BackgroundThe epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is p... more BackgroundThe epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.MethodsWe performed a case-control study comparing cases diagnosed with CAM and those who had recovered from COVID-19 without developing mucormycosis (controls). Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded.Results352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases carried conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95%CI 1.1-11), use of systemic steroids (aOR 7.7,95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6,95% CI 1.2-2.2). Zinc therapy, probably due to its utility in immune function, was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.ConclusionJudicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.
infection-control measures and had the opportunity to ask questions. The main limitation is we su... more infection-control measures and had the opportunity to ask questions. The main limitation is we surveyed patients who actually attended hospital for surgery, although a third of patients had COVID-19 risk factors and over a quarter were over 70 years old. In conclusion, it is clear that patients strongly appreciated continued MMS services during the pandemic and continuation of surgery helps reduce treatment delays and backlogs. Our key lessons for any future pandemic or second wave are that MMS services should continue to run with patients prioritized based on clinical judgement and limiting risks. Effective patient communication is vital prior to surgery to prepare patients and alleviate their concerns. Finally, it is important that multiple infectioncontrol measures are implemented to reduce transmission. We can and should strive to continue to deliver high-quality care and reduce associated risks to provide the best outcomes for patients. This will be critical in any second wave or future pandemics.
International Journal of Otolaryngology and Head & Neck Surgery, 2020
Background: Obstructive sleep apnea (OSA) has cardiovascular, neurological, and social complicati... more Background: Obstructive sleep apnea (OSA) has cardiovascular, neurological, and social complications. Surgical treatment has the potential to improve airway patency but when and which surgery should be done is a controversy.
Parotid gland swelling during/after surgery is a rare but known complication of general anesthesi... more Parotid gland swelling during/after surgery is a rare but known complication of general anesthesia. It has been found to be associated with patients of all age groups and various surgical procedures. We have found this rare complication to be associated with morbid obesity as well. A forty five year old morbid obese lady (BMI 50.5 kgm-2) was operated for fracture shaft of left humerous after positioning in right lateral position. Intraoperatively, her head was positioned using soft bandage head ring used commonly for such positioning. Postoperatively unilateral painful parotid gland swelling was noted on the dependent (right) side of face. Possible mechanism for such a scenario could be the vulnerable anatomy of short thick neck of morbid obese patient leading to compression of its vessels and compromising perfusion of the area supplied, hence resulting in ischemic sialadenities. Physicians treating these patients should be aware of this condition to avoid misdiagnosis. Minimum turn...
Evaluation was undertaken of the effect of chemotherapeutic drugs on the perioperative morbidity ... more Evaluation was undertaken of the effect of chemotherapeutic drugs on the perioperative morbidity of patients with ovarian malignancy undergoing radical surgery. Twenty patients who had received cytotoxic drugs pre-operatively (group I) were compared with 11 patients in whom radical surgery was the first line of treatment (group II). Pre and post-operative cardiac, pulmonary, renal, hepatic and coagulation functions were compared in both groups, as well as the critical intra- and post-operative events like cardiac pump failure, respiratory dysfunction, rhythm disturbances, blood loss, etc. Demographic data, ASA status, biochemical and haematological parameters and cardiac ejection fractions were comparable in the two groups but patients in group I had significantly higher left ventricular end diastolic dimensions (P < 0.01). A higher number of patients in group I had pre-operative respiratory and coagulation factor abnormalities but critical intra- and post-operative events in bot...
Our series have shown that psychotherapy and physiotherapy when incorporated with specific therap... more Our series have shown that psychotherapy and physiotherapy when incorporated with specific therapy, produced a much better relief from pain and that the functional return of ability of the affected part was quicker.
Objective. The aim of this study is to compare medical therapy alone and medical therapy with add... more Objective. The aim of this study is to compare medical therapy alone and medical therapy with add on extraoral glossopharyngeal nerve block in terms of analgesic efficacy and hemodynamic safety in patients with glossopharyngeal neuralgia (GPN). As GPN is a rare disease, our secondary targets were to review the demographic profile of the disease, clinical profile, and any associations with the disease. Design. This was a randomized, prospective, active-controlled, parallel group study conducted from 2007 to 2009 to determine the safety and efficacy of extraoral glossopharyngeal nerve block in GPN and compare it with pharmacological intervention. After institutional ethics committee approval and patient's consent, GPN patients were randomly allocated into two groups. Group A (N = 15) received standard medical therapy (gabapentin 300 mg, tramadol 50 mg TDS, methylcobalamin 500 mgm PO) and group B (N = 15) patients received extraoral glossopharyngeal nerve block together with standard medical therapy. Patients were analyzed for analgesic outcome using numerical pain scale (NPS) and brief pain inventory (BPI) assessing both analgesic effect and degree of interference in quality of life (QOL) during 3-month follow-up. They were also evaluated for any significant hemodynamic alterations. Results. Over the follow-up of 90 days, the mean NPS in group A decreased from 6 Ϯ 2 to 3 Ϯ 2 and in group B from 5 Ϯ 1 to 2 Ϯ 2. From the mean NPS scores, it can be interpreted that both the modalities were effective clinically in treating GPN. However, NPS scores were statistically similar by the end of 90 days. Improvement from baseline in BPI measurement of QOL (mood, interpersonal relationship, and emotion) was earlier in group B (1, 2, and 1 months, respectively) compared with group A (2, 3, and 2 months, respectively). However, there were no significant hemodynamic adverse outcomes after administration of the block. Conclusion. This study found that patients in both the groups had significantly lower pain intensities, improved pain relief, and reduced pain interference with QOL, which was especially evident on fourth visit (2 months) after the initiation of treatment regimen. Both were safe and well tolerated. The study advocates rational polypharmacy approach (oral and block) in difficult to treat painful conditions. Further controlled trials are warranted to further define the impact of such a combination therapy.
fection (8.6%, nϭ12) as the most frequent complication followed by temporomandibular dysfunction ... more fection (8.6%, nϭ12) as the most frequent complication followed by temporomandibular dysfunction (nϭ4) and nerve injury (nϭ3). Conclusion: This study shows that fractures of the mandible and zygoma are the most frequent maxillofacial fractures seen at Aalesund Central Hospital. The average person presenting with a maxillofacial fracture at Aalesund Central Hospital is a young male, who has been a victim of interpersonal violence often under the influence of alcohol or drugs and would have sustained his injury at night.
AAOMS guidelines mobility, pain, dehiscence, infection, and disability were not observed in any p... more AAOMS guidelines mobility, pain, dehiscence, infection, and disability were not observed in any patient. Five percent (nϭ1) of patients had occlusal discrepancy 2 months postoperatively, which was attributed to implant failure. Long-term follow-up (10 months) showed degradation products in 2 patients. There were sterile abscesses, which responded to evacuation. Conclusion: The use of bioresorbable plates was found to be efficacious in treatment of mandibular frac-Oral Abstract Session 4 e-34 AAOMS • 2011 tures as per parameters of care given by AAOMS even without post operative MMF. The avoidance of repeat surgery for plate removal is a definitive advantage of using a bioresorbable plating system.
CSF progesterone and spread of subarachnoid anaesthesia in pregnancy Sir,-Hirabayashi and colleag... more CSF progesterone and spread of subarachnoid anaesthesia in pregnancy Sir,-Hirabayashi and colleagues [1] suggested that a sustained (at least 3-4 months) increase in cerebrospinal fluid (CSF) progesterone concentration may be necessary to produce enhanced spread of spinal anaesthesia in pregnant women. We believe that these conclusions are misleading and unsupported by the results. Maximum cephalad spread of analgesia was quoted as being higher in the second trimester compared with the first, but there were no results of statistical tests that directly compared these two trimesters. Median maximum cephalad spread of analgesia was the same (T4) in the first and second trimesters, and this makes it unlikely, although not impossible, that there was a significant difference between the two groups. The figures do not show all data points, perhaps because overlapping points are not separated, and it was impossible for us to confirm the results. The CSF progesterone concentration data were also surprising. CSF progesterone concentrations were said to be increased similarly in the early and middle stages of pregnancy. This appeared to form the basis for Hirabayashi and colleagues suggesting that chronic exposure to progesterone increased spread of spinal anaesthesia (assuming that there really is increased spread in the second trimeter compared with the first). However, the results stated that there was no significant increase in CSF progesterone concentration during early and middle pregnancy compared with the control group. The CSF progesterone concentration data were further complicated by the larger number of patients with undetectable progesterone, even at term gestation. Other studies have detected CSF progesterone concentrations in all patients [2, 3], with mean concentrations at term gestation approximately double those reported by Hirabayashi and colleagues. Given the wide variation in both the CSF progesterone concentration and the spread of spinal anaesthesia, we are not convinced that a meaningful association can be made between chronic exposure to progesterone and increased spread of analgesia. The study design certainly does not permit one to conclude that progesterone may be a causative factor. The suggestion that chronic exposure to progesterone may be necessary for increased sensitivity of nerves to local anaesthetics was derived from a series of in vitro studies using rabbit vagus nerves [4]. However, the same research group has recently reported that bupivacaine conduction block of B and C fibres in desheathed vagus nerves was similar in pregnant and nonpregnant rabbits [5]. It was concluded that previous data on progesterone and nerve sensitivity to local anaesthetics were a result of increased diffusion of bupivacaine through the nerve sheath rather than a direct action on the nerve itself. Therefore, the effect of progesterone on nerve block after intrathecal administration of local anaesthetics remains uncertain. Hirabayashi and colleagues quickly dismissed mechanical factors as a possible cause for increased spread of spinal anaesthesia in the second trimester, but did not provide supporting evidence. Anatomically, the gravid uterus is first palpable above the pubic symphysis at 12 weeks' gestation. By 16 weeks' gestation, the uterus extends above the sacral promontory where the inferior vena cava usually bifurcates [6]. Caval compression may occur in early pregnancy. When pregnant women of 13-16 weeks' gestation were placed supine, direct femoral venous pressure measurements increased by 50 % [7]. It is thus possible that a progressive increase in caval compression throughout pregnancy may contribute to a progressive increase in the spread of spinal anaesthesia. Although not specifically stated in the article, we wonder if data from some of the patients in this study have been reported previously [8]. In that article, it was also concluded that maximum cephalad spread of analgesia was higher in the second trimester compared with the first. Again, there were no statistics provided that directly compared the two trimesters. By arguing that spread of sensory block in the second trimester is greater than that in the first trimester but similar to that at term, the authors have implied in both reports that there is a cutoff point in the second trimester where spread of sensory block increases. Given the progressive nature of pregnancy and artificial division of gestation into trimesters, it may be just as likely that there is a gradual increase in spread of sensory block from the nonpregnant state to term gestation, whatever the cause(s). We also suggest that there may be bias in the conclusion that CSF progesterone concentrations were greater in twin pregnancies compared with singleton pregnancies in the third trimester. Figure 1 shows that in the third trimester group (25-36 weeks), at least four of the singleton pregnancies were between 25 and 27 weeks, while none of the twin pregnancies was less than 32 weeks. There is an inconsistency between table 1, which lists the smallest weight in the second trimester group as 50 kg, and table 2, where the corresponding minimum weight is 40 kg.
The sonomatic confirmation of tracheal intubation (SCOTI) is a new device used to confirm the cor... more The sonomatic confirmation of tracheal intubation (SCOTI) is a new device used to confirm the correct placement of tracheal tubes. It utilises a sonic technique for recognition of a resonating frequency for detection of tracheal intubation. We compared its predictive value with that of the clinical auscultatory method and a capnograph to confirm 132 blind nasal intubations using three different tracheal tubes [red rubber (n 82), polyvinyl chloride (n 33) and RAE preformed nasal (n 17)]. SCOTI correctly identified 70.8% of intubations and chest auscultation did so 99.2% of times. All results were confirmed using a capnograph. The SCOTI device gave a false-negative value in 37 patients (28%) and a false-positive result in two patients (1.5%). The response time for confirming intubations was 2.5 (1.5) s for the SCOTI, 4.1 (1.1) s for a capnograph and 40 (9.4) s for the auscultatory method. The erroneous results shown by the SCOTI device were highest when polyvinyl chloride tubes with a Murphy's eye were used for intubation. This study shows that this device is not very useful for ascertaining the correct placement of tracheal tubes after blind nasal intubation.
A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent s... more A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.
We report a 10-year-old child with congenital methaemoglobinaemia and temporomandibular joint ank... more We report a 10-year-old child with congenital methaemoglobinaemia and temporomandibular joint ankylosis who presented for ophthalmic surgery. He had had two previous anaesthetics in another institution. The first was short and uneventful, and no abnormality was noted. During the second anaesthetic, low haemoglobin oxygen saturation on pulse oximetry was noted after an inhalational induction. The diagnosis was not apparent and the management of the apparent hypoxaemia markedly complicated the clinical course. The patient required prolonged intensive care and tracheostomy. The tracheostomy was ultimately decannulated. Before his third anaesthetic (after referral to the authors' institution) preoperative investigation revealed that the patient, his father and brother all had methaemoglobinaemia.
BackgroundThe epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is p... more BackgroundThe epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.MethodsWe performed a case-control study comparing cases diagnosed with CAM and those who had recovered from COVID-19 without developing mucormycosis (controls). Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded.Results352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases carried conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95%CI 1.1-11), use of systemic steroids (aOR 7.7,95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6,95% CI 1.2-2.2). Zinc therapy, probably due to its utility in immune function, was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.ConclusionJudicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.
infection-control measures and had the opportunity to ask questions. The main limitation is we su... more infection-control measures and had the opportunity to ask questions. The main limitation is we surveyed patients who actually attended hospital for surgery, although a third of patients had COVID-19 risk factors and over a quarter were over 70 years old. In conclusion, it is clear that patients strongly appreciated continued MMS services during the pandemic and continuation of surgery helps reduce treatment delays and backlogs. Our key lessons for any future pandemic or second wave are that MMS services should continue to run with patients prioritized based on clinical judgement and limiting risks. Effective patient communication is vital prior to surgery to prepare patients and alleviate their concerns. Finally, it is important that multiple infectioncontrol measures are implemented to reduce transmission. We can and should strive to continue to deliver high-quality care and reduce associated risks to provide the best outcomes for patients. This will be critical in any second wave or future pandemics.
International Journal of Otolaryngology and Head & Neck Surgery, 2020
Background: Obstructive sleep apnea (OSA) has cardiovascular, neurological, and social complicati... more Background: Obstructive sleep apnea (OSA) has cardiovascular, neurological, and social complications. Surgical treatment has the potential to improve airway patency but when and which surgery should be done is a controversy.
Parotid gland swelling during/after surgery is a rare but known complication of general anesthesi... more Parotid gland swelling during/after surgery is a rare but known complication of general anesthesia. It has been found to be associated with patients of all age groups and various surgical procedures. We have found this rare complication to be associated with morbid obesity as well. A forty five year old morbid obese lady (BMI 50.5 kgm-2) was operated for fracture shaft of left humerous after positioning in right lateral position. Intraoperatively, her head was positioned using soft bandage head ring used commonly for such positioning. Postoperatively unilateral painful parotid gland swelling was noted on the dependent (right) side of face. Possible mechanism for such a scenario could be the vulnerable anatomy of short thick neck of morbid obese patient leading to compression of its vessels and compromising perfusion of the area supplied, hence resulting in ischemic sialadenities. Physicians treating these patients should be aware of this condition to avoid misdiagnosis. Minimum turn...
Evaluation was undertaken of the effect of chemotherapeutic drugs on the perioperative morbidity ... more Evaluation was undertaken of the effect of chemotherapeutic drugs on the perioperative morbidity of patients with ovarian malignancy undergoing radical surgery. Twenty patients who had received cytotoxic drugs pre-operatively (group I) were compared with 11 patients in whom radical surgery was the first line of treatment (group II). Pre and post-operative cardiac, pulmonary, renal, hepatic and coagulation functions were compared in both groups, as well as the critical intra- and post-operative events like cardiac pump failure, respiratory dysfunction, rhythm disturbances, blood loss, etc. Demographic data, ASA status, biochemical and haematological parameters and cardiac ejection fractions were comparable in the two groups but patients in group I had significantly higher left ventricular end diastolic dimensions (P < 0.01). A higher number of patients in group I had pre-operative respiratory and coagulation factor abnormalities but critical intra- and post-operative events in bot...
Our series have shown that psychotherapy and physiotherapy when incorporated with specific therap... more Our series have shown that psychotherapy and physiotherapy when incorporated with specific therapy, produced a much better relief from pain and that the functional return of ability of the affected part was quicker.
Objective. The aim of this study is to compare medical therapy alone and medical therapy with add... more Objective. The aim of this study is to compare medical therapy alone and medical therapy with add on extraoral glossopharyngeal nerve block in terms of analgesic efficacy and hemodynamic safety in patients with glossopharyngeal neuralgia (GPN). As GPN is a rare disease, our secondary targets were to review the demographic profile of the disease, clinical profile, and any associations with the disease. Design. This was a randomized, prospective, active-controlled, parallel group study conducted from 2007 to 2009 to determine the safety and efficacy of extraoral glossopharyngeal nerve block in GPN and compare it with pharmacological intervention. After institutional ethics committee approval and patient's consent, GPN patients were randomly allocated into two groups. Group A (N = 15) received standard medical therapy (gabapentin 300 mg, tramadol 50 mg TDS, methylcobalamin 500 mgm PO) and group B (N = 15) patients received extraoral glossopharyngeal nerve block together with standard medical therapy. Patients were analyzed for analgesic outcome using numerical pain scale (NPS) and brief pain inventory (BPI) assessing both analgesic effect and degree of interference in quality of life (QOL) during 3-month follow-up. They were also evaluated for any significant hemodynamic alterations. Results. Over the follow-up of 90 days, the mean NPS in group A decreased from 6 Ϯ 2 to 3 Ϯ 2 and in group B from 5 Ϯ 1 to 2 Ϯ 2. From the mean NPS scores, it can be interpreted that both the modalities were effective clinically in treating GPN. However, NPS scores were statistically similar by the end of 90 days. Improvement from baseline in BPI measurement of QOL (mood, interpersonal relationship, and emotion) was earlier in group B (1, 2, and 1 months, respectively) compared with group A (2, 3, and 2 months, respectively). However, there were no significant hemodynamic adverse outcomes after administration of the block. Conclusion. This study found that patients in both the groups had significantly lower pain intensities, improved pain relief, and reduced pain interference with QOL, which was especially evident on fourth visit (2 months) after the initiation of treatment regimen. Both were safe and well tolerated. The study advocates rational polypharmacy approach (oral and block) in difficult to treat painful conditions. Further controlled trials are warranted to further define the impact of such a combination therapy.
fection (8.6%, nϭ12) as the most frequent complication followed by temporomandibular dysfunction ... more fection (8.6%, nϭ12) as the most frequent complication followed by temporomandibular dysfunction (nϭ4) and nerve injury (nϭ3). Conclusion: This study shows that fractures of the mandible and zygoma are the most frequent maxillofacial fractures seen at Aalesund Central Hospital. The average person presenting with a maxillofacial fracture at Aalesund Central Hospital is a young male, who has been a victim of interpersonal violence often under the influence of alcohol or drugs and would have sustained his injury at night.
AAOMS guidelines mobility, pain, dehiscence, infection, and disability were not observed in any p... more AAOMS guidelines mobility, pain, dehiscence, infection, and disability were not observed in any patient. Five percent (nϭ1) of patients had occlusal discrepancy 2 months postoperatively, which was attributed to implant failure. Long-term follow-up (10 months) showed degradation products in 2 patients. There were sterile abscesses, which responded to evacuation. Conclusion: The use of bioresorbable plates was found to be efficacious in treatment of mandibular frac-Oral Abstract Session 4 e-34 AAOMS • 2011 tures as per parameters of care given by AAOMS even without post operative MMF. The avoidance of repeat surgery for plate removal is a definitive advantage of using a bioresorbable plating system.
CSF progesterone and spread of subarachnoid anaesthesia in pregnancy Sir,-Hirabayashi and colleag... more CSF progesterone and spread of subarachnoid anaesthesia in pregnancy Sir,-Hirabayashi and colleagues [1] suggested that a sustained (at least 3-4 months) increase in cerebrospinal fluid (CSF) progesterone concentration may be necessary to produce enhanced spread of spinal anaesthesia in pregnant women. We believe that these conclusions are misleading and unsupported by the results. Maximum cephalad spread of analgesia was quoted as being higher in the second trimester compared with the first, but there were no results of statistical tests that directly compared these two trimesters. Median maximum cephalad spread of analgesia was the same (T4) in the first and second trimesters, and this makes it unlikely, although not impossible, that there was a significant difference between the two groups. The figures do not show all data points, perhaps because overlapping points are not separated, and it was impossible for us to confirm the results. The CSF progesterone concentration data were also surprising. CSF progesterone concentrations were said to be increased similarly in the early and middle stages of pregnancy. This appeared to form the basis for Hirabayashi and colleagues suggesting that chronic exposure to progesterone increased spread of spinal anaesthesia (assuming that there really is increased spread in the second trimeter compared with the first). However, the results stated that there was no significant increase in CSF progesterone concentration during early and middle pregnancy compared with the control group. The CSF progesterone concentration data were further complicated by the larger number of patients with undetectable progesterone, even at term gestation. Other studies have detected CSF progesterone concentrations in all patients [2, 3], with mean concentrations at term gestation approximately double those reported by Hirabayashi and colleagues. Given the wide variation in both the CSF progesterone concentration and the spread of spinal anaesthesia, we are not convinced that a meaningful association can be made between chronic exposure to progesterone and increased spread of analgesia. The study design certainly does not permit one to conclude that progesterone may be a causative factor. The suggestion that chronic exposure to progesterone may be necessary for increased sensitivity of nerves to local anaesthetics was derived from a series of in vitro studies using rabbit vagus nerves [4]. However, the same research group has recently reported that bupivacaine conduction block of B and C fibres in desheathed vagus nerves was similar in pregnant and nonpregnant rabbits [5]. It was concluded that previous data on progesterone and nerve sensitivity to local anaesthetics were a result of increased diffusion of bupivacaine through the nerve sheath rather than a direct action on the nerve itself. Therefore, the effect of progesterone on nerve block after intrathecal administration of local anaesthetics remains uncertain. Hirabayashi and colleagues quickly dismissed mechanical factors as a possible cause for increased spread of spinal anaesthesia in the second trimester, but did not provide supporting evidence. Anatomically, the gravid uterus is first palpable above the pubic symphysis at 12 weeks' gestation. By 16 weeks' gestation, the uterus extends above the sacral promontory where the inferior vena cava usually bifurcates [6]. Caval compression may occur in early pregnancy. When pregnant women of 13-16 weeks' gestation were placed supine, direct femoral venous pressure measurements increased by 50 % [7]. It is thus possible that a progressive increase in caval compression throughout pregnancy may contribute to a progressive increase in the spread of spinal anaesthesia. Although not specifically stated in the article, we wonder if data from some of the patients in this study have been reported previously [8]. In that article, it was also concluded that maximum cephalad spread of analgesia was higher in the second trimester compared with the first. Again, there were no statistics provided that directly compared the two trimesters. By arguing that spread of sensory block in the second trimester is greater than that in the first trimester but similar to that at term, the authors have implied in both reports that there is a cutoff point in the second trimester where spread of sensory block increases. Given the progressive nature of pregnancy and artificial division of gestation into trimesters, it may be just as likely that there is a gradual increase in spread of sensory block from the nonpregnant state to term gestation, whatever the cause(s). We also suggest that there may be bias in the conclusion that CSF progesterone concentrations were greater in twin pregnancies compared with singleton pregnancies in the third trimester. Figure 1 shows that in the third trimester group (25-36 weeks), at least four of the singleton pregnancies were between 25 and 27 weeks, while none of the twin pregnancies was less than 32 weeks. There is an inconsistency between table 1, which lists the smallest weight in the second trimester group as 50 kg, and table 2, where the corresponding minimum weight is 40 kg.
The sonomatic confirmation of tracheal intubation (SCOTI) is a new device used to confirm the cor... more The sonomatic confirmation of tracheal intubation (SCOTI) is a new device used to confirm the correct placement of tracheal tubes. It utilises a sonic technique for recognition of a resonating frequency for detection of tracheal intubation. We compared its predictive value with that of the clinical auscultatory method and a capnograph to confirm 132 blind nasal intubations using three different tracheal tubes [red rubber (n 82), polyvinyl chloride (n 33) and RAE preformed nasal (n 17)]. SCOTI correctly identified 70.8% of intubations and chest auscultation did so 99.2% of times. All results were confirmed using a capnograph. The SCOTI device gave a false-negative value in 37 patients (28%) and a false-positive result in two patients (1.5%). The response time for confirming intubations was 2.5 (1.5) s for the SCOTI, 4.1 (1.1) s for a capnograph and 40 (9.4) s for the auscultatory method. The erroneous results shown by the SCOTI device were highest when polyvinyl chloride tubes with a Murphy's eye were used for intubation. This study shows that this device is not very useful for ascertaining the correct placement of tracheal tubes after blind nasal intubation.
A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent s... more A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.
We report a 10-year-old child with congenital methaemoglobinaemia and temporomandibular joint ank... more We report a 10-year-old child with congenital methaemoglobinaemia and temporomandibular joint ankylosis who presented for ophthalmic surgery. He had had two previous anaesthetics in another institution. The first was short and uneventful, and no abnormality was noted. During the second anaesthetic, low haemoglobin oxygen saturation on pulse oximetry was noted after an inhalational induction. The diagnosis was not apparent and the management of the apparent hypoxaemia markedly complicated the clinical course. The patient required prolonged intensive care and tracheostomy. The tracheostomy was ultimately decannulated. Before his third anaesthetic (after referral to the authors' institution) preoperative investigation revealed that the patient, his father and brother all had methaemoglobinaemia.
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