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ABSTRACT
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 102-108

Selected Abstracts of Papers Presented at the 4 th National Conference of Association of Obstetric Anesthesia and the 1 st Joint AOA - OASAO (Obstetric Anesthesia Society Asia Oceania) Conference Hyderabad, India, September 16-18, 2011


Date of Web Publication17-Mar-2012

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. Selected Abstracts of Papers Presented at the 4 th National Conference of Association of Obstetric Anesthesia and the 1 st Joint AOA - OASAO (Obstetric Anesthesia Society Asia Oceania) Conference Hyderabad, India, September 16-18, 2011. J Obstet Anaesth Crit Care 2011;1:102-8

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. Selected Abstracts of Papers Presented at the 4 th National Conference of Association of Obstetric Anesthesia and the 1 st Joint AOA - OASAO (Obstetric Anesthesia Society Asia Oceania) Conference Hyderabad, India, September 16-18, 2011. J Obstet Anaesth Crit Care [serial online] 2011 [cited 2018 Aug 20];1:102-8. Available from: http://www.joacc.com/text.asp?2011/1/2/102/94002

Awareness and attitude towards labor analgesia of Indian pregnant women attending ANC at Pravara Rural Hospital, LONI

Shidhaye R. V., Ghosh Sujoy, Galande Mandar, Joshi S. S.


Pravara Rural Hospital, LONI, India

Background:
Epidural labor analgesia has not been fully accepted and is not routinely practiced in many centers in developing countries in spite of many advantages. Number of patients who demand labor analgesia is very less in Pravara Rural Hospital in spite of availability. The aim of this study was to find out the awareness and attitude towards labor analgesia of pregnant women attending ANC clinic of Pravara Rural Hospital.

Materials and Methods: Two hundred consecutive women attending antenatal clinic of Pravara Rural Hospital and willing to participate were included in the survey and were interviewed using a questionnaire that determined their knowledge of and attitudes regarding labor analgesia.

Results: 85% participants were between the age group of 19 to 25 (range 17-36).Most of them (89.5%) were from rural area. Level of acceptance of labor analgesia after full information was found to be significantly correlated with the level of education and socioeconomic status, fear of delivery complications, and fear of labor pains, and their desire to deliver without suffering from labor pains ( p -value <0.05). At the same time it was not correlated to age, geographical distribution, parity, time required for last delivery, perception of intensity of labor pains during last delivery ( p -value >0.05).

Conclusion: Most of the Indian parturients still suffer from agony of labor pains due to lack of adequate labor analgesia services and due to lack of awareness where services are available. They should be made aware wherever services of labor analgesia are available. Role of treating obstetricians is crucial in these regards.

Comparison of 0.125% ropivacaine with 0.2% ropivacaine with fentanyl 2 mcg/ml for epidural labor analgesia: A randomized clinical trial

Chhetty Yogesh Kumar, Sunanda Gupta, Doshi Vimla


Rabindra Nath Tagore Medical College, Udaipur, India

Background: Most authors agree that toxicity is not an issue when low doses and concentrations of local anesthetics are used. Therefore, strategies aiming reduction of consumption are more important than choice of the local anesthetic, when goal is optimal neuraxial obstetrical analgesia.

Aims: Evaluation of motor and sensory blockade characteristics of two doses of ropivacaine and fentanyl in labor analgesia.

Materials and Methods: This prospective randomized comparative study was conducted at Pannadhai Mahila Chikitsalaya, attached to R.N.T Medical College, Udaipur. After institutional review board approval and informed consent, 80 healthy term parturients of ASA Grade I/II were recruited into two groups (40 each). In both groups the following drug regimen was used as initial bolus and subsequent top-up dose:

  • Group A (0.2% ropivacaine 15 ml + 2 μgm/ml fentanyl)
  • Group B (0.125% ropivacaine 15 ml + 2 μgm/ml fentanyl)


Groups were compared on: onset/duration of analgesia, number of doses, maximum level of analgesia, pain scores, hemodynamic parameters, motor block and side effects.

Results: Onset of analgesia was significantly faster in Group A (75% in 0-5 min) versus Group B (75% in 5-10 min). Analgesia duration was significantly longer in Group A (132.05 min) versus Group B (72.25 min). Number of top-up doses being used was significantly lower in Group A (0.05) versus 0.80 in Group B. Analgesia was better in Group A with mean VAS at 5 min post bolus being 1.63 versus 5.00 in Group B. No significant cardiovascular changes or motor blockade was noted.

Conclusion:
It was concluded that ropivacaine (0.2%) is better in providing labor analgesia as compared with ropivacaine (0.125%), as lower doses of fentanyl are also utilized.

Our experience of Labor analgesia on previous LSCS patient

Souvik Paul, Shubhada Aphale, Pooja Bhosle, P. Jedge


Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India

Background:
In this study, 20 previous LSCS patients for vaginal delivery trial were analyzed for outcomes, after giving epidural labor analgesia.

Aim: To observe and analyze outcome of epidural labor analgesia on mother or fetus in previous LSCS patients for vaginal delivery trial.

Materials and Methods: This study was conducted in Bharati Hospital. Patients with previous LSCS willing for labor analgesia were carefully selected for vaginal trial by obstetrician. Before institution of the epidural block, a past obstetric history, vital parameters and FHR were ascertained. Standard resuscitation measures were kept ready. After assessment of cervical dilatation (less than 5 cm), epidural analgesia was administered. Vigilant frequent monitoring of mother and fetus by a trained anesthesiologist was done throughout the procedure till the end of delivery.

Results: Successful vaginal delivery was achieved in 14 (70%) patients and repeat emergency caesarean section (CS) was carried out in 6 (30%) patients. Leading indication for repeat CS was failure to progress, fetal distress and scar dehiscence. No maternal complication occurred. Out of 20 newborns, 2 of them had APGAR score <3. After resuscitation they were shifted to NICU. Rest did not have any serious complications.

Conclusion: Vaginal delivery trial to previous LSCS with epidural analgesia should be encouraged in well-equipped tertiary healthcare centers with adequate resources.

Audit of maternal deaths: A 10-year retrospective analysis of mortality in critically ill pregnant patients

Suneetha, Sunil T. Pandya
, Shanti Y., Sailaja K., Kausalya C.

Department of Anesthesia, Pain and Critical Care, Prerna Anesthesia and Critical Care Services, Fernandez Hospital, Hyderabad, India

Introduction: The improvement in the quality of care during pregnancy, early recognition of warning signs and early interventions has reduced the maternal morbidity and mortality rates worldwide. Failure to recognize the subtle signs of deterioration, suboptimal resuscitative measures and the late referral to the tertiary care centers are the major contributing causes of maternal mortality.

A regular audit facilitates recognition of the preventable causes of death and assists in improving of the quality of care rendered to these sick parturients.

This study is a retrospective analysis of all the maternal deaths at Fernandez Hospital from Jan 2001 to Dec 2010. Fernandez Hospital is a tertiary care center for referral perinatal center with an annual delivery rate of ~5000 and has a dedicated Obstetric Critical Care Unit.

Objective
: The objective of the study is:

  1. To do a root cause analysis of all maternal deaths that occurred during a 10-year period from Jan 2001 to Dec 2010;
  2. To arrive at the means to identify the early markers of increased morbidity and mortality; and
  3. To develop appropriate screening and training modules to prevent the maternal deaths


Materials and Methods: The retrospective study was conducted on 445 critically ill pregnant women, admitted between Jan 2001 and December 2010 in Fernandez Hospital, Hyderabad, a tertiary care referral center for obstetrics and perinatology. Patients requiring only high dependency care were excluded from the study. The data analyzed included the total number of maternal deaths, the number of in-house patients, the total number of referrals, the primary cause of death, associated co-morbid conditions, number of patients with sepsis and multi-organ dysfunction syndrome (MODS) involving three or more than three organs and the most common organs involved in MODS. Required data was retrieved from ICU records and database.

Observation and Results:


  • Total number of deliveries during this period: 40499
  • Total number of critically ill parturient admitted: 494
  • Total number of deaths: 26
  • In-house patients: 02
  • Outside referrals: 24
  • Patients with co-morbidities other than the presenting illness: 09
    • AMA (Age > 35 years): 4
    • Obesity (BMI >30): 4
    • Anemia: 14
    • GDM: 4
    • Chronic hypertension: 3
  • Patients succumbing to severe sepsis with MODS: 14
  • Hepatic failure, AKI, DIC: 12


Analysis: The altered immunological status of pregnancy may lead to exaggerated systemic inflammatory response syndrome (SIRS) leading to multiorgan dysfunction syndrome, which is a grave condition in pregnancy with fatal outcome. Kidneys get compromised early in critically ill parturient. The suboptimal resuscitation received in the initial 6 h of hypovolemia, underlying pre-eclampsia aggravates the AKI. Prognosis is worsened with the onset of DIC and jaundice. Early and aggressive organ support and goal-directed therapy may have a more favorable outcome. Respiratory failure, DIC, AKI, cardiovascular instability and hepatic involvement was seen in most patients. Of the infectious causes, Hepatitis E complicating pregnancy is associated with poor prognosis with early onset of encephalopathy, DIC and renal failure.

Conclusion:


  • All patients with suspected non-obstetric causes of jaundice should be screened for Hep-E and all organ functions evaluated early and sequentially. Jaundice associated with Oliguric Acute Kidney Injury and DIC is a strong predictor of maternal mortality.
  • Early multidisciplinary care and aggressive multiorgan support including early RRT is warranted if patient with AKI remains to be oliguric or anuric.
  • Have low threshold for doing blood gas analysis. Admission pH <6.9 is a strong predictor of maternal mortality.
  • All tertiary referral centers should have sepsis screening and management, obstetric hemorrhage and hypertensive management audit and outreach programs within the hospital.
  • The concept of Early Warning chart, regular drills in common Obstetric emergencies and HDU is the need of the hour for all obstetric centers irrespective of the number of deliveries conducted
  • Need to develop a special severity scoring system in parturients.


Low-dose bupivacaine with fentanyl in spinal anesthesia for cesarean section

Samina K. Khatib, Gayatri V. Tadwalkar


Department of Anesthesia, Government Medical College, Aurangabad, India

Background: Spinal anesthesia for Cesarean section with low dose of bupivacaine along with fentanyl has been advocated to provide more intense sensory blocks with lower doses of bupivacaine and thus decreasing the severity of hypotension and other related side effects.

Aim : To study the effect on maternal hemodynamics of three different mini doses of bupivacaine with addition of fentanyl in spinal anesthesia for Cesarean section.

Materials and Methods: Prospective single blind controlled study in patients undergoing Cesarean section. Group C - control group - received 2 cc (10 mg) of 0.5% bupivacaine intrathecally, Group 4F - received 0.8 cc (4 mg) of 0.5% bupivacaine plus 25 ug fentanyl intrathecally, Group 5F and Group 6F received 5 mg and 6 mg of 0.5% bupivacaine, respectively, along with 25 ug fentanyl intrathecally. Thirty patients were studied in each group. Vitals were monitored every 2 min till baby is delivered and then every 5 min till the completion of surgery. Intra op and post op complications such as hypotension, bradycardia, respiratory insufficiency, vomiting, shivering, pruritus, were noted till complete recovery. APGAR scores at 1 and 5 min were taken to assess neonatal outcome.

Results: Significantly lower incidence of hypotension ( p <0.05) was seen in low dose bupivacaine groups (4F,5F, 6F) as compared to the control group. The requirement of vasopressors, duration of hypotension, incidence of nausea and vomiting is also comparatively lower ( p < 0.05) in low dose groups. However, the duration of surgical anesthesia is significantly short ( p < 0.05) in 4F and 5F groups. Patients who received intrathecal fentanyl have significantly better postop analgesia and early recovery ( p < 0.05) compared to the control group. No adverse outcome was seen in neonates of low dose fentanyl groups.

Conclusion: Thus low dose bupivacaine with fentanyl is a useful approach not only for decreasing the incidence of maternal hypotension but also for early post op recovery and improved maternal satisfaction.

Prediction of hypotension following spinal anesthesia in normal and hypertensive parturients using Supine stress test

Malsawmtluangi, Sandhya Yaddanapudi, Kajal Jain, Vanita Jain


PGIMER, Chandigarh, India

Background: A supine stress test (SST), which identifies the parturients prone to develop aorto-caval compression, was found to predict post-spinal hypotension in normal parturients.

Aims: To assess if preoperative SST is effective in predicting post-spinal hypotension in parturients with mild pre-eclampsia or pregnancy-induced hypertension.

Materials and Methods: 25 normotensive and 25 parturients with mild pre-eclampsia or gestational hypertension scheduled for elective cesarean section under spinal anesthesia underwent pre-operative supine stress test. The test was considered positive if there was a persistent increase in heart rate by >10 bpm or a decrease in systolic blood pressure by >20% or any sign or symptom of hypotension on change of position from lateral to supine. Hypotension after spinal anesthesia was defined as predelivery systolic blood pressure <20% below the baseline value and was treated with a bolus of 50 μg of phenylephrine.

Results: Incidence of hypotension was similar in normotensive (68% [95% CI: 50-86%]) and hypertensive (64% [95% CI: 45-83%]) groups. The sensitivity of the SST to predict hypotension was 41.2% and 12.5% in normotensive and hypertensive groups, respectively; specificity and positive predictive value was 100% in both the groups; and the negative predictive value was 44.4% and 39.1 % in normotensive and hypertensive groups, respectively.

Conclusion: SST is a highly specific non-invasive method for predicting post-spinal hypotension and phenylephrine requirement in both normotensive and hypertensive parturients undergoing elective cesarean section.

Prevention of hypotension following spinal anesthesia for caesarean section: Comparison between prophylactic phenylephrine infusion and colloid co-hydration

Amitabh Lalji Sahoo, R. V. Shidhaye, V. K. Badhe, D. S. Divekar


Pravara Institute of Medical Sciences, Maharashtra, India

Background: Maternal hypotension after spinal anesthesia for cesarean section may have detrimental effects on uterine blood flow, fetal well-being and ultimately neonatal outcome as measured by umbilical artery pH and Apgar scores. An effective method for preventing hypotension has been referred to as the "Holy Grail" of obstetric anesthesia and has yet to be described. Prophylactic infusion of phenylephrine to prevent spinal hypotension was studied and compared with colloid co-hydration therapy.

Materials and Methods:
Forty full-term pregnant patients of ASA grade I and II, posted for cesarean section were randomly distributed into two groups. In Group I patients, immediately after intrathecal injection, phenylephrine was infused at 60 microgram/min for 2 min unless SBP was greater than 120% of baseline. From that point until delivery, phenylephrine infusion was continued at 60 microgram/min whenever systolic arterial blood pressure (SAP), measured each minute, was less than or equal to baseline. In group II patients, rapid colloid infusion (12 ml/kg of Hydroxy Ethyl Starch 6%) was given immediately after intrathecal injection.

Results:
Blood pressure remained mostly stable in phenylephrine group. (111.57 ± 10.72 mm of Hg.) Number of occasions of fall in B.P. below 80% of baseline were 0.5 ± 0.76 in phenylephrine group as against 1.65 ± 1.9 in co-hydration group (P < 0.05). Umbilical artery pH was 7.28 ± 0.05 (range: 7.15, 7.37) in phenylephrine group as against 7.27 ± 0.05 (range 7.14, 7.33) in co-hydration group (P > 0.05).

Conclusion: Prophylactic phenylephrine infusion is more effective than colloid co-hydration therapy in preventing spinal hypotension.

A comparative evaluation of epidural volume extension using sequential combined spinal epidural anesthesia in cesarean section

Shamim Gauhar, Shahla Haleem, Shyam Bhandari, Dheeraj Sharma, Rohit Varshney


J. N. Medical College, Aligarh Muslim University, Aligarh, India

Background:
Sequential Combined Spinal Epidural Anaesthesia (SCSEA) is gaining recognition in high risk patients.

Aim: We undertook this study with null hypothesis that Epidural Volume Extension (EVE) with local anesthetic or normal saline results in augmentation of initial intrathecal block.

Material and Methods: After ethical clearance and written informed consent, 30 ASA I and II parturient recruited for elective LSCS into three groups. Group I received 1.5 ml bupivacaine (0.5%) + 25 μg fentanyl in subarachnoid space, and epidural catheter was inserted without any top ups in Group II and III with the same technique; top ups were given through epidural catheter after 10 min of initial block in the form of 10 ml NS and 10 ml of 0.125% bupivacaine, respectively. Block characteristics and hemodynamic parameters were assessed at 3-, 5- and 10-min intervals by independent blinded observer.

Results: Significant increase in height of block was noted after EVE in Groups II and III, respectively, as compared to Group I. No additional enhancing effect of 10 ml of 0.125% plain bupivacaine over normal saline was found in EVE.

Conclusion: Low doses of bupivacaine heavy with intrathecal opioids can be used successfully to attain adequate levels of sensory block, which can be enhanced by EVE effect with normal saline or plain bupivacaine.

A randomized double blind comparison of low-dose and high-dose bupivacaine for cesarean section in severely preeclamptic women using invasive blood pressure monitoring

Iswarya Anbarasan, Kajal Jain, Jeetinder Kaur Makkar,

Sandhya Yadanappudi, Shalini Gainder


Post Graduate Institute of Medical Education and Research, Chandigarh -160012, India

Background: The effect of a low dose of spinal local anesthetic on the incidence of hypotension has not been evaluated till date in severely preeclamptic women undergoing cesarean delivery. In this study, we compared the mean arterial pressure changes associated with low and conventional doses of spinal anesthetic in these women using invasive pressure monitoring.

Materials and Methods:
Twenty four severely preeclamptic women scheduled for elective cesarean delivery were randomly allocated to receive 7.5 mg (Group 1) or 10 mg (Group 2) of bupivacaine with 20 μg of fentanyl for spinal anesthesia. Heart rate and mean arterial pressure (MAP) were measured continuously using invasive arterial pressure monitoring. Phenylephrine boluses were used to maintain the MAP of >80% of baseline. The incidence of hypotension was compared between the two groups. Neonatal outcome was assessed using Apgar scores, umbilical cord blood gases and need for resuscitation.

Results:
Incidence of hypotension (41.6% vs. 91.6%, p = 0.009) was less in Group 1 compared to Group 2. More phenylephrine boluses were required in Group 2 (150 {100-150 } μg) compared to Group 1 (0 {0-87.5} μg) ( p = 0.006) to keep the MAP in the target range. The maximum decrease in MAP from the baseline values was 17% (15-24.8%) in Group 1 and 25.5% (23.3%-32.5%) in Group 2 ( p = 0.04). There was no difference in Apgar scores, umbilical cord blood gases and need for resuscitation between the two groups.

Conclusion: Low dose of spinal bupivacaine resulted in a lower incidence of hypotension, higher predelivery MAP and decreased use of vasopressors in severely preeclamptic women undergoing cesarean section.

Anesthetic management of a molar pregnancy and associated complications: Five years experience

Kulkarni V. V., Agrawal Pushpa, Adke N.S.


DR. V. M. Govt. Medical College, Solapur, India

Summary: Vesicular mole is best regarded as a benign neoplasia of the chorion with malignant potentials. It is a rare but life-threatening disorder that originates from the placenta. Serious morbidity and even mortality can be seen if no precautionary measures are taken during the evacuation of the molar pregnancy. We must be aware of the possibility of thyrotoxicosis, anemia and dehydration. Here we are presenting five year's (June 2006-June 2011) experience of anesthesia and postoperative management of patients who have undergone evacuation of molar pregnancy. We have come across 37 cases of vesicular mole pregnancy undergone for suction evacuation under anesthesia. Of the 37 cases, 6 cases were severe anemic and 5 cases were with comorbid disease. Postoperatively 2 patients required ventilatory support, 7 patients required PACU, and 4 patients required chemotherapy; rest of the patients had good outcome. Anesthesia management and associated complications will be discussed at the time of presentation.

Sepsis in pregnancy: Eight-year review at tertiary center

Sailaja Devi, Sunil T. Pandya


Fernandez Hospital, Hyderabad, India

Introduction : Sepsis is rare in obstetric population, but still a leading cause of maternal morbidity and mortality, and contributes to significant perinatal mortality. Sepsis is complex and often difficult to recognize and manage and represents continuing challenge.

Aim of the study: To analyze the incidence, cause, maternal and fetal outcome of sepsis during pregnancy and postnatal periods.

Materials and Methods: We did a retrospective study of pregnant women with sepsis in Fernandez Hospital Tertiary Referral Center from Jan 2003 to Dec 2010.

Results: We had 63 sepsis cases, accounting to 0.2% of deliveries. Mean maternal age was 25 years, primigravida were 49% (31 patients), parity 1 to 3 were 29% (18), mean gestational age at delivery was 33 weeks and mean birth weight was 2 kg.

Sepsis in early pregnancy related with miscarriage was seen in 11% of cases. During antenatal period 13% of the cases had sepsis. Rupture of membranes with chorioamnionitis were 19% (12) of which 2 patients received steroids for fetal lung maturity. Two patients developed sepsis following steroids and tocolysis for preterm labor. Intrapartum-related sepsis was seen in 8% (5) cases. Co-morbid conditions like jaundice were seen in 9% (14) of cases and preeclampsia in 8% (5) of cases. Coincidental causes were 6%, which includes hepatic abscess, pancreatitis, cholangitis and gut malrotation with gram-negative sepsis. Urosepsis was seen in 13% and respiratory tract infection in 6% of cases.

Most common etiological agent was E. coli i.e. 13% (8) and Hep. E infection which was 5% (3). Others were Klebsiella, pseudomonas,  Salmonella More Details, leptospira, mucormycosis, retroviral infection and dengue hemorrhagic fever.

Maternal mortality rate was 16% (10 cases); causes were pelvic organ sepsis, gram-negative sepsis with malrotation of gut, acute fatty liver of pregnancy, adult respiratory syndrome, hepatic encephalopathy, mucormycosis, HIV with pneumocystis carinii pneumonia, hepatitis E infection and dengue hemorrhagic fever. Maternal morbidity includes renal complications in 36%, hepatic involvement in 36%, respiratory system in 33%, encephalopathy 13%, coagulopathy 38%, 38% had multiorgan dysfunction and 24% required ventilation.

Mode of delivery in our study was spontaneous vaginal delivery in 29%, assisted vaginal deliveries in 13% and cesarean sections in 58%.

Perinatal mortality rate was 377 per 1000 births. After excluding fetal death that occurred before hospital admissions, pregnancy was terminated in 90% cases with fetal mortality rate of 19%. Among live births the neonatal mortality rate was 175 per 1000 live births.

Conclusion: Maternal mortality rate was 16% with perinatal mortality rate of 377 per 1000 births. Most common etiological agent was E. coli. Chorioamnionitis was seen in 19% of cases and Urosepsis in 13% of cases. Early diagnosis and early goal-directed therapy may save lives. Early referral, multidisciplinary care and use of sepsis bundles improve the outcome.

Anesthetic management of parturients presenting at term with large aortic aneurysm/s for operative delivery: A report of three cases

Niraj Kumar, Rajeshwari Subramaniam, Renu Sinha,

Sunil Nanda, Usha Kiran


All India Institute of Medical Sciences, New Delhi, India

Background: The overall incidence of thoracic aortic aneurysm is 6 per 100,000 patient years. Incidence of aneurysm rupture during pregnancy is 6% in the first, 10% in the second and 51% in the third trimester.

Materials and Methods: Cases 1 and 2 were primigravidas at 36 weeks gestation. Case 1 had a 13 × 8 × 8 cm aortic arch aneurysm and Case 2 had two saccular aneurysms in the juxtarenal aorta measuring 6.1 and 5.4 cm. Large-bore IV access, invasive arterial and central venous pressure monitoring were established after EMLA application. The OR was warmed. Blood, colloids and a rapid infusor system were primed and CPB standby ensured. Lower segment cesarean section was performed under combined spinal-epidural (CSE) block in both patients. Fundal pressure was avoided and the infants extracted by forceps. Case 3 was a 28-year-old multigravida at 34 weeks' gestation with acute onset retrosternal pain radiating to back. TTE showed ascending aortic aneurysm with dissection. Pre-operative treatment included esmolol infusion, IV ranitidine and metoclopramide. Invasive hemodynamic monitoring was established under LA infiltration. After induction and intubation, TEE, nasopharyngeal temperature, urine output monitoring and near-infrared spectroscopy (NIRS) was set up. LSCS was performed and the abdomen closed after hemostasis. CPB was instituted and Bentall's procedure performed. Trachea was extubated after 8 h.

Results: All mothers and babies were discharged well from the hospital.

Conclusions: Good outcome in parturients with large aortic aneurysms is possible with invasive monitoring and appropriate anesthetic technique.

Good maternal outcome in a patient of Guillain-Barre syndrome on ventilator

Dhannya Rachel Thomas, Sumalatha R. Shetty,

P. S. Balakrishna, Raveendra U.S., Soumya Rao


K. S. Hegde Medical Academy, Deralakatte, Manglore, Karnatka, India

Guillain-Barre (GB) syndrome is an acute inflammatory demyelinating polyradiculo- neuropathy. It is characterized by progressive motor weakness, areflexia and ascending paralysis. The incidence of Guillain-Barre syndrome during pregnancy is very low 1.7/100000 population. We report here a case of a 28-year primigravida who presented at 30 weeks of gestation with weakness of both lower limbs since 5 days, urinary incontinence and constipation for 3 days. The weakness of the lower limbs gradually worsened over 5 days after admission and she could not walk even with support. Clinically a diagnosis of GB syndrome was made which was later confirmed by nerve conduction studies. She was shifted to ICU when she developed acute onset of breathlessness. She was put on oxygen with Venturi mask, bronchodilators and steroid. The respiratory distress worsened with drop in saturation on fourth day in ICU. Patient was intubated and mechanically ventilated with synchronized intermittent mandatory ventilation. Plasmapheresis was done. On day two of ventilatory support, patient went into labor and delivered a live female baby weighing 1.6 kg with an APGAR score of 8. The mother was weaned off ventilator after 11 days and discharged from ICU after 18 days. The problems associated with GB syndrome and their management is discussed.

Evaluation of analgesic efficacy of two different doses of Gabapentin (300 mg and 600 mg) for postoperative pain relief following abdominal hysterectomy

Shweta Jagtap, Suresh Rajkumar, Vimla Doshi


RNT Medical College, Udaipur, Rajasthan, India

B0 ackground : Smooth postoperative course following major surgery should ensure adequate pain relief along with early discharge and reduction in incidence of chronic pain syndromes. Because of multiplicity of mechanisms involved in postoperative pain, a multimodal analgesia regimen with combination of opioid and non-opioid analgesic drug is used. Gabapentin, a structural analog of γ-amino butyric acid, has a selective effect on nociceptive process, reducing hyperexcitability of dorsal horn neurons.

A0 ims : The aim of this study was to explore the effects of Gabapentin along with combination of other analgesic drugs for postoperative pain management following hysterectomy.

M0 aterials 0 and M0 ethods : 120 ASA I/II patients undergoing total abdominal hysterectomy were randomized into three groups of 40 patients each. Following premedication, Group 0 received a diclofenac patch (100 mg) preoperatively, while Groups 1 and 2 also received Gabapentin 300 mg/600 mg orally one hour before the surgery. Postoperative monitoring included heart rate, blood pressure, ECG, SPO 2 and VAS score.

R0 esults : Use of Gabapentin 600 mg led to a significant decrease in postoperative heart rate, ( p <0.05) VAS and VRS scores ( p <0.01), delayed need for rescue analgesic, greater patient satisfaction and decreased need for antiemetic as compared to Gabapentin 300 mg or placebo.

C0 onclusion : The study showed that Gabapentin 600 mg combined with diclofenac transdermal patch provides an effective means of postoperative analgesia, reduces pain intensity, reduces postoperative analgesic and antiemetic requirement along with higher patient satisfaction as compared to Gabapentin 300 mg.

Comparison between the analgesic efficacy of morphine and Ganglion impar neurolysis in carcinoma cervix

Nazia Tauheed, Hammad Usmani, Anwar H. Siddiqui,

Shahla Haleem


Jawaharlal Nehru Medical College, AMU, Aligarh, India

B0 ackground : Optimal use of systemic analgesics, apart from causing a number of adverse effects, many a times fails to provide adequate pain relief in cancer patients. Nerve blocks are increasingly being used as a modality of pain relief for different causes. Their analgesic efficacy in comparison to morphine in patients of carcinoma cervix has not been compared yet.

A0 im : To compare the analgesic efficacy of morphine with ganglion impar blocks in the treatment of pain due to carcinoma cervix.

M0 aterials 0 and M0 ethods : In a randomized trial, 40 patients of carcinoma cervix were randomly allocated into groups I and II (of 20 each) to receive either oral morphine tablets as analgesic or subjected to ganglion impar neurolysis. Quality of analgesia, patient comfort/satisfaction and associated complications were recorded. Pain relief was evaluated in terms of visual analogue scale and global pain relief score.

R0 esults : Although pain relief was comparable in both groups, the efficacy was short lived in group I with a much higher incidence of adverse/side effects. Also, there was no reported complication in group II.

C0 onclusion: Ganglion impar block is an effective and better alternative to oral morphine as a treatment modality for pain in carcinoma cervix.

Iatrogenic pneumocephalus following unidentified dural puncture in an obstetric patient

Valluri S., Kajekar, Ranganathan M.


George Elliot Hospital, Nuneaton, Midlands, United Kingdom

B0 ackground: Use of air to identify epidural space is still a common practice among a few anesthetists. Iatrogenic pneumocephalus is a very rare complication observed after using the 'loss of resistance' technique with an air-filled syringe. Pneumocephalus has been associated mainly with the loss of resistance to air technique. It is more common to occur following cervical epidural placement than lumbar. The frequency of intracranial air after lumbar epidural placement is uncommon, with one case report per year. Other causes of pneumocephalus include head injury, neurosurgery, following long-term epidural catheterization - air being sucked in through the space along the epidural catheter.

Case Report: Here we report a case of classical presentation of pneumocephalus following use of air to identify epidural space and an unrecognized dural puncture.

A 38-year-old primigravida requested an epidural for labor analgesia. After two attempts, epidural was sited with moderate difficulty, using loss of resistance (LOR) to air. There was no evidence of dural puncture while inserting the epidural. However, immediately the patient complained of a strange sensation rising up her back followed by headache and one episode of vomiting. After careful aspiration and test dose, an epidural PCEA was started as per the protocol. The patient remained fairly comfortable, although the block was patchy.

Failure to progress in labor resulted in urgent LSCS, which was done under spinal as the epidural block was patchy. Within 24 h postoperatively, she developed intense headache with tinnitus. The headache being frontal in location and was worse on lying down. Investigations included a CT scan of head which showed air in anterior horn of lateral ventricle along with tiny scattered intracranial air bubbles.

It was decided to manage the pneumocephalus conservatively following discussion with neurosurgeons with high flow oxygen and bed rest. After 72 h due to persistent headache, a blood patch was performed, which helped to decrease the intensity of the headache. The symptoms slowly subsided over a week period.

Conclusion: The potential complications associated with the use of air for identifying the epidural space with the loss of resistance technique may outweigh the benefits. The use of saline to identify the epidural space may help to reduce the incidence of these complications.

Respiratory function assessment in advanced uncomplicated singleton and twin pregnancy

Anwar H. Siddiqui, Rajiv Gulati, Nazia Tauheed


Jawaharlal Nehru Medical College, AMU, Aligarh, India

Background: Pregnancy causes important changes in respiratory function as indicated by alterations in lung volumes and capacities caused by the mechanical impediment of the growing fetus. The increased maternal and fetal demands for oxygen are higher in twin pregnancies, and respiratory changes in twin pregnancy are likely to be greater than those of singleton pregnancy.

Aim: The study was undertaken to determine if changes in respiratory function during pregnancy in healthy women were greater in those with a twin pregnancy compared with those with a singleton pregnancy.

Material and Methods : A cross-sectional study of respiratory function was performed in 50 women with twin pregnancies (third trimester), 50 women with singleton pregnancies (third trimester) and 50 non-pregnant women. Pulmonary function test parameters FVC, FEV1, PEFR and FEF 25-75% recorded using automated spirometer. FEV1/FVC ratio was calculated.

Result : Both in twin and singleton pregnancy, all respiratory parameters except FEV1/FVC ratio were found to decline as compared to non-pregnant women. However, no significant differences were demonstrated in respiratory function in healthy women with twin as compared with singleton pregnancies.

Conclusion: The increased demands of twin pregnancy do not cause any significant compromise of the respiratory function as compared to singleton pregnan cy

Comparative study of different combinations of ketamine and propofol as intravenous induction agents

Kamakshi Garg, Avtar Singh, Anju Grewal


Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, India

Background: A thorough literature search does not reveal a hemodynamically stable combination of commonly used intravenous agent, propofol and ketamine.

Aims:
To evaluate different doses of propofol and ketamine in combination, as hemodynamically stable induction agents.

Material and Methods
: Thirty adult patients scheduled for daycare gynecological surgeries were randomly allocated into six groups. Group 1 received inj. propofol 2 mg/kg i.v. + inj. Normal saline (NS); Group 2 received ketamine 2 mg/kg i.v. + inj. NS; Group 3 was given inj. Propofol 2 mg/kg i.v. followed by inj. Ketamine 1 mg/kg i.v.; Group 4 received inj. Ketamine 2 mg/kg i.v. followed by inj. propofol 1 mg/kg i.v.; Group 5 received inj. Propofol 1 mg/kg i.v. followed by inj. Ketamine 1 mg/kg i.v.; Group 6 was given inj. Ketamine 1 mg/kg i.v. followed by inj. Propofol 1 mg/kg i.v. Following study drug administration, non-invasive systolic, diastolic and mean arterial pressures, heart rate, respiratory rate, arterial oxygen saturation and ECG were observed every minute for five minutes.

Results: Statistically significant hemodynamic alterations were observed in Groups 1 and 2. No significant changes in hemodynamics were seen in Groups 5 and 6. A lower incidence of apnea was observed in Group 5.

Conclusion:
We conclude that the combination of 1 mg Propofol followed by 1 mg ketamine produced better hemodynamic stability in comparison to other groups.

Cancer in pregnancy: Perioperative implications and challenges: A review of six cases in 2011

Aanchal R. Bharuka, Sunil T. Pandya, Sudha Sinha, S. Manimala Rao, S. Tarakeswari


Fernandez Hospital and Yashoda Hospital, Hyderabad, India

Introduction: Cancer during pregnancy is rare, occurring in approximately one out of every 1000 pregnancies and often leaves the patient devastated. The anesthesiologist may be involved in patient management for various reasons be it for surgical resection of the cancer, cesarean section, intrathecal chemotherapeutic drug injection, pain relief, chemoport insertions and rarely medical termination of pregnancy.

Objective: The aim of this paper is:

  1. To review the various dilemmas and optimal management of pregnant patients detected to have coincidental malignancies, during last seven months at Fernandez hospital.
  2. To provide a framework of the problems encountered while anesthetizing these patients.
  3. Measures undertaken to tackle them so as to optimize both maternal and fetal outcome.


Methods and Methods: This retrospective study was conducted on six pregnant women admitted between January 2011 and July 2011 with the following diseases - Carcinoma breast diagnosed in second trimester, ALL diagnosed in second trimester, CML diagnosed during pregnancy, AML in remission, NHL in remission and Krukenberg tumor.

  1. Ca. Breast diagnosed in 2 nd trimester
  2. All diagnosed in 2 nd trimester
  3. CML diagnosed during PAC
  4. AML in remission
  5. NHL in remission
  6. Krukenberg tumor


Conclusion:

  1. All patients except one, who came with missed abortion, had good maternal and neonatal outcome. Most patients had anemia. One patient needed 2 U packed cell transfusions.
  2. L-asparaginase can worsen hypercoagulable state by causing anti-thrombin III deficiency, warrants heparin therapy peripartum period.
  3. Anticipate and prevent PDPH using fine Whitacre needles if patient requires frequent intrathecal chemotherapy agents. It is better not to mix methotrexate with spinal bupivacaine.
  4. Profound immunosuppression, neutropenia and low platelets warrants strict asepsis and safety while performing neuraxial blocks.
  5. The anesthesiologist has to balance various psychosocial issues in addition to provide optimal and safe anesthesia technique, excellent pain management, chemoport insertions, good venous access, critical care needs so as to reduce morbidity and ensure maternal, fetal and neonatal well-being.


Amniotic fluid embolism - A Case Report

Sanjay Bhandari, M. V. Kumar, Raghunath, Medha Huilgol, Ajoy Raj Malpe


Columbia Asia Hospital, Bangalore, India

Amniotic fluid embolism is an obstetrical and medical emergency with an incidence ranging from 1 in 8000 to 1 in 80,000 in various studies with high mortality and morbidity. We present a case of a 26-year primi with labor epidural who came in for an emergency cesarean section. Patient was anesthetized with epidural top ups and 20 minutes later delivered a healthy baby. Patient had a seizure followed by cardiac arrest but cardiac output returned after a cycle of CPCR. Patient developed coagulation failure and bled profusely per vaginam which was controlled with bilateral internal iliac ligation. Patient was shifted to intensive care with high doses of inotropes. Patient's coagulation parameters continued to worsen which was treated with adequate blood products. Patient had two laparotomies to evacuate retroperitoneal hematoma. Patient continued to improve and after 3 weeks was discharged home with no neurological deficits.

Critical incidents in obstetric regional anesthetic practice: Clinical audit of 36130 obstetric epidurals

S. Sunitha, C. Kausalya, Y. Shanti, K. Sailaja, Sunil T. Pandya


Department of Anaesthesia, Pain and Critical Care, Prerna Anaesthesia and Critical Care Services, Fernandez Hospital, Hyderabad, India.

Introduction: Central neuraxial techniques in obstetrics have immensely improved the maternal safety and satisfaction. Epidural and combined spinal epidural are considered the gold standard techniques for providing pain relief in labor and for operative deliveries. These techniques has an excellent safety track record, however, occasionally atypical presentations do occur either because of faulty technique, equipment, drug swaps or underlying undiagnosed co-morbid pathology, which if unattended, can lead to a serious critical incident.

Aim:


  1. To retrospectively evaluate the atypical presentations of central neuraxial blockade in pregnant patients.
  2. To evaluate the process that lead to this atypical presentation.
  3. To upgrade the risk management protocol in obstetric anesthetic practice.


Materials and Methods: The required data was retrieved from anesthesia records and hospital database. Medical data of parturient with atypical presentations of central neuraxial blockade admitted between Feb 1997 and June 2011 were compiled and audited.

Atypical block was defined as, any block which has resulted in rare complications, unusual presentation of common complications or atypical presentations.

Inclusion criteria : All epidurals or CSEA administered for labor analgesia or for cesarean section were included in the study.

Exclusion criteria : The labor analgesia, obstetric anesthesia provided by SAB is excluded from the study. Classical PDPH, bloody taps etc. has also been excluded from the study.

Observation and Results:

  • Subdural: 14
  • Subdural with delayed respiratory depression: 1
  • Horner's Syndrome: 3
  • Catheter migration:
    • True IV after >3 top-ups: 5
    • True intrathecal after >3 Top-ups: 2
    • Multi compartmental block: 4
  • Total Spinal after uneventful Sequential CSEA: 3
  • PRES Syndrome after ADP: 1
  • GTCS following 1st dose: 1
  • Momentary Dystonia after top-up: 1
  • Shooting pain during LORS technique: 1
  • Prolonged paraparesis: 1
  • Bead of Pus at epidural removal site: 3


Conclusion:

  1. In our series even though several critical incidents were experienced, none had adverse maternal and neonatal outcome.
  2. Prompt identification of the problem and timely intervention, should avoid or minimize the catastrophes, and protocols and guidelines need to be periodically updated
  3. Awareness about the possible complications and atypical presentations should make the anesthesiologist more vigilant.





 

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