A 25 yr Female, posted for RT and D & C for primary sterility, pre op inv normal. WBC 8200. Nothing positive.
conducted with Medaz and Pentazocine, Propofol and O2 mask. Good recovery after a 10 min proceedure. Shifted to Wd.
Could not go home as she felt weak. By evening BP was 60/28 mm 124 Pulse
and 28 Breath PM . Rigors ++. Kept in hospital for observation.
Next day WBC 24000, fever, BP still 70 systolic. toxic look. Bil Patch in mid zone lungs. CVP line put and CVP 7 - 8 cm. Fluids, O2, Antibiotics started. Kept in ICCU. Dopamin support given. WBC 34000. Severe myealgia all over body.
Over next 2 days, Pulse slowly dropping, BP improving, renal output good. But took almost 5 days to recover.
Will you blame Propofol as the main cause? It was a fresh vial.  One more case was done after that from the same vial. Nothing happened to that patient.
Every time, when a cause is not found, some how Propofol manages to get blamed!!!!

Managed to break an epidural cath. Gave spinal and came out. Informed the surgeon. Finished the surgery ( IT #) and closed the chapter. It is now about 6 years. We have not heard from them since then. What all can happen is anybody's guess.
Either way let us have guesses.
A team had informed the surgeon and they opened up the spine and never found the cath piece. Is surgery an option to remove it?
Would CT or MRI show the cath?
Let us here it.

Had a case of Hystero-laparoscopic Myomectomy, a young girl of 16 yrs, who went in LVF, and all other signs of TURP syndrome. She was under GA. Her Sodium dropped to 109.
Can any one throw more light on sodium correction? How fast we can give 3 % NS?
Any other recommendation?
Does Soda Bi Carb Help in providing instant sodium?

I heard a new terminology. ICU Neuroptahy. Can some one enlighten me? Retrospectively I recollect a patient, who had gone in septicaemia, post hystrectomy due to sigmoid colon injury, and on venti with multi organ failure. Though she was out in about 10 days, she took her own sweet time, two months, to start moving her muscles. She had no movements, or responce, what so ever. Very gradually she improved and went home. But, since she was not responding to any stimuli, every one labled her brain dead. She did not recollect any event in those two months, nor did she recognise any one, who was treating her every day. She only remebered me, as I saw her almost 5 times every day.
Yes, this takes us back to septicaemia, which is a topic on itself.

    What is the choice sedation for a t plasty? I have tried a range, but still looking for an ideal one. It is very difficult for an anaesthesiologist, not to give anaesthesia, and just be an onlooker when a patient disturbs the surgeon and is not quiet. He must be having discomfort, but difficult for us to manage.
There is a place where the surgeon takes about 3 to 4 hours for a T- Plasty, and the patient is not comfortable in supine for that long, and to add to our pleasures, his bladder fills up.
Let me have a range of combinations.
I have tried, Pentazocine, Meparidine, buprenorphin, Butorphenol, Fentanyl ,Medazolam, Clonidine, and so on. But still far from happy.

Please do use the site. It is really very good. I miss you all guys!!!!!!!!!!!!! 

Female / 46 , C / O Hoarseness of Voice 3 days, H / O ingestion of chicken bone 5 days back. CT scan showed FB in Esophagus. Reports normal, but WBC count 17000. Posted for Rigid Esophagoscopy. Standard induction with Fentanyl, Medaz, Propofol, Scoline, O2, IPPV, Tube 6.5 with difficulty. Maintained on Propofol, Vecuronium, Gas Oxygen, IPPV. Over in 20 mins. Reversal started on attempts of breathing. Inadequate reversal picture. Extubated on struggles. SpO2 drops to 80. Reintubated and ???? pink liquid noted in throat. May be froath may be blood stained saliva.
    At that moment some one informed that actual printed report of CT has now come and it showed a rent in esophagus.
Pt given Medaz and O2 and shifted to Recovery for observation. ABG showed pH 7.2 and PCO2 70.Connected to venti and Vecuronium given. CXR showed pulm edema pattern.
OK by evening but not sustaining BP. Dopamin and Dobut given. 2D Echo 30% LVEF, WBC 24000.
Imporved over 24 hours and discharged in 2 days. and ok.

Question is was it a picture of early sepsis due to mediastinal infection which can spread rapidly or was it an improperly managed reversal? Later picture is of clear cut septic shock and septic cardiomyopathy.
I am putting this case for discussion tomorrow in society meet.
Let me many opinions.
The anaesthesiologist feels that it was her fault. I feel it was sepsis. Is it that uptill now the society used to say that it was over dose of anaesthesia, and now we have also started feeling the same!!!!!

    This young lady is 94 admitted with a fracture neck femur. She is totally fit on paper. But she has a clot in the left atrium, calcified aortic and mitral valve, giving Aortic stenosis and Mitral Regurg, ejection fraction 50%. Admited with Hb of 5.6 and irrelevant talk and behaviour. She was given pack cell with a central line and Hb was brought to 10.5 over 3 days.
    On table the patient was deeply drowsy. awakened only if the fracture leg was lifted. I did not like the patient and postponed the surgery. I  asked for a repeat work up and electrolytes. Sodium turned out to be 119. We explained a very high risk of surgery till all corrections were made. Relatives did not want to take risk and took her home.
    Next day, I get a call from another hospital, now a very small clinic, with hardly any facility, no ICU and not properly equipped. It turned out to be the same patient, with a surgeon now very keen on doing surgery. I am asked to give anaesthesia as the relatives are now willing to take risk.( Remember that in Mumbai we have hundreds of tiny clinics of 12 to 20  beds each, managed privately by surgeon alone.)
   I have given her fitness once, then made her unfit once, and now without any improvement in the condition of the patient, will it ever be right to give fitness and do surgery? The previous hopspital was much better with all departments, and an ICU managed by anaesthesiologists of my team and cardiologist.
What is my status, if I give anaesthesia to this patient in countries where you practice?

      We have been hearing of Pulmonary Edema during or after a laparoscopic surgery, more so in Lap Hystrectomy.
     How often have other Anaesthesiologists faced it? Can you throw more light on pathophysiology of it and how to prevent and treat it?

Recently I was called by an anaethesiologist as the patient was not coming out. A case of TKR where Epidural did not work and GA was given. Intubation was not possible and LMA was used. Patient did not come out of GA after reversal.  LMA was removed and mask ventilltion was going on.
     On reaching there I realised that ETCO2 was 90plus( we have a portable Capnogram of our own).These monitors are still not used as a routine over here. We intubated over a guide wire. ABG showed PCO2 of 86. We noticed convulsions on facial muscles. We just kept on ventillating with a venti for an hour and a half and she came out completely. Tube was removed and was shifted to ICU for observation.
     Many things were wrong in management.
     I want members to throw light on what all happens in CO2 narcosis, if they have seen one. and also the pathophysiology.

Is there a site or other study material where by common public may see the technique of giving an Epidural Labour Analgesia? Is there a site where an animation film is available? It would be then quite easy for us too if we can simply show it to patients.

There are times when we are trapped due to non action of epidural or very late call for an epidural, or technical difficulty in giving one.
Can one recommend a good alternative that can be given  I V?

Gas Embolism.
I know that this word can dilate our sphincters.
I had a case of Fistula in ano under GA with LMA.
Standard induction with Fentanyl, Medazolam, Glycopyrolate, Pre oxygenation, Propofol, Vecuronium, and intubation with LMA. All parameters normal till at about 20 mins after starting surgery things started happening.
I have  group of 4 qualified anaesthesiologists. One of them was on the pulse. Multi paramonitor was connected. Second anaesthesiologist was writing notes and drug list etc. I was just around in the OT.
First assistant started making movements. ON inquiring she said " No Radial"
Monitor took next NIBP reading:50/20mmBP.
SpO2 started dropping. N2O stopped. Quickly LMA removed and endotracheal tube put. 100% O2 with venti given.
No change. SpO2 now 70%. BP not recordable. Vaso Pressures given.
No improvement.
I went to surgeons trolly. Asked the sister about what is in the bowls. She said one is Savlon, Betadine, and Hydrogen Paroxide.
I asked the assistant to auscultate. She said air entry was equal on intubation. I asked for murmur, she said there was no murmur preop.
I asked her to re auscultate. She said there is some funny loud murmur. In a fluke I said this is called a Mill Wheel Murmur. I had never heard it before.
The surgeon had injected 10ml of Hydrogen Paroxide to find the internal opening of the Fistula in ano.
The murmur vanished in about a min and SpO2 was about 52%.
It was not possible to give  Durrant's position from lithotomy possision.  nor was it possible to put in a central line.
We were just waiting for the fate. Suddenly the SpO2 started rising. BP came up till 120 systolic. And Patient was fully conscious at reversal.
Was discharged on third day and he had no clue about the diagnosis.
Any one can throw some light on this case.
any easier way to manage this crisis.
Any one with a simillar experience?

How oftern one encounters a segmental block in Epidural.
One of my patient recently was given Epidural Labour Analgesia. She did very well and was very comfortable till she was taken up for a section. She was a qualified nurse. She had pain on incision only on the right side of midline, with a total lack of action of block. The left side was perfect. Another for a Vag Hyst, same way only one side acted. Second no action at all.
Any light on this issue? Any suggestions to improve the block?