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Succinylcholine used for difficult airway lead to difficult airway- a case report Nazir, Nazia; Jain, Shruti; Singh, Shipra
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Succinylcholine (Sch) is usually given for intubation in suspected difficult airway due to its fast onset and short duration of action. We report a case of Masseter Muscle Rigidity (MMR) after giving Sch to a patient for lap cholecystectomy with difficult airway.A healthy, 40 year old female weighing 85 kg was posted for laparoscopic cholecystectomy. She was Mallampatti grade III, mouth opening 4.5 cm, upper lip bite test class I, thyromental distance 6.5 cm and neck circumference 55 cm. She had no medical illness, no previous exposure to anaesthetic agents or family history of myopathy with normal investigations.In operating room (OR), difficult intubation cart was kept ready. Pre-medication was done with glycopyrrolate 0.2 mg intravenous (IV), midazolam 1 mg IV and fentanyl 100 µg IV. After pre-oxygenation with 100% O2, patient was induced with propofol 120mg IV. On confirming adequacy of bag and mask ventilation, Sch 120 mg IV was given. Laryngoscopy was attempted once Sch induced fasciculations were over. However, teeth were tightly clenched and it was impossible to open the mouth to allow advancement of the laryngoscope. Again, after few moments, attempt to open the mouth failed. Keeping masseter spasm in mind, mask ventilation was continued with 100 % oxygen and no further anaesthetics were administered. There was no disproportionate increase in EtCO2 or body temperature during this period. After 5 minutes, jaw started relaxing and patient resumed spontaneous respiration. She was sent to the ICU for observation without surgery being performed.In ICU, after 1st post operative hour, blood test revealed normal ABG, slightly raised serum potassium (5.8meq/l) and creatinine phosphokinase (CPK) levels (188 IU/L). Patient remained afebrile throughout with clear urine. Next day, patient was discharged with a special note regarding not to use Sch and counselling for risk of malignant hyperthermia (MH) in future anaesthesia. Muscle biopsy for halothane caffeine test was advised. The case was done at a later date under Total intravenous anaesthesia uneventfully.Our patient presented with difficult airway on account of Mallampati III, increased body weight and neck circumference. In our institute, Sch is routinely used in suspected difficult airway cases as newer short acting non depolarizing muscle relaxants (NDMR) are not available. A rare adverse effect of Sch is MMR which can occur in isolation or can be an early indicator of malignant hyperthermia (MH).(1) Recent findings state that increased tone in the masseter muscle after giving Sch may be a normal pharmacological response of masseter muscle to Sch.(2). MMR causes difficult or impossible laryngoscopy leading to difficult or failed intubation. Alternative techniques like retrograde endotracheal intubation, fiberoptic nasotracheal intubation, trachlight?, laryngeal mask airway and surgical cricothyroidotomy (3) may be required to secure airway. In our patient, though Sch triggered MMR leading to difficult intubation, we were able to ventilate the patient with bag and mask.Surgery was abandoned and patient monitored as there is a possibility of development of MH even after a lag of 20 -30 min (4). Patient did not develop any signs and symptoms of MH during ICU stay. Mild elevation in CPK and K levels could suggest rhabdomyolysis secondary to MMR.To summarize, this case highlights that Sch may produce isolated MMR leading to difficult laryngoscopy and intubation. In such patients, trigger factors of MH should be avoided during maintenance of anaesthesia and availability of dantrolene in OR ensured. We also suggest that the use of Sch is fraught with too much potential for a disastrous outcome and should not be relied upon in cases where difficult intubation is suspected.

Acinetobacter baumannii Is an opportunistic pathogen as an MDRO especially on intensive ward Suranadi, I Wayan; Dwi Fatmawati, Ni Nengah; Aryabiantara, I Wayan; Sinardja, Cynthia Dewi; Saputra, Darmawan Jaya
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Acinetobacter baumannii is an opportunistic bacterial pathogen that is associated with hospital acquired infections and is a major cause of nosocomial infections especially in intensive spaces; this is becoming increasingly a widespread concern in various hospitals around the world. Acinetobacter baumannii, which is resistant to many antibiotics, is now recognized as clinically very important. Reports suggest that the spread of A. baumannii in the hospital environment led to an increase in nosocomial outbreaks associated with high mortality rates. However, many other Acinetobacter spp. can also cause nosocomial infections. This review focuses on the role of Acinetobacter spp. as nosocomial pathogens, resistance patterns and epidemiology.

Fibreoptic intubation under conscious sevoflurane sedation in anticipated difficult intubation cases with unfavorable conventional airway preparation Karim, Habib Md Reazaul; Panda, Chinmaya Kumar; Arora, Prateek; Basumatary, Kartik
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Airway management in maxillofacial and head and neck cancer patients has remained a challenge even after significant development towards difficult airway management. When such patients have multiple difficult intubation predictors, management becomes more thought-provoking. Mucosal preparation and sedation play a vital role in producing co-operative patient and successful procedure but is not always feasible. On the other hand, intravenous sedation lacks titratability and reversibility. We describe awake fiberoptic intubation in three adult patients having multiple difficult intubation predictors whose airway preparation was not feasible due to obscured surface anatomy and nil mouth opening. The cases were done under titrated conscious sevoflurane sedation of MACage 0.4-0.6 using nasopharyngeal airway and closed circuit. This report highlights that Sevoflurane based conscious sedation is a feasible alternative for awake fiberoptic intubation in patients whose airway anesthesia and blocks are not possible.

Vecuronium in tuberculosis: a rare case report of reversible quadriparesis Kumar, Amarjeet; Kumar, Neeraj; Sinha, Chandni; Kirti, Ravi; Kumar, Sanjeev
Bali Journal of Anesthesiology Vol 3, No 1 (2019)
Publisher : DiscoverSys Inc.

ABSTRACTTuberculosis is a major health burden worldwide. The National treatment regimens for tuberculosis (TB) patients recommend the use of the five first lines anti TB drugs: isoniazid (INH), rifampicin (R), ethambutol (E), pyrazinamide (P) and streptomycin (S). Maintaining of oxygenation are very much challenging in tuberculosis patients associated with Acute Respiratory Distress Syndrome (ARDS). Often we need muscle relaxation with adequate sedation for maintaining oxygen saturation and lung recruitment. Skeletal muscle weakness has a confusing list of names and syndromes, including Acute Quadriplegic Myopathy Syndrome (AQMS), floppy man syndrome, critical illness polyneuropathy (CIP), and acute myopathy of intensive care. In disseminated tuberculosis with ARDS, we recommend the use of short-acting muscle relaxant drugs like cisatracurium whose metabolism not depends upon the liver. Interrupting the vecuronium infusion (vecuronium holiday) as its action was potentiated by streptomycin and corticosteroid which may result in the development of Critical Illness Polyneuro Myopathy (CIPM). Targeting Train of Four (TOF) of two rather than zero of four has been shown to be beneficial for a period of fewer than 48 hours.

Comparative evaluation of low-dose levobupivacaine and ropivacaine in patients undergoing inguinal herniorrhaphy under walking spinal anaesthesia as daycare surgery Singh, Priyanka; Kapur, Anu; Gupta, Sanjay Kumar
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Background: Ropivacaine and levobupivacaine possess the property of sensory-motor dissociation. Hence these drugs allow a faster recovery of motor function and hence, these are potentially useful agents for walking spinal anaesthesia in daycare surgeries.Patients and Methods: This is a prospective, double-blind, randomized study involving 120 adult ASA 1 and 2 patients who were randomly allocated into two groups. Group R (n = 60) received 7.5 mg 0.75% ropivacaine + 25 ?g fentanyl + 1.5 ml sterile water. Group L (n = 60) received 5 mg 0.5% levobupivacaine + 25 ?g fentanyl + 1.5 ml sterile water. Each solution was made to a total volume of 3 ml, administered intrathecally. Sensory and motor block characteristics, hemodynamic changes and postoperative recovery profile characteristics were noted. Paired/unpaired t-test and chi-square test were used wherever applicable for statistical analysis using SPSS version 15.0. Results: Sensory block onset time and time to reach the maximal cephalic spread were comparable in both the groups, whereas time to the two-segment regression and time to first analgesic requirement were significantly shorter in group RF. Out of 60 patients in each group, 59 patients in group RF and 57 patients in group LF were MBS grade 5. Time to home discharge was also significantly shorter in group RF.Conclusion: We concluded that both local anaesthetics could be used in the walking spinal technique; however, ropivacaine is preferred because of its favourable block characteristics and early ambulation time.

Clinical profile comparison of cisatracurium and rocuronium in elective surgery Meena, Reema; Jain, Priyanka; Rana, Divya; Verma, Indu; Chauhan, Sunil
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Background: Most surgeries are carried out with ease using neuromuscular blocking agents. This study was aimed to compare the intubating dose of cisatracurium and rocuronium regarding the onset of action, clinical duration, recovery index, intubating conditions, efficacy, and safety in elective surgery.Method: 60 adult patients of American Society Anesthesiology (ASA) grade I & II, underwent elective laparoscopic surgery were randomized to receive either cisatracurium 0.1 mg/kg (Group C) or rocuronium 0.6 mg/kg (Group R). Neuromuscular monitoring was done using STIMPOD Xavant NMS450. Relaxogram interpretation was carried out for the onset of action, clinical duration, and recovery index.Results: Cisatracurium had significant longer onset (233.33±62.31 vs. 86.66±28.62 seconds, p <0.001) and significant longer clinical duration (40±3.56 vs. 27.46±2.14 minutes, p <0.001) than rocuronium. Recovery index was significantly longer in the cisatracurium group (12.23±1.54 vs. 8.30±1.80 minutes, p <0.001). Clinically acceptable intubating conditions were achieved in 180 seconds (C group) compared to 60 seconds in the R group. No untoward or adverse response and complications were distinguished in either group.Conclusion: Cisatracurium 0.1 mg/kg exhibited a slower onset of action than rocuronium 0.6 mg/kg and provided excellent intubating conditions in the majority of patients after 180 seconds. The clinical duration and recovery index were significantly longer in cisatracurium compared to rocuronium. Both are potent and safe agents with excellent cardiovascular stability.

Role of flow velocity and transient hyperemic response evaluated by transcranial doppler for assesing brain autoregulation in mild traumatic brain injury: a case report Demoina, I Gede Patria; Wiryana, Made; Suarjaya, Putu Pramana; Pradhana, Adinda Putra
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Head injuries are a common case throughout the world, based on data from the Centers for Disease Control, emergency cases, hospitalization cases, and also deaths due to head injuries have increased in the decade 2001-2010. Cerebral autoregulation (CA) is a mechanism for cerebral blood flow (CBF) regulation if there is a change from cerebral perfusion pressure (CPP). The mechanism of brain autoregulation is negative feedback that holds back the increase in mean arterial pressure (MAP) by reducing the diameter of blood vessels so that CBF returns to normal, whereas if MAP falls, brain autoregulation tends to widen blood vessel diameter so that CBF is normal. Transcranial doppler examination can be one of the modalities of investigation that is very useful in patients with head injuries. Transcranial doppler in patients with a head injury can be used to measure mean flow velocity of cerebral artery media and transient hyperemic response test, both of which can assess the prognosis of a course of head injury.

Characteristics of cervical myofascial pain in medical students Samatra, Dewa Putu Gede Purwa; Widyadharma, I Putu Eka; Haditya, Yogi; Suryamulyawan, Kadek Adi; Devi, Gusti Ayu Putu Giti Livia; Lim, Demetria Jesica; Wijayanti, Ida Ayu Sri; Adnyana, I Made Oka; Purwata, Thomas Eko
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Background: Cervical myofascial pain or neck pain is in the fourth most disease that causes disability after back pain, depression, and other musculoskeletal diseases. Cervical myofascial pain is characterized by pain originating from a trigger point located in the skeletal muscle, commonly referred as myofascial trigger points (MTrPs).Methods: An observational study with a cross-sectional design, conducted on 3 to 9 of December 2018 with research subjects were medical students at Udayana University who undergoing 5th and 6th year in clinical clerkship at Sanglah General Hospital Denpasar. The data was taken using Google Form which was filled in online by the subject and then analyzed using SPSS version 21.Results: From 307 respondents, 62.2% stated experiencing neck pain (196 respondents) with the majority of women 65.4%, the duration of neck pain occurred for <24 hours with the most frequent frequency at least once per month (46.1%), and appeared most often at night (39.8%) and occurs after night shift in 106 subjects (55.5%). The pain was said getting worse by activity in 102 subjects (52.4%) and getting better when resting in 185 subjects (96.9%). Most of the subjects did not use pain relievers to treat neck pain experienced (84.3%). In subjects who use painkillers, Paracetamol is the most often drug of choice to relieve pain (11%). For non-pharmacological treatment, 53.4% of respondents chose to rest or sleep.Conclusion: Most of the respondents who were clerkship reported experiencing neck pain at least once a month and often felt after a night shift. Respondents who reported neck pain were mostly women.

Estimation of surgical blood loss and transfusion requirements in orthopaedic soft tissue tumor surgery: associated factors Auerkari, Aino Nindya; Tantri, Aida Rosita; Alatas, Anas
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

Over half of soft tissue tumor surgeries require intraoperative Packed Red Cell (PRC) transfusion. Transfusion should be sufficient, as inadequacy will increase risk of tissue ischemia, morbidity and mortality. On the other hand, liberal transfusion is related to infection, tumor recurrence, and immunosuppression. Therefore, good PRC planning measures in preoperative period are essential. Several factors that can be identified in the preoperative period, have been associated with surgical bleeding and transfusion in soft tissue tumor surgery. These factors are ASA score, preoperative hemoglobin (Hb) value, malignancy, size, and location of tumor. By acknowledging influencing factors, a system for predicting blood requirement can be established to promote patient safety and avoid waste. This study aimed to determine factors associated with surgical blood loss and intraoperative PRC transfusion.A retrospective cohort was analyzed on 84 records of orthopaedic soft tissue tumor surgery during 2014-2018. In all subjects, the aforementioned factors, amount of intraoperative bleeding and intraoperative PRC transfusion was recorded. Data was analyzed by linear regression to see the relationship of factors to the amount of bleeding and by logistic regression to assess the probability of receiving intraoperative PRC transfusions. A multivariate analysis identified tumor size as an independent determining factor of bleeding. In further analysis, it was found that tumor size and preoperative Hb value were predictors of the probability of requiring intraoperative PRC transfusion.

Awake Intubation Fiberoptic Bronchoscope on Pregnancy Patient Undergo Decompression Laminectomy and Cervical Fusion Stabilization Saputra, Darmawan Jaya; Senapathi, Tjokorda Gde Agung; Aribawa, I Gusti Ngurah Mahaalit; Ryalino, Christopher
Bali Journal of Anesthesiology Vol 3, No 2 (2019)
Publisher : DiscoverSys Inc.

The traumatic and ankylosing cervical spine being rare in pregnancy can cause serious problems continuing pregnancy. Extensive neurological involvement which is rapidly progressive due to compression should be considered for immediate decompression. We present a case of a patient in the 19th weeks with diagnosis C5 compression fracture and paracervical abscess C5 et causa suspect TB spondylosis, complaints with paralysis in all four limbs. Surgical intervention was deemed necessary and was performed in the prone position. The early operative treatment and appropriate anaesthetic procedure resulted in good clinical outcome with improvement of neurological recovery.

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Abstract

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Contact Name
-

Contact Email
-

Phone
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Journal Mail Official
-

Editorial Address
-

Location
Kota denpasar,

Bali

INDONESIA