Rakesh Garg - Academia.edu (original) (raw)

Papers by Rakesh Garg

Anaesthesia and Intensive Care, 2008

This report describes anaesthesia for consanguineous siblings with the rare genetic condition hyp... more This report describes anaesthesia for consanguineous siblings with the rare genetic condition hyperekplexia. This condition is also known as ‘stiff baby syndrome’ or ‘startle disease’. Hyperekplexia can present in major and minor forms and is caused by a mutation in chromosome 5 which results in a defect in the α-1 subunit of the inhibitory glycine receptors in the caudal pontine reticular formation leading to neuronal hyperexcitability. The patients present with a potentially life-threatening exaggerated startle reflex. Life-threatening spasms may be terminated by forced flexion of the head and legs towards the trunk. Anaesthesia management should avoid stimuli which trigger the reflex. Clonazepam and diazepam are used to prevent and control the spasms. Propofol and other agents with the ability to potentiate both GABAergic and glycinergic transmission may be appropriate choices for anaesthesia. Reaction to neuromuscular blockers may be unpredictable. Both our patients had relative...

Indian journal of anaesthesia, 2018

Indian journal of anaesthesia, 2017

The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (... more The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (CCLS) for management of the patient with cardiopulmonary arrest in adults provides an algorithmic step-wise approach for optimal outcome of the patient inside the hospital by trained medics and paramedics. This guideline has been developed considering the infrastructure of healthcare delivery system in India. This is based on evidence in the international and national literature. In the absence of data from the Indian population, the extrapolation has been made from international data, discussed with Indian experts and modified accordingly to ensure their applicability in India. The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their timely management before a cardiac arrest occurs. The basic components of CPR include chest compressions for blood circulation; airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and d...

Frontiers in Medicine, 2017

The perioperative management of post-craniotomy pain is controversial. Although the concept of pa... more The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients.

Journal of Anesthesia & Critical Care: Open Access, 2016

One lung ventilation (OLV) is required for surgical intervention in patients with lung cancer. On... more One lung ventilation (OLV) is required for surgical intervention in patients with lung cancer. One lung ventilation is needed for better exposure and maintenance of ventilation and oxygenation. One lung ventilation for lung surgeries are associated with changes in respiratory mechanics. Also, OLV may lead to lung injury to both the ventilated lung and the collapsed lung and is associated with hypoxia during the procedure. Various strategies like pulmonary rehabilitation, lung recruitment are required in perioperative period to optimize lung function. In spite of these strategies, hypoxic events occur during the OLV. We review the helpfulness of inhaled bronchodilators for improved oxygention in the perioperative period after lung surgery requiring OLV.

Burns & Trauma, 2015

Background Regional anaesthesia has been proposed to reduce intraoperative blood loss, duration o... more Background Regional anaesthesia has been proposed to reduce intraoperative blood loss, duration of hospital stay and in-hospital complications with improved postoperative pain control. General anaesthesia is advantageous for prolonged surgeries. We hypothesized that combined regional and general anaesthesia would offer advantages of both in pelvi-acetabular fracture surgeries. Methods We identified 71 patients who underwent open reduction and internal fixation of pelvi-acetabular fractures from May 2012 to 2013 in our trauma centre. We excluded patients with incomplete records (n = 4) and other injuries operated along (n = 8). Hence, 59 patients were divided into three groups: G group (general anaesthesia), R group (regional anaesthesia) and GR group (combined regional and general anaesthesia). Main outcome measurements studied were intraoperative blood loss, duration of hospital stay, duration of surgery and intraoperative and postoperative complications. Results No differences wer...

Journal of Neuroanaesthesiology and Critical Care, 2015

Introduction: Hyperbaric oxygen therapy (HBOT) is used to improve functional outcome following br... more Introduction: Hyperbaric oxygen therapy (HBOT) is used to improve functional outcome following brain injuries. Different number of sessions of HBOT have been reported but the frequency of HBOT sessions in head injured patients has not been standardized. We planned this prospective randomized study with an aim to compare the neurological effects of 10, 20 and 30 sessions of HBOT in the head injured patients. Materials and Methods: After review board approval, this study was conducted in 60 head injury patients with Glasgow Coma Scale (GCS) score ≤ 9. All patients were resuscitated, stabilized and received neurological care according to institutional protocol. Patients were randomly allotted to–Group H10 (n-20)–which received 10 sittings of HBOT, Group H20 (n-20)–which received 20 sittings of HBOT, Group H30 (n-30)–which received 30 sittings of HBOT. GCS score was recorded after every 10 sittings and at 30 days from initiation of HBOT. Improvement Global rating and Glasgow outcome sca...

Open Journal of Anesthesiology, 2011

We describe the anaesthetic management of 45 year female patient with pre-existing deep venous th... more We describe the anaesthetic management of 45 year female patient with pre-existing deep venous thrombosis (DVT) and pulmonary embolism (PE) who was subsequently scheduled for a laparotomy. Before planning the surgical procedures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism, and pulmonary embolism in particular. The risk of stopping the anticoagulation prior to surgery must be considered and adequately discussed with the patient and surgeons. The anaesthetic plan must be selected keeping in mind the coagulation status and the need of anticoagulation in the postoperative period.

Southern African Journal of Anaesthesia and Analgesia, 2010

This case report of neuraxial anaesthesia for emergency orthopaedic surgery serves to highlight t... more This case report of neuraxial anaesthesia for emergency orthopaedic surgery serves to highlight the dilemma faced by anaesthetists when surgical intervention becomes necessary in a patient on anti-rabies vaccine. The two issues of importance are the possible reduction in the ef cacy of vaccination by an immunosuppressive effect of anaesthesia and surgery, and the possible need to avoid local anaesthetics for the provision of postoperative analgesia to assist in the early detection of any neurological de cit.

Open Journal of Anesthesiology, 2012

Although nasogastric tube (NGT) is a simple procedure, the blind placement of nasogastric feeding... more Although nasogastric tube (NGT) is a simple procedure, the blind placement of nasogastric feeding tubes is not without risks. Chest radiogram is done to confirm the correct position of the NGT. We report a case where radiography could not be confirmatory for the correct position of the tube in a specific group of patients.

Brazilian journal of anesthesiology (Elsevier)

We evaluated the effects of epidural injection with levobupivacaine or serum physiologic, epidura... more We evaluated the effects of epidural injection with levobupivacaine or serum physiologic, epidural volume extension (EVE), when using combined spinal-epidural anesthesia (CSEA) for cesarean delivery. One-hundred and thirty-eight patients with a full-term pregnancy of 37-42 weeks that were scheduled for cesarean delivery were included. Group 1 (n=48) received single-shot spinal anesthesia (SSS), group 2 (n=45) received CSEA-EVE with saline, group 3 received CSEA-EVE with levobupivacaine. The characteristics of motor and sensory block, the effects on maternal hemodynamic changes and the effects on the newborn were compared. Time to reach maximum sensory block was significantly shorter in groups 3 than in group 1 and 2 (p<0.05). Two-segment regression time of sensory block was significantly shorter in group 1, whereas it was significantly longer in group 3 than in group 2 (p<0.05). Time to onset of motor block was significantly longer in group 1 than in groups 2 and 3 (p<0.05)...

Singapore medical journal, 2012

Lymphangioma is a congenital malformation of the lymphatic system, often involving areas of the h... more Lymphangioma is a congenital malformation of the lymphatic system, often involving areas of the head and neck. Patients may require surgical excision. Anaesthetic concerns include bleeding, difficulty visualising the airway, extrinsic and intrinsic pressure on the airway causing distortion, and enlarged upper respiratory structures, including the lips, tongue and epiglottis, which make airway management challenging. We report lymphangioma of the tongue in a six-year-old patient. There is limited information on the optimal anaesthetic management for this age group. The challenges with airway management, including bleeding, laryngospasm and difficult intubation, are outlined. Awareness of potential airway involvement and possible complications is necessary in order to provide safe anaesthesia to patients with lymphangioma.

Singapore medical journal, 2010

Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetio... more Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetiology. Anaesthesia for patients with Takayasu's arteritis is complicated by severe uncontrolled hypertension leading to end-organ dysfunction, stenosis of major blood vessels affecting regional circulation, and difficulties in the monitoring of arterial blood pressure. The anaesthetic approach for parturients with Takayasu's arteritis has not been standardised in the literature, and previous reports have documented the use of general as well as regional anaesthesia. There are few instances in the literature where low-dose spinal anaesthesia alone is used in patients with Takayasu's arteritis undergoing emergency caesarean section. We present a case of the successful management of a parturient with Takayasu's arteritis, who underwent an emergency caesarean section under low-dose spinal anaesthesia.

Singapore medical journal, 2011

Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. I... more Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. Intrathecal midazolam produces antinociception and potentiates the effect of local anaesthetics. We compared intrathecal bupivacaine with and without midazolam to assess its effect on the duration of sensory block, motor block and pain relief. A total of 100 patients scheduled for elective lower abdominal, lower limb and gynaecological procedures were selected to participate in this prospective, randomised, double-blind study. Patients were randomly allocated into two groups for intrathecal drug administration. Group B received 3 mL 0.5 percent bupivacaine with 0.4 mL saline, and group BM received 3 mL 0.5 percent bupivacaine and 0.4 mL (2 mg) midazolam mixture. The onset, duration of sensory/motor block, time to first rescue analgesia and side effects were noted. Demographic profile and duration of surgery were comparable between the two groups. The onset of sensory (4.8 versus 4.6 min) ...

Singapore medical journal, 2011

Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compare... more Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication. This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKL received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted. A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. At 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in Group MKL and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation ...

Singapore medical journal, 2012

We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary blad... more We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary bladder phaeochromocytoma with vertebral and rib metastasis following partial cystectomy and nephrectomy. His blood pressure was controlled with antihypertensive agents. Epidural analgesia was avoided in view of vertebral metastasis; instead, analgesia was provided with fentanyl infusion. Intraoperative hypertensive episodes were managed with nitroglycerine, sodium nitroprusside and esmalol. However, after surgery, the patient required inotropic support and was moved to the intensive care unit. Analgesia was maintained with fentanyl infusion, and inotropic support was gradually weaned off. Nuclear ablative therapy was planned for bony metastasis. We recommend that recurrences of extra-adrenal phaeochromocytoma be investigated for bony metastasis and cautiously managed in the perioperative period so as to avoid neurological complications.

Singapore medical journal, 2009

Technical issues with monitors remain a concern in the perioperative management of a patient. Ear... more Technical issues with monitors remain a concern in the perioperative management of a patient. Early detection avoids any mishap pertaining to monitoring. But sometimes, technical snags may go unnoticed in the absence of a suitable indicator (audio or visual). A 45-year-old male patient was undergoing emergency appendicectomy under general anaesthesia. In the operation room, routine monitors (Colin BP 508, Colin Corporation, Japan) were attached. Capnography was initiated after tracheal intubation. During surgery, the patient showed some physical movement even though the monitor displayed stable parameters, including the electrocardiographical, pulse oximetry, and capnographic tracings. On close observation, we realised that the display on the monitor was frozen. The monitor was restarted, after which the display could be seen with the cursor of the waveform trace moving. The rest of the operation was uneventful. A newer generation of monitoring devices is available, with the option of freezing the display for the purpose of looking closely at the trace, or for printing out a specific incident manifested on the waveforms. Usually the screen will indicate the frozen status when this option is selected. But due to the technical snag in our case, this option was self-activated without our notice. This could adversely affect the outcome of the surgery (and the patient) if the frozen screen was not observed and remained unrectified for any length of time. Thus, monitoring devices should have an alarm function which is automatically activated in the event of a device failure.° We want to highlight to our readers the possibility of frozen screens and its early detection. One must be careful to ensure that the screen is moving in real time (i.e. with the cursor showing movement). In addition, monitoring devices should come with an alarm activation for screen malfunctions, such as frozen displays. Yours sincerely,

Annals of Saudi medicine

Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia is a paraneoplastic syndrome, usually ... more Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia is a paraneoplastic syndrome, usually associated with mesenchymal tumors. TIO is probably an underreported entity owing to diagnostic and localizing limitations. With improvement in such modalities, patients with TIO are likely to be encountered more frequently in future anesthetic practice. It does not respond to conservative medical management; thus surgical resection of the lesion is the treatment of choice. Anesthetic management of such cases has not been reported in published studies and thus we report two such cases of hypophosphatemia, induced by frontoethmoidal tumors and the anesthetic implications and challenges of such a rare entity. Surgical excision of the causative lesion results in dramatic resolution of symptoms. Vigilant adherence to the pertinent perioperative concerns related to severe hypophosphatemia is crucial to a favorable surgical outcome in these patients.

Clinical Cancer Investigation Journal, 2013

Background: The primary aim of the study was to evaluate the effectiveness of sulfasalazine in re... more Background: The primary aim of the study was to evaluate the effectiveness of sulfasalazine in reducing the incidence of acute radiation-induced enteritis in carcinoma cervix patients receiving pelvic external beam radiotherapy along with concurrent cisplatin-based chemotherapy. Materials and Methods: Between November 2011 and July 2012 a total of 98 patients of locoregionally advanced carcinoma of cervix (49 each in study and control arms) were enrolled in this study. Patients in both the arms were treated with whole pelvis external beam radiotherapy with total dose of 50 Gy in conventional fractionation. Along with this inj. cisplatin was given concurrently at the dose of 40 mg/m 2 of body surface area every week during radiation for 5 weeks. Concurrent chemoradiation was followed by brachytherapy after a gap of 2 weeks. Patients in the study arm also received tablet sulfasalazine 1,000 mg orally twice daily from the day of starting of radiotherapy to 1 week after completion of treatment. Weekly follow-up of all patients to assess acute toxicities was done using common toxicity criteria version 4.0 (CTC v4.0) toxicity scores. Data analysis was carried out by SPSS version 20.0 software. Results: Incidence of grade II or higher grade, lower gastrointestinal toxicity was 19.14% (09/47) in study arm and 41.66% (20/48) in control arm which was statistically significant ( P = 0.017). Conclusion: The study shows that sulfasalazine can significantly reduce the acute radiation-induced diarrhea (ARID) in patients undergoing whole pelvis external beam radiotherapy for carcinoma cervix. The drug is safe, cheap, and readily available.

Case Reports in Anesthesiology, 2011

Pathogenesis of dengue involves suppression of immune system leading to development of characteri... more Pathogenesis of dengue involves suppression of immune system leading to development of characteristic presentation of haematological picture of thrombocytopenia and leucopenia. Sometimes, this suppression in immune response is responsible for deterioration in clinical status of the patient in spite of all specific and supportive therapy. Certain drugs like steroids are used for rescue therapy in conditions like sepsis. We present a novel use of filgrastim as a rescue therapy in a patient with dengue hemorrhagic fever (DHF) with acute respiratory distress syndrome (ARDS), myocarditis, and febrile neutropenia and not responding to standard management.

Anaesthesia and Intensive Care, 2008

This report describes anaesthesia for consanguineous siblings with the rare genetic condition hyp... more This report describes anaesthesia for consanguineous siblings with the rare genetic condition hyperekplexia. This condition is also known as ‘stiff baby syndrome’ or ‘startle disease’. Hyperekplexia can present in major and minor forms and is caused by a mutation in chromosome 5 which results in a defect in the α-1 subunit of the inhibitory glycine receptors in the caudal pontine reticular formation leading to neuronal hyperexcitability. The patients present with a potentially life-threatening exaggerated startle reflex. Life-threatening spasms may be terminated by forced flexion of the head and legs towards the trunk. Anaesthesia management should avoid stimuli which trigger the reflex. Clonazepam and diazepam are used to prevent and control the spasms. Propofol and other agents with the ability to potentiate both GABAergic and glycinergic transmission may be appropriate choices for anaesthesia. Reaction to neuromuscular blockers may be unpredictable. Both our patients had relative...

Indian journal of anaesthesia, 2018

Indian journal of anaesthesia, 2017

The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (... more The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (CCLS) for management of the patient with cardiopulmonary arrest in adults provides an algorithmic step-wise approach for optimal outcome of the patient inside the hospital by trained medics and paramedics. This guideline has been developed considering the infrastructure of healthcare delivery system in India. This is based on evidence in the international and national literature. In the absence of data from the Indian population, the extrapolation has been made from international data, discussed with Indian experts and modified accordingly to ensure their applicability in India. The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their timely management before a cardiac arrest occurs. The basic components of CPR include chest compressions for blood circulation; airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and d...

Frontiers in Medicine, 2017

The perioperative management of post-craniotomy pain is controversial. Although the concept of pa... more The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients.

Journal of Anesthesia & Critical Care: Open Access, 2016

One lung ventilation (OLV) is required for surgical intervention in patients with lung cancer. On... more One lung ventilation (OLV) is required for surgical intervention in patients with lung cancer. One lung ventilation is needed for better exposure and maintenance of ventilation and oxygenation. One lung ventilation for lung surgeries are associated with changes in respiratory mechanics. Also, OLV may lead to lung injury to both the ventilated lung and the collapsed lung and is associated with hypoxia during the procedure. Various strategies like pulmonary rehabilitation, lung recruitment are required in perioperative period to optimize lung function. In spite of these strategies, hypoxic events occur during the OLV. We review the helpfulness of inhaled bronchodilators for improved oxygention in the perioperative period after lung surgery requiring OLV.

Burns & Trauma, 2015

Background Regional anaesthesia has been proposed to reduce intraoperative blood loss, duration o... more Background Regional anaesthesia has been proposed to reduce intraoperative blood loss, duration of hospital stay and in-hospital complications with improved postoperative pain control. General anaesthesia is advantageous for prolonged surgeries. We hypothesized that combined regional and general anaesthesia would offer advantages of both in pelvi-acetabular fracture surgeries. Methods We identified 71 patients who underwent open reduction and internal fixation of pelvi-acetabular fractures from May 2012 to 2013 in our trauma centre. We excluded patients with incomplete records (n = 4) and other injuries operated along (n = 8). Hence, 59 patients were divided into three groups: G group (general anaesthesia), R group (regional anaesthesia) and GR group (combined regional and general anaesthesia). Main outcome measurements studied were intraoperative blood loss, duration of hospital stay, duration of surgery and intraoperative and postoperative complications. Results No differences wer...

Journal of Neuroanaesthesiology and Critical Care, 2015

Introduction: Hyperbaric oxygen therapy (HBOT) is used to improve functional outcome following br... more Introduction: Hyperbaric oxygen therapy (HBOT) is used to improve functional outcome following brain injuries. Different number of sessions of HBOT have been reported but the frequency of HBOT sessions in head injured patients has not been standardized. We planned this prospective randomized study with an aim to compare the neurological effects of 10, 20 and 30 sessions of HBOT in the head injured patients. Materials and Methods: After review board approval, this study was conducted in 60 head injury patients with Glasgow Coma Scale (GCS) score ≤ 9. All patients were resuscitated, stabilized and received neurological care according to institutional protocol. Patients were randomly allotted to–Group H10 (n-20)–which received 10 sittings of HBOT, Group H20 (n-20)–which received 20 sittings of HBOT, Group H30 (n-30)–which received 30 sittings of HBOT. GCS score was recorded after every 10 sittings and at 30 days from initiation of HBOT. Improvement Global rating and Glasgow outcome sca...

Open Journal of Anesthesiology, 2011

We describe the anaesthetic management of 45 year female patient with pre-existing deep venous th... more We describe the anaesthetic management of 45 year female patient with pre-existing deep venous thrombosis (DVT) and pulmonary embolism (PE) who was subsequently scheduled for a laparotomy. Before planning the surgical procedures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism, and pulmonary embolism in particular. The risk of stopping the anticoagulation prior to surgery must be considered and adequately discussed with the patient and surgeons. The anaesthetic plan must be selected keeping in mind the coagulation status and the need of anticoagulation in the postoperative period.

Southern African Journal of Anaesthesia and Analgesia, 2010

This case report of neuraxial anaesthesia for emergency orthopaedic surgery serves to highlight t... more This case report of neuraxial anaesthesia for emergency orthopaedic surgery serves to highlight the dilemma faced by anaesthetists when surgical intervention becomes necessary in a patient on anti-rabies vaccine. The two issues of importance are the possible reduction in the ef cacy of vaccination by an immunosuppressive effect of anaesthesia and surgery, and the possible need to avoid local anaesthetics for the provision of postoperative analgesia to assist in the early detection of any neurological de cit.

Open Journal of Anesthesiology, 2012

Although nasogastric tube (NGT) is a simple procedure, the blind placement of nasogastric feeding... more Although nasogastric tube (NGT) is a simple procedure, the blind placement of nasogastric feeding tubes is not without risks. Chest radiogram is done to confirm the correct position of the NGT. We report a case where radiography could not be confirmatory for the correct position of the tube in a specific group of patients.

Brazilian journal of anesthesiology (Elsevier)

We evaluated the effects of epidural injection with levobupivacaine or serum physiologic, epidura... more We evaluated the effects of epidural injection with levobupivacaine or serum physiologic, epidural volume extension (EVE), when using combined spinal-epidural anesthesia (CSEA) for cesarean delivery. One-hundred and thirty-eight patients with a full-term pregnancy of 37-42 weeks that were scheduled for cesarean delivery were included. Group 1 (n=48) received single-shot spinal anesthesia (SSS), group 2 (n=45) received CSEA-EVE with saline, group 3 received CSEA-EVE with levobupivacaine. The characteristics of motor and sensory block, the effects on maternal hemodynamic changes and the effects on the newborn were compared. Time to reach maximum sensory block was significantly shorter in groups 3 than in group 1 and 2 (p<0.05). Two-segment regression time of sensory block was significantly shorter in group 1, whereas it was significantly longer in group 3 than in group 2 (p<0.05). Time to onset of motor block was significantly longer in group 1 than in groups 2 and 3 (p<0.05)...

Singapore medical journal, 2012

Lymphangioma is a congenital malformation of the lymphatic system, often involving areas of the h... more Lymphangioma is a congenital malformation of the lymphatic system, often involving areas of the head and neck. Patients may require surgical excision. Anaesthetic concerns include bleeding, difficulty visualising the airway, extrinsic and intrinsic pressure on the airway causing distortion, and enlarged upper respiratory structures, including the lips, tongue and epiglottis, which make airway management challenging. We report lymphangioma of the tongue in a six-year-old patient. There is limited information on the optimal anaesthetic management for this age group. The challenges with airway management, including bleeding, laryngospasm and difficult intubation, are outlined. Awareness of potential airway involvement and possible complications is necessary in order to provide safe anaesthesia to patients with lymphangioma.

Singapore medical journal, 2010

Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetio... more Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetiology. Anaesthesia for patients with Takayasu's arteritis is complicated by severe uncontrolled hypertension leading to end-organ dysfunction, stenosis of major blood vessels affecting regional circulation, and difficulties in the monitoring of arterial blood pressure. The anaesthetic approach for parturients with Takayasu's arteritis has not been standardised in the literature, and previous reports have documented the use of general as well as regional anaesthesia. There are few instances in the literature where low-dose spinal anaesthesia alone is used in patients with Takayasu's arteritis undergoing emergency caesarean section. We present a case of the successful management of a parturient with Takayasu's arteritis, who underwent an emergency caesarean section under low-dose spinal anaesthesia.

Singapore medical journal, 2011

Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. I... more Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. Intrathecal midazolam produces antinociception and potentiates the effect of local anaesthetics. We compared intrathecal bupivacaine with and without midazolam to assess its effect on the duration of sensory block, motor block and pain relief. A total of 100 patients scheduled for elective lower abdominal, lower limb and gynaecological procedures were selected to participate in this prospective, randomised, double-blind study. Patients were randomly allocated into two groups for intrathecal drug administration. Group B received 3 mL 0.5 percent bupivacaine with 0.4 mL saline, and group BM received 3 mL 0.5 percent bupivacaine and 0.4 mL (2 mg) midazolam mixture. The onset, duration of sensory/motor block, time to first rescue analgesia and side effects were noted. Demographic profile and duration of surgery were comparable between the two groups. The onset of sensory (4.8 versus 4.6 min) ...

Singapore medical journal, 2011

Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compare... more Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication. This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKL received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted. A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. At 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in Group MKL and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation ...

Singapore medical journal, 2012

We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary blad... more We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary bladder phaeochromocytoma with vertebral and rib metastasis following partial cystectomy and nephrectomy. His blood pressure was controlled with antihypertensive agents. Epidural analgesia was avoided in view of vertebral metastasis; instead, analgesia was provided with fentanyl infusion. Intraoperative hypertensive episodes were managed with nitroglycerine, sodium nitroprusside and esmalol. However, after surgery, the patient required inotropic support and was moved to the intensive care unit. Analgesia was maintained with fentanyl infusion, and inotropic support was gradually weaned off. Nuclear ablative therapy was planned for bony metastasis. We recommend that recurrences of extra-adrenal phaeochromocytoma be investigated for bony metastasis and cautiously managed in the perioperative period so as to avoid neurological complications.

Singapore medical journal, 2009

Technical issues with monitors remain a concern in the perioperative management of a patient. Ear... more Technical issues with monitors remain a concern in the perioperative management of a patient. Early detection avoids any mishap pertaining to monitoring. But sometimes, technical snags may go unnoticed in the absence of a suitable indicator (audio or visual). A 45-year-old male patient was undergoing emergency appendicectomy under general anaesthesia. In the operation room, routine monitors (Colin BP 508, Colin Corporation, Japan) were attached. Capnography was initiated after tracheal intubation. During surgery, the patient showed some physical movement even though the monitor displayed stable parameters, including the electrocardiographical, pulse oximetry, and capnographic tracings. On close observation, we realised that the display on the monitor was frozen. The monitor was restarted, after which the display could be seen with the cursor of the waveform trace moving. The rest of the operation was uneventful. A newer generation of monitoring devices is available, with the option of freezing the display for the purpose of looking closely at the trace, or for printing out a specific incident manifested on the waveforms. Usually the screen will indicate the frozen status when this option is selected. But due to the technical snag in our case, this option was self-activated without our notice. This could adversely affect the outcome of the surgery (and the patient) if the frozen screen was not observed and remained unrectified for any length of time. Thus, monitoring devices should have an alarm function which is automatically activated in the event of a device failure.° We want to highlight to our readers the possibility of frozen screens and its early detection. One must be careful to ensure that the screen is moving in real time (i.e. with the cursor showing movement). In addition, monitoring devices should come with an alarm activation for screen malfunctions, such as frozen displays. Yours sincerely,

Annals of Saudi medicine

Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia is a paraneoplastic syndrome, usually ... more Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia is a paraneoplastic syndrome, usually associated with mesenchymal tumors. TIO is probably an underreported entity owing to diagnostic and localizing limitations. With improvement in such modalities, patients with TIO are likely to be encountered more frequently in future anesthetic practice. It does not respond to conservative medical management; thus surgical resection of the lesion is the treatment of choice. Anesthetic management of such cases has not been reported in published studies and thus we report two such cases of hypophosphatemia, induced by frontoethmoidal tumors and the anesthetic implications and challenges of such a rare entity. Surgical excision of the causative lesion results in dramatic resolution of symptoms. Vigilant adherence to the pertinent perioperative concerns related to severe hypophosphatemia is crucial to a favorable surgical outcome in these patients.

Clinical Cancer Investigation Journal, 2013

Background: The primary aim of the study was to evaluate the effectiveness of sulfasalazine in re... more Background: The primary aim of the study was to evaluate the effectiveness of sulfasalazine in reducing the incidence of acute radiation-induced enteritis in carcinoma cervix patients receiving pelvic external beam radiotherapy along with concurrent cisplatin-based chemotherapy. Materials and Methods: Between November 2011 and July 2012 a total of 98 patients of locoregionally advanced carcinoma of cervix (49 each in study and control arms) were enrolled in this study. Patients in both the arms were treated with whole pelvis external beam radiotherapy with total dose of 50 Gy in conventional fractionation. Along with this inj. cisplatin was given concurrently at the dose of 40 mg/m 2 of body surface area every week during radiation for 5 weeks. Concurrent chemoradiation was followed by brachytherapy after a gap of 2 weeks. Patients in the study arm also received tablet sulfasalazine 1,000 mg orally twice daily from the day of starting of radiotherapy to 1 week after completion of treatment. Weekly follow-up of all patients to assess acute toxicities was done using common toxicity criteria version 4.0 (CTC v4.0) toxicity scores. Data analysis was carried out by SPSS version 20.0 software. Results: Incidence of grade II or higher grade, lower gastrointestinal toxicity was 19.14% (09/47) in study arm and 41.66% (20/48) in control arm which was statistically significant ( P = 0.017). Conclusion: The study shows that sulfasalazine can significantly reduce the acute radiation-induced diarrhea (ARID) in patients undergoing whole pelvis external beam radiotherapy for carcinoma cervix. The drug is safe, cheap, and readily available.

Case Reports in Anesthesiology, 2011

Pathogenesis of dengue involves suppression of immune system leading to development of characteri... more Pathogenesis of dengue involves suppression of immune system leading to development of characteristic presentation of haematological picture of thrombocytopenia and leucopenia. Sometimes, this suppression in immune response is responsible for deterioration in clinical status of the patient in spite of all specific and supportive therapy. Certain drugs like steroids are used for rescue therapy in conditions like sepsis. We present a novel use of filgrastim as a rescue therapy in a patient with dengue hemorrhagic fever (DHF) with acute respiratory distress syndrome (ARDS), myocarditis, and febrile neutropenia and not responding to standard management.