The patient has received an excessive dose of ketamine for her body weight. Ketamine has a long duration of action and she is still experiencing its effects 12 hours later when she should have recovered much sooner. A lower and more appropriate dose of ketamine should have been used.

1. Dr. C.G.Raghuram
Professor,
Dept. of Anaesthesiology,
Osmania General Hospital,
Hyderabad.

2. PROBLEMS ASSOCIATED WITH PBC
NECK
 Grossly restricted neck movements
 Patients are likely to be malnourished ,anemic and
hypoproteinemic
 Possibility of restricted mouth opening and narrowed nasal
passages.
 Difficult laryngoscopy and endotracheal intubation
 Compromised airway
 Psychiatric tendencies in patients and possible drug
interactions in anaesthesia
 Poor oral hygeine in patients

3. RELEVANT ASPECTS IN
HISTORY
 Duration of contractures
 History of convulsions
 Difficulty in breathing and swallowing
 H/O motion sickness
 H/O snoring
 H/O epistaxis and bleeding from oral cavity
 H/O psychiatric problems
 H/O acid peptic disease and reflux

4. RELEVANT EXAMINATION OF
PATIENT
 Nature of contracture
- soft
- firm(hard)
 Location of contracture
 Duration of contracture
 Extent of contracture ( sterno cleido mastoid involved?)
 Is mouth opening restricted ?
 Can the mandible be moved up and down
 Are the nasal passages patent?
 Is the patient dyspneic, can he lie down comfortably ?
 Can he blow air through mouth and nose

5. INVESTIGATIONS
 SURGICAL PROFILE:
 Complete blood picture
 Blood Grouping
 Random blood sugar
 Urea and Creatinine
 Serum electrolytes
• X-Ray chest –PA view
• ECG – 12 lead
• HbsAg ,HIV , HCV
• THYROID PROFILE

6. PREPARATION OF THE
PATIENT
 Improve oral hygeine
 Correct anemia and hypoproteinemia
 H2 receptor antagonists, prokinetics
 Anti emetics
 Aggressive treatment of upper and lower
respiratory tract infections

7. PRE- MEDICATION
GUIDELINES
 Avoid heavy sedation.
 Preserve respiration – drugs that depress respiration
viz. narcotics are better avoided till airway is
secured
 I.M. glycopyrolate / atropine is better than I.V.
premedication.
 Continue H2 receptor blockers and antiemetics
 Consider pre-op nasal decongestants – they help
you in putting a naso-pharyngeal airway

8. PRE MEDICATION
(Cont..)
 Use topical viscous anaesthesia for oral
cavity and pharynx before induction of
anaesthesia - it helps in improving
quality of anaesthesia
 Consider superior laryngeal nerve block
if hyoid and upper margin of thryiod
cartilage are visible.- it reduces
incidence of laryngospasm during
anaesthesia

9. USEFUL TIPS IN
ANAESTHESIA
 Aim to have total control of the airway- that should
be the ultimate goal
 Preserve spontaneous respiration till trachea is
intubated
 Consider using nasopharyngeal airway, oro-
pharyngeal airway, and laryngeal mask airway
where ever feasible –these devices improve quality
of anaesthesia.
 Consider superficial cervical plexus block if
contracture is situated in between sternomastoids- it
gives useful analgesia for the operative field .

10.  I.M Ketamine is a more useful option than I.V. Ketamine in a
dose of 2-5 mg/kg
REASONS :
 Analgesia lasts longer upto 30-45 mins .By which time the
contracture release will mostly be released.
 Less risk of resp. depression
 Stable hemodynamics
 Provides an ideal environment along with tumescent or
regional technique.
 Patient can be smoothly transitioned into an inhalational
technique

11. USEFUL TIPS (Cont …)
 If using LMA , fix the LMA to the maxilla /upperlip
.Never to the mandible.
 Consider using a muscle relaxant only if mask/LMA
ventilation is possible . Otherwise avoid them
 Try endotracheal intubation in deep planes of
inhalational anaesthesia.In spontaneous respiration
as far as possible.
 Consider bougies ,tube exchangers where ever
laryngoscopy and endotracheal intubation obscures
visibility.

12.  Fix E.T tubes always to the maxilla .Fixing them to
mandible can soak them and soil them with blood
and secretions from the operative field and can also
interfere with field of surgery .
 Use narcotics like fentanyl etc ., only after
securing access to trachea.
 N.S.AIDS are very useful for post op analgesia
.Hence use them.
 Avoid narcotics , tramadol and metronidazole in
patients with migraine and motion sickness.

13. PRECAUTIONS IN THE POST-OP
PERIOD
 Extubate only when sure.
 Watch for airway obstruction .
 Observe resp. pattern.
 Use nasopharyngeal /oral airway if needed.
 Anti-emetics to be continued post-op

14. TUMESCENT TECHNIQUE
 Solution for tumescent contains lignocaine
,adrenaline,hyaluronidase and saline/water
 FORMULA :
0.5% Lignocaine solution with 1 in 1,00,000
adrenaline
{ 25 ml 2 % lignocaine
+ hyalase 1 to 2 ml
+ 1ml of 1 in 1,00,000 adrenaline
+ dist. Water to a total volume of 100ml }

15. Cont….
 Helps release of contracture without much
blood loss.
 Helps surgery in aspect of hydrostatic
cleavage of operative field and subsequent
dissection.
 Risk of toxicity less due to poor vascularity
of scar tissue and use of adrenaline .

16. PARTING TAIL PIECE
 A 35 yr old female, weighing 60 kgs is posted for a dense
tough contracture involving anterolateral aspects of neck .
 Contracture released with tumescent + IM .Ketamine .
 Patient intubated with 7.5mm cuffed ET tube under deep
inhalational anaesthesia with O2 +N2O+ Isoflurane .
 4 mg vecuronium given .
 Surgery lasts two hours
 At the end, patient reversed as there are respiratory efforts

17.  Patient regains respirations but is deeply
drowsy , reflexes sluggish.
 Patient regains consciousness 12 hrs
after surgery.
WHAT HAS GONE WRONG ??