A failed life - Mr Yeddyurappa.

It is not often that life presents somebody with an opportunity a chance that mere mortals will not get. It is not often that one becomes Chief Minister of a progressive state like Karnataka. A state with development indices far better than the ones in Hindi heartland of  India.

A state which has the ubiquitous Bangalore - The silicon valley of east, The health hub of the world in near future and so on....... The man  who got such an opportunity is no less a man himself  - the pracharak, the politician and now prisoner no 10462 in parappana agrahara former Chief Minister Mr Yedyurappa.

Recently I came across news of his compatriot from BJP, Mr Narendra Modi Chief Minister of Gujurat edified by USA, for good governance which once snubbed him by refusing visa to enter its territory. We come across another compatriot Mr Nitish Kumar of Bihar doing great work as Chief Minister with his new legislation to grant power to government to take over property of corrupt Babus is path breaking.  And here we have this gentleman Mr Yeddy who wasted an opportunity by doing exactly the opposite. A clear case of fence eating the crop. Greed and nepotism had become the hallmark and cornerstone of administration during his reign. I am unable to remember even one path breaking move made by him except for some populist schemes to garner votes in bye elections.

Mr Yeddy will be remembered for greed, Nepotism and Operation lotus - the most foul means of clinging to power. 

My views about Mr Yeddy are difficult to change - what can you say about a man whose defense was that he hasn't done anything which his predecessors did not do. In a way accepting his wrongs as a part and method of a system rewarding the winners of coveted CM post.

Mr Yeddy is very canny and has the character of coming back but will he change his ways only time will tell. All i can safely say is that - the end of Yeddy is not yet written.

But History shall judge him for wasting the very first opportunity he got when he became Chief Minister of a progressive state, with hopes of all the people on him - He failed miserably.

Drug Combinations in Anesthesia -2

Another pet combination of mine is!!!!!...... Hold your breath

Inj Diltiazem with Inj Nitroglycerine.

I generally take 5 mgs of Diltiazem and mix it with 25 mgs of Nitriglycerine. I find it especially useful when the pressures shoot up on initiation of  Cardipulmonarybypass(CPB).

Some of our patients( nearly 20%), happen to be neonates with or without Cyanaotic Heart disease requiring surgery by going on CPB. However skilled the surgeon may be one in three kids you do encounter times during initiation of bypass when the line pressures are very high probably due to initial struggling in placement or mal positioning of cannulas. These are extremely crucial times as any body who has worked with small neonates will vouch for. It takes a while for the pressures to settle down both for surgeon to rectify and position cannulas more correctly and the perfusionist to adjust to all this and still maintain proper perfusion and pressures.

It is during these times most of us including me are prone to use NTG or SNP to bring down or maintain more acceptable pressures. I have been using the above mentioned combination in a titrated way to a good effect for a long time and in quite a big number of surgeries. I find it very useful in the above scenario to say the least.

Most of our patients are for CABG, and today CPB is rarely used as we tend to go for OPCAB in almost all patients. At times during surgery when there are appreciable St changes i use the above combination. It has a tendency to produce less tachy or no tachy at all as compared to NTG alone, and the effect slightly lingers on....... even after stopping the infusion as compared to NTG alone; which i use for the benefit of patient.

Like in the previous combination I heartily recommend the use of this combination and please use it with caution till you get the hang of it. I hope there will be good peer review on this combination too.

Drug Combinations in Anesthetic practice

I find some mixtures of drugs produce better end results than when these drugs are used alone or together but separately ( not mixed into single combination/solution )

I shall highlight one today, I have used combination of Propofol and Ketamine regularly to sedate patients on surgery under regional blockade ( I have to date done more than a few thousand anesthetics in this manner ). I combine 100mgs of  Propofol with 100 mgs of Ketamine and induce sleep with 10 mgs of each purge. Once sleep is achieved, I titrate the infusion to maintain the patient in Ramsay Sedation score of 4/5 depending on the quality of block achieved. If the regional block quality is good then the sedation score is usually kept at 4 but if the block is patchy as it happens occasionally even in experienced hands I maintain a high Ramsay sedation score of 5. The combination pleasantly masks the patchy block albeit I generally advise my registrars and students to opt for General Anesthesia as first choice in case of a very unpleasant patchy block and/or an anxious patient.

Patients tolerate the combination better than either drug alone ( used alone to achieve target Ramsay score same as above ), requires less quantity of drug and surprisingly I found the emergence to be almost non existent. In a few patients where the emergence was seen it was not as bad as when Ketamine is used alone and was easily managed with Midazolam.

Drug combinations are dime a dozen with each practicing Anesthesiologist having one of his own ( the very basis of anesthesia being multi-modal approach or combined anesthesia approach ), it also makes sense as any single drug should not be treated as holy grail to achieve a  target - whatever the pharma companies may claim.

However I find this combination useful and recommend it heartily to my fellow practitioners and request them to use the combination and come up with good and critical peer reviews.