ECT in the time of the COVID-19 pandemic

Objective: The recent and ongoing COVID-19 pandemic outbreak has placed a huge burden on healthcare systems worldwide. This emergent situation applies invariably to mental health services, and policy makers have issued new directives to adequately deal with this crisis. The COVID-19 outbreak poses special challenges to the administration of electroconvulsive therapy (ECT) since the anaesthetic induction is an aerosol-generating process. The report provides a narrative account of modifications to the ECT practice at a tertiary care psychiatric hospital to mitigate the risk of COVID-19 transmission. Conclusion: We emphasise two main modifications: use of personal protective equipment (PPE) during the ECT and modifications in the anaesthetic procedure to mitigate potential transmission.

Falsely low arterial blood pressure due to pressure transducer damage in three horses

Three horses undergoing general anaesthesia for orthopaedic procedures between August 2018 and January 2019 at Langford Veterinary Equine Services, Bristol University had falsely low arterial blood pressures due to damage of the non-disposable invasive arterial blood pressure transducer interface. The invasive arterial blood pressure transducer interface is not currently a component that is checked during the anaesthetic machine check prior starting a general anaesthetic procedure. Starting treatment for hypotension based on incorrect information due to faulty equipment can have severe negative consequences for the patient, such as extreme hypertension, increased myocardial workload and oxygen demand, and reduced perfusion of splanchnic and muscle tissue due to vasoconstriction. Therefore, we recommend routinely using the square wave test and checking the integrity of the blood pressure transducer interface before starting a general anaesthetic procedure, and when unexpected hypotensive readings are obtained and/or a state of hypotension is not responsive to treatment.

Tumescent Local Infiltration Anesthesia for Mini Abdominoplasty with Liposuction

AIM: To evaluate the feasibility and safety of mini abdominoplasty with liposuction under local tumescent anaesthesia (LA) as the sole anaesthetic modality. METHODS: The study included 60 female patients with a mean age of 33.3 ± 5.6 years. Local infiltration using a mixture of 1:1000 epinephrine (1 ml), 2% lidocaine (100 ml) and 0.5% Levobupivacaine (50 ml) in 2500 ml saline was started with Local infiltration started with the abdomen, outer thigh, hips, back, inner thighs and knees. After Mini Abdominoplasty with supplemental liposuction was conducted and application of suction drains wound closure was performed, and the tight bandage was applied. Pain during injection, incision and surgical manipulations was determined. Duration of postoperative analgesia, till oral intake and return home, patients and surgeon satisfaction scores were determined. RESULTS: All surgeries were conducted completely without conversion to general anaesthesia. Injection pain was mild in 46 patients, moderate in 10 and hardly tolerated in 4 patients. Incision pain was mild in 16 patients, while 44 patients reported no sensation. During the surgical procedure, 6 patients required an additional dose of LA. Meantime till resumption of oral intake was 1.6 ± 0.9 hours. Meantime till home return was 5.6 ± 2.4 hours. Twelve patients were highly satisfied, 18 patients were satisfied, and these 42 patients were willing to repeat the trial if required. Eight patients found the trial is good and only one patient refused to repeat the trial and was dissatisfied, for a mean total satisfaction score of 3.1 ± 0.9. CONCLUSION: Mini Abdominoplasty with liposuction could be conducted safely under tumescent LA with mostly pain-free intraoperative and PO courses and allowed such surgical procedure to be managed as an office procedure. The applied anaesthetic procedure provided patients’ satisfaction with varying degrees in about 97% of studied patients.

Post anaesthetic care of emergency laparotomy patient for the optimization of surgical outcome

This is a case study of a 45 year old male patient who underwent an emergency laparotomy procedure. Perioperative risks and associated postoperative outcomes could occur from the complex interaction between the patient’s physical health status, the actual surgery performed, anaesthetic procedure and intra/postoperative events. The patient experienced renal compromise and physiological impairment during surgery. This article discusses his assessment and management as well as the various factors which have an impact upon his physiology.

Low dose spinal anesthesia for open cholecystectomy: a feasibility and safety study

Background: Cholecystectomy is performed either open or a laparascopic route. the traditional and invasive open cholecystectomy is still in frequent practice for various reasons. Spinal anesthesia (SA) has been widely used as alternative to General Anesthesia (GA) for laparoscopic cholecystectomy. SA could be a safe and effective anaesthetic procedure for open cholecystectomy. This study was conducted to uncover feasibility and safety of low dose SA for conducting open cholecystectomy.Methods: All consented patients of ASA grade I and II of either sex scheduled for elective open cholecystectomy received SA using 2 ml of 0.5% hyperbaric Bupivacaine mixed with 100 µg Morphine. Peri-operative preparations and management were all standardized. Other drugs being only administered to manage anxiety, pain, nausea/vomiting, hypotension, and any adverse event. Open cholecystectomy by right oblique incision. Intra-operative events and post-operative events were observed for 48 hours, operative difficulty, post operative pain free interval, analgesia requirements, hospital stay and the surgeon and patient satisfaction were studied.Results: 20 patients were included in the study from 1st may 2016 to December 2016. Spinal anesthesia was adequate for surgery in all patients. Operative difficulty scores were minimal and surgery in one patient was converted to open cholecystectomy. Intraoperatively, five patients presented hypotension and Ephedrine was given. Four patients experienced pain and received Fentanyl and midazolam. Postoperatively, pain scores were minimal and paracetamol was not sufficient only in four patients who received ketoprofen and no patient received opioid. One patient required antiemetic for vomiting and two patients suffered urinary retention and one headache. 19 patients were discharged within 48 hours of surgery and patient satisfaction scores were very good.Conclusions: Spinal anesthesia is safe and effective anesthetic technic for uncomplicated open cholecystectomy in terms of peri-operative events and, in prolonged post-operative analgesia, as well as in terms of patient and surgeon’s satisfaction.

Safe Deep Sedation with Midazolam and Propofol for Cerebral MRI in Young Children with Sickle Cell Disease Is Safe: A Single Center Experience in Belgium

Introduction Cerebral angio-MRI is required in children with Sickle Cell Disease (SCD) in case of abnormal blood flow velocities or lack of acoustic window at Trans-Cranial Doppler Echography (TCD) and to screen the presence of silent infarcts. MRI in young children requires deep sedation and could potentially lead to hypoxemia and increase the risk of SCD-related complications. For this reason, we studied whether deep sedation (DS) for cerebral MRI in young children with SCD might be associated with more frequent adverse events during and within 30 days after the procedure. Methods We identified all patients with SCD who were investigated by MRI under DS in our center (Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium) from Augustus 2005 to March 2016. Demographic data as well as data about the anaesthetic procedure and acute clinical events 30 days before and after sedation have been collected retrospectively. The anaesthetic procedure for patient with SCD was based on midazolam as premedication followed by propofol for deep sedation. Supplementary oxygen was added to all children to maintain FiO2 > 40%. No prophylactic red blood cell transfusion/exchange were administered before sedation. Data were analyzed for normality; parametric values were assessed by mean and SD, non-parametric values were assessed as medians and interquartile ranges. Student test was used to analyse continuous variable and Chi-square test for discrete variable. Results Seventy four SCD children were identified in whom 147 procedures were performed. 53% were female; 94% were HbSS or HbSβ0. Most of them have already experienced one or more previous acute clinical event (dactylitis 32.4%, vaso-occlusive crisis [VOC] 45.9%, acute chest syndrome [ACS] 32.4%). Hydroxyurea has been prescribed to 39 patients (52.7%) at a median age of 2.4 years (range: 0.6- 4.9 years) mainly for recurrent VOC/ ACS. Five patients were on chronic transfusion program beginning at a median age of 2.6 years (range: 2.1-4.7 years) for primary and secondary stroke prevention. Median age at procedure was 3.1 years (range: 0.9 - 6.1 years). The median number of MRI under DS per patient was 1.8 (range: 1-5). Seven MRI were associated to an incident linked to the DS: 3 episodes of agitation/irritability, 4 desaturations < 95% (with 1 requiring transient manual mask ventilation). Median saturation during the procedure was 100% (range: 84-100%). 28 clinical events (19%) occurred within the 30 days before DS while 16 (11%) occurred within the 30 days after DS. Considering hospitalisations, the number were 16 (11%) and 11 (7.5%) before and after respectively. Considering only VOC and ACS, the numbers were 8 (5.4%) before and 6 (4%) after DS. Patients developing SCD complications after DS were less frequently treated with hydroxyurea (18.8% vs. 44.3%, P=0.06), had longer procedure while Hb level, WBC count, MCV, HbF and LDH were not significantly different. Discussion Deep sedation with midazolam and propofol for Cerebral angio-MRI in SCD children was safe, with few side-effects and no increase of VOC and ACS within one month of sedation. Only one study analyzed the safety of deep sedation in young children with SCD (Belmont et al. J Pediatr May 2015; 166:1226-32) but reported a possible trend of increased complications after sedation with midazolam, phenobarbital and fentanyl. Compared to the series of Belmont (Table 1), our patients were younger, more often treated with hydroxyurea and had a shorter procedure duration with less deep desaturation. The combination of propofol with midazolam seems to be better tolerated by children with SCD than midazolam, pentobarbital and fentanyl and appears to be safe in very young children. Disclosures No relevant conflicts of interest to declare.

A case of convulsion resembling masseter muscle spasm (MMS) during caesarean delivery under subarachnoid block

A 28 yrs old female forty weeks gravida was scheduled for caesarean section for less fetal movement. She did not have any bad obstetric history and any complication during previous operation and anaesthetic procedure. Subarachnoid block was performed at L3-L4 interspace with 2.5ml (12.5mg)5% bupivacaine heavy. Suddenly the patient became cyanosed and she tried to tell something but could not talk. Then she was given 100% O2 by face mask but it was not fruitful. Then endotracheal intubation was attempted but failed to achieve due to increased jaw muscle tension and mouth could not be opened like masseter muscle spasm (MMS). At that stage patient became unresponsive and no pulse was palpable, blood pressure was not recordable. Intravenous adrenaline was given immediately and then 100mg of suxamethonium adminstered intravenously. The jaw relaxed within minutes and tracheal intubation was done. General Anaesthesia was maintained with O2/N2O, 0.4% halothane and atracurium. The reversal was good enough and the patient was haemodynamically stable. The patient transferred to the recovery room. DOI: http://dx.doi.org/10.3329/jbsa.v22i1.18100 Journal of BSA, 2009; 22(1): 35-37

A Study of the Haemodynamic Response to Oral Clonidine as Pre–Medication in Laparoscopic Surgeries

<strong>Introduction:</strong> Laparoscopic surgery is a boon for surgeons as it reduces tissue trauma, post-operative morbidity, hospital stay and healthcare costs. However, it is not possible to perform a laparoscopic procedure unless a proper anaesthetic procedure is available to combat the additional haemodynamic stress of pneumoperitoneum with CO₂ insufflation and the patient's position^1,2. Use of an alpha-2 against tablets such as clonidine helps in blunting the adverse haemodynamic response during laparoscopy^3,4. <strong>Aims of this study were:</strong> To study haemodynamic response to oral clonidine tablet during endotracheal intubation in laparoscopic surgery. To study haemodynamic response to oral clonidine tablet in the intraoperative period in laparoscopic surgery. To study side-effects of clonidine. <strong>Materials and Methods:</strong> This prospective placebo controlled study was conducted in the Department of Anaesthesiology, in a tertiary health care centre attached to a medical college. A total of 60 patients scheduled for laparoscopic surgery in the age group of 18-60 years belonging to ASA grade 1 &amp; 2 were included in the study. After appropriate preoperative evaluation they were divided into 2 groups. Group C (n = 30) received Tab. Clonidine 150 mcg orally. Group V (n = 30) received a placebo Vitamin tablet. After appropriate premedication, patients were given general anaesthesia. Various parameters like pulse rate, Non-Invasive Blood Pressure (NIBP) including systolic, diastolic and mean arterial pressure, ETCO₂ were measured pre-operatively, during intubation and at various points intraoperatively. Statistical analysis was done using statistical package for Social Sciences Ver. 18. The results was expressed in mean and standard deviation. Independent t-test was used to compare mean of the two groups. For the purpose of this study, 95% confidence limit was chosen and corresponding p-value &lt;0.05 was taken as statistically significant. <strong>Conclusion:</strong> We found that pre-medication with oral clonidine provides haemodynamic stability and protection against the stress response triggered by laryngoscopy, intubation and pneumoperitoneum with CO₂ in patients undergoing laparoscopic surgery. It also was found to reduce nausea, vomiting and shivering post-operatively.

Pediatric Dental Patients’ Attitudes to Rubber Dam

Objectives: To explore young patients’ experiences of rubber dam (RD) and determine how personal and clinical factors may influence opinions. Study design: A self-completed questionnaire was developed to capture pediatric patients’ experiences of treatment under RD in a hospital setting. Patients’ acceptance of RD and perceptions of how well it was explained to them were recorded on a 10cm Visual Analogue Scale (VAS), where zero represented the most negative score. The following clinical variables were also recorded: type of RD; procedure undertaken; use of local anaesthetic and procedure duration. Results: One hundred children (52 male, 48 female) with a mean age of 11.8 years (SD=2.29; range 7-17 years) participated. Overall, acceptance of RD was satisfactory (mean VAS=5.0). Patients were happy with the explanation of why RD was used (mean VAS=7.7). The type of RD, use of local anaesthetic, procedure undertaken and duration of the procedure did not significantly influence acceptance levels. However, RD was significantly less acceptable to patients who underwent radiographic examination whilst wearing the RD (P&lt; 0.05, t-test). Nearly five times as many patients expressed concern at being seen wearing RD when taken to the radiography department (39.2%, n=20/51), compared to those who were reportedly self-conscious about RD when treated only on the paediatric dentistry clinic (8.2%, n=4/49). Conclusions: The use of RD appears acceptable physically and psychologically to most pediatric patients, however, visibility of the RD to others was a potential concern to some children.