Original ArticleIntroduction T he field of cochlear implantation has been expanding rapidly and now it is an acceptable therapeutic option for those patients with irreversible hearing loss and deafmutism. It has been hailed as one of the greatest advances in otology [1]. Cochlear implants are extremely expensive computerised electric prostheses that partially replace the functions of the cochlea (Fig 1). The surgery is time consuming and is performed under general anaesthesia via a trans-mastoid approach. The operative technique is complicated and necessitates preservation of functional integrity of the facial and cochlear nerve. The anaesthesiologist is an integral member of the cochlear implant team whose anaesthetic as well as communication skills are put to test. The technique of anaesthesia plays a crucial role in success of cochlear implant surgery as the anaesthesiologist has to produce conditions which facilitate use of nerve stimulators and treat troublesome post-operative complications such as nausea, vomiting and vertigo. This paper highlights certain important technical aspects of the surgery and our anaesthetic experience in a series of cases performed till now. A brief review of literature is also presented. Material and MethodsThe present study was carried out in the form of retrospective analysis of medical, surgical and anaesthetic records of all the children (age upto 15 years) who underwent implantation of cochlear devices at our institute over last five years. The analysis included pre-implant work up and preoperative screening of each child. Surgical aspects along with incidence of complications were also recorded. Anaesthetic technique was screened in detail and adverse events during entire peri-operative period were noted.Patients with irreversible hearing loss and not responding to hearing aids, were selected by the implant surgeon. Each

For the first time, bispectral index (BIS) has been studied in patients being anesthetized solely with ether. Ether both causes an increase and decrease in BIS during induction and emergence. The index observed during the surgical stage of ether anesthesia is probably the correct value for the depth of hypnosis because no other volatile anesthetic can produce the true anesthetic state when used alone. This value could be taken as the value to be attained when balanced anesthesia is being practiced.

Context:Pain is a distressing symptom common to all stages and ubiquitous at all levels of care in cancer patients. However, there is a lack of scientific literature on prevalence, severity, predictors, and the quality of pain in cancer patients admitted to an Intensive Care Unit (ICU).Objectives:To elucidate the prevalence of pain, moderate to severe pain, neuropathic pain, chronic pain, and pain as the most distressing symptom in critically ill-cancer patients at the time of ICU admission.Methods:We prospectively interviewed 126 patients within first 24 h of admission to a medical ICU. The patients were assessed for the presence of pain, its severity, sites, duration, nature, and its impact as a distressing symptom. Numerical Rating Scale and self-report version of Leeds Assessment of Neuropathic Signs and Symptoms were used to elucidate intensity of pain and neuropathic pain, respectively. Demographic characteristics such as age and sex, primary site, and stage of cancer were considered for a possible correlation with the prevalence of pain.Results:Of 126 patients included in the study 95 (75.40%), 79 (62.70%), 34 (26.98%), and 17 (13.49%) patients had pain, moderate-severe, chronic, and neuropathic pain, respectively. The average duration of pain was 171.16 ± 716.50 days. Totally, 58 (46.03%) and 42 (42.01%) patients had at least one and more than equal to 2 neuropathic pain symptoms, respectively. The primary malignancies associated with the highest prevalence of pain were genitourinary, hematological, and head and neck whereas breast and lung cancers were associated with the highest prevalence of neuropathic and chronic pain, respectively.Conclusion:The prevalence of pain among critically ill-cancer patients is high. Assessment for pain at the time of ICU admission would ensure appropriate assessment for the presence, type, severity, and the significance imparted to it.

Background and Aims:Oncosurgeries may incur massive blood loss demanding frequent blood sampling to assess blood loss and the need for intraoperative blood transfusions. Accuracy of non-invasive spectrophotometric haemoglobin (hereafter to be referred as SpHb) monitoring has been studied in various perioperative settings. The intraoperative use of Radical-7®, Masimo Corp., (Radical-7®) for SpHb monitoring may be useful during cancer surgery. The aim of this study is to evaluate the intraoperative utility of SpHb monitoring by the Radical-7® to guide intraoperative transfusion in oncosurgeries.Methods:Fifty adult patients, undergoing oncosurgery with anticipated blood loss of more than 20% of blood volume, were selected. Continuous SpHb monitoring was performed intraoperatively and blood transfusion was based on SpHb values. Simultaneous laboratory haemoglobin (LabHb) samples were taken for validation. The accuracy of intraoperative blood transfusions based on SpHb was analysed using Error Grid Analysis. Paired measurements of SpHb and LabHb were compared using Bland–Altman plot analysis.Results:There were 66 paired data points for blood transfusion from fifty patients with a correlation of 73% (P < 0.001) between SpHb and LabHb. In the Bland–Altman analysis, the bias was − 0.313 g/dl with ~ 95% of values within the limits of agreement of 1.81 g/dl to −2.44 g/dl. In the Error Grid Analysis, most data points were in the least error zone (Zone A).Conclusion:The Radical-7® has the advantage of providing SpHb value continuously to take prompt decision regarding blood transfusion intraoperatively.

Aim:Peripherally inserted central venous catheters (PICCs) are popular due to the ease of insertion, low cost and low risk of complications. Anteroposterior (AP) chest radiograph (CXR) is then obtained to assess the location of the catheter tip. But poor-quality X-rays remain a significant problem. We planned a study using radiopaque marker at sternal angle, as a radiological landmark, to relate height of the patient and optimal length of PICC fixation, at the antecubital fossa, and to know the incidence of malpositioning.Materials and Methods:A total of 200 patients aged above 20 years, scheduled for elective major cancer surgeries were studied. Vygoflex PUR, 16-G catheter, length 70 cm was used. The right or the left arm was chosen depending on the availability of veins. Catheter tip was observed in the post procedure CXR.Results:200 patients [100 patients in group 1 (length of catheter fixation at antecubital fossa 45 cm) and 100 patients in group 2 (length of catheter fixation 50 cm)] were enrolled. The groups were further subdivided into 1a, 1b, 2a, 2b and results tabulated.Conclusions:Appropriate length of catheter fixation for group 1a was <45 cm, group 1b = 45 cm, group 2a = 50 cm, and for group 2b it was ≥50 cm. Gender and arm (right or left) did not have any bearing on the length of fixation. Incidence of malpositioning (15.5%) was more in right-sided catheters, more so, in short heighted people. PICC insertion via cubital route stands better compared with other routes, viz., Internal jugular vein IJV, subclavian and femoral.

Original ArticleIntroduction L abour and delivery results in severe pain for many women. The McGill Pain Questionnaire ranks labour pain in the upper part of the pain scale between cancer pain and amputation of a digit [1]. The goal of maternal labour analgesia is relief of pain without compromising maternal safety, progress of labour and foetal well-being. Epidural analgesia is the most effective and least depressant method of intrapartum pain relief in current practice [2]. Low concentration of bupivacaine combined with fentanyl, results in analgesia with minimal side effects [3]. The aim of the study, was to develop a safe dosing regime to provide satisfactory pain relief with minimal side effects. Material and MethodsIt was a prospective open label study. We studied 45 primiparous and five second gravida women with singleton foetus in vertex position admitted for parturition in the age group of 18-30 years. Parturients with obstetric complications like pre-eclampsia, preterm labour, previous caesarian, abnormal lie and placenta previa were excluded from the study. Once the parturient is in active phase of labour i.e. cervix is 3-4 cms dilated, anaesthesiologist was called for lumbar epidural block.After explaining the procedure, 500 ml of ringer lactate was infused as preload. Pre-epidural pulse, blood pressure (BP), SpO 2 and pain score (using Visual Analogue Scale-VAS) were checked. Foetal heart rate (FHR) was continuously monitored using cardiotocograph. All the parturient were kept fasting, but clear fluids were allowed till delivery. Epidural space was identified in L2-3 / L3-4 interspinous space using loss of resistance to saline and multiorifice epidural catheter inserted. Initial bolus of 10 ml of drug solution (0.1% bupivacaine and 0.0002% fentanyl) was injected in two aliquots, five ml in left lateral and five ml in right lateral position at an interval of five minutes. Maternal pulse, BP, SpO 2 and FHR were monitored every five minutes for the first 30 minutes. After 30 minutes pain score using VAS and motor blockade using modified Bromage Score (Table 1) was checked. If pain relief was satisfactory (VAS <5) and there were no motor block or evidence of significant hypotension an epidural infusion (with syringe infusion pump) of the same drug solution was started at the rate of 5ml /hour. Patient was assessed at 30 minutes interval for pain relief (objective assessment using VAS on 1-10 scale and subjective assessment by mother as excellent/good/fair/poor), maternal haemodynamics, foetal heart rate, motor block, duration of second stage of labour, incidence of caesarian section, instrumental delivery, side effects, complications (sedation, nausea, vomiting, itching, urinary retention) and total dose of bupivacaine and fentanyl used.

Background:Gross physiological perturbations necessitating the Intensive Care Unit (ICU) admission might exacerbate the already existing or initiate bothersome symptoms among cancer patients. There is a lack of conclusive evidence concerning the symptomatic experience among this subgroup of cancer patients particularly so in the Indian population. The aim of this prospective observational study was to elucidate the symptom prevalence and overall symptomatic distress among critically ill cancer patients at the time of admission to a medical ICU.Methods:We prospectively evaluated 110 consecutive cancer patients at the time of admission to our medical ICU for the presence and intensity of symptoms using a modified Edmonton Symptom Assessment Scale (ESAS). The patients/caregivers were also enquired regarding the most bothersome symptom in the past 1 week and the presence of “symptom associated sleep disturbance.” The primary outcome was the prevalence of patients with moderate (ESAS ≥ 40) and severe (ESAS ≥ 70) symptomatic distress.Results:The average age was 52.49 years with 75.45% of the respondents in the economically productive age group (21–60 years). Carcinoma breast (19.35%) and lung (14.58%) were the most common cancers among females and males, respectively. 87.27% and 60% of the patients had advanced cancer and multi-organ dysfunction, respectively. About 76.36% patients were able to complete ESAS either by themselves or with caregiver's assistance within first 24 h of ICU admission. The mean ESAS distress score was 48.04 (0–81) with 72.72% of the patients having moderate-severe symptomatic distress. Loss of appetite (92.73%) and nausea (54.55%) were the most common and the least common reported symptoms, respectively. Pain was the most common and “most distressing symptom” reported by 40% of patients with 64.55% patients reporting one or more symptoms severe enough to interfere with their sleep.Conclusion:ESAS is a user-friendly cognitive aid to make the healthcare team cognizant of the symptom existence and overall symptomatic burden among cancer patients with gross physiological perturbations. The high prevalence of moderate-severe symptom distress requires the concomitant provision of palliative and intensive care among this group of cancer patients.

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