Methods: One hundred ASA I or II patients aged 25 to 45 years who were to receive spinal anaesthesia to undergo subumblical surgery were included in the study. Patients were randomly divided into two groups, group I received spinal anaesthesia with 25G Quincke point needle and group II received spinal anaesthesia with 29G Quincke point needle. Difficulty in localising the space and time taken to administer spinal anaesthesia were noted. Post-operatively incidence and severity of headache, backache and any auditory symptoms were recorded. Results: PDPH occurred in 12 (24%) patients in the 25G group and two (4%) patients in the 29G group. Incidence of backache was also significantly higher in the 25G group. Two patients in the 25G group complained of impaired hearing. However, the total time taken to administer spinal anaesthesia and number of redirections of the needle to locate sub-arachnoid space were significantly more in the 29G group. Conclusion: Spinal anaesthesia with a 29G needle reduces the incidence of PDPH in young adults. However, it is technically more difficult and time consuming to give spinal anaesthesia with a 29G needle than with a 25G needle.
Postoperative visual loss following spinal surgery is a rare complication. Although a number of intraoperative and postoperative factors have been implicated exact etiology still may remain unclear. We report a case of unilateral postoperative visual loss in a patient who had undergone prolonged spine surgery in a prone position.
EDITOR: A 60-yr-old female weighing 90 kg was admitted to hospital with severe oral bleeding. She was a known case of carcinoma of the left pyriform sinus and had undergone chemotherapy and radiotherapy over the previous 12 months. An oropharyngeal pack was required to control the bleeding while an elective tracheostomy was undertaken. The bleeding was initially controlled but she again experienced massive bouts of bleeding and approximately 2 L of blood was lost. Clinical examination revealed bilateral cervical lymph node enlargement with the node on the left side probably eroding into the left external carotid artery. Due to her poor general condition, an angiography was not performed. She was scheduled for an emergency ligation of the left external carotid artery. Pre-anaesthetic examination revealed a conscious, spontaneously breathing, elderly woman with no other apparent co-morbidity. Auscultation of the chest revealed bilateral equal air entry with scattered wheezes. She had received 5 units of blood transfusion and was maintained on oxygen supplementation through a T piece. In the emergency operating theatre, she was connected to the anaesthetic circuit (Ohmeda Exel 210 SE, Ohmeda Madison, USA) and 100% oxygen was administered. Her tracheostomy tube was suctioned which showed a little blood stained fluid. The initial blood pressure reading was 92/40 mmHg and the arterial oxygen saturation was 95%. Her right femoral vein was cannulated. Soon after, the patient started bleeding through the oral packs and had bouts of vigorous coughing. Anaesthesia was induced with ketamine 100 mg intravenously and vecuronium 4 mg was given for muscle relaxation. On attempting manual ventilation, resistance was noted. Bilateral air entry was absent and peak airway pressures reached 60 cmH2O. The patient was immediately disconnected from the breathing circuit and tracheal suctioning revealed a 3 cm clot with a few millilitres of blood stained fluid. The breathing circuit was reconnected and ventilation attempted, but this again proved unsuccessful. The patient began to develop a bradycardia with hypotension and decreasing arterial oxygen saturation. The breathing circuit was immediately disconnected and manual ventilation begun with a self-inflating (airway mask breathing unit, AMBU) bag. Ventilation was easy and the patient quickly stabilized. Examination of the anaesthetic breathing circuit revealed a 35 cm long blood clot weighing 300 gm in the inspiratory limb (Fig. 1). The remainder of the anaesthetic proceeded uneventfully.Figure 1.: Massive clot.This case illustrates the possibility of the anaesthetic breathing circuit becoming obstructed due to a massive blood clot. Our patient had a tracheostomy and the cuff was kept inflated. The formation of a huge clot in the lower respiratory tract could have been due to seepage of blood around the tracheostomy tube cuff because of tight oropharyngeal packing. Though a small clot was aspirated on tracheal suction, we never anticipated such a massive clot in her lower respiratory tract, because auscultation of her chest preoperatively did not reveal significant findings. In a previous report, Arney and colleagues have emphasized that a large clot in the lower airway may cause only a minimal impact on the respiratory function [1]. Runciman and colleagues [2] suggested that in cases of unexpected obstruction to ventilation during anaesthesia, eliminating the anaesthesia breathing circuit, as the cause of obstruction should be an immediate priority. In their crisis management algorithm, the authors have outlined the steps involved in the process of eliminating the whole circuit. We had carried out a complete pre-anaesthetic check of the anaesthesia machine. The tracheostomy tube was in a satisfactory place and the patient had been breathing spontaneously. Our ability to ventilate the patient with a self-inflating (AMBU) bag ruled out patient airway obstruction and implicated the anaesthesia circuit as the cause of failure to ventilate. In conclusion, we present a case of obstruction of an anaesthetic breathing circuit by a massive blood clot. Apart from complete anaesthesia machine check, the availability of an auxiliary ventilating device should always be confirmed before induction of anaesthesia. Case reported from: Department of Anaesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. N. Gopinath I. Bala a1Department of Anaesthesia, Bradford Royal Infirmary, West Yorkshire, England, United Kingdom a2Department of Anaesthesia, PGIMER, Chandigarh, India
The Internet of Things (IoT) is present in every aspect of our lives. They are used in our households, in hospitals, and outside to monitor and report environmental improvements, deter fires, and perform a variety of other useful functions. However, both of these advantages can come at the expense of significant security and risks privacy. Several academic research have been conducted to counteract these issues and figure out a better way to remove or minimise the threats to the user’s privacy and protection specifications in IoT devices. The survey is divided into four parts. The first section would look at the most important shortcomings of IoT devices and how to overcome them. The description of IoT attacks will be presented in the second section. The final section would look at security problems at various layers.
Sir, We present a case report of anaesthetic management of a 12-year-old boy with sickle-cell disease (SCD) and congenital heart block (CHB) with pacemaker [Figure 1], undergoing laparoscopic splenectomy.Figure 1: 12-lead electrocardiography of the patientThe child had suffered sickle-cell crisis and pacemaker malfunction a month back. His preoperative investigations were normal and weight was 30 kg. He received intravenous (IV) fluids during fasting period, pneumococcal vaccine, antibiotic prophylaxis and cefotaxime 500 g IV. The cardiologist changed the mode of pacemaker to asynchronous (fixed rate). Standard American Society of Anesthesiologists monitoring, urine output and temperature monitoring were used. Morphine 4.5 mg IV, thiopentone 150 mg IV and atracurium 0.5 mg/kg IV were used for induction and intubation. Anaesthesia was maintained with isoflurane (MAC: 1.0), air and oxygen (FiO2: 0.5). Pneumoperitoneum was created with CO2 and intra-abdominal pressure was kept around 8–10 mmHg. The surgeon used bipolar cautery, blood loss was approximately 800 ml and 1 unit packed red cell was transfused. The patient was given fluid at 60 ml/h intra-operatively as he had been kept hydrated preoperatively. For post-operative analgesia, paracetamol 500 mg IV was given and skin incision was infiltrated with 12 ml 0.2% ropivacaine. Neuromuscular blockade was reversed and trachea was extubated. The patient remained haemodynamically stable, normothermic and had adequate urine output. Post-operative analgesia was maintained with paracetamol 500 mg IV 8th hourly and fentanyl boluses of 30 μg as rescue analgesic whenever visual analogue scale exceeded 3. The child was discharged on the 7th post-operative day after uneventful course. CHB (incidence 1 in 22,000 live births) with no structural abnormality and when diagnosis is established beyond neonatal period has better survival.[1] Intraoperatively, pacemaker mode is advised to be changed to asynchronous, and bipolar electrocautery is to be used. The availability of manual pacing should be ensured to manage pacemaker malfunction.[2] SCD is the disorder of beta-globin chain characterised by haemolytic anaemia, intermittent vascular occlusion, pulmonary compromise and multi-organ damage. Electrocardiogram changes are non-specific and first-degree heart block may be found.[34] Not usually associated with SCD, CHB in our patient is perhaps an additional finding. Splenectomy is recommended in children older than 2 years or after one major or two minor episodes of splenic sequestration crises.[34] When done laparoscopically, the duration of surgery increases, but hospital stay is decreased.[3] Any major surgery is associated with 7% mortality. Preoperatively, the history of episodes of painful crises must be sought.[4] Pre-operative examination should be thorough as SCD involves multiple organ systems. Neurological evaluation rules out the previous cerebrovascular accident as ischaemic infarcts are common in anaemic children.[3] Kidneys may get involved during advanced disease. Presence of rib infarcts can lead to hypoventilation. Perioperative cardiopulmonary manifestations such as acute chest syndrome usually remain undetected in young children.[34] As dehydration precipitates RBC sickling and occlusion of microvasculature at a level of precapillary sphincters, perioperative hydration must be ensured.[34] There is a controversy regarding blood transfusion, benefit being dilution of haemoglobin S and disadvantage being triggering of sickling.[34] Other factors leading to sickling crises are vascular stasis, hypoxia, metabolic acidosis, hypothermia and presence of infection.[3] Previous case reports have emphasised the importance of preventing sickling crisis perioperatively.[5] To conclude, perioperative anaesthetic management of children suffering from SCD and CHB needs meticulous pre-operative and intra-operative management and post-operative vigilance for preventing sickle-cell crisis and associated complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Background & Objectives: Perioperative administration of carbohydrates is considered as one of the non pharmacological strategies to decrease PONV.However due to the variation in the dose, route and timing of administration of carbohydrate supplementation there has been conflicting results of it’s efficacy on nausea, vomiting and state of well being. The aim of this study was to evaluate the effect of postoperative administration of IV dextrose on PONV in patients undergoing Laparoscopic Cholecystectomy. Materials & Methods: 150 ASA I OR II patients undergoing laparoscopic surgery were randomly allocated to Group 1 (N=75) to receive one litre of 5% dextrose or Group 2 (N=75) to receive one litre of Ringer Lactate (RL) over a period of 30-40 min after surgery in PACU. All episodes of PONV (nausea, vomiting, retching) for 0-6 hours and 6-24 hours were recorded. Blood glucose was measured before and after completion of study fluid infusion. Requirement of rescue antiemetic therapy, postoperative pain, state of well being and length of stay in PACU were also evaluated as secondary objectives. Results: The incidence of nausea in Group 1 and 2 was (30.3% Vs 57.6%, p=0.041) at 0-6 hrs,(12.5% Vs 18.6%, p=0.364) at 6-24 hours and (42.8% Vs 72.8%, p<0.001) at 0-24 h. The incidence of vomiting was 10.7% Vs 11.8%, 3.5% Vs 5% and 14.2% Vs 16.9% at 0-6h, 6-24h and 0-24h in Group 1 and 2 respectively. Complete response and requirement of rescue antiemetic were comparable in both the groups. Requirement of analgesics were higher in group II as compared to group I between 0-24 h (p=0.042). Incidence of fatigue and hunger were significantly higher in group II as compared to group I. Conclusion: Postoperative administration of iv dextrose reduced the incidence and severity of nausea during the first 24 postoperative hours. It resulted in lesser requirement of rescue analgesics,lesser hunger and fatigue but more thirst postoperatively References: 1. Dabu-Bondoc S, Vadivelu N, Shimono C, English A, Kosarussavadi B, Dai F et al. Intravenous dextrose administration reduces postoperative antiemetic rescue treatment requirements and post anesthesia care unit length of stay. Anesth Analg 2013;117:591-596 2. Patel P, Minhthy NM, Rasmussen T, Donald LA, Brown J, Siddighi S et al. The relationship of intravenous dextrose administration during emergence from anaesthesia to postoperative nausea and vomiting: A randomized control trail. Anaesth Analg July 2013; Vol 117: 1 Disclosure of Interest: None declared
Sir, Errors in medical practice are not an uncommon occurrence. These can be either due to the machine failure or human failure.[1] Such errors can be catastrophic, if timely appropriate corrective steps not instituted. Nowadays, the newer anesthesia work-stations are equipped with sensors to monitor the spiromtory functions of anesthetized patients. These sensors are attached on the patient's end of the ventilator tubings, proximal to the patient's airway. We report a case of respiratory obstruction due to the presence of an unusual foreign body on the reusable D-lite™ spirometer sensor of the Datex Omeda monitor. Following induction of anesthesia, the airway of the patient was secured with 8.5 mm ID cuffed endotracheal tube. On connecting the ventilator circuit, it was observed that the patient's chest was not moving. There were no breath sounds on auscultation. The peak pressures rose to 40-42 cm of H2O and the arterial oxygen saturation of the patient dropped to 85%. The ventilator circuit was immediately replaced with the Bains coaxial circuit and the Fio2 increased to 100%. The patient could then be ventilated easily. There was increased in the arterial saturation and the peak pressures dropped to the normal limits. The rest of the surgery went uneventful. On closer inspection of the ventilator circuit, it was detected that a piece of the plastic wrapping of the D-lite sensor was left in between the sensor and the ventilator circuit which was causing the obstruction [Figure 1]. This small piece of wrapping was not visible from outside, which led to this mishap [Figure 2].Figure 1: Plastic wrapping causing breathing circuit obstructionFigure 2: Plastic wrapping unnoticed from outsideEarlier, obstructions in the ventilator circuit due to blocked heat and moisture exchanging filters (HMEF), faulty equipment or unusual foreign bodies like plastic wrappings have been reported leading to anesthetic mishaps.[234] Such obstructions in the ventilator circuit can mimic a condition of pnemothorax, silent chest, or severe bronchospasm.[5] Reporting of such critical events, re-emphasizes the need to check all the parts of anesthesia equipment before use to prevent the occurrence of these anesthetic mishaps in future.
Premature graying of hair has major psychosocial and socioeconomic repercussion, as it is considered as a sign of hastily progressing old age, ill health and often leads to loss of self-esteem. Hair is said to gray prematurely when it happens before the age of 20 years in Caucasians, 25 years in Asians, and 30 years in Africans. The hair color chiefly depends on melanin pigment, and fabrication of this pigment takes place in melanosomes through the process of melanogenesis. This complex biochemical pathway (melanogenesis) is further dependent on tyrosinase which acts as fuel.The normal human scalp is subjected to various factors categorized as intrinsic and extrinsic leading to graying of hair. Intrinsic factors comprise of variants responsible for changes at genetic level while extrinsic factors include air pollution, ultraviolet radiation, smoking, and nutrition. It has been proposed that direct or indirect effect of all these factors results in the generation of reactive oxygen species (ROS), thus leading to further damage. Though research has expanded in last few years in terms of microscopic, biochemical (hormonal, enzymatic), and molecular changes happening within hair follicle/shaft, still the exact mechanism leading to premature graying of hair is not well understood. Probable solutions toward this quandary are diet, herbal remedies, and temporary hair colorants. Ironically, the latter one being the most common has various side effects such as allergic reactions, inflammation, and hair loss. The aim of this paper was to review the manifestation and probable future interventions in preventing premature hair graying.
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