Browsing by Author "Shrestha, BR"
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Publication A comparison of 25 gauge Quincke spinal needle with 26 gauge Eldor spinal needle for the elective Caesarian sections: Insertion characteristics and complications(Kathmandu University, 2003) Tabedar, S; Maharjan, SK; Shrestha, BR; Shrestha, BMObjective: The study was designed to compare the insertion characteristics and incidence of PDPH between 25 gauge Quincke needle and 26 gauge Eldor needle for spinal anaesthesia in elective c/s. Method: 60 pregnant women (aged 19-35yrs and weighing 58 –67kg) undergoing elective caesarean section were randomized into group A (Quincke spinal needle group) or group B (Eldor spinal needle group). Spinal anaesthesia was performed with 2.9 ml 0.5% heavy bupivacaine using 25 gauge Quincke spinal needle in group A and 26 Gauge Eldor spinal needle in group B. Onset, time of first identification of backflow of CSF, number of attempts, level of sensory and motor blockade, failure of anaesthesia, inadequate anaesthesia and incidence of PDPH were recorded. Result: Quincke spinal needle was found easy at insertion, first attempt was successful in 90% of cases, whereas Eldor spinal needle was successful at first attempt in only 60% of cases. Early identification of CSF was seen in Eldor spinal needle group in 3.5 seconds vs. 5.2 seconds in Quincke spinal needle group. Blood mixed CSF was seen in 8 Quincke spinal needle group vs. none in Eldor spinal needle group. Onset was similar between both groups i.e. in 6 minutes. Failure of anaesthesia was none in Eldor spinal needle group vs. 2 in quincke spinal needle group. Height of sensory block achieved was T4 level in 26 parturients,T6 in 1 ,T8 in 1 and no anaesthesia at all in another 2 parturient as compared to T4 level in 29 and T3 in 1 parturient in Eldor spinal needle group. The degree of motor block with the use of Bromage criteria showed a motor score of 1or 2 in 26 parturients in Quincke spinal needle group vs. same in all cases in Eldor spinal needle group. The total incidence of PDPH was 8.3 %( 5 out of 60 parturient) which occurred all in Quincke spinal needle group. 2 parturient who developed severe PDPH required epidural blood patch. Conclusion: 26 gauge Eldor spinal needle was found to be better than 25 gauge Quincke spinal needle for caesarian sections to decrease the incidence of PDPH, though not all insertion characteristics were in favour of the Eldor needle. Key Words: Anaesthetic technique, spinal; equipment, spinal needles; complications, headache.Publication A comparison of haemodynamic responses with pethidine vs. butorphanol in open cholecystectomy cases(Kathmandu University, 2004) Tabedar, S; Maharjan, SK; Shrestha, BR; Shrestha, SObjective: The present study was undertaken to compare the haemodynamic responses with pethidine vs. Butorphanol intraoperatively in open cholecystectomy cases in KMCTH. Method: In this randomized study, all together 40 patients undergoing routine cholecystectomy surgery were included. Group A received Pethidine 1mg/kg and Group B received Butorphanol 0.04mg/kg intraoperatively. Heart rate and blood pressure were recorded before injection of the drug, after injection, before intubation, after intubation, before skin incision, after incision, before extubation and after extubation Data analysis was done using independent sample “t” test. Result: Our study showed no statistical significance in haemodynamic responses with either pethidine or Butorphanol in open cholecystectomy cases. Conclusion: Both drugs appear equally good analgesics in our study. Key words: analgesics, pethidine, Butorphanol, haemodynamic responses, surgery, cholecystectomy.Publication Antiemetic prophylaxis against postoperative nausea and vomiting with ondansetron-dexamethasone combination compared to ondansetron or dexamethasone alone for patients undergoing laparoscopic cholecystectomy(Kathmandu University, 2008) Gautam, B; Shrestha, BR; Lama, P; Rai, SAbstract Background: Postoperative nausea and vomiting (PONV) is a common distressing experience in patients following laparoscopic surgeries. This study was aimed at comparing the ef cacies of Ondansetron-Dexamethasone combination with each drug alone as a prophylaxis against PONV in patients after elective laparoscopic cholecystectomy done under general anaesthesia. Materials and methods: Hundred and fty ASA I and II patients, aged 23 to 65 yrs, were enrolled in this prospective, randomized, double-blind trial to receive one of three treatment regimens: 4 mg Ondansetron (Group O), 8 mg Dexamethasone (Group D) or 4 mg Ondansetron plus 8 mg Dexamethasone (Group OD) (n=50 for each). A standardized balanced general anaesthetic technique was employed. Any episode of PONV and need for rescue antiemetic were assessed at six, 12 and 24 hrs post operation. Complete response was de ned as no PONV in 24 hrs and need for rescue antiemetic was considered as failure of prophylaxis. Pain scores, time to rst analgesia demand, amount of Meperidine consumption, adverse event(s) and duration of hospital stay were recorded. Results: Complete response occurred in 66.7, 66.0 and 89.4% in Groups O, D and OD respectively. Rescue antiemetics were required in 29.2, 31.9 and 8.5% of patients in Groups O, D, and OD respectively. Signi cantly high incidence of vomiting and failure of prophylaxis (19.1%) occurred in group D during the rst six hrs (P=0.023 versus O & 0.008 versus OD). More frequent antiemetic rescue was required in group O at 6 to 24 hr interval as compared to group OD (P=0.032). Conclusion: Combination of Ondansetron and Dexamethasone is better than each drug alone in preventing PONV after laparoscopic cholecystectomy. Dexamethasone alone is signi cantly less effective in preventing early vomiting compared to its combination with Ondansetron; whereas Ondansetron alone is less effective against late PONV as compared with combination therapy. Key words: Antiemetic prophylaxis; Dexamethasone; laparoscopic cholecystectomy; Ondansetron; postoperative nausea and vomiting (PONV)Publication Bilateral simultaneous total knee replacement under combined spinal epidural anaesthesia(Kathmandu Unviversity, 2005) Shrestha, BR; KC, NagendraThis is a case report of 68 yrs old lady who underwent simultaneous both knee joint replacement for chronic and advanced osteoarthritis. The case was performed solely under combined spinal and epidural anaesthesia (CSE). CSE is a neuroaxial block performed for different types of lower limb and abdominal surgeries. Key words: total knee replacement, combined spinal epidural, anaesthesiaPublication Cardiac arrest during laparoscopic cholecystectomy under general anaesthesia: A study into four cases(Kathmandu University, 2009) Gautam, B; Shrestha, BRAbstract Laparoscopic cholecystectomy (LapChole) has virtually superseded the more conventional open abdomen approach for the surgical treatment of symptomatic cholelithiasis. LapChole is however not a risk free procedure and serious, potentially fatal intra-operative complications can occur. Here we present case reports of four patients who suffered from intra-operative cardiac arrest during LapChole. All four recovered without residual morbidity and three of them underwent successful surgery in the same setting. No definite cause could be identified in any of the patients. We outline several possible mechanisms that could have been involved and discuss these events in face of published reports describing similar incidences. We infer that the creation of carbon-dioxide (CO2) pneumoperitoneum was involved in the causation of the cardiac arrest because all four incidences occurred within minutes thereafter. Although rare, such complications can be fatal and are thus demanding to the anaesthesiologist. Key words: Anaesthetic complications; carbon-dioxide pneumoperitoneum (CP); cardiac arrest; general anaesthesia; laparoscopic cholecystectomyPublication Celiac Plexus Denudation in Triangle Dissection in Pancreatico Duodenectomy: Perioperative Anesthetic Implications(Kathmandu University, 2022) Shrestha, BR; Sharma, M; Barahi Shrestha, S; Thapa, PB; Maharjan, DKABSTRACT This is a case report of inadvertent right celiac plexus denudation during triangle dissection during the surgery for carcinoma of pancreas under combined general epidural anaesthesia. Operative removal of the ganglia has its own autonomic effects, which are important to observe for anesthesiologists and perioperative critical care physicians alike. KEY WORDS Celiac plexus, Epidural, Hemodynamics, Pain, Triangle dissectionPublication Comparative study between bupivacaine heavy vs pethidine intrathecally to study early haemodynamic changes and postoperative analgesia in patients undergoing caesarean section(Kathmandu University, 2007) Shrestha, BR; Maharjan, SK; Thapa, CObjective: To study early hemodynamic changes and duration of postoperative analgesia between two study groups of intrathecal pethidine and bupivacaine heavy in patients undergoing caesarean section. Methodology: Total number of 60 patients of ASA I and II, undergoing caesarean section were enrolled in the study. All the patients were divided into two groups: Pethidine and Bupivacaine heavy. The dose of pethidine for subarachnoid block was 1mg/kg and in Bupivacaine group 2.2ml of 0.5% bupivacaine heavy was given intrathecally. Heart rate and blood pressure of all the patients were recorded before subarachnoid block. After giving spinal anesthesia, the heart rate and blood pressure were monitored and recorded in different time intervals. The duration of postoperative analgesia in all patients was recorded in postoperative ward. The APGAR Scores of the babies were recorded in 1and 5 minutes after delivery. The data were statistically compared using independent sample t-test. Conclusion: The hemodynamic parameters (HR & BP) were compared in different time intervals. The difference in heart rate and blood pressure at different time intervals in the two study groups were statistically insignificant as (p > 0.05). The total duration of postoperative analgesia in patients receiving sole intrathecal pethidine was 8 hours and 30 minutes. Where as, in Bupivacaine group the duration was 2 hrs and 36 minutes. This has been found statistically significant (p<0.05).Publication Comparative study of esmolol and labetalol to attenuate haemodynamic responses after electroconvulsive therapy(Kathmandu University, 2007) Shrestha, S; Shrestha, BR; Thapa, C; Pradhan, SN; Thapa, R; Adhikari, SObjective: The study was designed to evaluate the hemodynamic effects of Esmolol and labetalol in patients undergoing electroconvulsive therapy. Materials and Methods: Ninety patients undergoing electroconvulsive therapy treatment were studied according to randomized, double blind placebo controlled protocol. Ninety patients were divided into three groups with thirty patients in each group. Patients received either Esmolol (1mg/kg), Labetalol (0.25mg/kg) or Normal Saline (placebo) intravenously just after induction with propofol. The baseline heart rate and blood pressure were recorded. Hemodynamic parameters before and after drug therapy and after the ECT current application, were recorded at different time intervals. Results: It was found that Esmolol significantly attenuated the degree of tachycardia and hypertension after ECT in comparison with placebo in the first three minutes (p<0.05), whereas the rise in HR and blood pressure was significantly blunted in the labetalol group in comparison to placebo, from three minutes onward till ten minutes. (pPublication Diagnostic variability and therapeutic efficacy of ECT in Nepalese sample(Kathmandu University, 2008) Adhikari, SR; Pradhan, SN; Sharma, SC; Shrestha, BR; Shrestha, S; Tabedar, SAbstract Background: Though electroconvulsive therapy (ECT) has been used in Nepal for last twenty years, researches regarding its use, its efficacy and other data are non-existent. Aims: The objective of this study was to know about diagnostic variability and therapeutic efficacy of the use of ECT in hospitalized patients. Methods: This is a prospective comparative study between patients who received ECT and who did not using ICD- 10 as diagnostic confirmation. Psychopathology was evaluated using Brief Psychiatric Research Scale (BPRS), Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS) between the groups at admission, at discharge, at 1 Assistant Professors, Department of Anaesthesia, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal st month, at 6th month and at 12th month. Functional assessment of patients was done using Global Assessment of Function (GAF). Modified ECT was performed using general anaesthetic agent. Results: 47 patients received ECT as compared to 78 patients who were non-receivers. The patients with most common five diagnosis were paranoid schizophrenia (14.4%); psychotic depression (13.6%) ; undifferentiated schizophrenia (8.8%) ; bipolar mania (7.2% ) ;severe depression without psychosis (5.6%) . There was significant decrease in BPRS in ECT receiver as compared to non-receivers at discharge (p=0.0001), 1st month (p=0.0001), 6th month (p=0.0001) and 12th month (p=0.0001) ; in YMRS at discharge (p=.008), 1st month (p=.002) and at 12th month (p=.015) ; in HAMD-M at discharge (p=0.0001), at 1st month (p=0.0001), at 6th month (p=0.0001) and at 12th month (p=0.0001) ; in GAF at discharge (p=0.0001), at 6th month (p=0.0001) and at 12th month (p=0.0001). Conclusion: There was significant improvement in overall psychopathology of patients who received ECT as compared to non-receivers. The improvement was shown by decrement in scores in BPRS, YMRS, HDRS and GAF at the time of discharge, 1st month, 6th month and 12th month which were statistically significant. Day to day functional status of patients also improved as shown by GAF. The efficacy of ECT was very significantly shown in this study with all the psychiatric spectrum disorders. Key words: ECT, YMRS, HAM-D, BPRS, GAF, Diagnostic variability.Publication Do we have to hyperventilate during laparoscopic surgery?(Kathmandu University, 2007) Maharjan, SK; Shrestha, BRMaharjan SK1, Shrestha BR 2 1&2 Department of Anaesthesiology and Intensive care, Kathmandu medical college Teaching Hospital, Sinamangal, KathmanduPublication Inter pleural catheter technique for perioperative pain management(Kathmandu University, 2003) Shrestha, BR; Tabadar, S; Maharjan, S; Amatya, SRNA.Publication Oral administration of intravenous solution of midazolam mixed in syrup of paracetamol is an effective way of premedicating children undergoing surgery under general anaesthesia(Kathmandu University, 2007) Shrestha, S; Shrestha, BRAbstract Objective: The purpose of this study was to evaluate the efficacy of injection midazolam administered by oral route mixed in paracetamol syrup as a premedication in children undergoing surgery. Methods: 60 children undergoing elective hernia repair under general anaesthesia were randomized into two groups: the study group (group A) was given oral midazolam 0.5mg/kg (mixed in paracetamol syrup) and the control group (group B) was given just the paracetamol syrup before bringing them inside the operating theater. They were evaluated for ease of separation from their parents, ease of i.v. cannulation and induction, and for recovery time from anaesthesia. Results: it was found that in group A-96.7% of children showed satisfactory parent child separation while in group B- only 53.3% of children showed satisfactory separation (P < 0.05). Similarly in group A -73.3 % of children shad satisfactory induction while in group B only 33.3% of children had satisfactory induction. The recovery time from general anaesthesia did not differ in the two groups. No significant peri operative complications directly related to oral midazolam was noted. Conclusion: It was concluded that injection midazolam mixed in syrup paracetamol administered orally is a convenient and efficient method of premedicating children undergoing general anaesthesia. Parent-child separation and induction of anaesthesia was smooth and the recovery uneventful in children premedicated with oral midazolam. Key words: Anxiety, midazolam, paracetamol, premedication, oral, parent-child separation, induction, recovery.Publication Peripartum cardiomyopathy undergoing caesarean section under epidural anaesthesia(Kathmandu University, 2006) Shrestha, BR; Thapa, CPurpose: To report a case of peripartum dilated cardiomyopathy presenting for emergency caesarean section, this was successfully managed with Epidural Anaesthesia. Clinical features: A parturient suffering from idiopathic peripartum cardiomyopathy (E.F. 18%) was brought for an emergency caesarean section. Epidural anaesthesia was performed and 2% Lignocaine with adrenaline total 13ml was injected into the epidural space. The patient’s haemodynamic status was monitored with NIBP, ECG, pulse oximetry. Patient’s perioperative course was uneventful. Conclusion: In patients suffering from peripartum cardiomyopathy, undergoing caesarean section epidural anaesthesia is an acceptable anaesthetic alternative. Key words: Cardiomyopathy, epidural, caesarean section, anaesthesiaPublication Retrograde intubation: An alternative way for the management of difficult airway(Kathmandu University, 2008) Lama, P; Shrestha, BRAbstract Inserting a retrograde wire into the pharynx through a cricothyroid puncture can facilitate tracheal intubation in difficult situations where either a flexible fiber-optic bronchoscope or an expert user of such a device is not available.Even in cases when fibropric can not be negotiated for the purpose,this method has been claimed to be useful to manage the airway. Some mouth opening is essential for the oral or nasal retrieval of the wire from the pharynx. Here, a case of post mandibular reconstructed wound infection required surgical debridement and plate removal from reconstructed lower mandible under general anesthesia. We retrieved the guide wire passed through a cricothyroid puncture and subsequently accomplished wire-guided oro-tracheal intubation. In the absence of a flexible fiber-optic bronchoscope, this technique is a very useful aid to intubate patients with limited mouth opening. Key words: cricothyrotomy, guide wire, retrograde endotracheal intubation (REI), surgery.Publication Supraclavicular brachial plexus block with and without dexamethasone - A comparative study(Kathmandu University, 2003) Shrestha, BR; Maharjan, SK; Tabedar, STo compare the analgesic efficacy of local aesthetic with and without dexamethasone in supraclavicular brachial plexus block. Methods: Forty patients undergoing arm, forearm and hand surgeries were randomly selected. The forty patients were divided in two groups of 20 each. In-group one, a brachial plexus block was done with 40-50 ml of local anaesthetic with 1:200,000 adrenaline and in the other group the block was performed with the same amount of local anaesthetics with dexamethasone. The onset of action and duration of analgesia in the two groups were compared and any complications of the procedure were noted. Statistical analysis was done using the independent sample t-test. Results: The two groups were comparable in respect to age, sex, and weight. There was significant faster onset of action and prolonged duration of analgesia in the dexamethasone group than in the other group. There were no complications. Conclusion: Addition of dexamethasone for brachial plexus block significantly prolongs the duration of analgesia without any unwanted effects.Publication Three in one block for unilateral knee arthrotomy in an old lady(Kathmandu University, 2003) Tabadar, S; Shrestha, BR; Maharjan, SKAn old lady having septic arthritis of right knee joint underwent arthrotomy under three in one block for femoral, obturator and lateral cutaneous nerve of thigh in inguinal region, with catheter in situ. She was a case of chronic obstructive airway disease with ischaemic heart disease, so operation and postoperative pain management was planned under regional block. Anaesthesia was started by giving regional block with 0.25% bupivacaine at first and maintained with intermittent injection of 0.125% bupivacaine. The patient was pain free and comfortable though out the perioperative period Key words: Aesthesia, Regional Anaesthesia technique – 3 in 1 block, Surgery- U/L knee ArthrotomyPublication Tramadol along with local anaesthetics in the penile block for the children undergoing circumcision(Kathmandu University, 2005) Shrestha, BR; Bista, BObjective: This study was to find out the total duration of postoperative analgesia following circumcision in children when Tramadol was used as an adjunct to local anaesthetics in penile block. Methods: Forty children of age 5 – 13 yrs, ASA I & II were enrolled in this study. Patients were premedicated with ketamine and atropine intramuscularly prior to separation from their parents and IV cannulation. Penile block was then performed under strict aseptic precautions with paramedian approach by 3cm long 23g ordinary needle where 4 ml of mixture of local anaesthetics and tramadol was given on each side of the base of penis at 11 and 2 o~ clock positions. Duration of analgesia was recorded from the time of completion of surgery till the patients’ first complain of pain and when additional analgesic was given. Intraoperative analgesia duration achieved by the penile block was not included in this study due to unavoidable overlapping of sedation and analgesia produced by the premedicated IM Ketamine (4-5 mg/kg) ,which lasts for 25 minutes to 30 minutes. Unless complicated, this is the usual surgery time in our hospital for this procedure. Because of this reason, the sedation score was not used in this study. Moreover, paediatric sedation score remains too impractical and unreliable in our context. Results: Addition of Tramadol with local anaesthetics in penile block prolonged the postoperative analgesia even up to 40hours. Conclusion: Tramadol as an adjunct with Local Anaesthetics extends the duration of postoperative analgesia and can be used safely for this purpose in the children. Key words: Penile Block, Circumcision, Tramadol, Postoperative Analgesia.Publication Ultrasound Guided Stellate Ganglion Block with Dexmedetomidine as an Adjuvant in Complex Regional Pain Syndrome (CRPS)(Kathmandu University, 2021) Shrestha, BR; Lama, S; Shrestha, UABSTRACT This is a case report of successful use of ultrasound for stellate ganglion (SG) blocks in CRPS I in 11 patients using local anesthetic bupivacaine with injection dexmedetomidine as an adjunct. Ultrasound helped us to deposit Local anesthetics in target area without any noticeable side effects and trauma to adjacent structures. KEY WORDS Block, Complex regional pain syndrome, Dexmedetomidine, Stellate ganglion, UltrasoundPublication Ultrasound: An extension of clinical examination(Kathmandu University, 2007) Singh, DR; Joshi, MR; Dangol, UMS; Koirala, U; Pradhan, RL; Shrestha, BR; Mishra, CDAims and objectives: To study the impact the use of portable ultrasound can have for the benefit of the patients when used by doctors other than radiologist, in this case surgeons. Methods: Ultrasound performed by surgeons in the pre-operative, operative and post-operative period was studied. Patients presenting to the Hospital with acute abdomen was subjected to ultrasound. They were either pre-operative or post-operative patients. Five patients were scanned intraoperatively. The impact of these scans to the patients as well as the clinicians was studied. Results: This is an ongoing study and preliminary results of the scans show two pre-operative diagnosis of acute appendicular collection and one acute hydronephrosis. In the operation room, ultrasound was done on 5 cases. On three occasions, it was to locate renal stones so that it could be extracted with ease. On two of the case, it was t to confirm the adequacy of common bile duct exploration thereby allowing primary closure of the common bile duct. Post-operatively, it was used in four cases of which in two cases post-operative hemorrhage were detected timely within hours. In the other two cases, the surgical team was assured that the patient’s complaint was not surgically related. Conclusion: Ultrasound should be an extension of the clinical examination when indicated and all clinicians should be proficient in its use in their respective fields Keywords: ultrasound, non-radiologist, surgeons, per-operative ultrasoundPublication Unexpected Sudden Bouts of Coughing During Endourology Procedures: Sign of Impending Doom(Kathmandu University, 2019) Shrestha, BR; Khadgi, S; Piya, BABSTRACT Endourological procedures are commonly performed in our daily practice. Most of the time, this type of surgery is usually performed under regional anesthesia and is usually not associated with any complications. The irrigation pump used in such procedures consists of irrigating fluid flowing in high pressure. If left unnoticed, sometimes irrigating fluid can lead to passage of air into the patient venous system leading to air embolism. This can be a disastraous complication leading to even sudden mortality. Here we present a case of such incident where patient has sudden coughing followed by drop in oxygen saturation. KEY WORDS Air embolism, Anesthesia, Endourology, Persistent cough