Journal of Neuroanaesthesiology and Critical Care, Apr 24, 2023
Sickle cell disease (SCD) refers to a group of hemoglobinopathies that include mutations in the g... more Sickle cell disease (SCD) refers to a group of hemoglobinopathies that include mutations in the gene encoding the β subunit of hemoglobin. The glutamine in the heme portion of the hemoglobin molecule is abnormally substituted by valine. Sickle hemoglobin (hemoglobin type S), when gets deoxygenated, tends to polymerize and aggregate leading to vaso-occlusion and organ ischemia. Such patients are at increased risk of perioperative mortality and severe complications like vaso-occlusive crisis, acute chest syndrome, and congestive heart failure. We describe the perioperative management of a case of SCD with acromegaly scheduled for trans-sphenoidal removal of a functional pituitary adenoma. The acromegalic habitus, the cardiovascular effects of acromegaly, and the hormonal imbalances due to pituitary adenoma pose challenges in addition to the challenge of preventing complications of SCD making the anesthetic management more exigent.
Hearing rehabilitation treatment is dictated by the nature and etiology of hearing loss. Patients... more Hearing rehabilitation treatment is dictated by the nature and etiology of hearing loss. Patients with absent/destroyed cochlear nerves or complete labyrinthine aplasia (Michel's aplasia) render peripheral cochlear stimulation ineffective and such patients bene t from an auditory brainstem implant (ABI). A coordinated multidisciplinary team approach is necessary for the safe conduct of this challenging surgery using electrophysiologic measures to con rm the accurate placement of the ABI array. The role of the anaesthesiologist ranges from preoperative assessment of syndromal associations, di cult airway assessment, building rapport with the child, and counseling the family. Adequate premedication, smooth induction, and facilitation of neurophysiological monitoring are essential. The anaesthetist also plays a crucial role in decreasing intracranial pressure and improving surgical access while avoiding excessive cerebellar retraction. Close monitoring of vitals, care of the lumbar drain, provision of adequate analgesia, and antiemesis are the main concerns postoperatively.
Indian Journal of Otolaryngology and Head & Neck Surgery, Jul 25, 2020
We compared the use of palonosetron with combination of palonosetron and dexamethasone in prevent... more We compared the use of palonosetron with combination of palonosetron and dexamethasone in prevention of PONV in patients undergoing middle ear surgery under general anaesthesia. Prospective, randomized study was conducted including 90 adult patients who received either palonosetron (0.075 mg) (Group P) or combination of palonosetron (0.075 mg) and dexamethasone (8 mg) (Group PD). The primary outcome was incidence of nausea, vomiting and complete response. Secondary parameters were time to receive first rescue antiemetic, total dose required, patient's satisfaction, postoperative pain scores and total dose of rescue analgesic. The incidence of nausea was 15.5% and 8.8% (p = 0.522) and vomiting was 6.7% and 2.2% (p = 0.610) in group P and PD, respectively Complete response (CR) was observed in 84.4% patients in group P and 91% patients in group PD (p = 0.522). Combination of palonosetron and dexamethasone is not superior to use of palonosetron alone for PONV prevention.
Journal of Neuroanaesthesiology and Critical Care, Aug 1, 2015
C o m p a r a t i v e e v a l u a t i o n o f e s m o l o l a n d dexmedetomidine for attenuation... more C o m p a r a t i v e e v a l u a t i o n o f e s m o l o l a n d dexmedetomidine for attenuation of sympathomimetic response to laryngoscopy and intubation in neurosurgical patients
Journal of Neuroanaesthesiology and Critical Care, 2018
Introduction: Pituitary surgery presents challenges to anesthesiologists due to anatomic location... more Introduction: Pituitary surgery presents challenges to anesthesiologists due to anatomic location and physiological function. Postoperative disorders of fluid and electrolyte balance are very common, requiring prompt diagnosis and treatment. Methodology/Description: A 42-year-old obese, known diabetic man with subnormal mental development presented with headache for 6 months with fever. Examination revealed sparse facial hair, gynecomastia, and visual disturbances. MRI showed pituitary macroadenoma encasing bilateral cavernous internal carotid artery with mild hydrocephalus. Blood investigation showed hyperprolactinemia with hypothyroidism. After failure of medical management with cabergoline 0.5 mg twice a week, transcranial resection was planned. Anesthetic concerns were anticipated difficult airway, positioning, hemodynamic instability, and hormonal disturbances. Videolaryngoscope was used to secure airway. Balanced anesthesia technique with insulin infusion, anticonvulsants, and steroids was used for maintenance. Surgery lasted 7 hours with blood loss of 800 mL. Patient was extubated and monitored in ICU. On postoperative day 7, patient was put on ventilator due to decreased mentation. Patient had high urine output with hyponatremia, hypovolemia, natriuresis, low serum osmolality, and high urine osmolality, pointing toward diagnosis of cerebral salt wasting. Clinical condition improved with 3% sodium chloride at 10mL/hour and intravenous fluids. Patient was extubated on day 13 and discharged home on day 18. Conclusion: Postoperative polyuria can be challenging due to life-threatening hyponatremia. Fluid and electrolyte balance is very important. Good knowledge, planning, preparation, and teamwork are fundamental to successful perioperative patient care.
Journal of Neuroanaesthesiology and Critical Care, Aug 1, 2015
Background: Rocuronium may not be preferable for rapid sequence intubation due to its long intuba... more Background: Rocuronium may not be preferable for rapid sequence intubation due to its long intubation time compared to Succinylcholine. But, Rocuronium along with 2% Sevoflurane may produce comparable intubating time and conditions to that of Succinylcholine. This prospective, randomised, double-blind study was undertaken to compare the effect of Sevoflurane on intubation time and conditions with Rocuronium. Materials and Methods: 30 adult patients of ASA grade I and II of both sexes aged between 30 to 65 years undergoing neurosurgical operations were randomly allocated into 2 equal groups: one group received 0.8 mg/kg of Rocuronium and 2% Sevoflurane (Group-RS) and other received 0.8 mg/kg Rocuronium (Group-R). Onset time of intubation was assessed using Train of Four stimuli. The intubating conditions were compared by the Cooper scoring system and haemodynamic responses were compared between two groups. Results: The onset time of intubation was 60.4 ± 4.1 s in Group-RS and 101.73 ± 10.28 s in Group-R (P < 0.001), with excellent intubating conditions in both the groups and without any adverse effects. Significant differences in heart rate and mean arterial pressure were seen immediately after intubation, at 1 min, and at 3 mins (P < 0.05) between the two groups. Conclusion: Rocuronium with 2% Sevoflurane provides excellent intubating time and conditions comparable to Succinylcholine. Correlation of invasive intracranial pressure with optic nerve sheath diameter measured by ultrasonography and magnetic resonance imaging
Journal of Neuroanaesthesiology and Critical Care, Jun 1, 2019
Neurosurgical patients are a special subset of patients requiring postoperative care. Challenging... more Neurosurgical patients are a special subset of patients requiring postoperative care. Challenging neurosurgical disease processes, advanced surgical techniques, and unique individual patient requirements advocate the need of meticulous postoperative care to ensure safe transition toward recovery. Timely detection of systemic and neurological changes allows early diagnostic and therapeutic interventions. The mainstay of postoperative care revolves around airway, maintenance of hemodynamics, sedation, analgesia, nutrition, fluid management, and management of disease-specific complications. In addition to standard monitoring, multimodal neuromonitoring should be used in neurosurgical patients. Hence, four key elements in the postoperative management of neurosurgical patients involve profound insight, rapid response, good communication skills, and team collaboration.
Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019
Background: It is postulated that elevated blood pressure (BP) is a homeostatic response to eleva... more Background: It is postulated that elevated blood pressure (BP) is a homeostatic response to elevated intracranial pressure serving to maintain cerebral blood flow. Low BP results in cerebral hypoperfusion, which may aggravate ischemic injury. Studies to define the optimum BP associated with good neurological outcome are lacking. Therefore, we sought to observe the effect of perioperative blood pressure on long-term neurological outcome of patients with aneurysmal SAH. Materials and Methods: After Institute Ethics Committee approval and written informed consent from the patients or their nearest kin, 338 patients with SAH of all grades and age more than 18 years scheduled to undergo surgery were included in the study. The systolic, diastolic and mean blood pressures were recorded at admission, preoperatively and intraoperatively. Postoperative blood pressures were recorded till ICU stay of the patient. Results: Higher values of SBP, DBP, and mean arterial pressure (MAP) at the time of admission and in the preoperative period were associated with favorable neurological outcome at 3 months. There was no effect of intraoperative BP on the postoperative long-term neurological outcome. In the early postoperative period, patients with higher SBP, DBP, and MAP were associated with unfavorable neurological outcome. However, multiple logistic regression analysis did not demonstrate the effect of perioperative BP as an independent risk factor for long-term neurological outcome in patients with aneurysmal SAH. Conclusions: The perioperative blood pressure is not an independent predictor of long-term neurological outcome in patients undergoing aneurysmal neck clipping following SAH. Since admission, preoperative and early postoperative BPs have the potential to affect the outcome, BP should be meticulously observed and maintained within the normal physiological limits.
Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019
to PICU for elective postoperative mechanical ventilation and monitoring. The patient was extubat... more to PICU for elective postoperative mechanical ventilation and monitoring. The patient was extubated next day without any complication. The patient recovered with some residual weakness. Conclusions: The sitting position still has a role in modern neurosurgical practice but should be considered following consideration of its potential complications. Proper vigilance and monitoring with appropriate precautions can prevent complications both during and after the surgery.
Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019
and NSE between groups (p = 0.56 and 0.31, respectively) and over time in either groups (p = 0.31... more and NSE between groups (p = 0.56 and 0.31, respectively) and over time in either groups (p = 0.318 and 0.494 for S100B and p = 0.661 and 0.174 for NSE in RIPC and sham groups, respectively). None had adverse effects on transient limb ischemia with RIPC. Conclusions: This pilot trial showed that RIPC is feasible and safe. Our preliminary findings suggest a protective role of RIPC in prevention of vasospasm after aSAH, which needs confirmation by a larger trial.
Journal of Neuroanaesthesiology and Critical Care, Feb 1, 2017
of O2, surgical field flooded with saline. Central line (rt subclavian) was inserted and around 2... more of O2, surgical field flooded with saline. Central line (rt subclavian) was inserted and around 20 cc air was aspirated. Associated hypotension was managed with IV fluid boluses, vasopressor and ionotrops and shifted to neurosurgery ICU. Conclusion: Risk of venous air embolism during craniotomy requires high index of suspicion even in supine position though the incidence is very less. ISNACC-S-58 Anaesthetic management of drainage of brain abscess in a child with untreated TOF physiology: A case report
Journal of Neuroanaesthesiology and Critical Care, 2018
operating conditions as racemic bupivacaine and can be used routinely in our armamentarium of dru... more operating conditions as racemic bupivacaine and can be used routinely in our armamentarium of drugs for scalp block in awake craniotomy with better safety profiles.
Journal of Neuroanaesthesiology and Critical Care, Apr 24, 2023
Sickle cell disease (SCD) refers to a group of hemoglobinopathies that include mutations in the g... more Sickle cell disease (SCD) refers to a group of hemoglobinopathies that include mutations in the gene encoding the β subunit of hemoglobin. The glutamine in the heme portion of the hemoglobin molecule is abnormally substituted by valine. Sickle hemoglobin (hemoglobin type S), when gets deoxygenated, tends to polymerize and aggregate leading to vaso-occlusion and organ ischemia. Such patients are at increased risk of perioperative mortality and severe complications like vaso-occlusive crisis, acute chest syndrome, and congestive heart failure. We describe the perioperative management of a case of SCD with acromegaly scheduled for trans-sphenoidal removal of a functional pituitary adenoma. The acromegalic habitus, the cardiovascular effects of acromegaly, and the hormonal imbalances due to pituitary adenoma pose challenges in addition to the challenge of preventing complications of SCD making the anesthetic management more exigent.
Hearing rehabilitation treatment is dictated by the nature and etiology of hearing loss. Patients... more Hearing rehabilitation treatment is dictated by the nature and etiology of hearing loss. Patients with absent/destroyed cochlear nerves or complete labyrinthine aplasia (Michel's aplasia) render peripheral cochlear stimulation ineffective and such patients bene t from an auditory brainstem implant (ABI). A coordinated multidisciplinary team approach is necessary for the safe conduct of this challenging surgery using electrophysiologic measures to con rm the accurate placement of the ABI array. The role of the anaesthesiologist ranges from preoperative assessment of syndromal associations, di cult airway assessment, building rapport with the child, and counseling the family. Adequate premedication, smooth induction, and facilitation of neurophysiological monitoring are essential. The anaesthetist also plays a crucial role in decreasing intracranial pressure and improving surgical access while avoiding excessive cerebellar retraction. Close monitoring of vitals, care of the lumbar drain, provision of adequate analgesia, and antiemesis are the main concerns postoperatively.
Indian Journal of Otolaryngology and Head & Neck Surgery, Jul 25, 2020
We compared the use of palonosetron with combination of palonosetron and dexamethasone in prevent... more We compared the use of palonosetron with combination of palonosetron and dexamethasone in prevention of PONV in patients undergoing middle ear surgery under general anaesthesia. Prospective, randomized study was conducted including 90 adult patients who received either palonosetron (0.075 mg) (Group P) or combination of palonosetron (0.075 mg) and dexamethasone (8 mg) (Group PD). The primary outcome was incidence of nausea, vomiting and complete response. Secondary parameters were time to receive first rescue antiemetic, total dose required, patient's satisfaction, postoperative pain scores and total dose of rescue analgesic. The incidence of nausea was 15.5% and 8.8% (p = 0.522) and vomiting was 6.7% and 2.2% (p = 0.610) in group P and PD, respectively Complete response (CR) was observed in 84.4% patients in group P and 91% patients in group PD (p = 0.522). Combination of palonosetron and dexamethasone is not superior to use of palonosetron alone for PONV prevention.
Journal of Neuroanaesthesiology and Critical Care, Aug 1, 2015
C o m p a r a t i v e e v a l u a t i o n o f e s m o l o l a n d dexmedetomidine for attenuation... more C o m p a r a t i v e e v a l u a t i o n o f e s m o l o l a n d dexmedetomidine for attenuation of sympathomimetic response to laryngoscopy and intubation in neurosurgical patients
Journal of Neuroanaesthesiology and Critical Care, 2018
Introduction: Pituitary surgery presents challenges to anesthesiologists due to anatomic location... more Introduction: Pituitary surgery presents challenges to anesthesiologists due to anatomic location and physiological function. Postoperative disorders of fluid and electrolyte balance are very common, requiring prompt diagnosis and treatment. Methodology/Description: A 42-year-old obese, known diabetic man with subnormal mental development presented with headache for 6 months with fever. Examination revealed sparse facial hair, gynecomastia, and visual disturbances. MRI showed pituitary macroadenoma encasing bilateral cavernous internal carotid artery with mild hydrocephalus. Blood investigation showed hyperprolactinemia with hypothyroidism. After failure of medical management with cabergoline 0.5 mg twice a week, transcranial resection was planned. Anesthetic concerns were anticipated difficult airway, positioning, hemodynamic instability, and hormonal disturbances. Videolaryngoscope was used to secure airway. Balanced anesthesia technique with insulin infusion, anticonvulsants, and steroids was used for maintenance. Surgery lasted 7 hours with blood loss of 800 mL. Patient was extubated and monitored in ICU. On postoperative day 7, patient was put on ventilator due to decreased mentation. Patient had high urine output with hyponatremia, hypovolemia, natriuresis, low serum osmolality, and high urine osmolality, pointing toward diagnosis of cerebral salt wasting. Clinical condition improved with 3% sodium chloride at 10mL/hour and intravenous fluids. Patient was extubated on day 13 and discharged home on day 18. Conclusion: Postoperative polyuria can be challenging due to life-threatening hyponatremia. Fluid and electrolyte balance is very important. Good knowledge, planning, preparation, and teamwork are fundamental to successful perioperative patient care.
Journal of Neuroanaesthesiology and Critical Care, Aug 1, 2015
Background: Rocuronium may not be preferable for rapid sequence intubation due to its long intuba... more Background: Rocuronium may not be preferable for rapid sequence intubation due to its long intubation time compared to Succinylcholine. But, Rocuronium along with 2% Sevoflurane may produce comparable intubating time and conditions to that of Succinylcholine. This prospective, randomised, double-blind study was undertaken to compare the effect of Sevoflurane on intubation time and conditions with Rocuronium. Materials and Methods: 30 adult patients of ASA grade I and II of both sexes aged between 30 to 65 years undergoing neurosurgical operations were randomly allocated into 2 equal groups: one group received 0.8 mg/kg of Rocuronium and 2% Sevoflurane (Group-RS) and other received 0.8 mg/kg Rocuronium (Group-R). Onset time of intubation was assessed using Train of Four stimuli. The intubating conditions were compared by the Cooper scoring system and haemodynamic responses were compared between two groups. Results: The onset time of intubation was 60.4 ± 4.1 s in Group-RS and 101.73 ± 10.28 s in Group-R (P < 0.001), with excellent intubating conditions in both the groups and without any adverse effects. Significant differences in heart rate and mean arterial pressure were seen immediately after intubation, at 1 min, and at 3 mins (P < 0.05) between the two groups. Conclusion: Rocuronium with 2% Sevoflurane provides excellent intubating time and conditions comparable to Succinylcholine. Correlation of invasive intracranial pressure with optic nerve sheath diameter measured by ultrasonography and magnetic resonance imaging
Journal of Neuroanaesthesiology and Critical Care, Jun 1, 2019
Neurosurgical patients are a special subset of patients requiring postoperative care. Challenging... more Neurosurgical patients are a special subset of patients requiring postoperative care. Challenging neurosurgical disease processes, advanced surgical techniques, and unique individual patient requirements advocate the need of meticulous postoperative care to ensure safe transition toward recovery. Timely detection of systemic and neurological changes allows early diagnostic and therapeutic interventions. The mainstay of postoperative care revolves around airway, maintenance of hemodynamics, sedation, analgesia, nutrition, fluid management, and management of disease-specific complications. In addition to standard monitoring, multimodal neuromonitoring should be used in neurosurgical patients. Hence, four key elements in the postoperative management of neurosurgical patients involve profound insight, rapid response, good communication skills, and team collaboration.
Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019
Background: It is postulated that elevated blood pressure (BP) is a homeostatic response to eleva... more Background: It is postulated that elevated blood pressure (BP) is a homeostatic response to elevated intracranial pressure serving to maintain cerebral blood flow. Low BP results in cerebral hypoperfusion, which may aggravate ischemic injury. Studies to define the optimum BP associated with good neurological outcome are lacking. Therefore, we sought to observe the effect of perioperative blood pressure on long-term neurological outcome of patients with aneurysmal SAH. Materials and Methods: After Institute Ethics Committee approval and written informed consent from the patients or their nearest kin, 338 patients with SAH of all grades and age more than 18 years scheduled to undergo surgery were included in the study. The systolic, diastolic and mean blood pressures were recorded at admission, preoperatively and intraoperatively. Postoperative blood pressures were recorded till ICU stay of the patient. Results: Higher values of SBP, DBP, and mean arterial pressure (MAP) at the time of admission and in the preoperative period were associated with favorable neurological outcome at 3 months. There was no effect of intraoperative BP on the postoperative long-term neurological outcome. In the early postoperative period, patients with higher SBP, DBP, and MAP were associated with unfavorable neurological outcome. However, multiple logistic regression analysis did not demonstrate the effect of perioperative BP as an independent risk factor for long-term neurological outcome in patients with aneurysmal SAH. Conclusions: The perioperative blood pressure is not an independent predictor of long-term neurological outcome in patients undergoing aneurysmal neck clipping following SAH. Since admission, preoperative and early postoperative BPs have the potential to affect the outcome, BP should be meticulously observed and maintained within the normal physiological limits.
Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019
to PICU for elective postoperative mechanical ventilation and monitoring. The patient was extubat... more to PICU for elective postoperative mechanical ventilation and monitoring. The patient was extubated next day without any complication. The patient recovered with some residual weakness. Conclusions: The sitting position still has a role in modern neurosurgical practice but should be considered following consideration of its potential complications. Proper vigilance and monitoring with appropriate precautions can prevent complications both during and after the surgery.
Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019
and NSE between groups (p = 0.56 and 0.31, respectively) and over time in either groups (p = 0.31... more and NSE between groups (p = 0.56 and 0.31, respectively) and over time in either groups (p = 0.318 and 0.494 for S100B and p = 0.661 and 0.174 for NSE in RIPC and sham groups, respectively). None had adverse effects on transient limb ischemia with RIPC. Conclusions: This pilot trial showed that RIPC is feasible and safe. Our preliminary findings suggest a protective role of RIPC in prevention of vasospasm after aSAH, which needs confirmation by a larger trial.
Journal of Neuroanaesthesiology and Critical Care, Feb 1, 2017
of O2, surgical field flooded with saline. Central line (rt subclavian) was inserted and around 2... more of O2, surgical field flooded with saline. Central line (rt subclavian) was inserted and around 20 cc air was aspirated. Associated hypotension was managed with IV fluid boluses, vasopressor and ionotrops and shifted to neurosurgery ICU. Conclusion: Risk of venous air embolism during craniotomy requires high index of suspicion even in supine position though the incidence is very less. ISNACC-S-58 Anaesthetic management of drainage of brain abscess in a child with untreated TOF physiology: A case report
Journal of Neuroanaesthesiology and Critical Care, 2018
operating conditions as racemic bupivacaine and can be used routinely in our armamentarium of dru... more operating conditions as racemic bupivacaine and can be used routinely in our armamentarium of drugs for scalp block in awake craniotomy with better safety profiles.
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