Diastolic Dysfunction- Anaesthesiologist’s Dilemma!

Left ventricular systolic dysfunction is well recognized and ably managed by anesthesiologists. Left ventricular diastolic function needs to be reckoned as well, every single time anaesthesia is planned in a patient with cardiac disease. This article emphasizes why one should take cognizance of diastolic dysfunction during perioperative anaesthesia management. Diastolic dysfunction(DD) is the inefficiency of the left ventricle to allow filling at lower atrial pressures.[1] In other words, it is the abnormal relaxation during diastole along with the reduction in left ventricular compliance which culminates into higher filling pressures of the left ventricle.[2] It is associated with comorbid conditions such as hypertension, diabetes and atrial fibrillation. Oftentimes it is asymptomatic at rest but can manifest in stress-induced circumstances such as acute severe hypertension, tachycardia, overzealous fluid administration or arrhythmias especially atrial fibrillation.[3] Various reciprocal changes occur over time within the systolic function due to long-standing diastolic dysfunction. Also, mild to moderate diastolic dysfunction forms an independent predictor for the risk of mortality in addition to the established risk of hypertension, diabetes, coronary artery disease and advanced age.[4] It is also an independent predictor of major adverse cardiac events (MACE). (5) Most of the patients in whom anaesthesia is given for various surgical procedures have comorbidities like hypertension, diabetes, dyslipidemia, atrial fibrillation and ischemic heart disease which endure high risk for DD. They may have associated heart failure with preserved ejection fraction (HFpEF).DD can contribute to postoperative heart failure [6] and is associated with various complications in the postoperative period.[2] The act of administration of anaesthesia, mechanical ventilation and intraoperative events like tachycardia, hypertension, inordinate fluid therapy along with the overall surgic

Pocketbook on Regional Anesthesia Techniques: Each Line Matters

Dear editor, There has been an ardent interest noticed in the last decade amongst members of anaesthesia fraternity to learn the art of regional anaesthesia (RA). Use of ultrasound (US) has revolutionised the practice of RA all over the world. Every month there is a description of either a new block or a modification of an existing block. Although this keeps RA enthusiasts occupied with various experiments and thus reinventing his/her skills, it also adds to the confusion. The US workshops are useful to Anaesthesiologist’s who have access to the US. Practitioners in the periphery especially freelancers and Anaesthesiologists working in small, resource-limited setups are the ones who should be skillful in landmark/ loss of resistance (LOR) and peripheral nerve stimulation (PNS) guided RA techniques. Anatomy, landmarks, and techniques are equally important [1]. RA that is usually taught in medical colleges and teaching institutes to postgraduate students are spinal/epidural anaesthesia, few upper limb blocks (supraclavicular/axillary), and few lower limb blocks (femoral/sciatic/popliteal). The students do not get adequate confidence during training and later either have to attend workshops or become faculty in some teaching institutes to master RA skills. The relationship between nerve and needle tip at the moment of injection is critical. Nerve localisation techniques have evolved over the years [2]. There are workshops conducted all over the globe that teach US and PNS-guided RA techniques. However, it has been observed that the participants are mostly not actively practicing hands-on during such sessions. An illustrated pocketbook showing images, key points, and relevant landmarks of the regularly performed RA techniques were therefore long-awaited. Finally, three RA enthusiasts from India: Dr. Santosh Kumar Sharma, Dr. Tuhin Mistry, and Dr. Kala Eshwaran have compiled a book in which they have described LOR-based and PNS-guided techniques using illustrated and sel

Combating Airway Issues with Elective Use of an I Gel in a Child with Goldenhar Syndrome

Introduction: Goldenhar syndrome is an oculoauriculovertebral spectrum attributed to the developmental anomalies of the first and second brachial arches. Its typical presentation in children with hemifacial microsomia poses a dual challenge for the anaesthesiologist on account of difficult airway often compounded with systemic abnormalities. Case report: We describe a case report wherein a 5 year female presented to the oculoplastic clinic of our hospital for surgical removal of limbal dermoid under general anaesthesia. Airway examination revealed classical facial asymmetry with underdevelopment of jaw bone coupled with protruding incisors. A predicted difficult airway, more so in a child led us to choose an anaesthesia technique with preservation of spontaneous breathing and planned use of supraglottic device in the form of an I Gel for airway management. Conclusion: The aim of this case report is to highlight the anaesthetic implications of this not so uncommon entity presenting to ophthalmology and ENT clinics. A thorough preoperative assessment, adequate preparedness and alternative plans are keys for successful airway management in such syndromic children. Keywords: Goldenhar syndrome, hemifacial microsomia, I Gel

Peripheral Nerve Stimulator-Guided Regional Anaesthesia for Modified Radical Mastectomy in High-Risk Patients – A Case Series

Thoracic paravertebral block (TPVB) is an effective and time-tested regional anesthesia (RA) technique of anesthesia/analgesia for breast surgeries. It can be performed by landmark guided, peripheral nerve stimulator (PNS) guided or ultrasound-guided techniques. We used PNS guided TPVB for carcinoma breast surgery in fifteen high-risk patients where general anesthesia was not feasible. All patients had undergone surgeries under standalone RA techniques and without any block-related complications. We describe 15 cases in which PNS guided TPVB and supraclavicular brachial plexus block were performed to conduct modified radical mastectomy under RA and monitored anesthesia care. Keywords: Paravertebral block, Supraclavicular brachial plexus block, Carcinoma breast, Postoperative analgesia.

Airway Obstruction Caused by Sputa in Heat and Moisture Exchange Filter During Ventilation Using Supra-Laryngeal Mask Airway: A Case Report

Introduction: Supra-laryngeal mask airway (LMA) is widely accepted as an alternative to the tracheal tube. However, compared to the use of a tracheal tube, it may take longer to identify the many different causes of sudden respiratory distress. In particular, heat and moisture exchange filters are one of the most overlooked causes. Case presentation: The case was that of a 76-year-old male Japanese patient (161.9 cm, 66.5 kg) who underwent an open renal biopsy. He presented with chronic obstructive pulmonary disease, with a Hugh–Jones dyspnea score of 2. The patient did not discontinue smoking prior to the operation. Anesthesia was induced using propofol (100 mg), fentanyl (100 ?g), and remifentanil (0.3 ?g/kg/min). I-gel™ #4 was inserted following neuromuscular blockade with rocuronium (40 mg). Anesthesia was maintained with 3–6% desflurane under positive pressure ventilation. After induction in the left lateral and jackknife positions, the following ventilator settings were used: volume-controlled ventilation with tidal volumes of 450 mL, respiratory rate of 12 breaths per minute, an inspiratory: expiratory ratio of 1:2, and a positive end expiratory pressure of 5 cmH2O. With these settings, the peak inspiratory pressure was 16 cmH2O. Five minutes after initiating the operation, the peak inspiratory pressure steadily increased to 30 cmH2O. Although we administered rocuronium, the peak inspiratory pressure and end-tidal carbon dioxide concentration increased over time. When we disconnected the heat and moisture exchange filter and LMA, we noticed a large quantity of sputa. A suction catheter was passed down the LMA and the sputa was removed, but the LMA was not obstructed. The peak inspiratory pressure continued to increase with tidal volumes of only 20–30 mL. Despite a normal external appearance of the heat and moisture exchange filter, we replaced it with a new one. The ability to ventilate improved immediately and the SpO2 recovered from 92% to 100%. Conclusions

Spinal Myoclonus – A rare complication of spinal anaesthesia

Spinal segmental myoclonus is a rare type of myoclonic disorder that may occur during spinal anaesthesia. A few cases of spinal myoclonus have been reported after administration of intrathecal bupivacaine. The exact cause and pathophysiology of spinal myoclonus is unknown. We report a case of a 28-year-old female who underwent caesarean section under spinal anaesthesia with 0.5% hyperbaric bupivacaine. Myoclonic movements appeared in the early postoperative period in the left lower limb. The myoclonus was acute and transient. The patient recovered completely without any neurological complications. After ruling out all the possible causes, spinal myoclonus diagnosis was made, and the patient was discharged on the 3rd postoperative day. Keywords: Spinal anaesthesia, Spinal myoclonus, Myoclonus

Successful Conduction of Mid-Humeral Fracture Surgery Under Ultrasound- Guided Supraclavicular Block an a Case of Cervical Scoliosis with Fixed Contracture Deformity Neck and Multiple Comorbidities

Introduction: Regional anaesthesia has been proven lifesaver in many tough anaesthetic situations that demand good operative conditions yet are prone to put the patient under increased risk of post-operative complications including prolonged ICU stays even increasing overall mortality when general anaesthesia is chosen as primary anaesthesia modality. Use of ultrasound has revolutionised our approach to regional anaesthesia and many cases which would otherwise be deemed unfit for usual anatomy based approaches can now be conducted with enhanced precision and safety. Case presentation: We present on such case in a 69-year-old male patient with multiple high-risk factors that precluded safe conduction of general anaesthesia, with the presence of cervical scoliosis with fixed contracture neck making anatomy impossible for a blind approach to brachial plexus. Even with help of ultrasound interscalene level was not accessible due to contracture. The successful supraclavicular block was made possible as we could make a clear distinction between vessels, pleura and rib at that level although the cords appeared haphazardly placed and stretched not conforming to usual anatomy at the level. Conclusion: This case highlights the importance of regional anaesthesia under ultrasound guidance in such complex high-risk cases. As the experience with ultrasound-guided regional anaesthesia continues to grow internationally, we are on our steep learning curve appreciating the benefits and respecting the limitations of this developing technology.

An Unusual Cause of High Airway Pressures Using an Oesophageal Calibration Bougie in Bariatric Surgery- A Case Report

Background: Bariatric anaesthesia poses various challenges for the anaesthesiologist. We report a case of high airway pressures from the presence of the calibration bougie used in sleeve gastrectomy. This is the first time we have encountered raised airway pressures with the use of a calibration bougie. This underlines the need to be vigilant and consider the calibration bougie as a causative factor for raised airway pressures. Case presentation: The patient had a high Body Mass Index of 44 and no comorbid conditions. High airway pressures were noted on insertion of the calibration bougie by the anaesthesiologist. The common causes for intraoperative high airway pressures were ruled out and a fresh endotracheal tube was reinserted without any problems. After the second endotracheal tube was placed and the bougie was reinserted, the recurrence of the problem alerted us to the possibility of the bougie being the causative factor. With a change in ventilatory settings, the problem was circumvented and the procedure completed without any further problems. Conclusion: Bariatric anaesthetists should be aware that the calibration tube can lead to high airway pressures. This could be exacerbated especially if there are any unidentified underlying tracheal abnormalities. It is imperative to rule out the more common causes of high airway pressures. In retrospect it might have been useful to have used a reinforced endotracheal tube to determine if the problem recurred. Keywords: Calibration Bougie, Bariatric surgery, High airway pressure, Sleeve Gastrectomy

Technology: A Friend or Foe? Do Electronic Health Records Increase Burn Out Amongst Anaesthesiologists?

3D total laparoscopic hysterectomy in progress under general anaesthesia; steep head low, everyone delighted to see the 3D picture on screen with the goggles including the anaesthesia resident. I enter the OT (needless to say that as a senior one has to supervise more than one OT at a time). The high-end Anaesthesia machine standing tall inside the OT with all the sophisticated monitoring gadgets. I look at the ventilatory pattern on monitor: etCO2 graph upsloping with a value of 42mm of Hg, airway pressure 26mm of Hg and rising! I ask a rhetoric question to my resident as to where his attention is and to my dismay, he expresses his dissatisfaction that the monitors neither give us alarms against rising etCO2 or airway pressure nor do they warn us about changing capnograph slopes!! I am appalled. THROWBACK- Not long time ago when we were residents, we used our ‘educated hands’ to monitor the airway pressure with manual ventilation. Differential diagnosis of tight bag used to be one of the favourite questions seniors used to ask us during on-table teaching. We had no etCO2 monitor then (the mandatory minimum monitoring standard); leave alone the hi-tech ventilatory gadgets and associated airway gas monitoring. Sooner the educated hand was replaced by ventilator and arguments will continue whether to declare this as a loss of clinical skill; an unresolved riddle due to paucity of evidence. The least that I can say is with the hand on pulse and bag in hand, we used to ‘stay connected’ to the patient; with the technical advances this connection got lost. Does this make the ventilator and the advances in monitoring evil?? Obviously not. The advances in science and technology are not only for our comfort but they also play a pivotal role in improving patient’s safety and offering better patient care. Over years surgery has advanced enormously and most of these developments are attributed to advances in the field of anaesthesia which has evolved itself from the Stone Age t

Perioperative Anesthetic Management for Surgical Repair of an Adult with Supracardiac Total Anomalous Pulmonary Venous Communication and Pulmonary Hypertension: A case report and Mini Review

The total anomalous pulmonary venous communication [TAPVC] is a rare cyanotic congenital cardiac defect accounting for 1.5-3% of the congenital heart disease, in which pulmonary venous [PV] blood drains directly into the right side of the heart or into the systemic veins. Neonates with obstructive TAPVC may present with cyanosis, metabolic acidosis, respiratory failure, and shock. A subset of patients with unobstructed TAPVC may remain symptoms free and attain adulthood, or present with pulmonary congestion, pulmonary arterial hypertension [PAH]. The anesthetic management of either obstructed TAPVC or unobstructed with PAH can be quite challenging. The described patient is a 23-year male who presented with self – limiting single episode of chest pain, palpitations and dyspnea, diagnosed as supracardiac unobstructed TAPVC with ostium secundum atrial septal defect [OS – ASD] and PAH, who underwent successful intracardiac repair under cardiopulmonary bypass [CPB]. The protocol for the cardiac surgery during the COVID-19 pandemic for perioperative considerations and triage recommendations was strictly followed to reduce the risk of exposure to patients and healthcare workers. The objective of this case report and review is to recognize the spectrum of various clinical presentations in TAPVC, and to describe the diagnosis and perioperative management of TAPVC. Key Words: Adult Supra cardiac TAPVC, unobstructed, PAH, cardiopulmonary bypass, corrective surgery, balanced general anesthesia