features and response to treatment with prednisolone or thalidomide

INTRODUCTION

Erythema nodosum leprosum (ENL) is an inflammatory reaction, which may occur in the course of leprosy and may result in nerve function impairment and subsequent disability.

METHODS

This retrospective study explores demographic and disease specific parameters. Severity of ENL was assessed using the Reaction Severity Scale (RSS). Records of 94 patients were reviewed. The study reports also on the treatment of 76 of these patients who were treated with prednisolone alone or thalidomide in addition to prednisolone. RESULTS Thirty percent of patients presented with ENL at time of diagnosis; 41% developed ENL-reaction in the first year of MDT. Forty-eight percent of patients were treated for ENL-reaction for less than 12 months; 13% for more than 5 years. High RSS-scores correlated with a longer duration of treatment. In group A (prednisolone) 51.7% and in group B (prednisolone and thalidomide) 76.6% of patients were male. Age, leprosy classification, delay of multidrug treatment (MDT) and interval between MDT and first ENL-symptoms did not differ significantly in both groups. Median duration of ENL-treatment was 15 months in group A versus 38 months in group B (P < 0.001). At the start of treatment, ENL-reaction was less severe in group A (RSS = 12) than in group B (RSS = 18; P = 0.003).

DISCUSSION

ENL-symptoms may be of help in the early diagnosis and adequate treatment of ENL. Characterisation of (sub) groups of patients with ENL based on presence and severity of symptoms is important for future prospective studies to better evaluate the efficacy of interventions.

Anesthetic consideration in downs syndrome--a review

Downs syndrome constitutes to be the most common chromosomal disorder. Patients with Downs's syndrome are posted for several surgeries including dental procedures and even for facial reconstruction. They are associated with several congenital anomalies in different organ system. There is also increased incidence of atlanto axial instability and risk of spinal cord injury. These children are susceptible to infection and they are also considered to be hypersensitive to the effect or atropine. These all factors modify the anesthetic implication and also anesthetic management in these cases. We have highlighted all these factors and reviewed the anesthetic implication of these child posted for several procedures under anesthesia.