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Papers by divya sethi

Anaesthesia and Intensive Care, Oct 1, 2007

A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by ... more A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by hypocalcaemia secondary to hypoparathyroidism, presented for right cataract surgery. The hypocalcaemia and seizure activity had resolved with medical therapy, with normal calcium levels and no seizures for a month. Anaesthesia with halothane and isoflurane for left cataract surgery two days previously had been uneventful. During induction of anaesthesia with sevoflurane for the right cataract surgery, the patient had a focal seizure similar to those previously occurring when the patient was hypocalcaemic. The patient had normal calcium levels at the time of surgery. It appears likely that sevoflurane had triggered seizure activity in the apparently controlled focus. The potential for sevoflurane to induce epileptogenic activity in patients with reduced seizure threshold is discussed.

Anesthesia and Pain Medicine

An 18 years old girl presented to the preoperative anesthesia clinic for surgery of a distal phal... more An 18 years old girl presented to the preoperative anesthesia clinic for surgery of a distal phalanx fracture. She had a history of delayed milestones and irregular periods with easy fatigability. Physical examination revealed that the patient was short-statured with a webbed neck (Fig. 1A). Family history was not significant except for short-statured parents. Her heart rate was 70 beats/min, blood pressure was 100/66 mmHg, respiratory rate was 14 breaths per min and body temperature was 36.5ºC. Her preoperative investigations were normal except for an electrocardiogram, which showed low-voltage complexes (Fig. 1B), and chest radiographs, which showed a moneybag heart (Fig. 1C). Pointof-care ultrasound examination of the heart showed a swinging motion within the anechoic space (Fig. 2, video). In the four-chamber apical view, the anechoic space measured > 2 cm posterior and > 1 cm anterior to the heart, suggesting a large pericardial effusion (Fig. 2C). No collapse of the right atrium or ventricle was observed, which ruled out tamponade physiology and precluded the need for pericardiocentesis (video). A thyroid function test was also ordered, and its result showed severe hypothyroidism (thyroid stimulating hormone > 496 µIU/ml, T3 < 0.05 ng/ml, and T4 < 2 µg/dl). Other differential diagnoses included tuberculosis, autoimmune diseases, renal failure, and tumors, which were excluded based on biomarker and antibody measurements. Other routine hematological investigations were normal. A cardiologist's opinion was sought, who advised only correction of the hypothyroid status for the management of the effusion. The patient was started on thyroxin therapy at 100 µg, which was increased to 150 µg. One week later, the patient underwent an uneventful surgery under a wrist block. The thyroid function test and echocardiography were repeated after 4 weeks, which showed a return to the euthyroid status with minimal pericardial effusion. Karyotyping results showed a mosaic variant of Turner Syndrome, for which she was advised to undergo gynecological and endocrinological follow-up. Written informed consent was obtained from the patient to report this case without revealing her identity.

Indian Journal of Respiratory Care

Massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli leads to miliary t... more Massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli leads to miliary tuberculosis (TB). It is a potentially lethal disease if not diagnosed and treated early. It accounts for <2% of all TB cases and 20% of all extrapulmonary TB cases in immune-competent adults; the infection rate in immunocompromised patients is much higher. [1] Miliary TB can sometimes lead to acute respiratory distress syndrome (ARDS). [2] Patients of miliary TB with ARDS have a high mortality of 33%-90%. [3] We present a case of miliary TB with ARDS and discuss its diagnosis and management. cASe reporT A 23-year-old female at 8 weeks of gestation was diagnosed with hydatidiform mole, for which she underwent suction and evacuation of the uterus. After an uneventful postoperative period, she was discharged from the hospital but returned back after 4 weeks with complaints of high-grade fever and dry cough. For investigating the possible source of infection, cultures of blood, sputum, urine, and high vaginal swab were sent, and broad-spectrum antibiotics were started. The patient's hematological investigations were normal except for low hemoglobin of 7.7 gm%, for which one unit of packed red cells was transfused. Her chest X-ray was unremarkable and culture reports were negative, but fever persisted in spite of antibiotic therapy. Two weeks later, the patient developed tachypnea and her chest X-ray showed fluffy infiltrates over bilateral lung fields. She was transferred to intensive care unit (ICU), and noninvasive mask ventilation with pressure support of 15 cm of H 2 O and FiO 2 of 0.6 was started. Her arterial blood gas analysis was indicative of ARDS (PaO 2 of 55 mmHg at FiO 2 of 0.6; PaO 2 /FiO 2 = 92.5). Repeat cultures (blood, sputum, and urine) were sent which were again negative for any bacteriological growth. Other tests including Widal, malaria antigen, and dengue serology were also negative. In spite of broad-spectrum antibiotic therapy, her condition did not improve. On day 5 of ICU admission, a high-resolution computed tomography (HRCT) scan of the

Journal of Medical Science And clinical Research, 2020

Miliary tuberculosis is an uncommon cause of Acute Respiratory Distress Syndrome (ARDS) with a hi... more Miliary tuberculosis is an uncommon cause of Acute Respiratory Distress Syndrome (ARDS) with a high mortality. Early diagnosis and timely initiation of treatment are important for good outcome. We report a case of 23 years old female who needed admission to intensive care unit (ICU) due to ARDS. On routine investigations, the cause of ARDS could not be ascertained. Finally, high resolution computed tomography of chest and bronchoscopic guided lung biopsy were done which confirmed the etiology to be miliary tuberculosis. Patient showed improvement after starting anti-tubercular therapy with steroids. One week later, the patient's condition was stabilized and was shifted out of ICU. This case report emphasizes that miliary tuberculosis, though difficult to diagnose, should always be considered a differential diagnosis in patients with ARDS, as early initiation of treatment can prove to be lifesaving.

Background: Intraoperative hypotension increases 30-day mortality and the risks of myocardial inj... more Background: Intraoperative hypotension increases 30-day mortality and the risks of myocardial injury and acute renal failure. Patients with inadequate volume reserve before the induction of anesthesia are highly exposed. The identification of latent hypovolemia is therefore crucial. Ultrasonographic measurement of the inferior vena cava collapsibility index (IVCCI) is able to detect volume responsiveness in circulatory shock. No current evidence is available regarding whether preoperative measurement of the IVCCI could identify patients at high risk for hypotension associated with general anesthesia. Methods: A total of 102 patients undergoing elective general surgery under general anesthesia with standardized propofol induction were recruited for this prospective observational study. The IVCCI was measured under spontaneous breathing. A collapsing (IVCCI≧50%) (CI+) and a noncollapsing (CI-) group were formed. Immediate postinduction changes in systolic and mean blood pressure were ...

Journal of Evolution of Medical and Dental Sciences, 2017

BACKGROUND Sympathoadrenal response to laryngoscopy and intubation under general anaesthesia can ... more BACKGROUND Sympathoadrenal response to laryngoscopy and intubation under general anaesthesia can cause profound haemodynamic alterations, which at times can cause adverse myocardial events, especially in patients with reduced myocardial reserve and associated cardiovascular comorbidities. Various medications are used to suppress this reflex in such patients. We studied the effect of clonidine on this reflex and its effect on propofol consumption during induction of general anaesthesia. MATERIALS AND METHODS After permission from Hospital Ethics Committee, sixty ASA Class I and II patients were divided into two groups. Study group was given intravenous clonidine twenty minutes before induction and control group given intravenous normal saline under similar circumstances. Baseline haemodynamic parameters were recorded in both the groups and then after 5 minutes till 20 minutes after the start of infusion. After the induction of anaesthesia with propofol, haemodynamic parameters were recorded in both the groups every minute till five minutes after intubation of the patient. Consumption of propofol in both the groups was also recorded. RESULTS Baseline haemodynamic parameters and parameters after drug infusion in both groups are comparable. After induction of general anaesthesia, laryngoscopy and intubation, the haemodynamic parameters in control group have a significant (p < 0.001) elevation compared to study group. Study group shows a significantly lower consumption (p < 0.001) of propofol compared to control group. CONCLUSION Premedication with intravenous clonidine prevents haemodynamic response during laryngoscopy and intubation and significantly reduces propofol requirements for induction of anaesthesia in healthy subjects without inducing adverse effects on haemodynamic stability.

Saudi Journal of Anaesthesia, 2013

Background: Transversus abdominis plane (TAP) block is suitable for lower abdominal surgeries. Bl... more Background: Transversus abdominis plane (TAP) block is suitable for lower abdominal surgeries. Blind TAP block has many complications and uncertainty of its effects. Use of ultrasonography increases the safety and efficacy. This study was conducted to evaluate the analgesic efficacy of ultrasound (USG)-guided TAP block for retroperitoneoscopic donor nephrectomy (RDN). Methods: In a prospective randomized double-blind study, 60 patients undergoing laparoscopic donor nephrectomy were randomly divided into two groups by closed envelope method. At the end of surgery, USG-guided TAP block was given to the patients of both the groups. Study group (group S) received inj. Bupivacaine (0.375%), whereas control group (group C) received normal saline. Inj. Tramadol (1 mg/kg) was given as rescue analgesic at visual analog scale (VAS) more than 3 in any group at rest or on movement. The analgesic efficacy was judged by VAS both at rest and on movement, time to first dose of rescue analgesic, cumulative dose of tramadol, sedation score, and nausea score, which were also noted at 30 min, 2, 4, 6, 12, 18, and 24 h postoperatively. Total tramadol consumption at 24 h was also assessed. Results: Patients in group S had significantly lower VAS score, longer time to first dose of rescue analgesic (547.13±266.96 min vs. 49.17±24.95 min) and lower tramadol consumption (103.8±32.18 mg vs. 235.8±47.5 mg) in 24 h. Conclusion: The USG-guided TAP block is easy to perform and effective as a postoperative analgesic regimen in RDN, with opioids-sparing effect and without any complications.

Acta Anaesthesiologica Scandinavica, 1999

Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceuti... more Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceutical Insurance during the period 1993–1997. All were associated with spinal anaesthesia using hyperbaric 5% lignocaine. Five cases had single‐shot spinal anaesthesia and one had a repeat spinal anaesthetic due to inadequate block. The dose of hyperbaric 5% lignocaine administered ranged from 60 to 120 mg. Three of the cases were most likely caused by direct neurotoxicity of hyperbaric 5% lignocaine. In the other 3 cases, direct neurotoxicity was also probable, but unfortunately radiological investigations were not done to definitely exclude a compressive aetiology. All cases sustained permanent neurological deficits. We recommend that hyperbaric lignocaine should be administered in concentrations not greater than 2% and at a total dose preferably not exceeding 60 mg.

Brazilian Journal of Anesthesiology (English Edition), 2021

In five patient undergoing surgery for proximal humerus fracture we investigated into postoperati... more In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Turkish Journal of Anaesthesiology and Reanimation

Objective: The study compared spinal block characteristics of equipotent doses of plain 0.5% levo... more Objective: The study compared spinal block characteristics of equipotent doses of plain 0.5% levobupivacaine, plain 0.75% ropivacaine and hyperbaric 0.5% bupivacaine for elective caesarean (CS) delivery. Methods: A total of 100 parturient women undergoing elective CS under spinal anaesthesia were enrolled for the study. The parturients were randomly assigned to receive one of the following in a subarachnoid block: hyperbaric 0.5% bupivacaine 10 mg (group B), plain 0.5% levobupivacaine 10 mg (group L), or plain 0.5% ropivacaine 15 mg (group R).

Turkish Journal of Emergency Medicine

Korean Journal of Anesthesiology

Background: Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tun... more Background: Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the “subcoracoid tunnel block.”Case: Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%). Conclusions: Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brac...

Indian Journal of Critical Care Medicine, 2015

A young male with multiple lower limb fractures admitted to our Intensive Care Unit was diagnosed... more A young male with multiple lower limb fractures admitted to our Intensive Care Unit was diagnosed with cerebral fat embolism syndrome (FES) based on clinical features and initial magnetic resonance imaging (MRI) which showed multiple hyperintensities on T2-weighted imaging, involving bilateral cerebral and cerebellar hemispheres, predominantly in the watershed territory. The serial MRI done at 3 weeks showed more prominent and larger sized lesions which were in line with the patient&amp;amp;amp;amp;amp;amp;#39;s initial low Glasgow Coma Score and indicated severe cerebral insult. The patient responded well to supportive intensive care therapy; his neurological recovery though slow was consistent as he could return to his full functional status after 6 months. The follow-up MRI showed resolution of the most of earlier lesions. This indicates potentially good outcomes even in severe cases of cerebral FES with appropriate medical care.

Anaesthesia Critical Care & Pain Medicine, 2015

Southern African Journal of Anaesthesia and Analgesia, 2015

Journal of Clinical Anesthesia, 2015

Proteus syndrome (PS), a rare hamartomatous disorder, manifests itself in asymmetric and dispropo... more Proteus syndrome (PS), a rare hamartomatous disorder, manifests itself in asymmetric and disproportionate overgrowth of multiple body tissues. Because of complexity of the disorder, the anesthetic problems encountered during patients&amp;amp;amp;amp;amp;amp;amp;amp;#39; perioperative management are very varied. We discuss the case of a 14-year-old adolescent boy diagnosed with PS who underwent corrective osteotomy of right knee joint under subarachnoid block. The salient points the anesthetists need to be aware of while caring for patients with PS are highlighted.

Saudi Journal of Anaesthesia, 2014

Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following ... more Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following sedation with propofol infusion dose of 100, 75 and 50 mcg/ kg/min given after a bolus dose of ketamine and propofol. Materials and Methods: One hundred children of American Society of Anesthesiologists status 1/2, aged 6 months to 8 years, scheduled for elective MRI were enrolled and randomized to three groups to receive propofol infusion of 100, 75 or 50 mcg/kg/min (Groups A, B, and C, respectively). After premedicating children with midazolam 0.05 mg/kg intravenous (i.v.), sedation was induced with bolus dose of ketamine and propofol (1 mg/kg each) and the propofol infusion was connected. During the scan, heart rate, noninvasive blood pressure, respiratory rate, and oxygen saturation were monitored. Results: The primary outcome that is, discharge time was shortest for Group C (44.06 ± 18.64 min) and longest for Group A (60.00 ± 18.66 min), the difference being statistically and clinically significant. The secondary outcomes that is, additional propofol boluses, scan quality and awakening time were comparable for the three groups. The systolic blood pressure at 20, 25 and 30 min was significantly lower in Groups A and B compared with Group C. The incidence of sedation related adverse events was highest in Group A and least in Group C. Conclusion: After a bolus dose of ketamine and propofol (1 mg/ kg each), propofol infusion of 50 mcg/kg/min provided sedation with shortest discharge time for MRI in children premedicated with midazolam 0.05 mg/kg i.v. It also enabled stable hemodynamics with less adverse events.

Saudi Journal of Anaesthesia, 2014

or issues of funding of medical treatment. Thus, IHT of patients is now an integral process and e... more or issues of funding of medical treatment. Thus, IHT of patients is now an integral process and essential component of health-care system. Optimal health and well-being of the patient is the underlying goal of IHT. Therefore, the decision to transfer is patient-centered and is undertaken when the benefi ts of transfer outweigh the risks. [10] Choice of the destination hospital should be based primarily on infrastructure, availability of specialized care and proximity to the referring hospital, the aim being to seek transfer to a hospital nearby providing the highest quality care. [11] Once the decision is made, the transfer process must be initiated and completed as soon as possible. [12] Both the referring and receiving hospitals should thereafter focus on the continuity of medical care and not just on administrative procedures of discharge and re-admission. IHT carries its own risk and a poorly and hastily conducted transfer increases morbidity and mortality risk for patients. [13-15] Therefore, a well-organized system with appropriate equipment and personnel is crucial for a safe IHT.

Pediatric Anesthesia, 2008

... Anesthetic management of a child with functional adrenocortical tumor for resection. Divya Se... more ... Anesthetic management of a child with functional adrenocortical tumor for resection. Divya Sethi,; Mahesh Kumar Arora,; Renu Sinha,; Somnath Bose. Article first published online: 6 OCT 2008. DOI: 10.1111/j.1460-9592.2008.02674.x. © 2008 The Authors. ...

Journal of Clinical Anesthesia, 2013

Anaesthesia and Intensive Care, Oct 1, 2007

A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by ... more A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by hypocalcaemia secondary to hypoparathyroidism, presented for right cataract surgery. The hypocalcaemia and seizure activity had resolved with medical therapy, with normal calcium levels and no seizures for a month. Anaesthesia with halothane and isoflurane for left cataract surgery two days previously had been uneventful. During induction of anaesthesia with sevoflurane for the right cataract surgery, the patient had a focal seizure similar to those previously occurring when the patient was hypocalcaemic. The patient had normal calcium levels at the time of surgery. It appears likely that sevoflurane had triggered seizure activity in the apparently controlled focus. The potential for sevoflurane to induce epileptogenic activity in patients with reduced seizure threshold is discussed.

Anesthesia and Pain Medicine

An 18 years old girl presented to the preoperative anesthesia clinic for surgery of a distal phal... more An 18 years old girl presented to the preoperative anesthesia clinic for surgery of a distal phalanx fracture. She had a history of delayed milestones and irregular periods with easy fatigability. Physical examination revealed that the patient was short-statured with a webbed neck (Fig. 1A). Family history was not significant except for short-statured parents. Her heart rate was 70 beats/min, blood pressure was 100/66 mmHg, respiratory rate was 14 breaths per min and body temperature was 36.5ºC. Her preoperative investigations were normal except for an electrocardiogram, which showed low-voltage complexes (Fig. 1B), and chest radiographs, which showed a moneybag heart (Fig. 1C). Pointof-care ultrasound examination of the heart showed a swinging motion within the anechoic space (Fig. 2, video). In the four-chamber apical view, the anechoic space measured > 2 cm posterior and > 1 cm anterior to the heart, suggesting a large pericardial effusion (Fig. 2C). No collapse of the right atrium or ventricle was observed, which ruled out tamponade physiology and precluded the need for pericardiocentesis (video). A thyroid function test was also ordered, and its result showed severe hypothyroidism (thyroid stimulating hormone > 496 µIU/ml, T3 < 0.05 ng/ml, and T4 < 2 µg/dl). Other differential diagnoses included tuberculosis, autoimmune diseases, renal failure, and tumors, which were excluded based on biomarker and antibody measurements. Other routine hematological investigations were normal. A cardiologist's opinion was sought, who advised only correction of the hypothyroid status for the management of the effusion. The patient was started on thyroxin therapy at 100 µg, which was increased to 150 µg. One week later, the patient underwent an uneventful surgery under a wrist block. The thyroid function test and echocardiography were repeated after 4 weeks, which showed a return to the euthyroid status with minimal pericardial effusion. Karyotyping results showed a mosaic variant of Turner Syndrome, for which she was advised to undergo gynecological and endocrinological follow-up. Written informed consent was obtained from the patient to report this case without revealing her identity.

Indian Journal of Respiratory Care

Massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli leads to miliary t... more Massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli leads to miliary tuberculosis (TB). It is a potentially lethal disease if not diagnosed and treated early. It accounts for <2% of all TB cases and 20% of all extrapulmonary TB cases in immune-competent adults; the infection rate in immunocompromised patients is much higher. [1] Miliary TB can sometimes lead to acute respiratory distress syndrome (ARDS). [2] Patients of miliary TB with ARDS have a high mortality of 33%-90%. [3] We present a case of miliary TB with ARDS and discuss its diagnosis and management. cASe reporT A 23-year-old female at 8 weeks of gestation was diagnosed with hydatidiform mole, for which she underwent suction and evacuation of the uterus. After an uneventful postoperative period, she was discharged from the hospital but returned back after 4 weeks with complaints of high-grade fever and dry cough. For investigating the possible source of infection, cultures of blood, sputum, urine, and high vaginal swab were sent, and broad-spectrum antibiotics were started. The patient's hematological investigations were normal except for low hemoglobin of 7.7 gm%, for which one unit of packed red cells was transfused. Her chest X-ray was unremarkable and culture reports were negative, but fever persisted in spite of antibiotic therapy. Two weeks later, the patient developed tachypnea and her chest X-ray showed fluffy infiltrates over bilateral lung fields. She was transferred to intensive care unit (ICU), and noninvasive mask ventilation with pressure support of 15 cm of H 2 O and FiO 2 of 0.6 was started. Her arterial blood gas analysis was indicative of ARDS (PaO 2 of 55 mmHg at FiO 2 of 0.6; PaO 2 /FiO 2 = 92.5). Repeat cultures (blood, sputum, and urine) were sent which were again negative for any bacteriological growth. Other tests including Widal, malaria antigen, and dengue serology were also negative. In spite of broad-spectrum antibiotic therapy, her condition did not improve. On day 5 of ICU admission, a high-resolution computed tomography (HRCT) scan of the

Journal of Medical Science And clinical Research, 2020

Miliary tuberculosis is an uncommon cause of Acute Respiratory Distress Syndrome (ARDS) with a hi... more Miliary tuberculosis is an uncommon cause of Acute Respiratory Distress Syndrome (ARDS) with a high mortality. Early diagnosis and timely initiation of treatment are important for good outcome. We report a case of 23 years old female who needed admission to intensive care unit (ICU) due to ARDS. On routine investigations, the cause of ARDS could not be ascertained. Finally, high resolution computed tomography of chest and bronchoscopic guided lung biopsy were done which confirmed the etiology to be miliary tuberculosis. Patient showed improvement after starting anti-tubercular therapy with steroids. One week later, the patient's condition was stabilized and was shifted out of ICU. This case report emphasizes that miliary tuberculosis, though difficult to diagnose, should always be considered a differential diagnosis in patients with ARDS, as early initiation of treatment can prove to be lifesaving.

Background: Intraoperative hypotension increases 30-day mortality and the risks of myocardial inj... more Background: Intraoperative hypotension increases 30-day mortality and the risks of myocardial injury and acute renal failure. Patients with inadequate volume reserve before the induction of anesthesia are highly exposed. The identification of latent hypovolemia is therefore crucial. Ultrasonographic measurement of the inferior vena cava collapsibility index (IVCCI) is able to detect volume responsiveness in circulatory shock. No current evidence is available regarding whether preoperative measurement of the IVCCI could identify patients at high risk for hypotension associated with general anesthesia. Methods: A total of 102 patients undergoing elective general surgery under general anesthesia with standardized propofol induction were recruited for this prospective observational study. The IVCCI was measured under spontaneous breathing. A collapsing (IVCCI≧50%) (CI+) and a noncollapsing (CI-) group were formed. Immediate postinduction changes in systolic and mean blood pressure were ...

Journal of Evolution of Medical and Dental Sciences, 2017

BACKGROUND Sympathoadrenal response to laryngoscopy and intubation under general anaesthesia can ... more BACKGROUND Sympathoadrenal response to laryngoscopy and intubation under general anaesthesia can cause profound haemodynamic alterations, which at times can cause adverse myocardial events, especially in patients with reduced myocardial reserve and associated cardiovascular comorbidities. Various medications are used to suppress this reflex in such patients. We studied the effect of clonidine on this reflex and its effect on propofol consumption during induction of general anaesthesia. MATERIALS AND METHODS After permission from Hospital Ethics Committee, sixty ASA Class I and II patients were divided into two groups. Study group was given intravenous clonidine twenty minutes before induction and control group given intravenous normal saline under similar circumstances. Baseline haemodynamic parameters were recorded in both the groups and then after 5 minutes till 20 minutes after the start of infusion. After the induction of anaesthesia with propofol, haemodynamic parameters were recorded in both the groups every minute till five minutes after intubation of the patient. Consumption of propofol in both the groups was also recorded. RESULTS Baseline haemodynamic parameters and parameters after drug infusion in both groups are comparable. After induction of general anaesthesia, laryngoscopy and intubation, the haemodynamic parameters in control group have a significant (p < 0.001) elevation compared to study group. Study group shows a significantly lower consumption (p < 0.001) of propofol compared to control group. CONCLUSION Premedication with intravenous clonidine prevents haemodynamic response during laryngoscopy and intubation and significantly reduces propofol requirements for induction of anaesthesia in healthy subjects without inducing adverse effects on haemodynamic stability.

Saudi Journal of Anaesthesia, 2013

Background: Transversus abdominis plane (TAP) block is suitable for lower abdominal surgeries. Bl... more Background: Transversus abdominis plane (TAP) block is suitable for lower abdominal surgeries. Blind TAP block has many complications and uncertainty of its effects. Use of ultrasonography increases the safety and efficacy. This study was conducted to evaluate the analgesic efficacy of ultrasound (USG)-guided TAP block for retroperitoneoscopic donor nephrectomy (RDN). Methods: In a prospective randomized double-blind study, 60 patients undergoing laparoscopic donor nephrectomy were randomly divided into two groups by closed envelope method. At the end of surgery, USG-guided TAP block was given to the patients of both the groups. Study group (group S) received inj. Bupivacaine (0.375%), whereas control group (group C) received normal saline. Inj. Tramadol (1 mg/kg) was given as rescue analgesic at visual analog scale (VAS) more than 3 in any group at rest or on movement. The analgesic efficacy was judged by VAS both at rest and on movement, time to first dose of rescue analgesic, cumulative dose of tramadol, sedation score, and nausea score, which were also noted at 30 min, 2, 4, 6, 12, 18, and 24 h postoperatively. Total tramadol consumption at 24 h was also assessed. Results: Patients in group S had significantly lower VAS score, longer time to first dose of rescue analgesic (547.13±266.96 min vs. 49.17±24.95 min) and lower tramadol consumption (103.8±32.18 mg vs. 235.8±47.5 mg) in 24 h. Conclusion: The USG-guided TAP block is easy to perform and effective as a postoperative analgesic regimen in RDN, with opioids-sparing effect and without any complications.

Acta Anaesthesiologica Scandinavica, 1999

Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceuti... more Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceutical Insurance during the period 1993–1997. All were associated with spinal anaesthesia using hyperbaric 5% lignocaine. Five cases had single‐shot spinal anaesthesia and one had a repeat spinal anaesthetic due to inadequate block. The dose of hyperbaric 5% lignocaine administered ranged from 60 to 120 mg. Three of the cases were most likely caused by direct neurotoxicity of hyperbaric 5% lignocaine. In the other 3 cases, direct neurotoxicity was also probable, but unfortunately radiological investigations were not done to definitely exclude a compressive aetiology. All cases sustained permanent neurological deficits. We recommend that hyperbaric lignocaine should be administered in concentrations not greater than 2% and at a total dose preferably not exceeding 60 mg.

Brazilian Journal of Anesthesiology (English Edition), 2021

In five patient undergoing surgery for proximal humerus fracture we investigated into postoperati... more In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Turkish Journal of Anaesthesiology and Reanimation

Objective: The study compared spinal block characteristics of equipotent doses of plain 0.5% levo... more Objective: The study compared spinal block characteristics of equipotent doses of plain 0.5% levobupivacaine, plain 0.75% ropivacaine and hyperbaric 0.5% bupivacaine for elective caesarean (CS) delivery. Methods: A total of 100 parturient women undergoing elective CS under spinal anaesthesia were enrolled for the study. The parturients were randomly assigned to receive one of the following in a subarachnoid block: hyperbaric 0.5% bupivacaine 10 mg (group B), plain 0.5% levobupivacaine 10 mg (group L), or plain 0.5% ropivacaine 15 mg (group R).

Turkish Journal of Emergency Medicine

Korean Journal of Anesthesiology

Background: Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tun... more Background: Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the “subcoracoid tunnel block.”Case: Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%). Conclusions: Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brac...

Indian Journal of Critical Care Medicine, 2015

A young male with multiple lower limb fractures admitted to our Intensive Care Unit was diagnosed... more A young male with multiple lower limb fractures admitted to our Intensive Care Unit was diagnosed with cerebral fat embolism syndrome (FES) based on clinical features and initial magnetic resonance imaging (MRI) which showed multiple hyperintensities on T2-weighted imaging, involving bilateral cerebral and cerebellar hemispheres, predominantly in the watershed territory. The serial MRI done at 3 weeks showed more prominent and larger sized lesions which were in line with the patient&amp;amp;amp;amp;amp;amp;#39;s initial low Glasgow Coma Score and indicated severe cerebral insult. The patient responded well to supportive intensive care therapy; his neurological recovery though slow was consistent as he could return to his full functional status after 6 months. The follow-up MRI showed resolution of the most of earlier lesions. This indicates potentially good outcomes even in severe cases of cerebral FES with appropriate medical care.

Anaesthesia Critical Care & Pain Medicine, 2015

Southern African Journal of Anaesthesia and Analgesia, 2015

Journal of Clinical Anesthesia, 2015

Proteus syndrome (PS), a rare hamartomatous disorder, manifests itself in asymmetric and dispropo... more Proteus syndrome (PS), a rare hamartomatous disorder, manifests itself in asymmetric and disproportionate overgrowth of multiple body tissues. Because of complexity of the disorder, the anesthetic problems encountered during patients&amp;amp;amp;amp;amp;amp;amp;amp;#39; perioperative management are very varied. We discuss the case of a 14-year-old adolescent boy diagnosed with PS who underwent corrective osteotomy of right knee joint under subarachnoid block. The salient points the anesthetists need to be aware of while caring for patients with PS are highlighted.

Saudi Journal of Anaesthesia, 2014

Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following ... more Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following sedation with propofol infusion dose of 100, 75 and 50 mcg/ kg/min given after a bolus dose of ketamine and propofol. Materials and Methods: One hundred children of American Society of Anesthesiologists status 1/2, aged 6 months to 8 years, scheduled for elective MRI were enrolled and randomized to three groups to receive propofol infusion of 100, 75 or 50 mcg/kg/min (Groups A, B, and C, respectively). After premedicating children with midazolam 0.05 mg/kg intravenous (i.v.), sedation was induced with bolus dose of ketamine and propofol (1 mg/kg each) and the propofol infusion was connected. During the scan, heart rate, noninvasive blood pressure, respiratory rate, and oxygen saturation were monitored. Results: The primary outcome that is, discharge time was shortest for Group C (44.06 ± 18.64 min) and longest for Group A (60.00 ± 18.66 min), the difference being statistically and clinically significant. The secondary outcomes that is, additional propofol boluses, scan quality and awakening time were comparable for the three groups. The systolic blood pressure at 20, 25 and 30 min was significantly lower in Groups A and B compared with Group C. The incidence of sedation related adverse events was highest in Group A and least in Group C. Conclusion: After a bolus dose of ketamine and propofol (1 mg/ kg each), propofol infusion of 50 mcg/kg/min provided sedation with shortest discharge time for MRI in children premedicated with midazolam 0.05 mg/kg i.v. It also enabled stable hemodynamics with less adverse events.

Saudi Journal of Anaesthesia, 2014

or issues of funding of medical treatment. Thus, IHT of patients is now an integral process and e... more or issues of funding of medical treatment. Thus, IHT of patients is now an integral process and essential component of health-care system. Optimal health and well-being of the patient is the underlying goal of IHT. Therefore, the decision to transfer is patient-centered and is undertaken when the benefi ts of transfer outweigh the risks. [10] Choice of the destination hospital should be based primarily on infrastructure, availability of specialized care and proximity to the referring hospital, the aim being to seek transfer to a hospital nearby providing the highest quality care. [11] Once the decision is made, the transfer process must be initiated and completed as soon as possible. [12] Both the referring and receiving hospitals should thereafter focus on the continuity of medical care and not just on administrative procedures of discharge and re-admission. IHT carries its own risk and a poorly and hastily conducted transfer increases morbidity and mortality risk for patients. [13-15] Therefore, a well-organized system with appropriate equipment and personnel is crucial for a safe IHT.

Pediatric Anesthesia, 2008

... Anesthetic management of a child with functional adrenocortical tumor for resection. Divya Se... more ... Anesthetic management of a child with functional adrenocortical tumor for resection. Divya Sethi,; Mahesh Kumar Arora,; Renu Sinha,; Somnath Bose. Article first published online: 6 OCT 2008. DOI: 10.1111/j.1460-9592.2008.02674.x. © 2008 The Authors. ...

Journal of Clinical Anesthesia, 2013