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ABSTRACTS OF PAPERS AT THE 85TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 12TH MARCH 2001, 2.30 P.M. S.P. JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. INTERVENTIONAL PAIN MANAGEMENT WITH IOHEXOL (OMNIPAQUE)

DK Baheti, DB Modi
Interventional techniques in pain management include epidural, intrathecal, sympathetic block, trigeminal and various other nerve blocks. The confirmation of spread of contrast under the fluoroscopy, prior to the injection of the non-neurolytic and neurolytic agent, is the key, to the success in treatment of chronic pain management.

The fluoroscopic assisted visualization is manadatory as:-

1. It helps, in accurate visualization of the nerve or plexus, to be blocked.

2. The spread of contrast ascertains that, it is in the right plane and has not gone in vessel, viscera, epidural or intrathecal space, peritoneum, and pleura.

Iohexol (Omnipaque) is a non-ionic, monomeric, low osmolar X-ray contrast medium. In comparison to the conventional ionic contrast, it has less than half of the osmolality, extremely low intravenous toxicity, very low protein binding, low chemo toxicity, low influence on enzyme activity, low histamine release. All these factors lead, to its wider safety margin, in, various interventional procedures.

We are presenting the experience with lohexol in 320 interventional pain management procedures, at pain management clinic of Bombay Hospital Institute of Medical Sciences between 1994-1999.

The demography of patients includes 192 males and 128 females and age varied between 14 and 68 years. Out of 320 patients 45% were suffering from medical diseases. None of the patients had history of allergy or and were not on anticoagulants. The patients were admitted for a day and routine investigations including bleeding and clotting time were done.

A special informed consent was obtained from all the patients.

There were 151 neurolytic and 169 were non-neurolytic procedures. In each patients two x-ray plates of spread of contrast medium were taken, of which one was given to patient and other was preserved for departmental record.

The access to the desired nerve, plexus or space was excellent. Out of 320 patients, in one patient of coeliac plexus block, the contrast was seen in lumbar epidural space and in other patient of caudal epidural, the both the patients, the procedure went on well without any untoward reaction.

In our series we did not encounter any sensitivity or adverse reaction to lohexol. It is found to be well tolerated and accepted by the patients.

We conclude that lohexol (Omnipaque) is a useful contrast in interventional pain management procedures for excellent visualization of the site near the nerve or plexus to be blocked, and was devoid of any untoward reaction in this series.

2. A COMPARATIVE STUDY OF USE OF FENTANYL AND LIGNOCAINE TO ATTENUATE THE HAEMODYNAMIC RESPONSE TO LARYNGOSCOPY INTUBATION IN NORMAL PATIENTS.

Nipa Bhavsar, DK Baheti
The haemodynamic response to noxius stimuli of laryngoscopy and intubation manifests an increase in pulse rate, blood pressure and cardiac output. This inturn leads to increased cardiac workload and can cause catastrophic events such as intracerebral bleed, myocardial ischaemia, myocardial infarct or acute heart failure.

Various methods have been used to attenuate this response like use of topical lignocaine in the form of aerolised spray, intravenous lignocaine, intravenous nitroglycerine, intranasal nitroglycerine, intravenous betablockers like propranolol, esmolol and intravenous sodium nitroprusside. In this study, intravenous lignocaine and intravenous fentanyl have been used to attenuate pressor response in normal patients.

A total of 60 patients of ASA grade I and II were randomly assigned to one of the three groups of 20 patients each. In group I patients received intravenous Lidocaine (2 mg/kg). In group II - patients received intravenous fentanyl (2 mg/kg) and in group III - patients received normal saline before intubation. Haemodynamic parameters that were included in the study were pulse, blood pressure - systolic, diastolic and mean and make pressure product. These were measured and recorded as follows pre-operative baseline reading, after injection of pentothal, after injection of study drug, immediately after intubation and then every 2 minutes thereafter for 10 minutes.

Soon after the patient was intubated mean pulse rate in lignocaine group had increased to 91.10 æ 12.53, in fentanyl group it remained 73.45 æ 8.60 whereas in control group it increased to 101.55 æ 8.69. The mean changes from pre-operative level of heartrate after intubation was +8.35 æ 3.93 in Lignocaine group, -7.40 æ 2.86 in Fentanyl group +20.80 æ 2.79 in control group, which shows that there is significant increase in pulse rate with Lignocaine after intubation, significant decrease in pulse rate with fentanyl after intubation and statistically significant increase in pulse rate in control group after intubation (p < 0.05). Systolic blood pressure recording after intubation were 139.05 æ 31.52 with Lignocaine, 124.7 æ 22.85 with Fentanyl whereas 163.8 æ 20.34 in control group. Mean changes in blood pressure from pre-operative level to after intubation were +10.40 æ 8.19 with Lignocaine, -1.0 æ 6.23 in Fentanyl and +29.4 æ 6.83 in control group which was statistically significant. Rate pressure product after induction and injection of the study drug was 10307.35 æ 3442.76 in Lignocaine group, 9148.8 æ 1730.17 in Fentanyl group and 11128.35 æ 3259.64 in control group. The mean change in rate pressure product from pre-operative reading till after intubation were +2048.0 æ 919.4 in Lignocaine group, -975.65 æ 748.4 in Fentanyl group and +5712.1 æ 918.7 in control group. These changes are significantly low in Fentanyl group whereas in control group it is significantly high.

Where control of blood pressure and heart rate is not utmost important to prevent detrimental complications from occurring, there is a need for a safe and effective drug to attenuate the haemodynamic response to laryngoscopy and intubation. In this study where we compared Lignocaine and Fentanyl both are safe to use as bolus intravenous dose as none of the patients had any hypotension, bradycardia, arrhythmias, respiratory depression and muscular rigidity. As far as efficacy goes Fentanyl was found to be better than lignocaine. Thus we recommend that Fentanyl in bolus dose of 2 mg/kg intravenous is safe and effective to control response to laryngoscopy and intubation, heart rate control being better than control of blood pressure.

3. A COMPARISON OF INTRAVENOUS PETHIDINE AND TRAMADOL IN THE TREATMENT OF PERI-OPERATIVE SHIVERING

Preeti A Nanda, Mansoor Sange, DK Baheti
The incidence of peri-operative shivering ranges from 34% to 53% in various studies. We have compared injection Pethidine 0.5 mg/kg intravenously with injection Tramadol 1 mg/kg intravenously for post anaesthesia shivering.

90 patients of ASA grade I and II in age group 18-70 years, who developed post-operative shivering were selected for a randomised blind study. Patients received injection Pethidine 0.5 mg/kg intravenous, injection Tramadol 1 mg/kg and normal saline in blinded study. If the patient stops shivering within 3 minutes of injection, the treatment is considered successful, if patient is still shivering after 3 minutes the treatment is considered unsuccessful. Patient was watched for next 30 minutes for 1) any signs of respiratory depression 2) change in sedation score 3) nausea and vomiting 4) any other complication and side effects.

Both Pethidine (0.5 mg/kg) and Tramadol (1 mg/kg), given intravenously as treatment for shivering in patients recovering from general anaesthesia are equally effective. But, Tramadol scores over Pethidine as it causes less respiratory depression, less sedation and has a lesser incidence of nausea and vomiting.

Hence, we recommend that both Pethidine (0.5 mg/kg) and Tramadol (1 mg/kg) can be used intravenously in treatment of post-anaesthetic shivering but caution is to be practised in administration of Pethidine in patients who may sufferadversely due to respiratory depression or sedation.

4. ORO-FACIAL REHABILITATION (FOLLOWING BRAIN DAMAGE IN ADULT POPULATION)

Priti K Shah, Roshan Vania
The face forms an integral part of one’s personality. Face and the mouth are the means by which we express our feelings and ideas verbally and non-Verbally. Following brain damage, the patient’s face and mouth often suffer considerable sensorimotor disturbances. In the total rehabilitation programme where learning to walk and self-care are in the foreground, the asymmetrical face and the complex sensory motor problems associated with eating, drinking and swallowing receive very little attention and specific treatment.

Here we would like to share the therapeutic management of oro facial problems.

The patient’s being treated were affected with,

A) Stroke,

B) Parkinsonism

C) Multiple Sclerosis

D) GBS

E) Post Neuro Surgery

F) Head injuries

Main causes are

1) Abnormal tone : tone too high or too low.

2) Abnormal sensations

3) Selective movement is difficult.

Treatment is based on careful assessment, which is as follows.

Treatment is based on accurate assessment and approach is based on solving the patient’s problem step by step. Patient is treated as a whole and the orofacial treatment commences in the very acute stage.

Some of the guidelines for the treatment are, The patient’s and the relatives are actively involved in the treatment from very beginning. Every session includes 4-5 movements, repeated 4-5 times a day depending on endurance. Patients are regularly re-assessed and treatment is progressed accordingly.

On an average we treat 300-350 patients per year of these we are able to help 70% of the patients in successful and early removal of Ryle’s tube. Though it varies from lesion to lesion as brainstem lesions take long. We have seen results even when the cases have been referred to us as late as 3-4 months.

Application of early orofacial rehabilitative measures play a major role in enhancing the quality of patient’s life and general well being. The orofacial care and treatment is the responsibility of the whole team and the patient’s relatives.

5. GASTRO INTESTINAL STROMAL TUMOUR (GIST) OF NEUROGENIC ORIGIN - A VERY RARE TUMOUR

Niranjan Agarwal, MM Begani
Case 1 : A 46 year old male presented with 3 episodes of profuse bleeding PR since 10 days with no obvious clinical signs except pallor. He was investigated, and on CT scan a mass was detected in mid jejunum. He was taken up for surgery and on exploration was found to have ileo-ileal intusscuception with a polypoidal growth with broad base as the tip of the intussusceptum. Resection and anastomosis was done clearing the mesentery along with it, in a v-shaped manure. The Frozen section report was a carcinoid tumour. However the final histopathological diagnosis along with immunohistochemistry was a Gastrointestinal stromal tumour of neurogenic origin.

Case 2 : A 60 year old male presented with a short history of epigastric lump increasing in size, with the dull aching pain over it. On examination this was a large mass in epigastrium. On CT scan, a large mass was seen arising from the anterior wall of the stomach. FNAC was inconclusive. On laparotomy there was a pearly white bosselated mass along the lesser curvature with tiny growths on the greater curvature of stomach with seedlings over the lesser omentum. Excision along with a cuff of stomach wall was done. However in view of multiple seedlings all over complete clearance was not possible. Final histopathology was GIST mostly of neurogenic origin.

6. MECKEL’S DIVERTICULUM IN VENTRAL HERNIA

Prashant Pawar, Niranjan Agarwal, MM Begani
A 64 year male presented with Umbilical swelling for 10 years duration, for last 5-6 days the swelling had become painful red and irreducible, there was no vomiting and no abdominal distension. In 1984, patient had undergone ventral hernia repair. Patient was diabetic and hypertensive.

After investigation and medical fitness laparotomy was done on him which showed Gangeronus Meckels Diverticulum with Gangrenous omentum with paraumbilical Hernia.

Excision of Gangrenous Meckels Diverticulum with Gangrenous omentum done with Resection of Ileum and end to end Ileo-Ileal Anastomosis was done. Patient had uneventful recovery.

7.CASE PRESENTATION "APERT SYNDROME"

Geetha Bharathan, Veena Trivedi-Mhatre, Deepti Chugh, Asha Andyal
Paediatric Physical Therapy practice is very interesting and exciting. Sophistication in neonatology and knowledge explosion in developmental medicine has enabled the clinicians to understand and recognize variety of development disabilities including neuro behavioral challenges. APERT syndrome is a very rare autosomal dominant congenital malformation of skull and syndactyly of hands and feet. Frequency of Apert syndrome is reported to be 1 in 1,60,000 births. Apert syndrome also known as Acrocephalosyndactyly is characterised by high and flat frontal bones, under developed middle third face, hypertelorism, proptosis and variable degree of intellectual deficiency. Various visceral anomalies and synostosis of cervical vertebrae have also been reported. Some study has reported malformation of corpus callosum and limbic structures, probable cause for mental retardation. Chromosomal abnormalities with mutation has been reported in most of the cases.

Here we, present Aryaman 16 month old male child diagnosed as a c/o Apert syndrome referred to physiotherapy at 8 months of age. He had global developmental delay and gave a H/O frequent upper respiratory tract infection, and also was hydrocephalic. He underwent craniectomy at 6 months of age and has to undergo series of corrective surgeries in the future.

This case presentation describes the therapeutic framework employed in our set up. Early intervention and home management with appropriate parent training and education and comprehensive multipronged therapeutic approach forms the crux of our management strategy.

Broad based assessment including DASII Scale was used to plan our therapy for Aryaman. They included Infant. Stimulation programme, Bobath approach for facilitating the development of his sensori-motor-perceptual skills. He was on regular chest physiotherapy for controlling his frequent chest congestion.

The child has made significant progress and therapeutic interventions would continue till he achieves independent locomotor abilities, self sufficiency in self care activities and communication skills. Hence this is not a conclusive report on the effectiveness of our approach but it is to share our experience in handling a very rare developmental anomaly with encouraging outcome.


8.EXTENDED POSTERIOR TIBIAL NEUROLYSIS IN DIABETIC DISTAL SYMMETRIC POLYNEUROPATHY

Kumkum Khadalia, SR Tambwekar

A connection between DM and peripheral nerve dysfunction has been recognized since 100s of years. In 1864 neuropathy was accepted as a consequence and not a cause. Neuropathies are the most common of the late complications. The potentially preventable late sequelae of peripheral neuropathy are foot ulceration, Charcot osteoarthropathy and even amputation.

Diabetic neuropathies have been classified in various ways. We are focusing on Distal Symmetric Polyneuropathy with sensory loss in the stocking and glove distribution. This type of neuropathy results in the neuropathic ulcer-prone feet. The pathology affecting the peripheral nerves is still poorly understood. The currently accepted theories are

DM has long been listed as a cause of entrapment neuropathy and release has been recommended. In 1988 Dellon demonstrated the susceptibility of the diabetic nerve to chronic compression reconfirming Upton’s Double Crush Hypothesis’ application in diabetes. The metabolic derangement is one crush and the other is the anatomical compression. Dellon hypothesized that diabetic neuropathy has multiple causal components and that compressive neuropathy may be the most significant component in the evolution of symptomatic neuropathic complications.

In 1992 Dellon reported on the treatment of symptomatic diabetic neuropathy by surgical decompression of multiple peripheral nerves.

In 1994 Wieman reported the treatment of hyperaesthetic neuropathic foot pain in diabetics by neurolysis of the posterior tibial nerve in the ankle region. He pointed out that

Two more reports appeared in 2000. Aszmann’s "Decompression of peripheral nerves in diabetes" and Caffee’s "Decompression of the posterior tibial nerve".

In all these reports the results have not been predictable or consistent. Dr. Tambwekar et al have demonstrated on various leprosy affected nerves that the neurolysis must extend much more proximal to the site of anatomical compression than was previously accepted. They used intra-operative electrodiagnostic studies to define the upper limit of the release necessary to get good functional results. He has applied this to clinical information to diabetic neuropathy and has been getting consistently good results.

Case selection

Distal symmetrical polyneuropathy with h/o foot ulcers

Ischaemic feet excluded

Neurolysis undertaken only after control of infection in diabetic feet

Results

No. Of nerves : 9

Cases : 6 (4 male and 2 female)

Bilateral release : 2 cases

Sensory recovery : all

Pre-op foot ulcer present in : 2 feet and healed soon after neurolysis

Complications : purulent discharge from suture line and delayed healing : 1

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