Letters to Editor
taking Ginko biloba (GB) (approximately 180 mg/day) since last 5 months. At the time of discharge from hospital, the frequency of VPCs had decreased and the patient was discharged after stable post procedure course. GB is the drug mainly used for treatment of cognitive impairment and peripheral vascular disease and it is known to alter platelet function by inhibition of platelet activating factor.[1] Little is known about the pro‑arrhythmic side‑effects of GB. GB induced electrical storm in a patient with ischemic cardiomyopathy[2] and paroxysmal atrial fibrillation[3] has been reported previously. Occurrence of VPCs associated with GB has not been reported. The exact mechanism of cardiac arrhythmia by GB is unknown, but probably GB and its constituent alter the action potential duration and cationic currents as evident from animal studies.[3] Our assumption of GB to be the cause of VPCs in our patient is further supported by a decrease in the frequency of VPCs upon discontinuation of GB. Another problem associated with GB use is a risk of bleeding due to alteration of platelet function.[1] In our patient, there was no excessive bleeding and the pre‑operative investigations were normal. However, caution is advised while using drugs that are known to increase the risk of perioperative bleeding (i.e., warfarin) in patients taking GB. As there are chances of arrhythmia with GB caution is also advised in patients who are on medications that are known to cause perioperative arrhythmias. Nearly 22‑32% of patients coming for a pre‑anaesthetic checkup were on some or other type of herbal medications.[4,5] So an enquiry about herbal medications should always be made during the pre‑anaesthetic check‑up. After five halflives, the amount of any drug left in the body is unlikely to cause harm and ideally GB should be discontinued for at least 36 h before any elective procedure.[1] With this case report, we want to stress upon the fact that GB can be a cause of VPCs in otherwise asymptomatic patients. If possible one should discontinue GB intake for at least 36 h before any elective procedure. However, in emergent situations prior preparation should be made to deal with serious arrhythmia.
Surya Kumar Dube, Charu Mahajan, Hemanshu Prabhakar, Gyaninder Pal Singh Departments of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Hemanshu Prabhakar, Department of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]
634
References 1. Ang‑Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001;286:208‑16. 2. Pfister O, Sticherling C, Schaer B, Osswald S. Electrical storm caused by complementary medication with Ginkgo biloba extract. Am J Med 2008;121:e3‑4. 3. Russo V, Rago A, Russo GM, Calabrò R, Nigro G. Ginkgo biloba: An ancient tree with new arrhythmic side effects. J Postgrad Med 2011;57:221. 4. Tsen LC, Segal S, Pothier M, Bader AM. Alternative medicine use in presurgical patients. Anesthesiology 2000;93:148‑51. 5. Kaye AD, Clarke RC, Sabar R, Vig S, Dhawan KP, Hofbauer R, et al. Herbal medicines: Current trends in anesthesiology practice – A hospital survey. J Clin Anesth 2000;12:468‑71. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.123353
Use of laryngeal mask airway in premature infant Sir, Anaesthesia for neonates and infants require special considerations because of anatomical, physiological and pharmacological differences from adults. Their airway anatomy is quite different from that of adults[1] and therefore need utmost care while securing the airway under general anaesthesia (GA). It is our common practice to secure the airway using endotracheal tube (ETT). In children, Laryngeal Mask Airway (LMA) has also been used as an alternative to ETT for GA and it has now replaced ETT as well as a face mask for short surgical procedures.[2,3] Here, we would like to share our experience of using LMA for GA in a premature baby. A 40‑day‑old female infant diagnosed as retinopathy of prematurity (ROP) was posted for vitrectomy right eye under GA. Her gestational age at birth was 28 weeks and birth weight 800 g. Her pre‑anaesthetic evaluation 1 day prior to this surgery was unremarkable except small mouth opening and low body weight of 1335 g (normal weight of infant at this age is 4‑4.5 kg). Her haemoglobin was 9.2 g%. The baby was accepted for surgery under GA as a high risk case because of prematurity and low body weight. Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013
Letters to Editor
On the operation table, a vein was secured on the dorsum of the left hand and the baby was connected to electrocardiography monitor, pulse oximeter and temperature (temp) monitor. She was pre‑medicated with glycopyrrolate 5 mcg intravenously (IV). Following preoxygenation GA was induced with ketamine 3 mg IV supplemented with sevoflurane 3% in oxygen. After confirming bag and mask ventilation atracurium 0.5 mg was given IV to facilitate insertion of LMA (AmbuTM laryngeal mask) size 1 which could be inserted with some difficulty due to small mouth opening. GA was maintained with nitrous oxide in oxygen (50:50) and sevoflurane 1‑2% using Ayre’s T piece breathing system and controlled ventilation using ‘thumb technique’. Throughout surgery, which lasted for 45 min pulse rate remained steady between 145/min and 156/min. SpO2 99% and body temp 34‑35°C. A total volume of 15 ml paediatric electrolyte solution was infused IV in small boluses. After surgery residual effect of atracurium was reversed with glycopyrrolate 10 mcg/kg and neostigmine 50 mcg/kg body weight. LMA was removed after gentle oral suction when child regained good muscle tone and limb movements. Recovery from anaesthesia was rapid and uneventful. Post‑operatively the baby was observed for 24 h and vital parameters monitored closely, especially respiratory rate for any apnoeic spells and was discharged from the hospital next day. In our institute, LMA (AmbuTM Laryngeal Mask) is used routinely for all intraocular surgeries in paediatric age group. However, this was the first time we used LMA in a premature baby as it has the advantage of ease of insertion. It can be inserted with or without using the index finger or thumb as advocated for LMA classic or unique. Its insertion causes minimum trauma and is associated with minimum effect on intraocular pressure and pressor response as compared with ETT.[4] We found that use of LMA was associated with steady haemodynamic parameters and good oxygenation. As the baby was prematurely born with low body weight at the time of surgery, we considered it as a premature baby and planned our anaesthesia keeping in mind prematurity of all body systems and altered pharmacokinetics of drugs used in anaesthesia. We took all precautions to prevent hypothermia perioperatively. Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013
To conclude, use of AmbuTM Laryngeal Mask was safe in this premature infant for ROP surgery under GA.
Pramod Velankar, Milind Joshi1, Preety Sahu1 Pad. Dr. D. Y. Patil Medical College Hospital and Research Centre, 1 Department of Anaesthesiology, Pune, Maharashtra, India Address for correspondence: Dr. Pramod Velankar, Pad. Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra, India. E-mail: [email protected]
References 1. 2. 3.
4.
Adewale L. Anatomy and assessment of the pediatric airway. Paediatr Anaesth 2009;19 Suppl 1:1‑8. Ramesh S, Jayanthi R. Supraglottic airway devices in children. Indian J Anaesth 2011;55:476‑82. Bhardwaj N, Yaddanapudi S, Singh S, Pandav SS. Insertion of laryngeal mask airway does not increase the intraocular pressure in children with glaucoma. Paediatr Anaesth 2011;21:1036‑40. Jamil SN, Alam M, Usmani H, Khan MM. A study of the use of Laryngeal Mask Airway (LMA) in children and its comparison with endotracheal intubation. Indian J Anaesth 2009;53:174‑8. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.123354
Comment on “Anaesthetic management of a patient with amyotrophic lateral sclerosis for transurethral resection of bladder tumour” Sir, I read with interest the case reported by Thampi et al.,[1] and I would like to congratulate the authors. However, it is important to note some aspects about the anaesthetic management of patients with amyotrophic lateral sclerosis (ALS). The authors describe a 45‑year‑old male patient diagnosed to have ALS with weakness of upper and lower limbs and pulmonary compromise. General anaesthesia 635
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
taking Ginko biloba (GB) (approximately 180 mg/day) since last 5 months. At the time of discharge from hospital, the frequency of VPCs had decreased and the patient was discharged after stable post procedure course. GB is the drug mainly used for treatment of cognitive impairment and peripheral vascular disease and it is known to alter platelet function by inhibition of platelet activating factor.[1] Little is known about the pro‑arrhythmic side‑effects of GB. GB induced electrical storm in a patient with ischemic cardiomyopathy[2] and paroxysmal atrial fibrillation[3] has been reported previously. Occurrence of VPCs associated with GB has not been reported. The exact mechanism of cardiac arrhythmia by GB is unknown, but probably GB and its constituent alter the action potential duration and cationic currents as evident from animal studies.[3] Our assumption of GB to be the cause of VPCs in our patient is further supported by a decrease in the frequency of VPCs upon discontinuation of GB. Another problem associated with GB use is a risk of bleeding due to alteration of platelet function.[1] In our patient, there was no excessive bleeding and the pre‑operative investigations were normal. However, caution is advised while using drugs that are known to increase the risk of perioperative bleeding (i.e., warfarin) in patients taking GB. As there are chances of arrhythmia with GB caution is also advised in patients who are on medications that are known to cause perioperative arrhythmias. Nearly 22‑32% of patients coming for a pre‑anaesthetic checkup were on some or other type of herbal medications.[4,5] So an enquiry about herbal medications should always be made during the pre‑anaesthetic check‑up. After five halflives, the amount of any drug left in the body is unlikely to cause harm and ideally GB should be discontinued for at least 36 h before any elective procedure.[1] With this case report, we want to stress upon the fact that GB can be a cause of VPCs in otherwise asymptomatic patients. If possible one should discontinue GB intake for at least 36 h before any elective procedure. However, in emergent situations prior preparation should be made to deal with serious arrhythmia.
Surya Kumar Dube, Charu Mahajan, Hemanshu Prabhakar, Gyaninder Pal Singh Departments of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Hemanshu Prabhakar, Department of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]
634
References 1. Ang‑Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001;286:208‑16. 2. Pfister O, Sticherling C, Schaer B, Osswald S. Electrical storm caused by complementary medication with Ginkgo biloba extract. Am J Med 2008;121:e3‑4. 3. Russo V, Rago A, Russo GM, Calabrò R, Nigro G. Ginkgo biloba: An ancient tree with new arrhythmic side effects. J Postgrad Med 2011;57:221. 4. Tsen LC, Segal S, Pothier M, Bader AM. Alternative medicine use in presurgical patients. Anesthesiology 2000;93:148‑51. 5. Kaye AD, Clarke RC, Sabar R, Vig S, Dhawan KP, Hofbauer R, et al. Herbal medicines: Current trends in anesthesiology practice – A hospital survey. J Clin Anesth 2000;12:468‑71. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.123353
Use of laryngeal mask airway in premature infant Sir, Anaesthesia for neonates and infants require special considerations because of anatomical, physiological and pharmacological differences from adults. Their airway anatomy is quite different from that of adults[1] and therefore need utmost care while securing the airway under general anaesthesia (GA). It is our common practice to secure the airway using endotracheal tube (ETT). In children, Laryngeal Mask Airway (LMA) has also been used as an alternative to ETT for GA and it has now replaced ETT as well as a face mask for short surgical procedures.[2,3] Here, we would like to share our experience of using LMA for GA in a premature baby. A 40‑day‑old female infant diagnosed as retinopathy of prematurity (ROP) was posted for vitrectomy right eye under GA. Her gestational age at birth was 28 weeks and birth weight 800 g. Her pre‑anaesthetic evaluation 1 day prior to this surgery was unremarkable except small mouth opening and low body weight of 1335 g (normal weight of infant at this age is 4‑4.5 kg). Her haemoglobin was 9.2 g%. The baby was accepted for surgery under GA as a high risk case because of prematurity and low body weight. Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013
Letters to Editor
On the operation table, a vein was secured on the dorsum of the left hand and the baby was connected to electrocardiography monitor, pulse oximeter and temperature (temp) monitor. She was pre‑medicated with glycopyrrolate 5 mcg intravenously (IV). Following preoxygenation GA was induced with ketamine 3 mg IV supplemented with sevoflurane 3% in oxygen. After confirming bag and mask ventilation atracurium 0.5 mg was given IV to facilitate insertion of LMA (AmbuTM laryngeal mask) size 1 which could be inserted with some difficulty due to small mouth opening. GA was maintained with nitrous oxide in oxygen (50:50) and sevoflurane 1‑2% using Ayre’s T piece breathing system and controlled ventilation using ‘thumb technique’. Throughout surgery, which lasted for 45 min pulse rate remained steady between 145/min and 156/min. SpO2 99% and body temp 34‑35°C. A total volume of 15 ml paediatric electrolyte solution was infused IV in small boluses. After surgery residual effect of atracurium was reversed with glycopyrrolate 10 mcg/kg and neostigmine 50 mcg/kg body weight. LMA was removed after gentle oral suction when child regained good muscle tone and limb movements. Recovery from anaesthesia was rapid and uneventful. Post‑operatively the baby was observed for 24 h and vital parameters monitored closely, especially respiratory rate for any apnoeic spells and was discharged from the hospital next day. In our institute, LMA (AmbuTM Laryngeal Mask) is used routinely for all intraocular surgeries in paediatric age group. However, this was the first time we used LMA in a premature baby as it has the advantage of ease of insertion. It can be inserted with or without using the index finger or thumb as advocated for LMA classic or unique. Its insertion causes minimum trauma and is associated with minimum effect on intraocular pressure and pressor response as compared with ETT.[4] We found that use of LMA was associated with steady haemodynamic parameters and good oxygenation. As the baby was prematurely born with low body weight at the time of surgery, we considered it as a premature baby and planned our anaesthesia keeping in mind prematurity of all body systems and altered pharmacokinetics of drugs used in anaesthesia. We took all precautions to prevent hypothermia perioperatively. Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013
To conclude, use of AmbuTM Laryngeal Mask was safe in this premature infant for ROP surgery under GA.
Pramod Velankar, Milind Joshi1, Preety Sahu1 Pad. Dr. D. Y. Patil Medical College Hospital and Research Centre, 1 Department of Anaesthesiology, Pune, Maharashtra, India Address for correspondence: Dr. Pramod Velankar, Pad. Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra, India. E-mail: [email protected]
References 1. 2. 3.
4.
Adewale L. Anatomy and assessment of the pediatric airway. Paediatr Anaesth 2009;19 Suppl 1:1‑8. Ramesh S, Jayanthi R. Supraglottic airway devices in children. Indian J Anaesth 2011;55:476‑82. Bhardwaj N, Yaddanapudi S, Singh S, Pandav SS. Insertion of laryngeal mask airway does not increase the intraocular pressure in children with glaucoma. Paediatr Anaesth 2011;21:1036‑40. Jamil SN, Alam M, Usmani H, Khan MM. A study of the use of Laryngeal Mask Airway (LMA) in children and its comparison with endotracheal intubation. Indian J Anaesth 2009;53:174‑8. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.123354
Comment on “Anaesthetic management of a patient with amyotrophic lateral sclerosis for transurethral resection of bladder tumour” Sir, I read with interest the case reported by Thampi et al.,[1] and I would like to congratulate the authors. However, it is important to note some aspects about the anaesthetic management of patients with amyotrophic lateral sclerosis (ALS). The authors describe a 45‑year‑old male patient diagnosed to have ALS with weakness of upper and lower limbs and pulmonary compromise. General anaesthesia 635
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
