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Letters to Editor
Caffeine for the prevention
of postoperative nausea
and vomiting Reply
Sir,
I read with pleasure the letter to the editor regarding our paper
entitled Caffeine for the prevention of postoperative nausea and
vomiting (PONV),[1] which was published in your journal.
While our paper represents a first ever prospective, randomized,
double-blind, placebo-controlled study examining the effects
of intravenous caffeine on PONV rates and other side-effects
of general anesthesia, more studies are needed to potentially
uncover any positive effects of caffeine on postoperative recovery.
In our study, we attempted to account for as many PONV
risk factors as possible, and control for them appropriately.
For example, we controlled for four major risk factors such
as female gender, smoking status, prior history of PONV,
and perioperative opioid use.[2] In addition, we controlled for
baseline caffeine consumption, duration of anesthesia, and type
of surgery all known to potentially influence study results.[3]
In addition, we made every attempt to standardize induction
and maintenance of anesthesia among different practitioners.
All patients received intravenous induction with propofol,
and anesthesia was maintained with an inhalational agent.
Overall, this was a well-controlled study. In fact, the most
recent PONV guidelines from the Society for Ambulatory
Anesthesia published a list of overall positive risk factors, which
were all acknowledged and controlled for in our study.[4] As
far as intravenous fluid administration is concerned, we agree
that there is some evidence that high amount of intravenous
fluid administration can reduce postoperative emesis.[5,6] Our
ambulatory anesthesia practitioners follow internally developed
ambulatory anesthetic protocols that allow little room for
variation. In our study, most patients would have received similar
amounts of fluid as these cases were generally short and similar in
duration; similarly, although we did not report the intraoperative
dose of the inhalational agent(s), we believe it would have had
a minor effect on the reported outcomes. In summary, our pilot
study explores the possibility of using a different drug modality
(intravenous caffeine) for the prevention of PONV and other
anesthetic side-effects. Larger prospective studies are warranted
to further explore this drugs potential.
Acknowledgments
The authors thank Daniel W. Steinbrook, Anna T. R. Legedza,
ScD, and Valerie Banner-Goodspeed for assistance with data
analysis. ClinicalTrials.gov ID NCT00130026.
578 Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
Richard D Urman, Frances Garfield1,
Stacey H Batista1, Richard A Steinbrook1
Department of Anesthesiology, Perioperative and Pain Medicine,
Brigham and Womens Hospital, 1Department of Anesthesia,
Critical Care and Pain Medicine,
Beth Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA, USA
Address for correspondence: Dr. Richard D Urman,
Department of Anesthesiology, Perioperative and Pain Medicine,
Brigham and Womens Hospital, Harvard Medical School, 75 Francis
Street, Boston, MA 02115, USA.
E-mail: urmanr@gmail.com
References
1. Steinbrook RA, Garfield F, Batista SH, Urman RD. Caffeine for the
prevention of postoperative nausea and vomiting. J Anaesthesiol
Clin Pharmacol 2013;29:526-9.
2. Apfel CC, Lr E, Koivuranta M, Greim CA, Roewer N. A
simplified risk score for predicting postoperative nausea and
vomiting: Conclusions from cross-validations between two centers.
Anesthesiology 1999;91:693-700.
3. Gan TJ. Risk factors for postoperative nausea and vomiting. Anesth
Analg 2006;102:1884-98.
4. Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA,
et al. Consensus guidelines for the management of postoperative
nausea and vomiting. Anesth Analg 2014;118:85-113.
5. Goodarzi M, Matar MM, Shafa M, Townsend JE, Gonzalez I. A
prospective randomized blinded study of the effect of intravenous
fluid therapy on postoperative nausea and vomiting in children
undergoing strabismus surgery. Paediatr Anaesth 2006;16:49-53.
6. Maharaj CH, Kallam SR, Malik A, Hassett P, Grady D, Laffey JG.
Preoperative intravenous fluid therapy decreases postoperative nausea
and pain in high risk patients. Anesth Analg 2005;100:675-82.
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DOI:
10.4103/0970-9185.142877
Cesarean section under local
anesthesia: A step forward or
backward?
Sir,
Cesarean sections are most commonly performed under
spinal anesthesia. However, there are many cases where local
anesthesia has been highly useful and even life saving such as
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Letters to Editor
patients who are morbidly obese, have difficult airway or severe
coagulopathy.[1] We are highlighting the successful conduct of
Cesarean section under local anesthesia in a 26-year old, ASA
III woman, with previous one lower segment Cesarean section
(LSCS). She presented to casualty with scar tenderness and
fetal distress (fetal heart rate between 90 and 100 per minute),
hence was scheduled fo an emergency LSCS.
The patient gave history of weakness of all limbs for the past
2 years, associated with pain in lower back and both the hip,
knee, shoulder and elbow joints. On examination, she was
severely malnourished and pale. Motor power was 1/5 in all
the four limbs. She had no investigations available with her.
Hemoglobin by pin prick was 6.2 gm/dl.
The decision to give a subarachnoid block, without completely
investigating the patient, was questionable. We could not give
general anesthesia as there was no ventilator or ICU back up
at that time. We decided to get this life-saving surgery done
under local anesthesia along with Entonox.
Informed, high-risk consent was taken and the patient was
shifted to the operating room. The surgeons cleaned and
draped her abdomen and Entonox was administered through
a face mask. They gave local infiltration with 8 cc of 0.5%
bupivacaine in the skin and subcutaneous tissue and started
the surgery keeping in mind that they had to use no retractors
or packs, had to be very gentle and were to avoid any sudden
movement. After 5 minutes, a male baby of 1.9 kg with Apgar
of 8, 9 was delivered. The patient was given 20 g of fentanyl
intravenously and the uterine incision was closed.
Another 6 cc of 0.5% of bupivacaine was infiltrated in the
rectus sheath, subcutaneous tissue and skin, along with 10 g of
fentanyl intravenously, and her abdomen was closed. Her surgery
lasted around 45 minutes and her hemodynamic parameters
remained stable. She was transfused with two units of packed
cells postoperatively.
An orthopedic and physician referral was taken postoperatively
and she was diagnosed to be suffering from myopathy due to severe
oestomalacia. Her S. Calcium was-5.2 mg/dl, ionised Calcium was
2.8 mg/dl, S. Albumin was-2.2 g/dl 2.8, ALP was-688 I/L, Hb-
6.8 g/dl, S. Fe-25 g/dl, S ferritin-12.1 g/L, Vit D3-10.8 ng/ml.
MRI of whole spine revealed biconcave shaped vertebra with
pseudofractures (loosers zone), indicative of severe oestomalacia.
She was administered vitamin D3 intramuscularly as well
as orally and oral calcium for 6 weeks, along with oral iron.
When she came for follow-up after 12 weeks, she was walking
normally and was able to do her household chores though had
developed an incisional hernia.
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
Local anesthesia for LSCS causes loss of pain sensation
in selected areas only, with minimal disturbances of other
systems, especially the cardiovascular and respiratory system.
[2]
Rooney et al. noted the incidence of complications after
using local anesthesia for LSCS, including fetal demise, was
significantly lower.[3] Infact, majority of the mothers opted for
local anesthesia for a repeat LSCS.
Although we do not advocate the use of local anesthesia
for all Cesarean sections, it can be safely used in high-risk
patients where sub-arachnoid block or general anesthesia
can be associated with complications. There is no evidence
that Cesarean section under local anesthesia has an increased
incidence of mortality than any other form of anesthesia.
Bablesh Mahawar, Neha Baduni, Pooja Bansal
Department of Anaesthesiology, ESI Hospital, New Delhi, India
Address for correspondence: Dr. Neha Baduni,
ESI Hospital, Rohini, New Delhi, India.
E-mail: baduni.neha@gmail.com
REFERENCES
1. Patil S, Sinha P, Krishnan S. Successful delivery in a morbidly obese
patient after failed intubation and regional technique. Br J Anaesth
2007;99:919-20.
2. Nandgopal M. Local anesthesia for caesarean section. Tech Reg
Anesth Pain Manag 2001;5:30-5.
3. Ranney B, Stanage WF. Advantages of local anesthesia for
caesarean section. Obstet Gynecol 1975;45:163-7.
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10.4103/0970-9185.142878
Malfunctioning Pediatric
infusion set leading
to accidental fluid overload
and pulmonary edema
Sir,
Despite continuous strive for improved patient safety, there
can be situations in complex environments like operation
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