Madhya pradesh journal 04 nov 2014

CME & WORKSHOP - 2009
Message 1 2
Message
Message
President's Message
Editorial
Spinal Anaesthesa: A safe option in Multiple
Disease Patients 6 7
Anesthetic Management of a patient with
Becker's Muscular Dystrophy for ASD Closure 7 11
Postoperative Nausea and Vomiting 8 14
Malignant PDPH- A Case Report 9 22
Anesthesia Information Management System
(AIMS) Historical Overview and Future Trends 10 25
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CONTENTS
Dr. S.S.C. Chakra Rao- President (ISA-National)
OFFICE BEARERS
2013-2014
(M.P.State Branch ISA)
PRESIDENT
Dr. Dilip Kothari
VICE PRESIDENT
Dr. Urmila Kesari
Hon. Secretary
Dr. Meenu Chadha
Treasurer
Dr. Sonal Nivsarkar
Executive Members
Dr. Alok Pratap Singh
Dr. Amit Jain
Dr. Mayank Kulshreshta
Dr. Babbar
Dr. Mukesh Nigam
Dr. Ram Avtar Singh
Editor
Dr. Meenu Chadha
Dr. M.V. Bhimeswar Hon. Secretary (ISA-National)
Dr. S. Bala Bhaskar - Editor (IJA)
Dr. Dilip Kothari - President (M.P.Chapter)
Dr. Meenu Chadha - Hon. Secretary (M.P. Chapter)
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Dr. Dilip Kothari, Dr. Bhanu Choudhary
Dr. Sarika Katiyar, Dr. Saifullah Tipu, Dr. Rajnish kumar Jain
Dr. Jitendra Agarwal, Dr. Dilip Kothari, Dr. Bhanu Choudhary
Dr. Hiren Shah, Dr. Harsha Desai Phulambrikar
Dr. Ritesh Dixit

Message
Dear Dr. Meenu Chadha
Namaste
I am very happy to know that ISA MP state has an idea to start their own
Journal of Anaesthesiology from Indore. Indore has the experience of having
a Journal for the city branch itself. Now the state branch has been privileged
to start the Journal of Anaesthesiology. I learned that this Journal will help all
the practising Anaesthesiologists, academicians, Corporate Institutions and
the PG students for publishing their case reports and project themselves.
Review articles of interest, quiz, crossword puzzles related to
Anaesthesiology can be added. I suggest the ISA MP state branch to have it
online also so that it will be visible to the world, with increasing readership. 9th
November 2014 will be a good start for this venture during the MPISACON
2014 at Gwalior. All the experience and dedication of Dr.Meenu Chadha and
Dr. Dilip Kothari will definitely help the Journal to be more popular. I wish this
journal of Anaesthesiology of MP state will be a grand success and many will
follow.
2 3
LONG LIVE ISA
With warm regards,
Yours sincerely,
n Dr. S.S.C. Chakra Rao
Dear Dr. Meenu Chadha
I am very happy to hear that the Madhya Pardesh Society of
Anaesthesiologists is starting the Madhya Pradesh Journal of
Ananesthesia.
Madhya Pradesh has always been in the fore front with regards to
academics, and bringing out the Madhya Pradesh Journal will be another
feather in the cap of the ISA Madhya Pradesh.
The Madhya Pradesh Journal by publishing quality articles will benefit
many of the PG Students, Private practitioners and Academicians.
I sincerely appreciate te efforts of the Madhya Pradesh Hon. Secretary
Dr. Meenu Chadda and the Governing Council of ISA Madhya Pradesh and
wish the Madhya Pradesh Journal of Anaesthesia all success.
LONG LIVE ISA
n Dr. M.V. Bhimeswar
DR. S.S.C. Chakra Rao
President
(ISA -National)
DR. M.V. Bhimeswar
Hony. Secretary
(ISA -National)
Message
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Message
Dear Dr. Dilip Kothari & Dr. Meenu Chadha
It was pleasant to note that the Indian Society of Anaesthesiologists
(ISA), Madhya Pradesh Branch is launching its own academic journal.
Any development contributing to growth and dissemination of research
is incomplete without its actual publication. Explosive improvements in the
field of anaesthesia and critical care in the last few decades have been
marked simultaneously by landmark publications; and the benefits are seen
worldwide, among the practicing anaesthesiologists and of course, the
millions of patients.
Publications by dozens have been sprouting in the Indian scenario
recently but it is imperative that for a journal to acquire popularity the editorial
group maintains highest standards of publication and strive to reach greater
heights. Launch of a new journal of anaesthesia by the ISA, MP State Branch
is a step in the right direction, that is expected to meet the demands for
publication from within the anaesthesia fraternity in M.P. The publications
should reflect the sincere desire of our members to share the research
evidences and not just as a cursory submission for career enhancement.
As editor of the Indian Journal of Anaesthesia, I would always be ready to
submit suggestions and inputs to improve the editorial and publishing
processes, standards of publication and the visibility of the journal.
I wish the journal a successful launch and also congratulate the office
bearers of ISA, Madhya Pradesh, the Editor and the Editorial Board
members of the journal for their decision to have an academic mouthpiece to
ISA, MP state.
Long Live ISA!
n Dr. S Bala Bhaskar
It gives me immense pleasure in writing this message for the inaugural
issue of a new journal entitled” M.P.State Journal of Anaesthesia” published
by M.P.Chapter of Indian Society of Anaesthesiologists. I take this
opportunity to congratulate Dr. Meenu Chadha Hon Secretary, M.P.Chapter
of Indian Society Of Anesthesiologists for her solo efforts in presenting the
first issue of the journal.
I hope that this journal will provide a platform to promote research
through an intellectual exchange of ideas between the students,
researchers and academicians, and would go far beyond its regional and
national boundaries for dissemination of original and high quality research in
the field of Anaesthesiology, Pain and Critical Care.
n Dr. Dilip Kothari
DR. S. Bala Bhaskar
Editor-
Indian Journal of Anaesthesia
DR. Dilip Kothari
President
(M.P. Chapter-ISA)
President's Message

6
SPINAL ANAESTHESA: A SAFE OPTION IN
MULTIPLE DISEASE PATIENTS
Table A.1: List of Medication.
Tab Amlodepin 5 mg OD (Anti hypertensive)
Tab Telmisartan 20 mg OD (Anti hypertensive)
Tab. Clopidogrel 75 mg OD (Anti platelet aggregation)
Tab Aspirin 75mg OD (Anti platelet aggregation)
Tab Carvedilol 6.25 mg OD (â1, â2 and á1 receptor antagonist)
Tab Vildagliptin 50 mgOD (Oral antidiabetic )
Tab Metformin 500 mgOD (Oral antidiabetic )
Tab Voglibose 0.3 mgOD (Oral antidiabetic )
Tab Thyroxine 100 mg OD (Thyroid hormone)
Tab Trihexyphenidyl 2 mg BD (Antiparkinson drug)
Tab Torasemide 10 OD (Diuretic)
Tab Tamsulosin 0.4 mg OD (á1 receptor antagonist)
Inj Human Actrapid 12.12,10 units SC ( Soluble Insulin)
7
l 1 2 Dr. Dilip Kothari Dr. Bhanu Choudhary
ABSTRACT
Anesthetic management of geriatric
patients with multiple diseases like
Hypertension, Coronary artery disease,
Diabetes Mellitus, Hypothyroidism and so
many other is often difficult for surgical
procedures especially in emergency
situations due to various anatomical, patho-physiological
/ biochemical changes along
with polypharmacy . Spinal anesthesia is a
safe option in these patients due to simplicity,
reliability, cost effectiveness, minimal peri-operative
biochemical changes, stress
induced hemodynamic changes, rapid
recovery, better cognitive function,
oxygenation, superior analgesia and minimal
nausea & vomiting in post operative period.
INTRODUCTION
The worldwide prevalence
of Hypertension, Coronary
artery disease, Diabetes
mellitus are common due to
various etiological factors like
obesity, physical inactivity and
dietary habits.1-3 Subclinical
hypothyroidism is more
c o m m o n t h a n o v e r t
hypothyroidism, and its
prevalence ranges from 1 to
10%.4 Parkinsonism is another
commonly found disease in
elderly patients worldwide.5
Anesthesiologist often finds
difficulty in the anesthetic management of
such geriatric patients with multiple diseases
for surgical procedures especially in
emergency situations due to various
anatomical, patho-physiological /biochemical
changes and polypharmacy .
CASE
A 75 year old, male patient (82 kgs) with
obstructed right sided inguinal hernia was
admitted for hernioplasty in a nursing home.
The patient was suffering from multiple
diseases like DM II (10 years), Hypertension,
Coronary artery disease (5 years),
Hypothyroidism (5 years), Parkinson disease
(3 years),Chronic renal failure/Diabetic
Nephropathy (3 Years), Gout (2 years) with
Benign Prostatic enlargement (2 Years). For
these diseases he was taking different drugs.
1. MD Associate professor, Dep. of Anaesthesiology G.R. Medical College, Gwalior, M.P
2. MD Associate professor, Dep. of Anaesthesiology G.R. Medical College, Gwalior, M.P
Wish you all a very Happy 2015.
The best way to gain knowledge is to share it.
Bringing out a journal for our own state Madhya Pradesh has been a
thought that has been in our minds since a long time. This Journal would
give a platform our post graduates & Consultant Anesthetists to publish their
work. In the long run we would try to get the Journal registered & indexed if
possible. The contents of the Journal would also be posted on the M.P. State
web site www.mpisa.in.
Suggestions regarding future publications are invited during the
General Body Meeting at Gwalior on 9th November 2014.
“A good teacher can inspire hope, ignite the imagination & instill a love of
learning.''
n Dr. Meenu Chadha
DR. Meenu Chadha
Hon. Secretary & Editor
M.P. Chapter ISA
Message

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halothane and neuroleptics, post operative
shivering, nausea, vomiting and poor reflexes
can worsen the situation further. 20
In view of above facts and the possibility of
drug interactions with anesthetic drugs due to
polypharmacy we decided to manage this
case under spinal anesthesia which is well
known for its simplicity, reliability, cost
effectiveness, minimal peri-operative
biochemical, stress induced hemodynamic
changes, rapid recovery, better cognitive
function, oxygenation, superior analgesia and
minimal nausea & vomiting in post operative
period.21-22 Rodgers A et al23 in an overview
found decreased risk of post operative venous
thrombo-embolism, myocardial infarction,
bleeding complications, pneumonia,
respiratory depression, and renal failure with
neuraxial blocks. Our main concern was to
prevent sudden hemodynamic changes like
hypotension / hypertension, bradycardia /
tachycardia and fluctuation in blood glucose
levels along with rapid recovery. Since we
used only 2.0 ml of bupivacaine, no serious
alteration in these parameters was recorded.
Intra-operative blood glucose was maintained
around 150-160 mg% with non glucose
containing crystalloid fluids. The post
operative period was uneventful. One year
back his left side hernioplasty was done under
spinal anesthesia almost in similar conditions
and was uneventful too. Lumbar epidural
anesthesia was not considered as a patient
was taking aspirin and Clopidogrel for a long
time and these drugs are known to increase
the bleeding time due to synergistic action.[24]
The risk of hemorrhage is lowest in spinal
anesthesia, due to use of fine needles(25/26
SWG), and highest in epidural catheter
anesthesia, which requires larger needle
gauges(16/18SWG).25 -26
CONCLUSION
Spinal anesthesia due to its simplicity,
reliability, minimal systemic/ biochemical
effects and lesser chances of drug interactions
due to polypharmacy is a safe option in elderly
patients with multisystem diseases in contrast
to general anesthesia which could lead to high
morbidity and mortality especially in places
lacking such facilities. Not much literature is
available on the role of spinal anesthesia for
safe anesthetic practice in patients with
multisystem diseases, therefore multicenter
randomized controlled studies could be
conducted to obtain guidelines for the
management of such patients.
References:
1. Kearney PM, Whelton M, Reynolds K,
Munter P, Whelton PK, He J. Global burden
of hypertension: an analysis of worldwide
data. Lancet 2005; 365:217-23.
2. Roger VL, Go AS, Lloyd-Jones DM, Adams
RJ, Bery JD, Brown TM et al. American
Heart Association Statistics Committee
and Stroke Statistics Subcommittee Heart
disease and stroke statistics—2011
update: a report from the American Heart
Association. Circulation 2011;123:e18-
e209.
3. Haffner MS. Relationship of Metabolic Risk
F a c t o r s a n d D e v e l o pme n t o f
Cardiovascular Disease and Diabetes.
Obesity 2006 ;14: 121S–127S.
4. Karmisholt J, Andersen S, Laurberg P.
Variation in thyroid function tests in patients
with stable untreated subclinical
h y p o t h y r o i d i s m . T h y r o i d
2008;18:303–308.
5. Moghal S, Rajput AH, D'Arcy C, Rajput R.
Prevalence of movement disorders in
e l d e r l y c ommu n i t y r e s i d e n t s .
Neuroepidemiology 1994; 13: 175–8.
6. Malik AM, Khan A, Talpur KA, Laghari AA.
Factors influencing morbidity and mortality
in an elderly population undergoing
inguinal hernia surgery. J Pak Med Assoc
2010;60:45–7.
7. James MFM, Dyer RA, Rayner BL. A
modern look at hypertension and
(Table A.1) Patient revealed a past history of
treatment for acute renal failure about 2 years
back .On clinical examination patient was
comfortable with mild pain in inguinal region,
PR 66 / min, BP 180/104 mm of Hg, RR 22 /
min, had mild anemia and edema over both
legs. On admission his investigation reports
revealed : Hb 10.02 gm%, TLC 11000/cu mm,
DLC P 70,L25, M3 E 2, Platelet 100 000/cu
mm, , RBS 197 mg%, Blood Urea 66.3 mg%,
Serum Creatinine 2.34 mg%, Serum Na+
131.5 mEq/l, Serum K+ 5.2 mEq/L,
UrineSugar ++, Urine albumin ++, Serum Uric
acid 9.2 mg%, Serum Protein 4.8 gm%, Serum
TSH 6.107 μgm/ml ( done 6 months back)
The ECG showed ST, T changes in antero
lateral leads, ECHO showed normal LV size
and function.
X-ray Chest PA view showed no gross
anomaly.
Since on admission patient was
comfortable and showed no signs of
strangulation of hernia, the surgery was
deferred till the next day. Meanwhile Aspirin,
Clopidogrel and Oral hypoglycemic drugs
were stopped and the dose of insulin was
increased. The patient was kept nil orally for 6
hours except for Tab Amlodepin 5 mg, Tab
Telmisartan 20 mg, Tab Thyroxine 100 mcg
and Tab Trihexyphenidyl 2 mg were given with
25 ml of water orally at 5AM on the day of
surgery. After obtaining the detailed informed
consent in operation room we again checked
the FBS (190mg %), PR (90/Min), BP (170/100
mm of Hg), SpO2 (98%). After securing an
intravenous line with 0.9% NaCl, under all
aseptic condition the sub-arachnoid block
(SAB) was performed with 0.5 % Bupivacaine
2.5 ml to obtain a sensory block up to T8.
Monitoring of ECG, PR, BP, SpO2, UOP was
done till the end of surgery (55 min). No
e p i s o d e o f h y p o t e n s i o n ,
bradycardia/tachycardia (± 20% of base line)
was recorded. A total of 600 ml of non glucose
containing crystalloid (NS/RL) was infused
intravenously to maintain the vital signs.
DISCUSSION
Geriatric patients with multisystem disease
are at increased risk due to complex patho-physiological
changes along with polypharmacy
especially when general anesthesia is required.
A high morbidity and mortality has been reported
in geriatric patients especially in emergency
situations due to multi system disease.6
Presence of hypertension increases the risk
of myocardial infarction, heart failure, renal
failure and stroke.7 In hypertensive patients
increased hemodynamic responses during
laryngoscopy and intubation,8 peri-operative
hypotension and hypertension during general
anesthesia have been observed by many
investigators.9 These fluctuations have been
associated with a 20% or more increased risk of
coronary events, cerebral stroke and renal
failure.10 Due to various micro vascular and
macro vascular changes, diabetic patients are
at increased risk of painless myocardial
ischemia and infarction due to associated high
incidence of coronary artery disease,11-13 and
intra-operative instability.14 Difficult intubation,
undiagnosed reflux and delayed gastric
emptying associated with diabetes can
contribute to problems during general
anesthesia.11
Increased airway problems due to
obstructive sleep apnea, gastrointestinal
dysfunction, hypodynamic cardiovascular
system, decreased neuromuscular excitability,
increased response of narcotics, muscle
relaxants and inhalational agents and
hypothermia are the factors known to cause
additional problems during general anesthesia
in hypothyroid patients.15-19 Apart from various
cardio-respiratory and neurological problems,
potential anesthetic drug interactions are often
found in patients with Parkinson disease. Drugs
used in general anesthesia like fentanyl,

10
ANESTHETIC MANAGEMENT OF A
PATIENT WITH BECKER’S MUSCULAR
DYSTROPHY FOR ASD CLOSURE
l Dr. Sarika Katiyar, Dr. Saifullah Tipu,Dr. Rajnish Kumar Jain
11
anaesthesia. South Afr J Anaesth Analg
2011;1:168-73.
8. da Silva Neto WV, Azevedo GS, Coelho
FO, Netto EM, Ladeia AM. Evaluation of
hemodynamic variations duringanesthetic
induction in treated hypertensive patients.
Rev Bras Anestesiol 2008; 58: 330-41.
9. Balick Weber CC, Brillouet Banchereau
AC, Blanchet AD, Blanchet P, Safar ME,
Stephan F. General Anesthesia in
Hypertensive Patients: Impact of Pulse
Pressure but not Cardiac Diastolic
Dy s f u n c t i o n o n I n t r a o p e r a t i v e
Hemodynamic Instability. J Anesthe Clinic
Res 2011; 2:114.
10. Aronson S, Fonts ML. Hypertension: A new
look at an old problem. Curr Opin Anesth
2006; 19:59-64.
11. Vinik AI, Maser RE, Mitchell BD, Freeman
R. Diabetic autonomic neuropathy.
Diabetes Care 2003; 26:1553–79.
12. Rodriguez BL, Lau N, Burchfield CM,
Abbott RD, Sharp DS, Yano K, et al.
Glucose intolerance and 23-year risk of
coronary heart disease and total mortality.
The Honolulu Heart Program. Diabetes
Care. 1999; 22:1262-5.
13. Ziegler D Cardiovascular autonomic
neuropathy: clinical manifestations and
measurement. Diabetes Reviews
1999;7:342–57.
14. Knuttgen D, Buttner-Belz U, Gernot A,
Doehn M. Unstable blood pressure during
anesthesia in diabetic patients with
autonomic neuropathy. Anasth Intensivther
Notfallmed 1990 . 25:256–62.
15. Rajagopal RK, Abbrecht PH, Derderian
SS,Pickett C, Hofeldt F, Tellis CJ,et al.
Obsructive sleep apnea in hypothroisim.
Ann Intern Med 1984;101:491-4.
16. Yaylali O, Kirac S, Yilmaz M, Akin F, Yuksel
D, Demirkan N, et al. Does hypothyroidism
af fec t gas t rointes t inal mot i l i t y?
Gastroenterol Res Pract. 2009;52:9802.
17. Klein I, Danzi S. Thyroid disease and the
heart. Circulation 2007;116:1725-1735.
18. Kim JM, Hackman L. Anesthesia for
untreated hypothyroidism: Report of three
cases. Anesth Analg 1977;52:299–302.
19. Stathatos N, Wartofsky L. perioperative
ma n a g eme n t o f p a t i e n t s w i t h
hypothyroidism. Endocrinol Metab Clin N
Am 2003;32:503-18.
20. Nicholson G, Pereira AC, Hall GM.
Parkinson's disease and anaesthesia. Br J
Anaesth 2002;89:904-16
21. Handley GH, Silbert BS, Mooney PH,
Schwitzer SA, Aleen NB. Combined general
and epidural anaesthesia versus general
anaesthesia for major abdominal surgery:
post anaesthesia recovery characteristics.
Reg Anesth 1997;22;:435-41.
22. McKenzie P J, Wishart HY, Dewar KMS,
Gray I , Smith G. Comparison of the effects
of spinal anaesthesia and general
anaesthesia on postoperative oxygenation
andperioperative mortality. Br J Anaesth
1980; 52: 49-53.
23. Rodgers A, Walker N, Schug S, McKee A,
Kehlet H, van Zundert A, et al. Reduction of
postoperative mortality and morbidity with
epidural or spinal anaesthesia: Results from
overview of randomised trials. BM J
2000;321:1493–7.
24. Tam NLK , Pac-Soo C, Pretorius PM.
Epidural haematoma after a combined
spinal–epidural anaesthetic in a patient
treated with clopidogrel and dalteparin. Br J
Anaesth 2006; 96: 262-5.
25. Gogarten W, Vandermeulen E, Van Aken H,
Kozek S, Llau J, Samama C. Regional
Anesthesia and Antithrombotic/Antiplatelet
Drugs Recommendations of the European
Society of Anaesthesiology. Eur J
Anaesthesiol 2010;12:999–1015.
26. Vandermeulen EP, Van Aken H, Vermylen J.
Anticoagulants and Spinal-Epidural
Anesthesia. Anesth Analg 1994;79:1165-77.
Abstract: Becker's Muscular Dystrophy is
considered to be a milder form of Duchenne's
muscular dystrophy, as both are caused by
mutations in the dystrophin gene and thus
present with almost the same manifestations.
We present the case of a patient with Becker's
Muscular Dystrophy who underwent ASD
(Atrial Septal Defect) closure and discuss the
anaesthetic issues that are associated with
such a condition.
Key Words: Becker's Muscular Dystrophy,
Hyperkalemia, Rhabdomyolysis,
Case Report: A 36 kg 15 year old boy
presented for surgical closure of an osteum
secundum type ASD. He was being treated
for hypothyroidism with 50 microgram per day
of Thyroxine. At the age of 8 years he had
presented with LMN weakness in the left leg
and was diagnosed as a case of Becker's
Muscular Dystrophy. There was no family
history of congenital heart disease, early
deaths or anesthesia related problems.
Pulmonary Function Tests were done prior to
surgery which showed moderate restrictive
lung disease. He had no other co morbidity
and all his preoperative investigations were
n o rma l e x c e p t C P K ( C r e a t i n i n e
Phosphokinase) of 1700U/L and an ECG
which showed RBBB (Right Bundle Branch
Block).
The patient was premedicated with Inj.
Midazolam 3 mg intravenous and anaesthesia
was induced with Inj. Morphine 10 mg
intravenous and Inj. Thiopentone 200 mg
intravenous. Neuromuscular blockade was
achieved with 30 mg of Atracurium intravenous
and trachea was intubated with an 8 mm ID
endotracheal tube. Anaesthesia was
maintained with Fentanyl infusion of 100
mcg/hr intravenously and Propofol infusion
(15ml-35ml/hr) intravenously to keep the
patient at a BIS level of less than 60. In
addition, intraarterial BP (Blood Pressure),
CVP (Ce n t r a l Ve n o u s Pr e s s u r e ) ,
nasopharyngeal temperature, neuromuscular
transmission and urine output monitoring was
carried out during the procedure. Intra
operative antibiotic was restricted to Inj.
Cefuroxime 1.5 Gm IV. Amikacin was avoided.
Total CPB (Cardiopulmonary Bypass) and
cross clamp times were 37 min and 20 minutes
respectively. During CPB care was taken to
a v o i d h y p e r t h e rmi a a c i d o s i s a n d
hyperkalemia. Serum potassium levels were
maintained between 3.2-3.7 meq/l and hourly
serum potassium levels were checked to rule
out rhabdomyolysis. Urine output was
adequate throughout the procedure. Patient
came off bypass smoothly. Drugs
supplemented during and after CPB were
Propofol and Morphine along with small
a l i q u o t s o f At r a c u r i um b a s e d o n
neuromuscular monitoring. In the ICU patient
was extubated an hour later following
spontaneous reversal of neuromuscular
1. Department of Anesthesiology and Critical care,
BMH & Research center, Bhopal

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blockade and kept on noninvasive ventilation
for the next 3 hours. Postoperative analgesia
was maintained with Fentanyl boluses of 25-
50mcg intravenously. On the second
postoperative day CPK levels were 2763 U/l.
Patient stood the procedure well, had a trouble
free recovery and was safely discharged home
on the seventh postoperative day. A letter of
caution was issued to the patient detailing his
condition and the precautions which should be
taken in case of future anaesthetics. A copy of
the letter was kept in the patients hospital
records and the issue highlighted on its cover
for future safety.
Discussion: Becker's Muscular Dystrophy
(BMD) is an X-linked recessive inherited
disorder. It affects 1 in 30000 live male births.
Some people with BMD's are able to walk well
into adulthood. BMD therefore may not be
diagnosed until after adolescence. Clinically it
presents with muscle weakness, muscle
deformities, psuedohypertrophy of calf
muscles and unusual walking gait. A history of
motor delay in the developmental milestones
of children should be thoroughly investigated
as part of the preoperative evaluation. A blood
test may demonstrate higher than normal
levels of CPK. If CPK levels are increased,
elective surgery should be delayed until
specific tests are carried out. There may be
involvement of respiratory muscles with
deterioration of respiratory function and later
patient may develop kyphoscoliosis. A
preoperative respiratory evaluation including
pulmonary function tests would give an
indication of the severity of the problem and
also provide a base line for further
assessments postoperatively or for later in life.
Ra r e l y, h e a r t p r o b l ems , s u c h a s
cardiomyopathy will occur as the disease
progresses and some BMD children may
develop intellectual problems or learning
difficulties. DNA studies , muscle biopsy are
required to confirm the diagnosis.
Many case reports with alarming cardiac
arrests in children undergoing anesthesia in
1980's were found to be related to the use of
Succinylcholine or volatile anaesthetic agents
in patients with undiagnosed myopathies.1
More recently, Sevofluorane has also been
shown to be associated with rhabdomyolysis in
patients with Duchenne's Muscular Dystrophy.2
This is due to acute rhabdomyolysis and
hyperkalemia that can occur after the use of
volatile anesthetics and depolarizing muscle
relaxants in muscular dystrophy. On this basis
some authors advocate the routine avoidance
of these drugs.
The defect in dystrophies such as Becker's
muscular dystrophy is in the membrane
stabilizing protein Dystrophin. This protein is
present in the post synaptic nicotinic receptors
of muscles but its function has not been clearly
delineated. Although unproven, these case
reports lead to the speculation that defective
Dystrophin destabilizes the cell membrane and
the additive effect of another destabilizing
agent, a volatile anesthetic agent or a
depolarizing muscle relaxant, could predispose
these pat ients to mi ld to severe
rhabdomyolysis leading to hyperkalemia and
on rare occasions, death. Rhabdomyolysis may
lead to post operative acute kidney injury which
has its own morbidity and mortality.
Aminoglycoside antibiotics are known to
prolong the action of Non depolarizing muscle
relaxants and thus we avoided their use. Short
acting drugs like Fentanyl and spontaneously
lysing drugs like Remifentanil, Atracurium or
Mivacurium would avoid the problems of
accumulation and prolonged effect in such an
eventuality. Spontaneous reversal of
neuromuscular blockade may also avoid the
possibility of hyperkalemia which may be
triggered off by reversal with neostigmine.3 The
fact that these events occur in awake recovering
children also suggests that the dose of volatile
agents required may be minimal and at levels
less than MAC awake for volatile agents.
Alternatively, destabilization may have occurred
earlier during the anaesthetic when drug
concentrations were higher. The precipitating
event could be movement during recovery
which may simply be the trigger. There are no
known reports of any such problem with the
use of intravenous anaesthetics or even local
anaesthetic agents.4 Muscular dystrophies
thus make a good indication for the use of
TIVA(Total Intravenous Anesthesia), local,
regional or neuraxial techniques.
We therefore resorted to total intravenous
anesthesia (TIVA) with Propofol and Fentanyl.
Ordinary syringe pumps were used for this
purpose. BIS monitoring was used during the
anesthetic to guide the rate of administration
of Propofol.
Cardiopulmonary Bypass can also trigger
rhabdomyolysis.5 In our case though, total
bypass time was short and patient was
minimally cooled. To be cautious we monitored
potassium levels hourly and checked the urine
myoglobin and CPK levels postoperatively.
Our patient had moderate restrictive lung
disease as demonstrated by preoperative
pulmonary function tests. We therefore
extubated onto non invasive ventilation and
used it to gradually wean him off from
ventilatory support. Incentive Spirometry was
advised thereafter. It is generally this phase
where many patients who have had a safe
anaesthetic land into trouble and develop
respiratory failure.
These patients are generally on chronic
steroid therapy which may lead to obesity,
glucose intolerance, osteoporosis and may
require stress doses during surgery. Our
patient though, had no history of steroid
therapy.
In summary, careful history can alert an
astute anesthesiologist towards the possibility
of a muscular dystrophy. Serum CPK levels
have a high negative predictive value for these
conditions. Preoperative workup should
include pulmonary function testing. Total
intravenous anesthesia (TIVA) with propofol is
a safe option as it avoids the use of volatile
anesthetic agents. Atracurium not just avoids
the use of Succinylcholine but is preferred
over other nondepolarisers because its
spontaneous reversal obviates the use of
neostigmine and does not carry the risk of
accumulation if a patient were to go into renal
failure from rhabdomyolysis. Prompt
recognition and management of hyperkalemia
is paramount for a successful outcome.
Written information to the patient and
recording of the problem prominently in the
case notes may avoid future anesthetic
mishaps.
References:
1. Poole TC, Lim TYJ , Buck J et al. Perioperative
cardiac arrest in a patient with previously
undiagnosed Becker's Muscular Dystrophy
after isofluorane anesthesia for elective
surgery. British Journal of Anesthesia;
2010;104(4):487-9.
2. Obata R, Yasumi Y, Suzuki A, et al.
Rhabdomyolysis in association with
Duchenne's muscular dystrophy. Canadian
Journal of Anesthesia 1999; 46:564-6.
3. Buzello W, Krieg N, Schlickwei A. Hazards of
neostigmine inpatients with neuromuscular
disease: report of two cases. British Journal of
Anesthesia; 1982:54:529-532.
4. Birnkrant DJ, Panitch HB, Benditt JO, Boitano
LJ, Carter ER, Cwik VA et al. American College
of Chest physicians Consensus statement on
respiratory and related management of
patients with Duchenne Muscular Dystrophy
undergoing anesthesia or sedation. Chest
2007:132:1977-1986
5. Maccario M, Fumagalli C, Dottori V et al. The
association between rhabdomyolysis and
acute renal failure in patients undergoing
cardiopulmonary bypass. Journal of
Cardiovascular Surgery.1996:37:153-159.

14
15
POSTOPERATIVE NAUSEA
AND VOMITING
l 1 Dr. Jitendra Agrawal, Dr. Bhanu Choudhary, Dr. Dilip Kothari
espite having the better understanding
knowledge about the pathophysiology of Dnausea and vomiting and use of more stable
and effective anti-emetics like ondansetron,
granisetron, the postoperative nausea /
vomiting (PONV) continues to be the most
disturbing complication following surgery and
anaesthesia.1 The negative impact of PONV
on patient's physical, metabolic and
psychological condition not only delays
discharge from or cause re-admission to
hospital but also decreases the confidence
level in future surgery and anaesthesia.1
PONV is considered by some patients to be
even worse than postop pain. While the
incidence of postoperative nausea and
vomiting (PONV) varies considerablyin both
the inpatient and outpatient setting, 2-5
studies indicatethat the incidence of nausea
ranges from 22% to 38%6and the incidence of
vomiting ranges from 12% to 26%.6
Definitions
Nausea: It is an unpleasant sensation
referred to a desire to vomit, not associated
with expulsive muscular movement.
Retching: When no stomach contents are
expelled even with expulsive muscular efforts.
Vomiting:It is the forceful expulsion of even
a small amount of upper gastrointestinal
contentsthrough mouth.
Physiology of nausea and Vomiting
There are three major components of vomit
1. Department of Anaesthesia
GRMC Gwalior
reflexemetic detectors, integrative mechanism
and motor output .
The main sensors of somatic stimuli are
located in the gut and chemo-receptor trigger
zone (CTZ). The emetic stimuli in gut are
detected by two types of vagal afferent fibers.
(a) Mechanoreceptors:They are located
in the muscular wall of the gut and are
activated by contraction and distension of the
gut, on physical damage and manipulation
during surgery. Distension of the proximal gut
may induce vomiting such as in overeating.
(b) Chemoreceptors: They are located
in the mucosa of the upper gut and sensitive to
noxious chemical stimuli. CTZ (chemoreceptor
trigger zone) lies withinthe portion of brain
stem. The area postrema is able todetect the
circulating toxins in the CSF and activates
thevomiting centre in the medulla. Afferent
impulses fromother areas can also influence
the vomiting centre (Vestibularlabyrinthine e.g.
morning sickness, input from higher
centresuch as limbic system and visual
cortex). Vestibular cardiacafferent may induce
nausea and vomiting as in MI.
The vomiting centre in medulla oblongata is
inthe close proximity to other visceral centres
like the respiratory and vasomotor centres.
Four types of receptorsare involved
cholinergic, dopaminergic, histaminic
andserotonergic.
Integrative mechanism: It is a motor
CME & WORKSHOP - 2009 programmeinvolving coordination between
many physiological systemsand autonomic
and somatic components of the nervous
system. These occur in brain stem.
The motor component of vomiting reflex is
mediatedby both autonomic and somatic
senses, and is coordinatedby the vomiting
system in the brainstem. The vagal motor
neurons supplying the gut and the heart
originate in dorsalmotor vagal nucleus and
nucleus ambiguous. The dorsal and ventral
respiratory groups regulating phrenic
nerveoutput from the cervical spine, located in
the brainstem,are parasympathetic neurons
(which also maintain sympathetic tone to heart
and blood vessels). The output of these nuclei
is coordinated to produce the physiological
pattern associated with vomiting.
The vomiting reflex is divided into two
phases.
1. Pre-eject ion phase: This is
characterized by a sensation of nausea
associated with cold, sweating, pupil dilatation,
salivation and tachycardia mediated
bysympathetic and parasympathetic nerves.
2. Ejection phase: This comprises of
retching and vomiting with expulsion of gastric
contents.
Causes of vomiting
1. Pharyngeal stimulation.
2. Gastrointestinal distension.
3. Abdominal surgery.
4. Anaesthetic agents.
5. Pain.
6. Opioid medication.
7. Hypoxia.
8. Hypertension.
9. Vestibular
RISK FACTORS
PONV is supposed to be multifactorial in
origin, involving anaesthetic, surgical, and
individual risk factors. Apfel and colleagues7
identified four risk factors that form the basis
for the Apfel scoring system: female gender,
history of PONV/motion sickness, non-smoking
status, and use of postoperative
opioids. Each risk factor increases the
likelihood of PONV by ~18–22%7. Although
Apfel defined the risk criteria with the largest
impact on PONV, multiple other risk factors
have been identified. These can be broadly
divided into three categories: patient risk
factors, anaesthetic technique, and surgical
procedure.Only some of these factors can be
influenced by the anaesthetist (Table I).
Factors not under the control of the
anaesthetist
There are so many factors which affect the
incidence of PONV include age, sex, history of
previous PONV or motion sickness, smoking,
surgical procedure, duration of surgery and
anaesthesia, and patient and parental anxiety.
Sinclair et al reported that the incidence of
PONV decreased after age of 50 years. Age
decreased the likelihood of PONV by 13% for
each 10-year increase8. In patients between
18-49 years, the incidence of PONV was 24%,
and the incidence decreased to 6% among
patients from 49-79 years.9
Women have three times the risk for
PONVcompared to men9. This gender
difference has beenattributed to variations in
serum gonadotropin or other hormone
levels10.
History of previous PONV or motion
sickness is a strong predictor and increases
the risk for PONV by two to three times.
Smoking is associated with a decreased
risk forPONV. The relative risk for PONV in
smokers is0.6. Sinclair et al reported that
smoking decreased the likelihood of PONV by
34%. Preoperative factors like food, anxiety
and premedication also has a role in PONV.

2) Sex
3) History of previous PONV or motion
sickness
4) Smoking
5) Surgical procedure
6) Duration of surgery and anaesthesia
7) Patient and parental anxiety
Factors under the control of the
anaesthetist
1) Premedication
2) Type of anaesthesia
3) Intraoperative anaesthetic drugs
(a) Nitrous oxide
(b) Intravenous agents
(c) Inhalation agents
(d) Antagonists of non-depolarising
neuromuscular blocking drugs
4) Postoperative management
(a) Pain management
(i) Local anaesthetics
(ii) NSAIDs
(iii) Opioids
(b) Movement
(c) Oral intake
( d ) N o n - p h a rma c o l o g i c a l –
acupressure/acupuncture
5) Antiemetic drugs
6) Other factors – hypovolemia, gastric
distension
ANTIEMETIC DRUGS
There are at least four major receptor
systems involvedin the aetiology of PONV.
Currently, available antiemeticsmay act at the
cholinergic (muscarinic), dopaminergic(D2),
histaminergic (H1), or serotonergic (5HT3)
receptors.Neurokinin-1(NK-1) receptor
16 17
antagonists are also beinginvestigated.
Cholinergic receptors are found in the
vomitingcenter and vestibular nuclei. The area
postrema is rich indopamine (D2), opioid, and
serotonin (5HT3) receptors. Thenucleus
tractus solitaries is rich in enkephalins and in
histaminic(H1), muscarinic cholinergic, and
NK-1 receptors. The latter are also found in the
dorsal motor nucleus of thevagus nerve.
Butyrophenones
Droperidol is the only commonly used
butyrophenonefor its antiemetic action. It is a
heterocyclic neurolepticwhich inhibits
d o p a m i n e r g i c r e c e p t o r s i n t h e
chemoreceptor t r igger zone of the
medulla.Droperidol in small doses (e.g. 0.625
mg) is highly effective in adults and has
minimal side-effects.Droperidol, in doses as
low as 0.625 or 1.25 mg has been shown to be
as effective as ondansetron 4 mg without
increasing sedation, agitation, anxiety or
delaying discharge.
Benzamides
Metoclopramide is the most effective
antiemetic ofthis class and has been used for
almost 40 years. Its antiemetic effect results
fromantagonism of dopamine's effects in the
chemoreceptortrigger zone. At high doses, it
also antagonises 5-HT3receptors. Additional
antiemetic effects are dueto its dopaminergic
and cholinergic actions on thegastrointestinal
t r a c t w i t h i n c r e a s e s i n l o w e r
esophagealsphincter tone and facilitation of
gastric emptyinginto the small intestine. These
latter effects reverse thegastric immobility and
cephaled peristalsis thataccompany the
vomiting reflex. Opioid-induced PONVcan be
treated with metoclopramide because it
reversesthe gastric stasis induced by
morphine. There wasno evidence of dose-responsiveness,
with the bestdocumented
regimen in adults being intravenous(i.v.) 10 mg
and in children i.v. 0.25 mg/kg. Side
effectsinclude abdominal cramping, sedation,
Some surgeries eg. plastic (breast
augmentation), ophthalmologic (strabismus
repai r ) , ENT-dental , gynaecologic,
laparascopic(sterilisation), genitourinary,
orthopaedic surgery(shoulder procedures),
mastectomies and lumpectomies are
associated with higher incidence of PONVthan
others.With increasing duration of surgery and
anaesthesia,the risk of PONV increases
possibly because of greateraccumulation of
emetogenic anaesthetic agents.The incidence
of PONV increases from 2.8% in patientswith a
surgical duration of less than 30 minutesto
27.7% in patients with a surgical duration of
between151 to 180 minutes. The duration of
anaesthesiaincreases the risk for PONV by
59% for each 30 minute increase8.
Factors under the control of the
anaesthetist
Factors such as premedication, type of
anaesthesia, intraoperative anaesthetic
drugs, postoperative management and
antiemetic drugs can affect the incidence of
PONV.
Premedication
Atropine delays gastric emptying and
lowers the esophageal tone, opioids like
morphine andpethidine increase gastric
secretion, decrease GImotility delay gastric
emptying increases the risk of PONV.The a2
agonist clonidine can reduce PONV in children
after strabismus repair.
Type of anaesthesia
When possible, regional anaesthetic
should be given as patients receiving general
anaesthesia are more likely to experience11
foldincreased risk of PONV monitored
anaesthetic care8.When general anaesthetic
is required, the use ofpropofol as the induction
agent is effectivein reducing early PONV
incidence when comparedwith thiopentone12
and other induction agents13.Nitrous oxide
omission reduces incidence of vomitting14,
keeping in mind that omission may increase the
risk of intraoperative awareness.Ether and
cyclopropanecause a higher incidence of
PONV due tocatecholamines. Sevoflurane,
enflurane, Desflurane and halothane are
associated with lesser degree ofPONV.It is
commonly thought thatneostigmine,reversal of
non-depolarizing is associated with increased
PONV due to the muscarinic actions on
thegastrointestinal tract. It is interesting then
that someauthors reported no significant
difference in PONVbetween those who
received a reversal agent and those who did
not.
Postoperative factors
Pain can increase the incidence of
PONV15by prolonginggastric emptying time
resulting in nausea andvomiting.Opioids are
often used to treat postoperativepain. However,
the use of postoperative opioids canincrease
PONV.Balanced analgesiausing combinations
of systemic opioids, regionalnerve blocks, local
anaesthetic, and other forms ofanalgesia like
n o n - s t e r o i d a l a n t i - i n f l a m m a t o r y
drugs(NSAIDS) can be used to manage pain
and reducethe incidence of opioid-related
PONV16.Regional anaesthesia can be used as
the soleanaesthetic or as a supplement to
general anaesthesia to reduce PONV.
Postoperative hypovolemia can result in
orthostatichypotension, dehydration and
dizziness, all of whichcan increase PONV.
Appropriate intraoperative fluid administration
h a s b e e n r e p o r t e d t o r e d u c e
postoperativenausea and vomiting following
ambulatory surgery.
Gastric distension, early ambulation and
postoperative oral intake affect PONV as well.
Table I. Factors affecting the incidence of
postoperative nausea and Vomiting11.
Factors not under the control of the
anaesthetist
1) Age

18
19
dizziness, andrarely dystonic extrapyramidal
reactions (oculogyriccrises, opisthotonus,
trismus, torticollis), and cardiacdysrhythmias.
Metoclopramide has been shown notto be as
effective as ondansetron and droperidol
inpreventing postoperative vomiting in a meta-analysis17.
Histamine Receptor Antagonists
The most commonly used drug is
dimenhydrinate.Intravenousdimenhydrinate
2 0 mg d e c r e a s e s v omi t i n g a f t e r
outpatientsurgery in adults. In children, i.v.
dimenhydrinate0.5 mg/kg significantly
decreases the incidence ofvomiting after
strabismus surgery and is not associatedwith
prolonged sedation.
Muscarinic Receptor Antagonists
Scopolamine blocks transmission of
impulses to the medulla arising from
overstimulation of the vestibular apparatus.
Application of a scopolamine patchbefore the
induction of anesthesia protects against PONV
after middle ear surgerythat is likely to alter the
function of the vestibular apparatus.
5-HT3 Receptor Antagonists
Ondansetron, granisetron, dolasetron,
tropisetron, palonosetron andother serotonin
antagoni s t s have been shown to
provideeffective treatment and prophylaxis of
PONV and are associatedwith a low incidence
of side effects. These agents arenot
dopamine,muscarinic, or histamine receptor
antagonistsand, as such, are not associated
with the side effects commonto those classes.
Side effects common to the serotonin
a n t a g o n i s t s i n c l u d e h e a d a c h e ,
l i g h t h e a d e d n e s s , d i z z i n e s s , a n d
constipation.They are highly effective in the
preventionand treatment of postoperative
nausea and vomiting.They are not effective in
the treatment of motion induced nausea and
vomiting.
Ondansetron
Ondansetronwas the firstdrug of this class
to become available for clinical use in1991.It is
a carbazalone derivative that isstructurally
related to serotonin and possesses specific5-
HT3 subtype receptor antagonist properties,
withoutaltering dopamine, histamine,
adrenergic, or cholinergic receptor activity.The
usual clinical doses of ondansetron is 4 to 8
mg.for the treatment of established PONV,
Tramèret al concluded that there were no
differences in the effectiveness of 4, or 8 mg
ondansetron when usedfor rescue from PONV
in the PACU.
Granisetron
Granisetron is a more selective 5-HT3
receptorantagonist than ondansetron. An i.v.
dose as low as0.04 mg/kg is effective in the
prevention of PONV.The elimination half-life of
granisetron (nine hours) is2.5 times longer
than that of ondansetron and thusmay require
less frequent dosing. The high cost
ofgranisetron may limit its clinical application.
Dolasetron
Dolasetron is a highly potent and selective
5-HT3receptor antagonist. The optimal dose
for prophylaxisis 50 mg if given at induction of
anaesthesia.Established PONV is effectively
ameliorated by IVdolasetron 12.5 mg. After its
administration,dolasetron is rapidly
metabolised to hydrodolasetron,which is
r e s p o n s i b l e f o r t h e a n t i eme t i c
effect.Hydrodolasetron has an elimination
half-life ofapproximately eight hours and is 100
times more potentas a serotonin antagonist
than the parent compound.
Tropisetron
Tropisetron is an indoleacetic acid ester of
tropine thatpossesses 5-HT3 receptor
antagonist activity. Intravenoustropisetron 2
mg in adults or 0.1 mg/kg in children may be
effective against PONV. It has a longer half-lifethan
ondansetron but whether this
translates to a clinicaladvantage remains
unclear.
Palonosetron
Palonosetron is a second generation 5-
HT3 receptor antagonist with longer half-life
and higher receptor binding affinity than
Ondansetron.Palonosetron was initially
approved for prophylaxis of nauseaand
vomiting in cancer patients, as it improves
theprevention of chemotherapy induced
nausea andvomiting and proved superior to
ondansetron in thesepatients.Because of its
unique chemical structure, greater binding
affinity with additional allosteric site binding
property and a substantially longer half-life of
almost 40 hours made palonosetron suitable
for its use in prevention of PONV1.It is given as
a single dose of 0.25 mg IV dose be
administered over 30 seconds. Maximum dose
0.75 mg
NK1 receptor antagonists
Aprepitant , a novel NK-1 receptor
antagonist ,the first of this class, has been
approved by the FDA for the prevention of both
acute and delayed chemotherapy-induced
nausea and vomiting (CINV).The dose of
aprepitant for PONV prophylaxis is 40
Table 2. Prophylactic doses and timing for the administration ofantemetics
Drug Dose Timing Adverse effects
Ondansetron 4-8 mg IV30 At end of Surgery31 Headache, lightheadedness, elevated liver enzymes
Dolasetron 12.5 mg IV32 At end of Surgery32 Headache, lightheadedness, elevated liver enzymes
Granisertron 0.35-1 Mg IV33-35 At end of Surgery33,35 Headache, lightheadedness, elevated liver enzymes
Tropisetron 5 mg IV 36-37 At end of Surgery36-37 Headache, lightheadedness, elevated liver enzymes
Dexamethasone 5-10 mg IV38-40 Before induction41 Vaginal itching or anal irritation with IV bolus
Droperidol 0.625-1.25 mg IV36-37 At end of Surgery42 Sedation, dizziness, anxiety, hypotension, EPS
Dimenhydrinate 1-2mg/kg IV43 Sedation, dry mouth, blurred vision, dizziness, urinary retention
Prochlorperazine 5-10mg IV44 At end of surgery44 Sedation, hypotension, EPS
Promethazine 12.5-25 mg IV44 At end of surgery44 Sedation, hypotension, EPS
Scopolamine Transdermal patch4546 Prior evening or 4 hours Sedation dry mouth, visual disturbances; CNS effects in elderly
before end of surgery patients, renal or hepatic impairment sedation, hypotension,
EPS
Metoclopramide 25 or 50 mg IV for Sedation, hypotension, EPS
Prophylaxis47
Diclectin 10 mg doxylamine Before induction
Succinate and 10 mg Prior evening 2 tablets
Pyridoxine Before induction,
hydrochloride moming of
surgery, 1 tablet
After surgery, 1 tablet
Aprepitant 40 mg PO 1-3 hours prior to Headache, fatigue, dizziness elevated liver enzymes
induction of
anaesthesia

20
21
mgadministered 3 hours or less prior to
surgery. Aprepitanteffectively diminishes post-operative
nausea and vomitingwhile
increasing analgesic tolerance in laparoscopic
gynecological procedures.18It appears
c o n c e i v a b l e t h a t a t l e a s t i n
certaincircumstances NK-1 receptor
antagonists and 5-HT3 antagonists may be
somewhat synergistic.
Other Drugs
Dexamethasone has antiemetic effects
that are reportedly comparable with
conventional antiemetic agents. Antiemetic
efficacy is better when it is used in combination
with another antiemetic drug than when it is
used as the sole agent.
Combination Drug Therapy
Despite the many drugs available for
PONV, there is no single drug that can claim to
be the definitive treatment of this
problem.Combination drugtherapy could do as
due to different mechanisms of action,
combination of drug should be more effective
than single drugs alone ininhibiting the
complex emetic reflex.
The combination ofdexamethasone with a
serotonin receptor antagonistdroperidol with
ondansetron has been reported to bemore
effective than either drug alone in
preventingPONV.Other combinations like
ondansetron and cyclizine, ondansetron and
p r o m e t h a z i n e , d r o p e r i d o l a n d
metoclopramide,dimenhydrinate and
metoclopramide, dimenhydrinateand
droperidol, have been tried with varying
efficacyin preventing PONV.
NON-PHARMACOLOGIC METHODS
T h e s e i n c l u d e a c u p u n c t u r e ,
electroacupuncture, transcutaneouselectrical
nerve stimulation, acupoint stimulation,
andacupressure. Lee and Done, in their meta-analysis,
showed that nonpharmacologic
techniques wereequivalent to commonly used
antiemetic drugs inpreventing PONV in adults
but not in children.19Supplemental oxygen has
also been shown to have aprotective effect
against PONV.20 The cost of newerantiemetic
drugs and their possible side effects
maywarrant renewed interest and research in
this area.
SUMMARY
PONV is one of the commonest complaints
following anaesthesia, and can result in
morbidity like wound dehiscence, bleeding,
pulmonary aspiration of gastric contents, fluid
and electrolyte disturbances, delayed hospital
discharge, unexpected hospital admission, and
decreased patient satisfaction. Despite the vast
amount of research done in this field and the
variety of antiemetic drugs available, PONV still
has a high incidence. Knowledge of the risk
factors of PONV can assist the anaesthetist in
the judicious use of pharmacotherapy to
ameliorate this problem, especially in the high-risk
patient. The management of PONV requires
a multi-modal approach which can include the
use of less emetogenic anaesthetic techniques,
balanced analgesia, appropriate intravenous
hydration, the use of pharmacotherapy and
possibly nonpharmacologic methods.
References
1. Shadangi BK, Agrawal J, Pandey R, Kumar A,
Jain S. Mittal R and Chorasia. A prospective,
randomized, double-blind, comparative study
of the efficacy of intravenous ondansetron
and palonosetron for prevention of
postoperative nausea and vomiting. Anaesth
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2. Apfel CC, Kranke P, Katz MH, et al. Volatile
anaesthetics may be the main cause of early
but not delayed postoperative vomiting: a
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CH, Wu CT. A lethal pulmonary embolism
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18. Kakuta N, Tsutsumi YM, Horikawa YT, et al.
Neurokinin-1 receptor antagonism,
aprepitant,effectively diminishes post-operative
nausea and vomiting while
increasing analgesic tolerance in
laparoscopic gynecological procedures. J
Med Invest 2011; 58:246-51.
19. L e e A , D o n e ML . T h e u s e o f
nonpharmacologic techniques to prevent
postoperative nausea and vomiting: A meta-analysis.
AnesthAnalg 1999; 88:1362-9.
20. Greif R, Laciny S, Rapf B, Hickle RS, Sessler
DI. Supplemental oxygen reduces the
incidence of postoperative nausea and
vomiting. Anesthesiology 1999; 91:1246-52.

MALIGNANT PDPH - A CASE REPORT
l 1 2 3 4 Dr. Hiren Shah, Dr. Harsha Desai Phulambrikar, Dr. Renuka Gupta, Dr. Seema Khandelwal,
22
23
27 year old female, Primigravida, 37
weeks pregnancy with gestational Adiabetes mellitus, presented with history of
leaking since 1day, for emergency LSCS and
Mcdonald Stitch removal.
Her Pre op sugar was 55mg%, for which
she was given dextrose 25%, 50ml. She was
on regular Insulin 6u and 4 u BD.
A male child of weight 2.99 kg delivered
uneventfully.Baby CIAB with normal Apgar
scores, shifted to nursery.
Post op, Patient was shifted to ward with
pulse 52 pm, BP108/60, RBS118 and sp02
100%.
Patient previous history included H/o
migrainous attacks with photophobia since
childhood days.She had no other positive
medical history. Her sugar levels were
normalised after delivery.
On Day 1 - Post operatively her vitals were
normal and liquids were started.
On Day 2 - She complained of headache, for
which treatment on line of PDPH was started,
which included , I/M Dexona, Plenty of fluids and
Deriphyline retard tablet, NSAIDS and Antax
0.5mg symptoms gradually improved.
On day 4 - Her discharge was planned but
she complained of severe cervical pain and
nausea. Pain relieved by fentanyl injection.
On day 5 - Headache persisted and she
had an episode of vomiting. Her BP was
Indeed, lumbar puncture to diagnose SAH
is indicated in the scenario of a negative CT
scan when the clinical suspicion is high, or in
centres which lack facilities for radiological
detection of SAH.
Intracerebral haemorrhage and SAH
following subarachnoid block have been
reported in the literature, but this appears to be
a rare event and the pathophysiology is
unclear.
To avoid the occurrence of an inadvertent
dural puncture, an epidural technique was not
selected because of the longer time of onset,
relatively lower density of sensory blockade
and increased risk of significant CSF leak or
Post-Dural Puncture Headache (PDPH).
A possible problem of a spinal block is the
potential for sudden hypotension, which can
not only compromise uterine perfusion, but
also precipitate nausea and vomiting, which
can aggravate raised ICT, this was prevented
by maintaining a narrow blood pressure margin
with the use of small boluses of phenylephrine.
Patients with peripartum SAH generally
present with headache.This can potentially
confound diagnoses more commonly
associated with pregnancy such as Severe
Pre-Eclampsia and PDPH. The latter is of
particular concern for anaesthetists when
assessing obstetric patients with atypical
headaches after central neuraxial blockade.
Conversely, worsening headache due to
PDPH may confound the evaluation of a re-bleed.
Conclusion;
Loss of Cerebrospinal fluid (CSF) from the
puncture site with a subsequent decrease in
CSF pressure and an increase in transmural
wall tension of the vessels might be
predisposing factors for the rupture of a pre-existing
cerebral aneurysm.
180/100mm Hg. for which Depin-R was given
and CBC and Urine for albumin sent. Physician
opinion sought and CT scan was advised.
Pt. convulsed on same day (GTCS 1
episode), Neurologist opinion sought and he
ma d e d i a g n o s i s o f Hy p e r t e n s i v e
Encephalopathy / CVST. She was given
Epsolin, Mannitol and supportive treatment.
CT Venogram revealed Good opacification
of superficial and deep cerebral venous sinuses
with no evidence of thrombosis. no obvious
brain parenchymal hemorrhage or major
territory inshemic infarct. Evidence of minimal
sub arachnoid hemorrhage in Left sylvian
fissure and along Left MCA .Mild cerebral
edema.
Patient was discharged on day 8 in stable
condition, with no headache,no convulsion or
vomiting.
Discussion
The leakage of Cerebrospinal fluid following
lumbar puncture (LP) is usually of a minor
degree and seldom gives rise to any symptoms.
The incidence of Spontaneous SAH is
increased five-fold in a pregnant woman
compared to a non-pregnant woman.
Spontaneous SAH is a rare event, ruptured
intracranial aneurysms being the main cause
(51-80%) followed by hypertensive diseases
Severe headache following Spinal
Anesthesia (SA) in the lower segment
caesarean section (ISCS) may be due to
varieties of causes viz. postdural puncture
headache (PDPH), pre-eclampsia migraine,
drug induced headache and intra cranial
pathology which includes hemorrhage, venous
sinus thrombosis and post-partum cerebral
angiopathy and PDPH in 6 hrs. After Spinal
Anaesthesia and the incidence of which may
vary with the size of the needle used.
Peripartum SAH provides a unique clinical
challenge, because there is a requirement to
consider both Obstetric and Neuroanaesthetic
issues during management.
A Recent Cochrane database systematic
review has not shown that either Regional
Anaesthesia (RA) or General Anaesthesia
(GA) for LSCS is superior with respect to major
maternal or neonatal outcome measures.
General anaesthetic management of
caesarean section in a patient with intracranial
haemorrhage has been described. The
administration of a single shot of spinal block
was based on the following maternal-foetal
considerations: Avoidance of airway
manipulation and aspiration risk, minimization
of foetal drug exposure, excellent
postoperative analgesia, earlier return to oral
intake and facilitation of maternal bonding with
the new-born. Additionally, there were
neurosurgical concerns regarding the
possibility of an unsecured ruptured vascular
lesion.
A regional technique would enhance safety
by preventing hypertensive responses to
intubation and surgical stimuli as well as allow
better perioperative monitoring for headache,
focal neurological symptoms and GCS.
The major concern with central neuraxial
blockade is the potential for cerebral herniation
or worsening of Intracranial haemorrhage in
the setting of raised ICP, secondary to a rapid
decrease in CSF pressure. However, despite
the evidence of raised elevated ICP being
absent, the technique is reasonably safe.
1. Consultant Anaesthesiologist, GK Hospital, Indore
2. Consultant Anaesthesiologist and Head of Department of Anaesthesia GK Hospital, Indore
3. Consultant Obstetrics and Gynecology Greater Kailash Hospital Indore
4. Consultant Obstetrics and Gynecology Greater Kailash Hospital Indore

CONFERENCE CALENDER
24
ANESTHESIA INFORMATION
MANAGEMENT SYSTEM (AIMS):
HISTORICAL OVERVIEW AND FUTURE
TRENDS
“Processed data is information.
Processed information is knowledge
Processed knowledge is Wisdom.”
¯ Ankala V Subbarao
25
Intracranial subarachnoid haemorrhage
should be listed among the rare complications
of spinal anaesthesia.
A dural leak following lumbar puncture
might persist for months or even years without
causing symptoms.
In case of a planned second puncture,
persisting leakage should be ruled out by
taking a thorough history.
Spinal and epidural anaesthesia are
contraindicated in patients with persisting low
pressure in the CSF system or known
intracranial vascular malformations.
Reference
1. British Journal of Anesthesia
86(3):442-4(2001)
2. www.oapublishinglondon.com/article/508.
3. www.ncbi.nlm.nih.gov/pubmed/1570889
Imagine if clinicians of earlier ages didn't share their experiments and practices,
successes and failures! Experiences of
clinicians in form of case record and data have
become foundation of
e v i d e n c e b a s e d
medicine. Experience
of others teaches us
a n d c o l l e c t e d
evidence is used in
making guidelines and
standards. A dynamic
b r a n c h a s
a n e s t h e s i o l o g y i s n o e x c e p t i o n .
Comprehensively recorded data will not only
help to understand the clinical practices and
pharmacologic properties of drugs used, but
will also be helpful in medico legal instances. It
will help the administration to keep check on
drugs used and thus billing properly.
Historical view1
Though every event related to evolution of
anesthesiology was well published and
discussed, recording details of each and every
case was practiced sparingly. In 1894, at
Massachusetts General Hospital, Boston,
surgeons Ernst A Codman (1869–1940) and
Harvey Cushing (1869–1939) established the
practice of keeping a careful written record (on
graph paper) of the patient's pulse and
l 1 Dr. Ritesh Dixit
respiration rate during operations—known as
the 'ether chart', Thus initiating the era of what
we today know as "case record"2. Apparently
this was prompted by
a d e a t h u n d e r
anesthesia in 1893.3
Ra l p h Wa t e r s
c h amp i o n e d a n d
emp h a s i z e d t h e
importance of written
anesthetic records
and later Noseworthy
(1945) produced special cards on which to
record anesthetic details.4
Manual record keeping had various
advantages as ease of availibilty, ease of input
and required less technical skill. Lack of better
technology also favored use of manual case
records. They became very popular with every
institute developing its own version suited
better to their functioning. But it had serious
limitations of difficulty in reproduction,
comparability, compilation, interpretation and
analysis.
Machines moved the world and also
science. The first mechanical device capable
of printing an anesthetic record was the
Nargraf machine of 1930 developed by EI
McKessons (Westhorpe 1989) which
1. Associate Professor, Department of Anesthesiology
RD Gardi Medical Colege, Ujjain
RSACPCON 2014
(November 14th-16th, 2014)
24th National Conference of Research Society of
Anaesthesiology Clinical Pharmacology at Dehradun
Contact Person : Dr. JP Sharma
Telephone : +91 9411718466
Email Id : rsacpcon2014@gmail.com
Website : http://www.rsacpcon2014.com
6th Annual Conference of ICA
(21st-23rd November, 2014)
6th Annual Conference of the Indian College of
Anaesthesiologists in collaboration with University of
Minnesota, USA at Bangalore
Contact Person :Dr. Murlidhar K
Telephone : +91 8027836966
Email Id : muralidhar.kanchi.dr@nhhospitals.org
CAAP 2014 (22-23 November 2014)
Calicut Anaesthesia Academic Programme at Kozhikode
Contact Person : Fijul Komu
Telephone : 9865660004
Email Id : calicutcaap@gmail.com
Website : http://www.caap2014.com
ISACON 2014 (25th-29th December, 2014)
62nd Annual National Conference of Indian Society of
Anaesthesiologists at Madurai
Contact Person :Dr. SC Ganesh Prabu
Telephone : +91 9443496835
Email Id : isacon2014madurai@gmail.com
Website :http://isacon2014.com
ISNACC 2015 (30th January-1st February 2015)
16th Annual National Conference of Indian Society of
Neuroanesthesiology and Critical Care at Lucknow
Contact Person : Dr. Shashi Srivastava, Dr. Devendra
Gupta
Email Id : isnacc2015@gmail.com
Website : http://www.isnacc.org/isnacc-2015/index.html
ISSPCON 2015
DR. Karthic Natarajan
Back and pain Centre
The Apollo clinic
62, GN Chetty Road,
T. Nagar Chennia
Email: isspcon2015@gmail.com
IAPCON 2014 (13-15 February, 2015)
22nd International Conference of Indian Association of
Palliative Care at Hyderabad
Contact Person :Dr. Gayatri Palat
Telephone : 09848021801
Email Id : info@iapcon2015hyd.com
Website :http://iapcon2015hyd.com
IACTA 2015 (20-22 February, 2015)
18th Conference of Indian Association of Cardio-Vascular
Thoracic Anaesthesiologists at Jaipur
Contact Person : Dr. Navneet Mehta
Email Id : info@iacta2015.com
Website : http://iacta2015.com/index.html
CRITICARE 2015 (4-8 March, 2015)
21st Annual Conference of Indian Society of Critical Care
Medicine at Bangalore
Contact Person :Dr. Pradeep Rangappa
Telephone : +91 9611700888
Email Id : drpradeepr@aol.com
Website :http://www.criticare2015.com

26
Figure 1. Basic structure of AIMS (from Philips health care)
27
generated a semi-automated record of
inspired oxygen, tidal volume and inspiratory
gas pressure.5
With advent of computers, data collection
and analysis peaked new heights. The monitors
fed the vital data in computers which could store
and reproduce data in various forms and ready to
be analyzed as needed by the clinician. A feature
known as RS-232 port was incorporated into all
early medical monitoring devices. Equally
significant, IBM decided to incorporate the same
RS-232 port into the IBM Personal Computer
since1981.6 Thus facilitating use of a PC to
access various measured parameters by
patient monitoring devices with a view to
develop useful trend displays of measured data,
real-time calculation of derived parameters and
hard-copy data printouts.
The RS-232 interface is to be replaced in
future by the Medical Interface Bus. This is a high-tech
high-speed medical plug-and-play version
of the familiar domestic USB interface and will
greatly facilitate medical device inter-connectivity,
largely by allowing the relevant
interface software to be more easily
standardized.
Anesthetic Data: an important but tedious
task!
Various institutions and associations have
clearly lined out the list of parameters that
should be monitored, documented and ready
to be analyzed as part of standard anesthetic
care. One comprehensive list can be viewed in
Table 1 provided by American Association of
Nurse Anesthetists (AANA) Practice
Committee standard.
Just glancing over the exhaustive list given in
Table 1, it is quite obvious that it's practically
impossible to cover all these parameters
manualy. Also bothering anesthesiologist with
the task can interfere with the care and safety of
the patient. Thus we entered the world of
automation.
Automated anesthesia information
management systems (AIMS)
AIMS is a specialized form of electronic
health record (EHR) system that allows the
automatic and reliable collection, storage and
presentation of patient data during the
Perioperative period. This data is also used for
management, quality assurance and research.7
in simple terms; it is a highly sophisticated
hardware and software system which keeps
track of all the events that happens during
conduct of anesthesia. It also records all the
drugs or instrument used. All the clinical
parameters are continuously recorded and can
be viewed or analyzed by any statistical tool.
In 2002, Anesthesia Patient Safety
Foundation (APSF) formally endorsed the use
of automated anesthesia information
management systems (AIMS). The advantages
and emphasis on AIMS can easily be decoded
by excerpts quoted from Anesthesia Information
Management Systems and Sharing Your
Patient Data: A Resource for Potential Users
(Prepared by Amer i can Soc iet y of
Anesthesiologists Committee on Information
Management)
"Concerns over required behavior changes,
costs and legal implications have been the
primary deterrents in migrating to electronic
records.11 Advances in computational power,
ease of use and hardware pricing have
diminished many of these concerns. All the
while, clinicians have intuitively recognized the
potential for electronic records to provide value
and improve patient safety. The directors of the
Anesthesia Patient Safety Foundation (APSF),
a patient safety–focused group sponsored
primarily by the American Society of
Anesthesiologists (ASA), have gone on record
to state “The APSF endorses and advocates the
use of automated record keeping in the
perioperative period and the subsequent
retrieval and analysis of the data to improve
patient safety.”
Described by some as the “black box” or
flight recorder for anesthesiology, AIMSs have
been recognized and advocated as a method
by which to provide better tools to analyze
adverse events and near misses and to
provide a global repository of outcomes data
that may help to shape future safety efforts.
Properly configured and implemented, an
AIMS should facilitate the collection of
accurate and comprehensive clinical data,
thereby representing the anesthetic
management of a given patient. From these
data, it should be easier for institutions to
demonstrate compliance with regulatory
requirements, better charge capture of
professional fees, and clinical competency
through performance measurement."8
Specific benefits of AIMS as in Peer
reviewed literature are as follows7
1. Cost and Billing improvements
2. Controlling and Reducing anesthesia drug
costs
3. Clinical Decision Support
4. Training and provides education
5. Patient Safety and Quality Assurance
6. Enhancement of clinical quality
improvement programs
7. Monitoring of controlled substances
8. Data quality and clinical research
9. Improved intraoperative record quality
Limitations of AIMS
1. Clinicians's hesitation – it can be either
due to lack of exposure to new
technologies, uncomfortable to work
under continuous surveillance of

28
29
Standard perioperative record as given by AANA
(American association of Nurse Anesthetists)
Information to be contained in the Anesthesia Record
A. Patient Information - 1. Name, 2 .Age, 3. Identification number, 4. Sex, 5. Weight, 6. Height,
7. Allergies, 8. Physical status
B. Provider Information - 1. Primary anesthetist, 2. Secondary anesthetist, if any, 3. Relief
provider, times of relief, credentials
C. Anesthesia Equipment - Safety Check - 1. Equipment functioning, 2. Check performed
just prior to case, 3.If indicated, list equipment numbers
D. Monitors to be Used - Minimal Standard - 1. Electrocardiogram, 2. Blood pressure, 3.
Precordial stethoscope, 4. Pulse oximetery, 5. Oxygen analyzer, 6. End tidal carbon dioxide
E. Monitoring Information - Minimal Standard - On Graphic Display - 1. Electrocardiogram,
2. Blood pressure, 3. Heart rate, 4. Ventilation status, 5. Oxygen saturation,
F. Additional Monitors if Indicated - 1. Esophageal stethoscope, 2. Thermometer, 3. Nerve
stimulators, 4. Respirometers, 5. Arterial catheters, 6. Central lines/pulmonary artery catheters,
7. Mass spectrometry, 8. Electroencephalography
G. Monitoring Information Indicated by Type of Procedure - Graphic Recording or Other
Continuous Trending- 1. Temperature, 2. Inspired oxygen, 3. End tidal CO2 level, 4. Ventilator
information - a. Tidal/minute volume, b. Peak inspiratory pressure, c. Rate, 5. Central line
pressure readings - a. Pulmonary artery, b. Central venous pressure, 6.
Electroencephalographic changes, 7. Other readings as indicated, i.e., degree of muscle
paralysis
H. Airway Management Techniques - Indicated on Anesthesia Record - 1. Mask, 2. Intubation
- a. Oral, nasal, double lumen, b. Endotracheal tube size and type, c. Cuff - absent, present, d.
Laryngoscope - blade type and size, e. Performed awake or asleep, f. Technique: direct vision,
blind, fiber optic, 3. Difficulties with intubation, 4. Assessment of tube placement- a. Breath
sounds checked, b. Presence of EtCO2 readings, c. How secured and depth (cm) at lips/teeth,
5. Cuff inflation-air, saline, amount/pressure, 6. Times of intubation/extubation, 7. Ventilation
parameters - a. Respiratory rate, b. Tidal/minute volumes, c. Peak inspiratory pressures, d.
Positive end expiratory pressure, 8. Artificial airway- a. Oral, nasal.
I. Medications Administered (anesthetics, adjuncts, antibiotics, etc.) - 1. Names, 2.
Routes, 3. Amounts/concentrations, 4. Times - use of graphic or continuous flow charting most
desirable for anesthetic drugs, 5. Totals, when indicated, 6. Unusual patient responses (i.e.,
rash)
J. Techniques Used - 1. Type of anesthesia - a. General, mask or Endotracheal, b. Regional, c.
Monitored care, d. Other, 2. Induction - a. Inhalation, b. Intravenous, c. Rectal, d. Intramuscular,
3. Maintenance, general anesthetics - a. Circle system, b. Non-rebreathing, 4. Intravenous
routes established - a. Location of IV(s), size and patency, 5. Monitoring lines placed - a.
Technique, equipment, problems, 6. Regional - a. Specific technique, equipment, problems,
levels achieved, results
K. Intake - 1. Crystalloid, 2. Blood/blood products, 3. Colloids, 4. Volume expanders
L. Output - When Indicated, Should be on Record- 1. Urine, 2. Blood loss, 3. Nasogastric
(may be on operative record), 4. Other, i.e., ascites could be on the anesthesia record /
operating room nurse’s record
M. Procedural Data- 1. Actual operative procedure performed, 2. Date, 3. Times of starting
and stopping anesthesia using 24-hour clock, 4. Times of starting and stopping procedure
N. Patient Protection - 1. Position, position changes, 2. Eye protection, 3. Securing of
monitoring lines
Information to be Immediately Available in the Patient’s Operative Chart
A. Preanesthesia Assessment - 1. Review of systems, 2. Current diagnosis, 3. Pertinent
lab data, 4. Pertinent physical examination findings, 5. Allergies/sensitivities, 6. Airway
assessment- a. Anatomy, b. Dentures/teeth, c. Previous problems under anesthesia, 7.
Surgical/anesthesia history, 8. Medication history, 9. Social history - a. Smoking, b. ETOH
use, c. Drug use, 10. Family problems with anesthesia, 11. Other - a. Transfusion history, b.
Disabilities, c. Communication problems, d. Prosthetics
B. Physicalal Status Assigned
C. Patient Interview Accomplished - 1. Risks/benefits discussed 2. Anesthesia plan
discussed 3. Patient consent obtained
D. Patient and Procedure Identification - 1. Surgery consent form signed and dated, 2.
Anesthesia consent form signed and dated, 3. Patient identified 4. Proposed procedure, 5.
Surgical site affirmed
E. Patient Protection (may be on operating room nurse’s record) 1. Padding of pressure
points created by surgical position requirements, 2. Special anatomical considerations, 3.
Safety strap, 4. Tourniquets, placement and times, 5. Grounding plate, site
F. Transfer of Care Information - 1. To what unit (ICU, PACU, etc.) 2. Report given on - a.
Patient identification, name, age, b. Allergies,c. Anesthetic type, drugs used, d. Blood/fluid
status,e. Complications, if any, f. Procedure performed, g. Vital signs, h. Pre-existing
conditions/medications, i. Condition, j. Airway status/oxygen requirements
Anesthesia Related Information to Appear in the Patient’s Hospital Chart
A. Post anesthesia Note - 1. Time and date of visit, 2. Complications, if any, 3. General
status- a. Systems reviewed should reflect care given, 4. Signature
B. Additional Comments (May be in anesthesia record if space allows, or in progress
notes. Should be indexed to events on record, if indicated.)
1. Unanticipated patient responses,
2. Emergency measures
TABLE-1

30
TABLE - 2
31
automated record, less inclined for
training and update, fear of increase in
medico legal cases
2. Financial considerations – right way from
inception to full functioning of AIMS
require full monetary flow. Though
beneficial in later stages, the early burdon
may be too much, especially in developing
countries
3. Infrastructure and Logistics – every part of
AIMS will require round the clock support
system along with proper training and
updating of IT (Information Technology)
wing of a hospital.
4. Ensuring that the data collected and
analyzed is not merely used for billing and
monetary gains but should reach the
desired researchers and policy makers.
5. No standardization of AIMS regarding
features among venders.
Broadly, there are three types of AIMS
available. Examples of these types with
various manufacturers are listed below. Salient
features of all the options are collected from
product brochures available online listed in
Table 2 and listed to give a better
understanding of AIMS, comparison with peers
and emphasize their unique features to make a
wise choice. Though efforts are made to
include important features of each system,
readers are requested to access to various
websites given in Table 2 for a detailed
understanding.
1. AIMS integrated with anesthesia
monitors – examples
(A) GE- Aestiva's 7900 – Its open
architecture allows you to use your current
monitors and data management systems or
purchase a fully integrated anesthesia system
with GE CARESCAPE Monitors
(B). Philips – Besides the beautiful
illustration of working of an AIIMS in figure 1
(courtesy Phillips aims product brochure) its
preoperative module provides missing or
abnormal test results or special conditions, can
display cost alerts and alternatives as soon as a
drug is selected. Charges captured from clinical
data (such as administration of a drug) can be
exported to pharmacy or billing. Intraoperative
“Event keys” are tailored to specific procedures,
Intuitive touch screen interface, Case
templates, and Automatic integration of data
from anesthesia machines, ventilators and
patient monitors are other features.
(C). Drager-It provides Web-based pre-anesthesia
assessment, comprehensive Intra-operative
patient record, accurate and complete
billing information data capture, supports
anesthesia clinical workflow, configurable case
environments to support various types of cases.
Back office- Web-based access to patient
records. Data can be used for research
purposes and to support patient safety
initiatives. Data capture of regulatory and
compliance elements required for anesthesia
billing.
2. AIMS integrated with operating room
management systems
(A) GE (B) PICIS / OPTUM - Preop Clinical
Decision Support, O R Scheduling and
Workflow Management to combine superior
multi-facility features with Flexible local and
remote scheduling tools for better utilization of
resources, Intelligent Patient Tracking, O R
Dashboard and Analytics, Intelligent Supply
Chain Automation and Interoperability.
(C) McKESSON – Customizes anesthesia
EMR (Electronic Medical Record) in form of
patient history documentation, Medication
alerts to promote timely drug delivery,
Formulary reference for allergies and
medication increasing patient safety, Cross-checking
for adverse events reduces
medication errors by notifying clinicians of
potential contraindications, Templates for
common procedures help speed the clinical
documentation process, Automated capture of
physiological data adds accuracy to the
anesthesia EMR.
(D) SIS (Siemens) – Anesthesia is
integrated with Other Surgery Solutions,
Soarian's advanced workflow management
technology, “Notify Me” workflow for reminder
of patients test results, Urinary catheter
workflow, Venous thrombosis embolism (VTE)
workflow.
(E) CERNER - Through web based
features such as automatic methods to
capture information and simple reporting tools
device integration, intuitive real-time
documentation resources and immediate
access to patient records helps to provide
effective anesthesia care.
(F) EPIC - Integrated with Operating Room
Management and EpicCare EMR to
streamline documentation workflows across
roles. Epic Anesthesia provides dedicated
support for documentation of all events from
pre to post operative stage. Have multiple
other modules for intensive care, nursing care,
emergency, radiology, home care, pathology,
biochemistry, etc.
3. Exclusively sell anesthesia
information management systems (AIMS)
(A) MERGE - Besides routine features it
has SAM (Smart Anesthesia Manager) which
is a decision support system working in
conjunction with Merge AIMS to find issues
related to quality of care, billing and
compliance and will be notified via pop-up
screens or text pages
(B) iMD Soft – Uniquely flexible, with
various advantages as Clinical decision
support, Adaptability to all workflows,
Reporting and analysis, Data continuity across
the entire continuum of care, Full integration
with healthcare IT infrastructure
(C) ACUITEC- VPIMS (Vi g i l a n t
Perioperative Information Management

CME & WORKSHOP - 2009 Solution), a comprehensive solution for
32
perioperative setting that scales to facilities of
all sizes, includes scheduling, preference
cards, nurse documentat ion, case
management, reports, anesthesia charting,
mobile capabilities, etc.
(D) PLEXUS- Anesthesia Touch™ is an
easy to use, full-featured AIMS for both iPad
and Windows, with cloud based support and
storage. Pharmacy Touch™, a modular add-on
to Anesthesia Touch further helps with
drugs administered in various clinical,
administrative and billing aspects.
This collection of information about
newer frontiers of data and information
management can only provide only an
overview of exhaustive newer trends in
a n e s t h e s i a d a t a a n d i n f o rma t i o n
management. Though in a developing cost
conscious country like India, it may appear
distant dream. But with advent of medical
tourism, advanced cutting edge technologies
and health care setups, the IAMS are just
round the corner. I hope this piece of
information will stimulate your intellect and
helps you to be ready for future. Remember,
anesthesiologists are usually the last warriors
between patient and distress and AIMS
definitely proves to be a valuable ally besides
being a multi level performer.
References
1. Richard W. D. Nickalls, Simon
Dales,Adrian K. Nice; Chapter 2-Data
processing in anesthesia, An Open Source
Anaesthesia Workstation (Linux)
2. Beecher HK (1940). The first
anesthesia records (Codman, Cushing).
Surg.Gynecol. Obstet., 71, 689–693.
3. Rushman, Davies and Atkinson 1996,
p.128
4. Noseworthy M (1945), Anesthesia and
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5. Westhorpe R (1989). McKesson
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ISBN 0-521-46280-0; pp 402 (Cambridge
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o o o

Madhya pradesh journal 04 nov 2014

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