Letters to Editor

administered at T12/L1 level with an 18 G Touhy needle. 40 ml of solution containing 17 ml 0.5% bupivacaine and 7 ml 2% lignocaine in 16 ml normal saline was injected in graded doses. The height of block was titrated to achieve a block extending uptil T4. 40 ml  was chosen as paravertebral block requires higher volume to achieve adequate spread to cover the necessary number of nerves in this case.A sensory block from T4 till L2 level was achieved on one side over 10 min after the beginning of injection. In view of critical nature of the patient, no intravenous analgesic was administered. Only 100% O2 was administered by face mask intra‑operatively. BP was maintained with inotropic support and the surgery was allowed to proceed. The incision was paramedian from subcostal margin to 2 inches below level of umbilicus to enable drainage of pancreatic abscess. Monitoring included SpO2, electrocardiography and non‑invasive blood pressure. There were no facilities for monitoring arterial blood gases or invasive BP. The SpO2 remained between 92% and 96%. His haemodynamics remained steady during the procedure. The surgery was restricted to right half of abdomen. The pus was drained and abdominal lavage was given and abdomen closed after placing drains. Total surgical time was 35 min. The patient was shifted to intensive care unit under cover of inotropic support. Post‑operative analgesia was administered as 0.125% bupivicaine infusion at 3 ml/h via catheter using disposable elastomeric pump for 48 h. He improved over the next week and the inotropes were gradually weaned off. His liver and renal parameters also improved. He was discharged from hospital on 12th post‑operative day. Paravertebral blocks have been utilised for providing analgesia for chest and abdominal surgical procedures for many years.[1‑4] and have lower incidence of complications. It has also been used in a septic patient with mild coagulopathy.[5] A large volume of local anaesthetic solution can be injected blocking multiple levels of paravertebral nerves. The advantages include haemodynamic stability due to the sparing of the sympathetic chain of the uninjected side. Various surgeries described under such blocks include mastectomies, inguinal herniorrhaphies, etc., Laparotomy is not performed usually under paravertebral block as it would entail a bilateral block where the advantage of sympathetic preservation would be lost. We were in a desperate situation when routine anaesthesia techniques were deemed hazardous to the patient. A decision to attempt unilateral surgery under paravertebral block was made. Adequate sensory block Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014

was obtained; abdominal relaxation was not optimum for a classic laparotomy but allowed conditions for pus drainage on the affected side. This procedure certainly cannot be recommended for all laparotomies but it may be considered as an option in such situations, provided the surgeon restricts the procedure aimed at immediate retrieval of patient.

Rajesh K Lalla, Chethan M Koteswara1, S Ananth Departments of Anaesthesiology, Command Hospital Air Force, Domlur, Bengaluru, 1AJ Institute of Medical Sciences, Mangalore, Karnataka, India Address for correspondence: Dr. Rajesh K Lalla, Department of Anaesthesiology, Command Hospital Air Force, Domlur, Agaram Post, Bengaluru, Karnataka, India. E‑mail: [email protected]

REFERENCES 1. Tsai T, Rodriguez‑Diaz C, Deschner B, Thomas K, Wasnick JD. Thoracic paravertebral block for implantable cardioverter‑defibrillator and laser lead extraction. J Clin Anesth 2008;20:379‑82. 2. Mehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic‑assisted coronary artery bypass surgery. Ann Card Anaesth 2008;11:91‑6. 3. Falkensammer J, Hakaim AG, Klocker J, Biebl M, Lau LL, Neuhauser B, et  al. Paravertebral blockade with propofol sedation versus general anesthesia for elective endovascular abdominal aortic aneurysm repair. Vascular 2006;14:17‑22. 4. Rudkin GE, Gardiner SE, Cooter RD. Bilateral thoracic paravertebral block for abdominoplasty. J Clin Anesth 2008;20:54‑6. 5. Visoiu M, Yang C. Ultrasound‑guided bilateral paravertebral continuous nerve blocks for a mildly coagulopathic patient undergoing exploratory laparotomy for bowel resection. Paediatr Anaesth 2011;21:459‑62. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.126839

Palatal obturator: Perioperative concerns Sir, A 46‑year‑old male, weighing 60 kg with diabetes mellitus type II since 10 years was scheduled for debridement of the nasal cavity under general 87

Letters to Editor

anaesthesia (GA). Patient had undergone surgical procedure for mucormycosis under GA uneventfully one year ago. Systemic examination was unremarkable. The airway examination showed a Mallampati (MMP) class IV [Figure 1a] with mouth opening of 3 cm, thyromental distance of 10 cm and possible anterior mandibular protrusion. Patients blood biochemistry and other routine investigations were acceptable. Patient was kept nil per oral and premedicated with anxiolytics and antacids on the night before and on the morning of surgery while morning dose of insulin was omitted. On the day of surgery blood sugar and electrolytes were within the normal range. In the operating room, a multi parameter monitor (AS5, Datex Ohmeda, Finland) was attached to the patient and after securing intravenous (IV) access, IV glycopyrrolate 0.2 mg and IV fentanyl 120 µg were given. Difficult airway cart was kept ready. GA was induced with IV propofol 120 mg and IV succinylcholine 100 mg was given after confirmation of ability to ventilate the lungs. Oral endotracheal intubation was performed with 8.0 mm cuffed endotracheal tube with Glidescope® (GVL; Verathon Inc., Bothell, WA). During intubation, the posterior end of palatal obturator was visualized. Following correct placement of endotracheal tube, the palatal obturator was removed [Figure 1b]. Rest of the perioperative period was unremarkable. Palatal obturator is a prosthetic device and is indicated in patients with cleft palate, traumatic injuries and tumours of palate.[1,2] Palatal obturator consists of an acrylic plate and retention clasps of orthodontic wire, which covers a fistula of the palate. It serves to restore speech, mastication, deglutition and aesthetics.[1,2] Successful obturation depends on the volume of the defect, tissue retention available around the cavity and development of muscular control.[3,4] It must be as light as possible as its weight may act as a dislocating force.[3] The palatal obturator can cause anaesthetic complications including airway obstruction, inability to pass endotracheal tube

due to dislodgement of prosthesis, limitation of the space for a laryngoscope and a traumatic intubation. According to recent practice guidelines for management of the difficult airway, video‑assisted laryngoscopy can now be used as an initial approach to intubation in patients in non‑emergent pathway with difficult airway.[5] We administered succinylcholine considering uneventful previous anaesthetic exposure of the patient and MMP class IV being the only predictor for difficult airway and rest of the airway examination also being normal.[5] The difficult airway cart with other alternative intubation devices were however kept ready. The absence of symptoms of regurgitation of food or water, MMP class IV on airway examination and observer limitation of not able to differentiate between similar looking palatal obturator with the oral mucosa in room light; all probably contributed to the cause of missed finding in the present case. However, we did not encounter any complication during the anaesthetic procedure. Pre‑anaesthesia evaluation is considered as basic element of anaesthesia care and includes a multi‑disciplinary approach including patient’s medical record, history taking, physical examination and findings from medical tests and evaluations. At the same time, anaesthesiologist should consult other health‑care professionals to obtain information relevant to perioperative care to avoid any catastrophe. Assessment performed during pre‑anaesthetic evaluation may be used to formulate plans for intraoperative care, post‑operative recovery, perioperative pain management and patient education.[6]

Vanita Ahuja, Sunita Kazal, Shradha Sinha Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India Address for correspondence: Dr. Vanita Ahuja, Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh, India. E‑mail: [email protected]

REFERENCES 1. 2. 3. a

b

Figure 1: (a) Airway examination of patient shows a mallampati grade IV. (b) The palatal obturator after removal 88

4.

Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821‑9. Hou YZ, Huang Z, Ye HQ, Zhou YS. Inflatable hollow obturator prostheses for patients undergoing an extensive maxillectomy: A case report. Int J Oral Sci 2012;4:114‑8. Bagis  B, Aydoğan E, Hasanreisoğlu U. Rehabilitation of a congenital palatal defect with a modified technique: A case report. Cases J 2008;1:39. Roumanas ED, Nishimura RD, Davis BK, Beumer J 3rd. Clinical evaluation of implants retaining edentulous maxillary Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014

Letters to Editor obturator prostheses. J Prosthet Dent 1997;77:184‑90. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology 2013;118:251‑70. 6. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG, American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, et al. Practice advisory for preanesthesia evaluation: An updated report by the American society of anesthesiologists task force on preanesthesia evaluation. Anesthesiology 2012;116:522‑38.

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Figure 1: Chest X-ray anteroposterior view DOI: 10.4103/0019-5049.126840

Dexmedetomidine to wean patient of severe kyphoscoliosis with cerebral palsy in intensive care unit Sir, Patients with severe kyphoscoliosis with cerebral palsy may present with an acute respiratory failure (ARF) precipitated by an acute respiratory infections, requiring invasive mechanical ventilation.[1] Weaning from ventilator support may be challenging due to agitation and lack of patient co‑operation. A 27‑year‑old male patient suffering from cerebral palsy and congenital kyphoscoliosis (scoliotic angle>1000) was admitted to the intensive care unit with dyspnoea, cough and fever. Patient was drowsy with tachycardia, tachypnoea, blood pressure (BP) 90/66 mm Hg and saturation (SpO2) 86%. On auscultation bibasilar inspiratory crackles were heard. There were no signs of congestive cardiac failure. Arterial blood gas (ABG) showed pH of 7.32, pCO2 45 mm Hg, pO2 50 mm Hg and haematocrit 40%. Chest X‑ray showed severe chest deformity and haziness [Figure 1]. Patient was intubated and mechanically ventilated without much difficulty. Initial ventilator settings were volume control ventilation, tidal volume 400 ml, FiO2 1.0, positive‑end expiratory pressure 8 Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014

mm Hg and frequency 20/min. ABG sample taken after an hour showed pO2  250 mm Hg, pCO2  40 mm Hg, SpO2 100% and FiO2 was hence subsequently reduced to 0.5 while maintaining adequate saturation. On 2nd day ventilation was changed to the synchronized intermittent mandatory ventilation mode with pressure support of 12 cm H2O, but he became visibly agitated, developed tachypnoea and his heart rate rose to 160/min. On auscultation bilateral crackles were still present with lot of secretions. Infusion of midazolam 2 mg/h was started to sedate the patient. Injection paracetamol 1 g 8 hourly was started for analgesia. Fluids were given to increase central venous pressure from 2 to 6 cm H20, which settled his HR to 130/min and BP 106/70 mm Hg. On day 3, secretions reduced, but reducing the midazolam infusion lead to tachypnoea and HR of 164/min. We then started patient on injection dexmedetomidine (DEX). A loading dose 1 mcg/kg for 10 min was given followed by 0.2 mcg/kg/h maintenance infusion. Injection midazolam was stopped and no haemodynamic compromise was observed. After 18 h of starting DEX, patient was successfully breathing on continuous positive airway pressure and subsequently T‑piece. Injection DEX was stopped. ABG after half an hour was good, vitals were stable and patient was no longer agitated and hence he was extubated. The primary goal in patients presenting with ARF in severe kyphoscoliosis is correction of arterial hypoxemia. Our patient was intubated considering his mental condition[2] and he developed agitation requiring 89

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