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Study Objective: To assess outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy. Design: Retrospective study. Measurements: Preoperative Hb%, serum potassium, coagulation profile electrocardiography (ECG) changes, 2D Echography, x-ray chest, haemodynamic changes, end-tidal carbon dioxide (EtCO 2 ), fluid management and postoperative analgesia. Results: The mean age was 24.75 ± 14.35 years. The mean duration of surgery was 120 ± 80 minutes. The Hb%, serum creatinine and serum potassium were 9.4 ± 1.04%, 6.79 ± 4.91 meq/L and 3.61 ± 0.51 meq/L, respectively. Pulse rate mean blood pressure and EtCO 2 were recorded after creation of pneumoperitoneum and at 15, 30, 45 and after exsufflation of pneumoperitoneum. After pneumoperitoneum, there was increase in pulse rate, systolic blood pressure, diastolic blood pressure and EtCO 2 . After 30 minutes and throughout the surgery, these variables remained stable. Four patients required nitroglycerine infusion for intraoperative hypertention. Only one patient required packed cell volume (PCV) transfusion and total intravenous fluid was 1 ± 0.5 L. At the time of exsufflation, there was decrease in pulse rate, systolic and diastolic blood pressure and EtCO 2 . Conclusion: Because of advancement in anaesthetic agents and muscle relaxant, there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy.

A 24-year-old female at 34-week gestation, presented with malaise, nausea, vomiting, jaundice, and absent foetal movements. A clinical diagnosis of acute fatty liver of pregnancy was made. Although early caesarean section was performed, postoperative course was complicated by acute respiratory distress syndrome (ARDS) sepsis, and continuing coagulopathy. Supportive management in an intensive care unit resulted in successful outcome.

Percutaneous nephrolithotomy (PCNL) is a common endourologic procedure with less morbidity than open surgery. However, pain around the nephrostomy tube requires good post operative analgesia. So we hypothesize that infiltration of local anesthetic from the renal capsule to the skin around the nephrostomy tract would relieve the pain in the initial postoperative period.60 adult patients of either sex with ASA physical status I to III and undergoing percutaneous nephrolithotomy were randomized for a prospective double-blind controlled study. Patients were divided into control group (n = 30) and ropivacaine group (n = 30). Balanced general anesthesia was given. After completion of surgical procedure, 23 gauge spinal needle was inserted at 6 and 12 o'clock position under ultrasonic guidance up to therenal capsule along the nephrostomy tube. 10 ml of 0.25% ropivacaine or normal saline solution was infiltrated in each tract while withdrawing the needle from renal capsule to the skin. Post-operative pain was assessed using visual analogue scale (VAS) and dynamic visual analogue scale (D-VAS) during deep breathing and coughing on a scale of 0-10 during the initial postoperative 24 hours. Rescue analgesia was given in the form of injection tramadol 1.0 mg/kg intravenously when VAS4 and maximum up to 400mg in 24 hours. Time to first rescue analgesic, number of doses of tramadol and total amount of tramadol required in the initial postoperative 24 hours were noted. Patients were observed for any side effect and treated accordingly.VAS at rest (VAS) as well as during deep breathing and coughing (DVAS) were significantly lower in ropivacaine group during first 24 hours. Mean time to 1st rescue analgesic in ropivacaine group was longer (10.7 +/- 2.64 hours) as compared to control group (2.05 +/- 1.44 hours) (P = 0.0001). Mean number of doses of tramadol in 24 hours in group-R were less (2.25 +/- 0.51) than group-C (4.4 +/- 0.68) (P = 0.0001). The mean total amount of tramadol in 24 hours in group-R was significantly lower than group-C. Side effects like nausea and vomiting and sedation were minimum and non-significant in both groups.Local anesthetic infiltration of 0.25% ropivacaine along the nephrostomy tract is efficient in alleviating post-operative pain after percutaneous nephrolithotomy surgery. The number of doses and total consumption of rescue analgesic were also decreased in the initial postoperative 24 hours.

Background: Epidural analgesia with opioid provides good control of postoperative pain in cesarean section, thereby improving the mother's ability to mobilize and interact with her newborn infant. Aim: The aim of this study is to evaluate and compare the analgesic actions and side effects of epidural analgesia with sufentanil, morphine or combination of the two after cesarean section. Materials and Methods: 60 women undergoing elective cesarean section were allocated into three groups of 20 each in a randomized blinded fashion. Epidural analgesia was administered with sufentanil 50 mcg in Group S; morphine 4 mg in Group M; and, a combination of sufentanil 25 mcg and morphine 2 mg was used in Group SM. Analgesic efficacy in terms of onset of action and duration of analgesia was assessed by using the Visual Analog Scale (0 to 10 cm) for 24 hours. Number of opioid doses needed in 24 hours was noted. Side effects like respiratory depression /excessive sedation, pruritus and nausea were recorded. Results: Onset of action were at 7.6 ± 1.5 minutes in group S, 67.6 ± 1.5 minutes in group M and 12.2 ± 2.6 minutes in group SM. Duration of analgesia was longer in group M 17.5 ± 1.9 hours and SM 13.8 ± 1.6 hours than in group S 5.2 ± 1.2 hours. More doses of analgesia were required in group S compared to group M and SM. Side effects were comparable in the three groups. Conclusion: Epidural administration of a combination of sufentanil and morphine offered the advantage of faster onset of action and longer duration of analgesia as compared to the two drugs administered alone.

Background: As an anesthetic adjuvant dexmedetomidine has been shown to provide good perioperative hemodynamic stability with minimum alveolar concentration sparing effect on inhalational anesthetic agents during laparoscopic surgeries performed under general anesthesia. Aim: The study was planned to investigate the effects of dexmedetomidine on attenuation of hemodynamic changes and requirements of intra-operative analgesic and inhalational anesthetic during laparoscopic surgeries and its postoperative side effects. Materials and Methods: A total of 70 patients scheduled for elective laparoscopic surgeries were randomized to receive bolus infusion of dexmedetomidine (group D) or saline (group S) 1 mcg/kg/h, followed by continuous infusion of the same, at the rate of 0.5 mcg/kg/h. Anesthesia was maintained with nitrous oxide in oxygen, muscle relaxant and isoflurane. Supplementation with end-tidal isoflurane was considered when heart rate (HR) and mean arterial blood pressure (BP) exceeded 20% of the baseline value. Hemodynamics, end-tidal isoflurane concentration and adverse events were recorded. Results: Intra-operative mean HR and mean BP in group D were lower than group S (P < 0.05) throughout the laparoscopy surgery. Requirement of intra-operative fentanyl, end-tidal isoflurane and postoperative tramadol were significantly more in group S compared to group D (P < 0.05) Statistically significant nausea and vomiting were noted in group S. Undue sedation and other adverse effects are comparable in both the groups. Conclusion: Dexmedetomidine as an adjuvant in general anesthesia for laparoscopic surgeries provided a stable hemodynamic profile in the perioperative period and effectively blunted pressor response to intubation and extubation, leading to minimal requirements for additional analgesics and potent inhalational agents. There were less adverse events.

Background and Aims: Minimal consumption of local anesthetic and opioid for epidural labor analgesia has been advocated for safe obstetric outcome and superior maternal satisfaction. The primary objective of this study was to evaluate and compare the analgesic efficacy of mode of administration of epidural 0.1% ropivacaine with 0.0002% fentanyl via continuous infusion or intermittent boluses during labor. Material and Methods: Sixty term primi or second gravida healthy parturients in labor requesting epidural analgesia were recruited in this study. Lumbar epidural catheter was inserted, and analgesia initiated with 0.2% ropivacaine. Patients were randomized to receive ropivacaine 0.1% with fentanyl 0.0002% via either continuous infusion (Group A) or intermittent boluses (Group B) on an hourly basis. If the parturient complained of pain and visual analog scale (VAS) score was >3, an additional bolus of the study drug was given. VAS score, motor blockade, maternal hemodynamics and fetal heart sounds were frequently monitored . Side effects, mode of delivery and neonatal outcome were noted. Results: To achieve similar VAS, the mean total dose of ropivacaine was 18.78 ± 3.88 mg in Group A and 16.86 ± 4.3 mg in Group B, the difference being statistically significant (P = 0.04). Seventeen out of 30 patients in Group A that is, 56.6% and nine patients in Group B that is, 30% required additional top-ups, and this was significantly higher (P = 0.037). Side effects, mode of delivery and neonatal outcome were comparable in both groups. Conclusion: Intermittent bolus administration provides a more efficacious route of drug delivery when compared to continuous infusion by significantly decreasing the total amount of local anesthetic plus opioid without adversely affecting patient safety or maternal satisfaction.

Carbon dioxide (CO2) embolism is a rare but potentially fatal complication of laparoscopic surgery. We report a case of presumed CO2 embolism in a 35-year-old female during laparoscopic ureteric reconstructive surgery. After 2 h of operating time, a sudden decrease in end-tidal carbon dioxide and deterioration of hemodynamic status followed by cardiac arrest with pulseless electrical activity suggested gas embolism. Immediate cardiopulmonary resuscitation and inotropic support resulted in successful outcome. Thus, early recognition of the complication and prompt treatment can avoid catastrophy.

Objective : To compare effectiveness of inhalation sevoflurane and intravenous (IV) propofol anaesthesia with the laryngeal mask airway (LMA) in children undergoing surgeries below umbilicus. Method : Sixty premedicated children 3-12 years old with the American Society of Anaesthesiologists physical status of I to II were enrolled and received either induction with sevoflurane 7% by face mask and maintained with a 50% oxygen and 50% nitrous oxide mixture followed by 1.7% sevoflurane or induction with 3 mg/kg propofol IV followed by infusion of 170µg/kg/min with LMA. Demographic data, induction time, number of attempts, LMA insertion, removal and recovery times, haemodynamic parameters, complications, Aldrete score and child’s behaviour score were recorded. Results: Demographic data and induction time were similar for the 2 treatment groups. LMA insertion was successful at the first attempt in 93% with sevoflurane and 83% with propofol. LMA insertion, removal and recovery times were significantly longer in the propofol group (1.56±0.22, 5.89±1.23, 12.3±3.09 minutes respectively) than in the sevoflurane group (1.26±0.36, 2.76±0.51, 5.16±1.6 minutes respectively) (P Conclusions: Sevoflurane provided shorter LMA insertion, removal and recovery times than IV propofol in children undergoing minor surgeries below umbilicus with comparable perioperative complications. Agitation was significantly more with sevoflurane. Sri Lanka Journal of Child Health , 2014; 43 (2): 77-83 (Key words: Sevoflurane; laryngeal mask airway; propofol; paediatric) DOI: http://dx.doi.org/10.4038/sljch.v43i2.7004

Background and Aim: Percutaneous nephrolithotomy (PCNL) is a common for managing renal calculi. Pain in the initial post operatie period is relieved by infiltration of local anaesthetic around the nephrostomy tract.We aimed to compare the analgesic efficacy of bupivacaine and ropivacaine. Methods: A total of 100 adult patients undergoing elective PCNL- under balanced general anaesthesia were randomly divided into bupivacaine group (Group B) and ropivacaine group (Group R). After completion of procedure, 23G spinal needle was inserted at 6 and 12 O′clock position under ultrasonic guidance up to renal capsule along the nephrostomy tube. A volume of 10 ml of either 0.25% bupivacaine or 0.25% ropivacaine solution was infiltrated in each tract while withdrawing the needle. Post-operative pain was assessed using visual analogue scale (VAS) and dynamic visual analogue scale (D-VAS) for initial 24 h. Intravenous tramadol was given as rescue analgesia when VAS >4. Time to first rescue analgesic, number of doses and total amount of tramadol required in initial 24 h and side-effects were noted. Results: Visual analogue scale and D-VAS at 6 h and 8 h in Group B was significantly higher than Group R. Mean time to first rescue analgesia in Group R was significantly longer than Group B. Mean number of doses of tramadol and total consumption of tramadol in 24 h was less in Group R, though not statistically significant. Conclusion: Peritubal infiltration of 0.25% ropivacaine infiltration along the nephrostomy tract is more effective than 0.25% bupivacaine in alleviating initial post-operative pain after PCNL.

Aim The aim of the study was to identify the prevalence of internal jugular vein (IJV) thrombosis and usefulness of preoperative color Doppler study in chronic renal failure patients undergoing live related renal transplant surgery. Materials and methods Two hundred and fifty adult patients of either sex having history of prolonged IJV cannulation were enrolled in this study. They were advised to undergo Doppler neck vessels study. Normal IJV was used to measure central venous pressure during renal transplantation surgery. Results Results are shown as mean±SD. Two hundred and fifty adult patients were included in the study, aged 36 ± 12 years. All patients were cannulated with Mahorkar 16 Fr double-lumen catheter. Duration of catheterization was 52.38 ± 18.91 days. Of the 250 patients, 50 were female patients. The cause of removal was infection, blockage, or maturation of arteriovenous fistula. All patients were clinically asymptomatic. Color Doppler study showed chronic thrombosis either complete/partial in 93 (37.2%) patients. Five (2%) patients had bilateral thrombosis, 80 (86%) patients had partial thrombosis, and 13 (14%) patients had complete thrombosis. The incidence and prevalence were 0.62 and 37.2%, respectively. Right IJV was the common site for insertion [right: 70 (75.2%) and left: 23 (24.7%)]. Conclusion To prevent inadvertent catheter placement and embolism, all patients having history of prolonged IJV cannulation should undergo preoperative color Doppler study.

In a developing country such as India, deceased donor renal transplantation (DDRTx) accounts for only about 1% of all renal transplants (RTx). Our institute initiated an intercity DDRTx in the year 2006, which significantly increased the number of RTx. We retrieved 74 kidneys from 37 deceased donors from various cities of Gujarat from January 2006 to December 2009. We transplanted the allografts in 66 recipients and a retrospective analysis of the donor profile and management and recipient outcome was performed. The mean age of the donors was 43.3 ± 18.8 years. The causes of death included road traffic accident in 51.35% of the donors and cerebrovascular stroke in 48.65% of the donors; 83.78% of the donors required ionotropes for hemodynamic stability in addition to vigorous intravenous fluid replacement. The average urine output of the donors was 350 ± 150 mL. The organs were perfused and stored in HTK solution. The mean cold ischemia time (CIT) was 9.12 ± 5.25 h. The mean anastomosis time in the recipient was 30.8 ± 8.7 min. 57.6% of the recipients established urine output on the operating table and 42.4% developed delayed graft function. At the end of 1 month after transplantation, the mean serum creatinine was comparable to the Ahmadabad city DDRTx, although the CIT was significantly longer in the intercity patients. Intercity organ harvesting is a viable option to increase the donor pool. Distance may not be an impediment, and good recipient outcome is possible in spite of prolonged CIT in case of proper harvesting and preservation.