Introduction: Benzodiazepines primarily acts on the central nervous system. Most patients are extremely anxious in the pre-operative period. Excessive anxiety adversely influences anaesthetic induction and often leads to functional impairment and poor recovery after surgery.
Background: Spinal anesthesia with 0.5% hyperbaric bupivacaine is an approved technique for lower segment cesarean sections. This study compared two different hyperbaric bupivacaine doses for spinal anesthesia in the lower segment cesarean section. We hypothesized that low-dose spinal anesthesia had similar outcomes as conventional doses of bupivacaine. Methods: This was a comparative observational study involving seventy healthy parturients who were posted for elective cesarean section. Patients were supposed to receive 0.5% hyperbaric bupivacaine and were divided into groups, low dose (LB-1.8 ml) and conventional-dose (HB-2.2 ml) group. The extent of motor blockade, sensory blockade, hemodynamic effects, visual analog scale for pain, and patient satisfaction were measured. The data were analyzed using the median and interquartile range for all parameters. A statistical package SSPS version 25.0 was used to do the analysis. Results: Hemodynamic stability was well maintained in both groups. Almost 100% of the patients in both groups achieved a grade 3 motor blockade in 8 min. T6 level of sensory blockade was achieved in 6 min by 100% of the patients. The low-dose group made a faster recovery compared with the high-dose group. Conclusion: Low-dose spinal anesthesia can cause similar hemodynamic and analgesic effects as the conventional-dose group. The only benefit of low dose spinal as compared with conventional-dose group was faster recovery from the anesthetic effects.
Respiratory distress associated with vocal cord palsy can be attributed to recurrent laryngeal nerve injury. Bilateral vocal cord palsy can cause adduction of cords and respiratory distress. Airway, in these patients, can be compromised and result in unanticipated difficult intubation. The time frame to pass tube in such situations are less. This is a case series on successful airway management of three patients who presented with recurrent nerve palsy and airway obstruction. Thus the “cannot intubate-cannot oxygenate” situation was avoided in all the patients.
A 14-year-old female child, weighing 16 kilograms, known case of Down's syndrome posted for Heller's cardiomyotomy. A thorough pre-anaesthetic evaluation was done. Child was irritable and poorly built. Airway examination revealed receding mandible, high arched palate, and Mallampatti grade 3. Auscultation of lung fields revealed occasional crepitations. A pan systolic murmur was heard in the mitral area.A 2D echo revealed mitral valve prolapse with mitral regurgitation with normal LV function and no pulmonary hypertension. Chest X-ray revealed dilated oesophagus [Table/ Fig-1]. Computerized tomography of thorax and barium swallow revealed entire thoracic oesophagus grossly dilated and distended with fluid and food particles [Table/ Fig-2]. This patient was diagnosed to have Achalasia cardia and was planned for Heller's cardiomyotomy. It was an anticipated difficult intubation situation in view of Down's syndrome.The patient was shifted to the operation room and monitors connected. Acid aspiration prophylaxis was given. Ryle's tube was inserted and oesophagus was decompressed. The equipments for difficult airway were kept ready. Our plan was to go ahead with rapid sequence induction.The child was preoxygenated with 100% Oxygen for 3 minutes. She was premedicated with 0.2mg midazolam and 20µg fentanyl.Rapid sequence induction done with Ketamine 20mg, Propofol 20mg and Succinyl choline 20mg along with application of cricoids pressure. Under direct laryngoscopic vision, bilateral vocal cords were visualized with difficulty as the child had enlarged glossoepiglottic folds and enlarged hanging epiglottis. Trachea was intubated with 5mm Cuffed Oral Endotracheal Tube (COETT) and fixed at 17 centimeters after confirming bilateral air entry. We made sure that cuff was inflated immediately after intubation. Cricoid pressure was released. Achalasia cardia is a disorder of the gastrointestinal tract characterized by dilatation of the oesophagus and collection of food and fluids in the oesophagus leading to massive regurgitation and aspiration of gastric contents. Down's syndrome has multisystem effects which can also present as difficult airway. Here, we present a case of a 14-year-old girl, a case of Down's syndrome with Achalasia cardia and mitral valve prolapse posted for Heller's cardiomyotomy. Anaesthetic concerns were difficult airway due to Downs's syndrome, massive aspiration risks of Achalasia cardia and haemodynamic instability due to mitral regurgitation. In spite of proper preparation of the patient there was massive regurgitation of oesophageal contents during intubation which was managed successfully. Haemodynamic changes due to mitral valve prolapse also had to be taken care of during the intraoperative period. Postoperative period was uneventful and the child was discharged after one week. Keywords[
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