Ramamani Mariappan - Academia.edu (original) (raw)

Papers by Ramamani Mariappan

Research paper thumbnail of Importance of Multimodal Spinal Cord Monitoring and Hemodynamic Augmentation during High Thoracic Ventral Dural Tear Repair Using the Posterior Approach

Journal of neuroanaesthesiology and critical care, Feb 19, 2024

Research paper thumbnail of A Child with a Large Posterior Mediastinal Mass with Intraspinal Extension—Perioperative Anesthetic Challenges and Importance of Postoperative Analgesia

Journal of neuroanaesthesiology and critical care, Sep 1, 2023

Research paper thumbnail of Role of intravenous mannitol in patients undergoing laparoscopic nephron-sparing surgery: A prospective randomized double-blinded placebo-controlled trial

European urology open science, 2024

Research paper thumbnail of The effect of bilateral superficial cervical block in the prevention of post operative pain, nausea and vomiting in patients undergoing thyroidectomy – a randomised controlled study

Indian Journal of Endocrine Surgery and Research

Research paper thumbnail of Perioperative management of obstructive sleep apnea in transsphenoidal neurosurgery

F1000Research, Oct 25, 2012

Research paper thumbnail of The Effect of Increased Intracranial Pressure on Pulmonary Compliance in a Neonate

Journal of Neurosurgical Anesthesiology, 2017

discharged to a rehabilitation center where he fully recovered. The use of TCCD allowed rapid det... more discharged to a rehabilitation center where he fully recovered. The use of TCCD allowed rapid detection of severe intracranial hypertension causing a critical reduction of the cerebral blood flow. Direct visualization of middle and anterior cerebral arteries with use of TCCD showed the vascular lumen closing during the diastolic phase of the cardiac cycle and opening only during the systolic phase. After exclusion of rebleeding, the hydrocephalus appeared to be the likely cause leading to emergent EVD placement. Invasive monitoring confirmed the estimated ICP that was well above established threshold for treatment. Rapid improvement of the neurological condition after cerebrospinal fluid drainage definitely confirmed the diagnosis of hydrocephalus-associated intracranial hypertension. Intracranial hypertension due to rebleeding and hydrocephalus occurs in nearly 50% of aneurysmal subarachnoid hemorrhage patients, including those presenting with good clinical grades, and can be associated with secondary cerebral infarction and worsening of outcome.4 However, ventricular volume may not always correlate with increased ICP causing delays in decision making. In fact, as shown in this case, acute hydrocephalus may lead to a critical reduction of cerebral blood flow dispite apparently unchanged cerebral ventricle volumes. Transcranial Doppler can be used for noninvasive ICP estimation, both through use of PI, indicating intracranial hypertension if above 1, and with estimation of specific ICP values. Importantly, TCCD provides a unique method for directly visualizing major cerebral arteries of the circle of Willis and their acute modification due to intracranial hypertension.

Research paper thumbnail of Endotracheal Tuberculous Stenosis: Ventilation Rescue and Bronchography Guided Stenting

The Indian journal of chest diseases & allied sciences, Jun 10, 2022

Research paper thumbnail of An uncommon cause for severe hypophosphataemia after transsphenoidal pituitary surgery

Journal of Neuroanaesthesiology and Critical Care, May 1, 2014

Research paper thumbnail of Anaesthetic management of craniosynostosis repair – A retrospective study

Indian Journal of Anaesthesia, 2020

Craniosynostosis, the premature fusion of skull sutures, results in failure of normal bone growth... more Craniosynostosis, the premature fusion of skull sutures, results in failure of normal bone growth perpendicular to the suture and the compensatory growth at other suture sites resulting in an abnormally shaped head. Eighty percent of craniosynostosis occurs in isolation; the remaining occur as part of a syndrome.[1] Syndromic craniosynostosis (SC) is commonly associated with multiple suture involvement with facial bone anomalies and congenital aberrations involving many organ systems.[1]

Research paper thumbnail of Feasibility and diagnostic accuracy of intra-operative monitoring of motor evoked potentials in children <2 years of age undergoing tethered cord surgery: results in 100 children

Childs Nervous System, Mar 24, 2021

This study documents the monitorability using different anesthesia regimes and accuracy of muscle... more This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS). Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation. Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%. Baseline mMEPs were obtained in >85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.

Research paper thumbnail of Intracarotid Etomidate is a Safe Alternative to Sodium Amobarbital for the Wada Test

Journal of Neurosurgical Anesthesiology, Oct 1, 2013

Research paper thumbnail of Comparing two techniques of performing an epidural catheter-assisted epidural blood patch using a 20 ml syringe versus a 5 ml syringe and its effect on clotting time, the strength of clot retraction and haemolysis – A prospective in vitro study (EC-EBP study)

Indian Journal of Anaesthesia

Research paper thumbnail of Can the Processed EEG Be Utilized as a Cerebral Ischemia Monitor during the Temporary Clip Application in Anterior Circulation Aneurysm Surgery?

Journal of Neuroanaesthesiology and Critical Care

Patients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolera... more Patients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolerance varies among individuals. Hence, multimodal intraoperative neuromonitoring (IONM) is essential. IONM is not available in many centers. This case report highlights the utilization of processed electroencephalography (EEG) as a cerebral ischemia monitor during temporary clip application. Our patient underwent clipping of a ruptured anterior-communicating artery aneurysm. After the temporary clip applications on the right and left, A1 arterial segments led to a transient drop of somatosensory evoked potentials (SSEPs). At the same time, the frontal four-channel processed EEG showed a burst suppression (BS) pattern. Blood pressure augmentation and the removal of temporary clips helped restore the SSEP back to baseline and the disappearance of the BS pattern in processed EEG. During the steady state of anesthesia, the sudden appearance of the BS pattern in processed EEG can be attributed ...

Research paper thumbnail of Haemodynamic and anaesthetic management of patients undergoing endovascular therapy for cerebral vasospasm

Journal of Neuroanaesthesiology and Critical Care, Dec 1, 2014

Research paper thumbnail of The effect of continuing versus withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers on mortality and major adverse cardiovascular events in hypertensive patients undergoing elective non-cardiac surgery: study protocol for a multi-centric open-label randomised con...

Trials

Background Angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) ... more Background Angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) are commonly prescribed to patients with hypertension. These drugs are cardioprotective in addition to their blood pressure-lowering effects. However, it is debatable whether hypertensive patients who present for non-cardiac surgery should continue or discontinue these drugs preoperatively. Continuing the drugs entails the risk of perioperative refractory hypotension and/or angioneurotic oedema, while discontinuing the drugs entails the risk of rebound hypertension and myocardial ischaemia. The aim of this study is to evaluate the effect of continuation vs withholding of ACEIs/ARBs on mortality and other major outcomes in hypertensive patients undergoing elective non-cardiac surgery. Methods The continuing vs withholding of ACEIs/ARBs in patients undergoing non-cardiac surgery is a prospective, multi-centric, open-label randomised controlled trial. Two thousand one hundred hypertensive p...

Research paper thumbnail of A0018 Anesthetic Management of Children with Craniosynostosis for Corrective Surgery: A 10-Year Experience

Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019

Materials and Methods: Perioperative data of infants and children who had undergone craniosynosto... more Materials and Methods: Perioperative data of infants and children who had undergone craniosynostosis correction surgery by a single surgical team over a period of 10 years were retrospectively collected after IRB approval. Results: There were 22 patients, of whom 9 (40.9%) were females; Mean age-21.4 months; weight of 8.6 kg. The most common suture involved was coronal in 18 (81.8%), followed by sagittal 13 (59.1%), metopic in 12 (54.6%), and lambdoid in 11 (50%). Seven (31.8%) infants had all four-suture involvement, two had three sutures, seven had two sutures, and six had single-suture involvement. Of these, 13 (59.1%) were syndromic (Crouzon's, Apert's, and Down's syndromes). Sevoflurane induction was performed in 17 (77.3%), and rest had intravenous induction. Anesthesia was maintained with inhalational in 18 (81.8%), and 4 (18.2%) had combination of IV and inhalational agents. Eighteen (81.8%) had an anticipated difficult airway; of these, 5 had CL grade of 3, most of them (4/5) were syndromic. Average blood loss was 40.9 mL/kg; syndromic group had higher loss 51.2 mL/kg vs. 25.9 mL/kg (p = 0.049). Three out of 22 patients did not receive tranexamic acid, these children had increased blood loss 68.3 vs. 36.5 mL/kg (p = 0.09). Hypofibrinogenemia was the most common coagulation abnormality. Those who had intraoperative coagulation abnormality had higher blood loss, 58.0 mL/kg vs. 29.7 mL/kg (p = 0.004). 14/22 (64%) had intraoperative hypotension requiring nor-adrenaline infusion. Few (2/22) had both noradrenaline and adrenaline. Children who had intraoperative ABG (15/22), six (40%) had lactate of > 2 mmol/L. Hyperchloremia (45.4%) was the most commonly observed electrolyte abnormality, followed by hypocalcemia. Average duration of anesthesia was 352 minutes. There was no correlation between the number of sutures involved and the duration of surgery (p = 0.418) nor with the blood loss (p = 0.331). Four (18%) out of 22 children had postoperative ventilation. The mean ICU and hospital stays were 1.7 and 5 days, respectively. Seven out of 22 had postoperative coagulation profile, of whom 1 had both low levels of fibrinogen and a prolonged APTT and 4 had purely hypofibrinogenemia; 1 had thrombocytopenia. No postoperative complication or death noted in these series. Conclusions: Anticipation, adequate preparation for airway and blood loss, administration of titrated anesthetic, maintenance of hemodynamics, and timely administration of tranexamic acid and blood and blood products reduced the complication in these children.

Research paper thumbnail of A0011 Efficacy of Targeted Epidural Blood Patch Treatment for Spontaneous Intracranial Hypotension: A Retrospective Study

Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019

ventilated after the surgery and extubated successfully on second postoperative day. She was disc... more ventilated after the surgery and extubated successfully on second postoperative day. She was discharged on the 14th postoperative day without any neurological deficit. Conclusions: Ankylosing spondylitis and consequent fixed flexion neck deformity bring forth tremendous anesthetic challenges. In this context, the role of preoperative planning, anticipation of complications, and preparedness to deal with complications may not be overemphasized .

Research paper thumbnail of Awareness during anaesthesia for surgery requiring evoked potential monitoring: A pilot study

Journal of Neuroanaesthesiology and Critical Care, 2017

Background: Evoked potential monitoring such as somatosensory-evoked potential (SSEP) or motor-ev... more Background: Evoked potential monitoring such as somatosensory-evoked potential (SSEP) or motor-evoked potential (MEP) monitoring during surgical procedures in proximity to the spinal cord requires minimising the minimum alveolar concentrations (MACs) below the anaesthetic concentrations normally required (1 MAC) to prevent interference in amplitude and latency of evoked potentials. This could result in awareness. Our primary objective was to determine the incidence of awareness while administering low MAC inhalational anaesthetics for these unique procedures. The secondary objective was to assess the adequacy of our anaesthetic technique from neurophysiologist’s perspective. Methods: In this prospective observational pilot study, 61 American Society of Anesthesiologists 1 and 2 patients undergoing spinal surgery for whom intraoperative evoked potential monitoring was performed were included; during the maintenance phase, 0.7–0.8 MAC of isoflurane was targeted. We evaluated the intra...

Research paper thumbnail of Intubating Laryngeal Mask Airway-Fastrach: An Alternative to the Stabilizing Rod

Anesthesia & Analgesia, 2007

of the bupivacaine. Furthermore, there were no paresthesias. Surgery lasted 54 min with no hypote... more of the bupivacaine. Furthermore, there were no paresthesias. Surgery lasted 54 min with no hypotension, nausea, vomiting, brachycardia, or arrhythmia. After signs of sensory and motor recovery, the patient complained of urinary incontinence, which did not respond to 20 mg dexamethasone, 0.375 mg hyoscyamine sulfate, or 5 mg oxybutynin chloride, and has persisted for more than 2 yr. Our patient had no history of a neurological disorder or neurotoxic drug use of any kind. The subarachnoid block was easily performed on the first attempt, and there were no signs of hematoma, abscess, or other causes of spinal cord or nerve root compression. Combined radiological studies (i.e., tomography and magnetic resonance imaging) did not reveal any volumetric, morphological, or structural alterations in the surrounding organs and glands (i.e., liver, pancreas, kidneys, adrenal glands, and spleen). Moreover, no stones were present in the lower or upper urinary tract, and urethrocystoscopy showed a normal urethra. Cystomanometry revealed that the detrusor was unstable and the bladder was insensible to filling and bladder hyperreflexia was manifested. Lastly, the patient was unable to void in the presence of detrusoral contractions of high amplitude (detrusoral pressure 31.9 cm H2O) and when the bladder volume was 150 mL. As stated by Basaranoglu et al. (1), hyperbaric solutions of local anesthetics could lead to an increased risk of nerve-root toxicity in the lower parts of the spinal canal. Because the dorsal roots of L5 and S1 have the most dorsal position with the patients’ supine, they would be the most exposed to the hyperbaric solution. Conversely, if the lesion occurred in the sacral roots, depending on the lesion site, a flabby or spastic or paraplegia would have been observed. In this latter case, hypertonus, spasticity, local anesthesia, fecal, and urinary incontinence generally associated with incomplete bladder emptying would appear. Initially, the bladder would be areflexic and acontractile and only subsequently hyperreflexic associated with dyssynergia of the striated sphincter to which a dyssynergia of the smooth sphincter would follow.

Research paper thumbnail of Analgesic Efficacy of Ultrasound-Guided Quadratus Lumborum Block (QLB) for Anterior Iliac Crest Graft Site Pain in Patients Undergoing Cervical Corpectomy with Iliac Bone Grafting: A Retrospective Case Control Study

Abstracts of 21st Annual Conference of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC 2020), Mar 1, 2020

receive QLB served as controls and patients who received QLB were taken as cases. Results: A tota... more receive QLB served as controls and patients who received QLB were taken as cases. Results: A total of 25 patients were studied. The baseline demographics, intraoperative variables (opioid consumption and duration of anesthesia), and postoperative variables (time of ambulation and discharge time) between the groups were compared. All patients received 30 to 40 mL of either 0.2% ropivacaine or 0.25% bupivacaine for intraoperative analgesia. During the postoperative period, 30 mL of 0.2% ropivacaine or 0.2% bupivacaine was given Q12H for 60 hours. There were no complications such as infection, hematoma or motor weakness noticed with QLB placement. Patients with QLB could be ambulated earlier compared with patients without block. Conclusion: Administration of QLB decreased intraoperative opioid usage and helped in early ambulation and early discharge during the postoperative period.

Research paper thumbnail of Importance of Multimodal Spinal Cord Monitoring and Hemodynamic Augmentation during High Thoracic Ventral Dural Tear Repair Using the Posterior Approach

Journal of neuroanaesthesiology and critical care, Feb 19, 2024

Research paper thumbnail of A Child with a Large Posterior Mediastinal Mass with Intraspinal Extension—Perioperative Anesthetic Challenges and Importance of Postoperative Analgesia

Journal of neuroanaesthesiology and critical care, Sep 1, 2023

Research paper thumbnail of Role of intravenous mannitol in patients undergoing laparoscopic nephron-sparing surgery: A prospective randomized double-blinded placebo-controlled trial

European urology open science, 2024

Research paper thumbnail of The effect of bilateral superficial cervical block in the prevention of post operative pain, nausea and vomiting in patients undergoing thyroidectomy – a randomised controlled study

Indian Journal of Endocrine Surgery and Research

Research paper thumbnail of Perioperative management of obstructive sleep apnea in transsphenoidal neurosurgery

F1000Research, Oct 25, 2012

Research paper thumbnail of The Effect of Increased Intracranial Pressure on Pulmonary Compliance in a Neonate

Journal of Neurosurgical Anesthesiology, 2017

discharged to a rehabilitation center where he fully recovered. The use of TCCD allowed rapid det... more discharged to a rehabilitation center where he fully recovered. The use of TCCD allowed rapid detection of severe intracranial hypertension causing a critical reduction of the cerebral blood flow. Direct visualization of middle and anterior cerebral arteries with use of TCCD showed the vascular lumen closing during the diastolic phase of the cardiac cycle and opening only during the systolic phase. After exclusion of rebleeding, the hydrocephalus appeared to be the likely cause leading to emergent EVD placement. Invasive monitoring confirmed the estimated ICP that was well above established threshold for treatment. Rapid improvement of the neurological condition after cerebrospinal fluid drainage definitely confirmed the diagnosis of hydrocephalus-associated intracranial hypertension. Intracranial hypertension due to rebleeding and hydrocephalus occurs in nearly 50% of aneurysmal subarachnoid hemorrhage patients, including those presenting with good clinical grades, and can be associated with secondary cerebral infarction and worsening of outcome.4 However, ventricular volume may not always correlate with increased ICP causing delays in decision making. In fact, as shown in this case, acute hydrocephalus may lead to a critical reduction of cerebral blood flow dispite apparently unchanged cerebral ventricle volumes. Transcranial Doppler can be used for noninvasive ICP estimation, both through use of PI, indicating intracranial hypertension if above 1, and with estimation of specific ICP values. Importantly, TCCD provides a unique method for directly visualizing major cerebral arteries of the circle of Willis and their acute modification due to intracranial hypertension.

Research paper thumbnail of Endotracheal Tuberculous Stenosis: Ventilation Rescue and Bronchography Guided Stenting

The Indian journal of chest diseases & allied sciences, Jun 10, 2022

Research paper thumbnail of An uncommon cause for severe hypophosphataemia after transsphenoidal pituitary surgery

Journal of Neuroanaesthesiology and Critical Care, May 1, 2014

Research paper thumbnail of Anaesthetic management of craniosynostosis repair – A retrospective study

Indian Journal of Anaesthesia, 2020

Craniosynostosis, the premature fusion of skull sutures, results in failure of normal bone growth... more Craniosynostosis, the premature fusion of skull sutures, results in failure of normal bone growth perpendicular to the suture and the compensatory growth at other suture sites resulting in an abnormally shaped head. Eighty percent of craniosynostosis occurs in isolation; the remaining occur as part of a syndrome.[1] Syndromic craniosynostosis (SC) is commonly associated with multiple suture involvement with facial bone anomalies and congenital aberrations involving many organ systems.[1]

Research paper thumbnail of Feasibility and diagnostic accuracy of intra-operative monitoring of motor evoked potentials in children <2 years of age undergoing tethered cord surgery: results in 100 children

Childs Nervous System, Mar 24, 2021

This study documents the monitorability using different anesthesia regimes and accuracy of muscle... more This study documents the monitorability using different anesthesia regimes and accuracy of muscle motor evoked potentials (mMEPs) in children ≤2 years of age undergoing tethered cord surgery (TCS). Intraoperative mMEP monitoring was attempted in 100 consecutive children, ≤2 years of age, undergoing TCS. MEP monitoring was done under 4 different anesthetic regimes: (Total intravenous anesthesia (TIVA); balanced anesthesia with sevoflurane and ketamine; balanced anesthesia with isoflurane and ketamine; and balanced anesthesia with sevoflurane). Factors analyzed for their effect on monitorability were: age, neurological deficits, type of anesthesia, and the number of pulses used for stimulation. Baseline mMEPs were obtained in 87% children. Monitorability of mMEPs was similar in children ≤1 year and 1-2 years of age (85.7% and 87.5%). In multivariate analysis, anesthesia regime was the only significant factor predicting presence of baseline mMEPs. Children undergoing TIVA (p=0.02) or balanced anesthesia with a combination of propofol, sevoflurane, and ketamine (p=0.05) were most likely to have baseline mMEPs. mMEPs had a sensitivity of 97.4%, specificity of 96.4%, negative predictive value of 98.2% and accuracy of 96.8%. Baseline mMEPs were obtained in >85% of children ≤2 years of age including those who had motor deficits. TIVA and balanced anesthesia with sevoflurane and ketamine are ideal for mMEP monitoring. mMEPs have a high accuracy although, false positive and false negative results can occasionally be experienced.

Research paper thumbnail of Intracarotid Etomidate is a Safe Alternative to Sodium Amobarbital for the Wada Test

Journal of Neurosurgical Anesthesiology, Oct 1, 2013

Research paper thumbnail of Comparing two techniques of performing an epidural catheter-assisted epidural blood patch using a 20 ml syringe versus a 5 ml syringe and its effect on clotting time, the strength of clot retraction and haemolysis – A prospective in vitro study (EC-EBP study)

Indian Journal of Anaesthesia

Research paper thumbnail of Can the Processed EEG Be Utilized as a Cerebral Ischemia Monitor during the Temporary Clip Application in Anterior Circulation Aneurysm Surgery?

Journal of Neuroanaesthesiology and Critical Care

Patients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolera... more Patients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolerance varies among individuals. Hence, multimodal intraoperative neuromonitoring (IONM) is essential. IONM is not available in many centers. This case report highlights the utilization of processed electroencephalography (EEG) as a cerebral ischemia monitor during temporary clip application. Our patient underwent clipping of a ruptured anterior-communicating artery aneurysm. After the temporary clip applications on the right and left, A1 arterial segments led to a transient drop of somatosensory evoked potentials (SSEPs). At the same time, the frontal four-channel processed EEG showed a burst suppression (BS) pattern. Blood pressure augmentation and the removal of temporary clips helped restore the SSEP back to baseline and the disappearance of the BS pattern in processed EEG. During the steady state of anesthesia, the sudden appearance of the BS pattern in processed EEG can be attributed ...

Research paper thumbnail of Haemodynamic and anaesthetic management of patients undergoing endovascular therapy for cerebral vasospasm

Journal of Neuroanaesthesiology and Critical Care, Dec 1, 2014

Research paper thumbnail of The effect of continuing versus withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers on mortality and major adverse cardiovascular events in hypertensive patients undergoing elective non-cardiac surgery: study protocol for a multi-centric open-label randomised con...

Trials

Background Angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) ... more Background Angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) are commonly prescribed to patients with hypertension. These drugs are cardioprotective in addition to their blood pressure-lowering effects. However, it is debatable whether hypertensive patients who present for non-cardiac surgery should continue or discontinue these drugs preoperatively. Continuing the drugs entails the risk of perioperative refractory hypotension and/or angioneurotic oedema, while discontinuing the drugs entails the risk of rebound hypertension and myocardial ischaemia. The aim of this study is to evaluate the effect of continuation vs withholding of ACEIs/ARBs on mortality and other major outcomes in hypertensive patients undergoing elective non-cardiac surgery. Methods The continuing vs withholding of ACEIs/ARBs in patients undergoing non-cardiac surgery is a prospective, multi-centric, open-label randomised controlled trial. Two thousand one hundred hypertensive p...

Research paper thumbnail of A0018 Anesthetic Management of Children with Craniosynostosis for Corrective Surgery: A 10-Year Experience

Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019

Materials and Methods: Perioperative data of infants and children who had undergone craniosynosto... more Materials and Methods: Perioperative data of infants and children who had undergone craniosynostosis correction surgery by a single surgical team over a period of 10 years were retrospectively collected after IRB approval. Results: There were 22 patients, of whom 9 (40.9%) were females; Mean age-21.4 months; weight of 8.6 kg. The most common suture involved was coronal in 18 (81.8%), followed by sagittal 13 (59.1%), metopic in 12 (54.6%), and lambdoid in 11 (50%). Seven (31.8%) infants had all four-suture involvement, two had three sutures, seven had two sutures, and six had single-suture involvement. Of these, 13 (59.1%) were syndromic (Crouzon's, Apert's, and Down's syndromes). Sevoflurane induction was performed in 17 (77.3%), and rest had intravenous induction. Anesthesia was maintained with inhalational in 18 (81.8%), and 4 (18.2%) had combination of IV and inhalational agents. Eighteen (81.8%) had an anticipated difficult airway; of these, 5 had CL grade of 3, most of them (4/5) were syndromic. Average blood loss was 40.9 mL/kg; syndromic group had higher loss 51.2 mL/kg vs. 25.9 mL/kg (p = 0.049). Three out of 22 patients did not receive tranexamic acid, these children had increased blood loss 68.3 vs. 36.5 mL/kg (p = 0.09). Hypofibrinogenemia was the most common coagulation abnormality. Those who had intraoperative coagulation abnormality had higher blood loss, 58.0 mL/kg vs. 29.7 mL/kg (p = 0.004). 14/22 (64%) had intraoperative hypotension requiring nor-adrenaline infusion. Few (2/22) had both noradrenaline and adrenaline. Children who had intraoperative ABG (15/22), six (40%) had lactate of > 2 mmol/L. Hyperchloremia (45.4%) was the most commonly observed electrolyte abnormality, followed by hypocalcemia. Average duration of anesthesia was 352 minutes. There was no correlation between the number of sutures involved and the duration of surgery (p = 0.418) nor with the blood loss (p = 0.331). Four (18%) out of 22 children had postoperative ventilation. The mean ICU and hospital stays were 1.7 and 5 days, respectively. Seven out of 22 had postoperative coagulation profile, of whom 1 had both low levels of fibrinogen and a prolonged APTT and 4 had purely hypofibrinogenemia; 1 had thrombocytopenia. No postoperative complication or death noted in these series. Conclusions: Anticipation, adequate preparation for airway and blood loss, administration of titrated anesthetic, maintenance of hemodynamics, and timely administration of tranexamic acid and blood and blood products reduced the complication in these children.

Research paper thumbnail of A0011 Efficacy of Targeted Epidural Blood Patch Treatment for Spontaneous Intracranial Hypotension: A Retrospective Study

Journal of Neuroanaesthesiology and Critical Care, Mar 1, 2019

ventilated after the surgery and extubated successfully on second postoperative day. She was disc... more ventilated after the surgery and extubated successfully on second postoperative day. She was discharged on the 14th postoperative day without any neurological deficit. Conclusions: Ankylosing spondylitis and consequent fixed flexion neck deformity bring forth tremendous anesthetic challenges. In this context, the role of preoperative planning, anticipation of complications, and preparedness to deal with complications may not be overemphasized .

Research paper thumbnail of Awareness during anaesthesia for surgery requiring evoked potential monitoring: A pilot study

Journal of Neuroanaesthesiology and Critical Care, 2017

Background: Evoked potential monitoring such as somatosensory-evoked potential (SSEP) or motor-ev... more Background: Evoked potential monitoring such as somatosensory-evoked potential (SSEP) or motor-evoked potential (MEP) monitoring during surgical procedures in proximity to the spinal cord requires minimising the minimum alveolar concentrations (MACs) below the anaesthetic concentrations normally required (1 MAC) to prevent interference in amplitude and latency of evoked potentials. This could result in awareness. Our primary objective was to determine the incidence of awareness while administering low MAC inhalational anaesthetics for these unique procedures. The secondary objective was to assess the adequacy of our anaesthetic technique from neurophysiologist’s perspective. Methods: In this prospective observational pilot study, 61 American Society of Anesthesiologists 1 and 2 patients undergoing spinal surgery for whom intraoperative evoked potential monitoring was performed were included; during the maintenance phase, 0.7–0.8 MAC of isoflurane was targeted. We evaluated the intra...

Research paper thumbnail of Intubating Laryngeal Mask Airway-Fastrach: An Alternative to the Stabilizing Rod

Anesthesia & Analgesia, 2007

of the bupivacaine. Furthermore, there were no paresthesias. Surgery lasted 54 min with no hypote... more of the bupivacaine. Furthermore, there were no paresthesias. Surgery lasted 54 min with no hypotension, nausea, vomiting, brachycardia, or arrhythmia. After signs of sensory and motor recovery, the patient complained of urinary incontinence, which did not respond to 20 mg dexamethasone, 0.375 mg hyoscyamine sulfate, or 5 mg oxybutynin chloride, and has persisted for more than 2 yr. Our patient had no history of a neurological disorder or neurotoxic drug use of any kind. The subarachnoid block was easily performed on the first attempt, and there were no signs of hematoma, abscess, or other causes of spinal cord or nerve root compression. Combined radiological studies (i.e., tomography and magnetic resonance imaging) did not reveal any volumetric, morphological, or structural alterations in the surrounding organs and glands (i.e., liver, pancreas, kidneys, adrenal glands, and spleen). Moreover, no stones were present in the lower or upper urinary tract, and urethrocystoscopy showed a normal urethra. Cystomanometry revealed that the detrusor was unstable and the bladder was insensible to filling and bladder hyperreflexia was manifested. Lastly, the patient was unable to void in the presence of detrusoral contractions of high amplitude (detrusoral pressure 31.9 cm H2O) and when the bladder volume was 150 mL. As stated by Basaranoglu et al. (1), hyperbaric solutions of local anesthetics could lead to an increased risk of nerve-root toxicity in the lower parts of the spinal canal. Because the dorsal roots of L5 and S1 have the most dorsal position with the patients’ supine, they would be the most exposed to the hyperbaric solution. Conversely, if the lesion occurred in the sacral roots, depending on the lesion site, a flabby or spastic or paraplegia would have been observed. In this latter case, hypertonus, spasticity, local anesthesia, fecal, and urinary incontinence generally associated with incomplete bladder emptying would appear. Initially, the bladder would be areflexic and acontractile and only subsequently hyperreflexic associated with dyssynergia of the striated sphincter to which a dyssynergia of the smooth sphincter would follow.

Research paper thumbnail of Analgesic Efficacy of Ultrasound-Guided Quadratus Lumborum Block (QLB) for Anterior Iliac Crest Graft Site Pain in Patients Undergoing Cervical Corpectomy with Iliac Bone Grafting: A Retrospective Case Control Study

Abstracts of 21st Annual Conference of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC 2020), Mar 1, 2020

receive QLB served as controls and patients who received QLB were taken as cases. Results: A tota... more receive QLB served as controls and patients who received QLB were taken as cases. Results: A total of 25 patients were studied. The baseline demographics, intraoperative variables (opioid consumption and duration of anesthesia), and postoperative variables (time of ambulation and discharge time) between the groups were compared. All patients received 30 to 40 mL of either 0.2% ropivacaine or 0.25% bupivacaine for intraoperative analgesia. During the postoperative period, 30 mL of 0.2% ropivacaine or 0.2% bupivacaine was given Q12H for 60 hours. There were no complications such as infection, hematoma or motor weakness noticed with QLB placement. Patients with QLB could be ambulated earlier compared with patients without block. Conclusion: Administration of QLB decreased intraoperative opioid usage and helped in early ambulation and early discharge during the postoperative period.