The trigemino-cardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity, sympathetic hypotension, apnea, or gastric hypermotility during central or peripheral stimulation of any of the sensory branches of the trigeminal nerve. Clinically, the TCR has been reported to occur during craniofacial surgery, manipulation of the trigeminal nerve/ganglion and during surgery for lesion in the cerebellopontine angle, cavernous sinus, and the pituitary fossa. Apart from the few clinical reports, the physiologic function of this brainstem reflex has not yet been fully explored. The manifestation of the TCR can vary from bradycardia and hypotension to asystole. From the experimental findings, the TCR represents an expression of a central reflex leading to rapid cerebrovascular vasodilatation generated from excitation of oxygen-sensitive neurons in the rostral ventro-lateral medulla oblongata. By this physiologic response, the systemic and cerebral circulations may be adjusted in a way that augments cerebral perfusion. This review summarizes the current state of knowledge about TCR.

Intraoperative use of dexmedetomidine in children undergoing spinal surgery results in a favorable recovery profile with reduced postoperative pain and EA, without adverse perioperative hemodynamic effects.

The main aims of anesthesia for pituitary surgery include maintenance of hemodynamic stability, provision of conditions that facilitate surgical exposure, and a smooth emergence to facilitate a prompt neurologic assessment. The primary aim of our study was to compare the effects of 3 anesthetic regimens on hemodynamics and recovery characteristics of the patients. Ninety patients undergoing transsphenoidal surgery were enrolled in the study. Standard anesthesia technique was followed for induction. Patients were randomly divided to receive propofol, isoflurane, or sevoflurane for maintenance of anesthesia. The bispectral index target range during maintenance was 40 to 60. The hemodynamic variables (heart rate and mean arterial pressure) and bispectral index were noted during the various stages of the surgery. The time to emergence and extubation was noted. We evaluated cognitive function at 5 and 10 minutes posttracheal extubation. The 3 study groups were comparable with respect to age, sex, weight, and duration of surgery. We observed an increase in heart rate and blood pressure during intubation, nasal packing, and insertion of self-retaining nasal speculum. After tracheal intubation, the rise in blood pressure was more in sevoflurane group than propofol. During emergence, hypertensive response was seen in all patients. Emergence and extubation times were significantly shorter with propofol and sevoflurane. Patients who received propofol had better cognition scores. Aldrete scores were better with propofol and sevoflurane than isoflurane. The pressor response after intubation and emergence hypertension was significantly less with propofol. Better recovery profile was seen in sevoflurane and propofol groups and a better cognition in patients receiving propofol. Propofol plus nitrous oxide anesthesia could be the technique of choice in patients undergoing transnasal transsphenoidal pituitary surgery.

Background:Considering the important role of pituitary gland in regulating various endocrine axes and its unique anatomical location, various postoperative complications can be anticipated resulting from surgery on pituitary tumors. We examined and categorized the immediate postoperative complications according to various tumor pathologies.Materials and Methods:We carried out a prospective study in 152 consecutive patients and noted various postoperative complications during neurosurgical intensive care unit stay (within 48 hrs of hospital stay) in patients undergoing transsphenoidal removal of pituitary tumors.Results:In our series, various groups showed different postoperative complications out of which, cerebrospinal fluid leak was the commonest followed by diabetes insipidus, postoperative nausea and vomiting, and hematoma at operation site.Conclusion:Various immediate postoperative complications can be anticipated in transsphenoidal pituitary surgery even though, it is considered to be relatively safe.

Major vascular injury during lumbar disc surgery has been recognized as an unusual but well described complication. A potentially fatal outcome can be avoided by a high index of suspicion and an early diagnosis. We present a rare case of aortic and inferior vena caval injury in a 50-year-old female patient undergoing intervertebral disc surgery at lumbar one and two levels. A quick diagnosis and prompt management resulted in a favourable outcome for the patient.

Both PRGR and RF techniques can achieve acceptable pain relief with minimal side effects.

The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hyper-motility during stimulation of any of the sensory branches of the trigeminal nerve. The proposed mechanism for the development of TCR is--the sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. It has been demonstrated that the TCR may occur with mechanical stimulation of all the branches of the trigeminal nerve anywhere along its course (central or peripheral). The reaction subsides with cessation of the stimulus. But, some patients may develop severe bradycardia, asystole, and arterial hypotension which require intervention. The risk factors already known to increase the incidence of TCR include: Hypercapnia; hypoxemia; light general anesthesia; age (more pronounced in children); the nature of the provoking stimulus (stimulus strength and duration); and drugs: Potent narcotic agents (sufentanil and alfentanil); beta-blockers; and calcium channel blockers. Because of the lack of full understanding of the TCR physiology, the current treatment options for patients with TCR include: (i) risk factor identification and modification; (ii) prophylactic measures; and (iii) administration of vagolytic agents or sympathomimetics.

Upper lip bite test (ULBT) is a simple test for predicting difficult intubation. However, it has not been evaluated in acromegalic patients. The primary aim of this study was to compare ULBT with modified Mallampati classification (MMPC) to predict difficult laryngoscopy in acromegalic patients. Over a 5-year period, 64 acromegalic and 63 nonacromegalic patients presenting for excision of pituitary tumor were enrolled. Preoperative airway assessment was done using MMPC and the ULBT. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL) grading. MMPC III/IV and ULBT grade III were considered predictive of difficult laryngoscopy that was defined as Cormack-Lehane grades III or IV. Difficult intubation was defined as more than 2 direct laryngoscopy attempts involving change of blade or use of bougie/fiberoptic bronchoscope/intubating laryngeal mask airway. Sensitivity, specificity, positive and negative predictive values, and accuracy of both tests in predicting difficult laryngoscopy were calculated. Incidence of difficult laryngoscopy and intubation in acromegalics were 24% and 11%, respectively. MMPC and ULBT predicted difficulty in 61% and 14% acromegalics, respectively. However, only 26% and 44% of the laryngoscopies predicted to be difficult by MMMC and ULBT, respectively, were actually difficult. MMPC failed to predict 33% of difficult laryngoscopies whereas ULBT failed to predict 73%. Neither test predicted difficulty in 33% laryngoscopies that turned out to be difficult. Twenty-seven percent of the difficult laryngoscopies were correctly predicted by both tests. In acromegalic group, MMPC was more sensitive, whereas ULBT was more specific. Sensitivity and accuracy of both tests were less in acromegalic patients compared with nonacromegalic controls.