Purpose of review We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition, we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we highlight educational approaches that may lead to an enhanced learning experience and development of necessary skills for neurosciences trainees. Recent findings Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there is increasing international interest for standardization and accreditation of neuroanesthesia fellowship programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation improves cognitive and technical skills in acute neurological crises. Summary High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal neuroanesthesia and NCC curricula, and potentially impact trainees' proficiency. A research agenda is needed to validate the assessment of most effective educational interventions in neurosciences trainees with diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in future studies. Correspondence to Angela Builes-Aguilar, MD, MSc, MsEpi, Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, 275 Regent Street, London, ON, Canada N6A2H3. Tel: +1 519 671 0313; e-mail: Angelitabuiles@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2N4Sgtr
Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Τρίτη 10 Ιουλίου 2018
Anesthesia for awake craniotomy
Purpose of review The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. Recent findings Both approaches for anesthesia for awake craniotomy, asleep–awake–asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. Summary Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research. Correspondence to Alexander Kulikov, MD, PhD, Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia. Tel: +7 903 963 73 64; e-mail: akulikov@nsi.ru Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2KKGzeI
https://ift.tt/2KKGzeI
Opioid-free anesthesia: a different regard to anesthesia practice
Purpose of review In the past two decades, opioids have been prescribed increasingly for the treatment of various chronic pain conditions and during the perioperative period. Perioperative opioid administration is associated with well known adverse effects and recently to long-term use and poor surgical outcomes. In this context, the anesthesiologists have to face their responsibilities. The review discusses the neurophysiological basis of opioid-free anesthesia (OFA), the rational supporting its use in perioperative medicine as well as barriers and future challenges in the field. Recent findings OFA has gained in popularity as a way to enhance early recovery and to spare opioids for the postoperative period. Whether it is possible to deliver safe and stable anesthesia without intraoperative opioids to many patients undergoing various surgical procedures, OFA still raises questions. Accurate monitoring to measure intraoperative nociception and guide the use of adjuvants are not available. There is a need for the development of procedure-specific strategies as well as indications and contraindications to the technique. Finally, objective assessment of OFA use on patient outcomes should be recorded in large multicenter studies. Summary OFA stands as a new paradigm, which questions anesthesiology practice and might help to rationalize perioperative opioids use. Correspondence to Patricia Lavand'homme, MD, PhD, Department of Anesthesiology, Cliniques Universitaires St Luc - University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium. Tel: +32 2 764 18 21; fax: +32 2 764 36 99; e-mail: patricia.lavandhomme@uclouvain.be Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2N5zRN5
https://ift.tt/2N5zRN5
Genetics and genomics in postoperative pain and analgesia
Purpose of review The review describes recent advances in genetics and genomics of postoperative pain, the association between genetic variants and the efficacy of analgesics, and the role of pharmacogenomics in the selection of appropriate analgesic treatments for postoperative pain. Recent findings Recent genetic studies have reported associations of genetic variants in catechol-O-methyltransferase (COMT), brain-derived neurotrophic factor (BDNF), voltage-gated channel alpha subunit 11 (SCN11A) and μ-opioid receptor (OPRM1) genes with postoperative pain. The recent pharmacogenetics studies revealed an association of the organic cation transporter 1 (OCT1) and ATP-binding cassette C3 (ABCC3) polymorphisms with morphine-related adverse effects, an effect of polymorphisms in cytochrome P450 gene CYP2D6 on the analgesic efficacy of tramadol and no effect of CYP2C8 and CYP2C9 variants on efficacy of piroxicam. Summary Genetic variants associate with inter-individual variability in drug responses and they can affect pain sensitivity and intensity of postoperative pain. Despite the recent progress in genetics and genomics of postoperative pain, it is still not possible to precisely predict the patients who are genetically predisposed to have severe postoperative pain or who develop chronic postoperative pain. Correspondence to Eija Kalso, MD, PhD, Pain Clinic, PB 140, 00029 HUS, Finland. Tel: +358 9 47175885; e-mail: eija.kalso@helsinki.fi Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2KMTwVu
https://ift.tt/2KMTwVu
Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery
Purpose of review Although thoracic epidural analgesia (TEA) is considered often as gold standard in multimodal analgesia with regard to major abdominal surgery, there is an ongoing debate if it is still a viable option for enhanced recovery because of its potential severe complications. Recent findings In addition to the unsurpassed analgesic quality, a TEA offers several advantages. Studies have shown that a TEA does have a positive effect on perioperative morbidity and mortality, bowel function, the occurrence of ileus and patient mobility. Furthermore, TEA can reduce opioid-induced side effects, cardiac arrhythmias and pneumonia. When it is embedded into a multimodal fast-track program, it also shortens intensive care and hospital stay. Summary TEA provides superior pain control with a handful of important advantages if used sensibly and with caution. Because of associated risks for severe neurological complications, clear contraindications should be ruled out. Special attention needs be paid to potential hypotension in the setting of epidural analgesia. If these key points are considered, a TEA still represents a viable option for enhanced recovery after major abdominal surgery. Correspondence to Raphael Weiss, MD, University Hospital Münster, Departement of Anesthesiology and Intensive Care Medicine, Albert-Schweitzer-Campus 1, 48149 Münster, NRW, Germany. Tel: +49 251 83 47266; fax: +49 251 83 47257; e-mail: r_weiss@anit.uni-muenster.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2N8oXpN
https://ift.tt/2N8oXpN
The road to accreditation for fellowship training in regional anesthesiology and acute pain medicine
Purpose of review The purpose of this review is to provide the background and rationale for pursuing accreditation of regional anesthesiology and acute pain medicine (RAAPM) fellowships, explain specific steps and challenges in the process, and forecast the future of fellowship training. Recent findings In 2016, the first fellowship program in RAAPM was able to apply for accreditation from the Accreditation Council for Graduate Medical Education (ACGME). The establishment of this newly accredited subspecialty fellowship and the announcement of the first accredited programs represented a tremendous achievement in anesthesiology training and medical education in general and was the culmination of nearly 4 years of dedicated effort. Summary Programs with initial ACGME accreditation are on a 2-year term and will be reviewed to evaluate adherence to the program requirements and the quality of fellowship training. Deficiencies identified will need to be resolved or face loss of accreditation. However, a program's maintenance of accreditation represents a commitment to its fellows to provide a training experience that can be held as a benchmark for all programs. Correspondence to Edward R. Mariano, MD, MAS, Anesthesiology and Perioperative Care Service; VA Palo Alto Health care System; 3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA. Tel: +650 849 0254; fax: +650 852 3423; e-mail: emariano@stanford.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2KPYqB2
https://ift.tt/2KPYqB2
Anesthesia for electroconvulsive therapy
Purpose of review Electroconvulsive therapy (ECT) is a well established and effective therapy in treatment-resistant depression. It is performed under general anesthesia, but no consensus exists regarding the optimal anesthetic drugs. A growing interest in optimizing adjunctive medication regimes in ECT anesthesia has emerged in recent years. Moreover different methods of seizure induction have been evaluated. Recent findings Pretreatment with dexmedetomidine eased the propofol injection pain and reduced the hyperdynamic response to ECT, but prolonged recovery. Remifentanil exhibited no proconvulsive effect and had no effect on seizure quality. Ketamine showed an antidepressive effect but was associated with cardiovascular side effects and an increased recovery time. A bispectral index-guided anesthesia or a time delay between anesthesia and seizure induction resulted in a better seizure quality presumably by avoiding high concentrations of (anticonvulsive) hypnotics. Seizure induction by magnetism seems to be an alternative to ECT, as the former is associated with less cognitive side effects but comparable antidepressive efficacy. Summary The current practice of anesthesia for ECT should not be modified, as the evidence of studies is either too low or the results are inconsistent. Some approaches are promising but require validation in further studies with a higher number of participants. Correspondence to Prof Dr Martin Soehle, Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, D-53127 Bonn, Germany. Tel: +49 228 28714127; e-mail: martin.soehle@ukbonn.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2N6VA7A
https://ift.tt/2N6VA7A
Recent developments in ultrasound imaging for neuraxial blockade
Purpose of review Recent research has shed further light on the place of ultrasound imaging in neuraxial blockade in routine clinical practice, its use in thoracic epidurals, and real-time ultrasound-guided techniques. Recent findings Compared with the conventional technique of surface landmark palpation, preprocedural ultrasound imaging minimizes technical difficulty associated with lumbar neuraxial blockade in patients with poor-quality surface landmarks. Novice practitioners are able to learn to employ the technique effectively. Safety benefits include a reduction in postprocedural back pain associated with fewer needle passes and a lower risk of procedure-associated bleeding. The advantage of ultrasound is minimal however in patients with easily discernible surface landmarks, especially if the practitioner is highly experienced. Recent trials show that preprocedural ultrasound scanning for thoracic epidural insertion reduces needle punctures and increases early analgesic efficacy compared with the palpation technique. Real-time ultrasound-guided techniques, while feasible, remain challenging and may not offer significant benefit over preprocedural imaging in lumbar neuraxial blockade. Their role in thoracic epidural insertion requires further investigation. Summary Ultrasound imaging of the spine is a valuable technique that, while not indicated for routine use, should be part of the skillset of any practitioner that regularly performs lumbar and thoracic neuraxial blockade. Correspondence to Ki Jinn Chin, MBBS, MMed, FRCPC, Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St, McL 2–405, Toronto, Ontario M5T 2S8, Canada. Tel: +1 416 603 5118; fax: +1 416 603 6494; e-mail: gasgenie@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
https://ift.tt/2KPYosU
https://ift.tt/2KPYosU
Interleukin-18 as a diagnostic marker of adult-onset Still’s disease in older patients: a case report and review of the literature
Adult onset Still's disease is a systemic auto-inflammatory condition of unknown etiology characterized by intermittent spiking high fever, an evanescent salmon-pink or erythematous maculopapular skin rash, ar...
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Multisystem amyloidosis as the unifying diagnosis for constipation, collapse and cardiomyopathy
Amyloidosis a rare disorder characterised by the deposition of amyloid protein aggregates in different organ systems throughout the body with resulting functional impairment of affected organs. It can present with localised or multisystemic deposits. Diagnosis is often delayed due to the non-specific nature of the symptoms. We present the case of a 59-year-old man with a 12-month history of non-specific symptoms. Investigations revealed Helicobacter pylori positive gastritis. Blood tests showed only a normocytic anaemia and thrombocytopaenia. CT scan showed proximal sigmoid thickening. Biopsies were unremarkable. Echocardiogram and cardiac MRI scan showed restrictive cardiomyopathy. Congo red staining of gastric biopsies showed amyloid deposition. The patient had elevated serum kappa light chains and a bone marrow biopsy confirmed multiple myeloma and he was subsequently diagnosed with systemic light chain (AL) amyloidosis secondary to this. He was started on chemotherapy and parenteral nutrition; however, he deteriorated rapidly and so was started on palliative treatment and discharged home.
https://ift.tt/2ufg4Dc
Bilateral serpentine radio-opaque shadows near the urinary bladder: nothing but calcified vas deferens!
Description
A 77-year-old man presented with voiding lower urinary tract symptoms with history of terminal haematuria. His ultrasonography (USG) was suggestive of a 58 g prostate with thickened urinary bladder walls along with two vesical calculi. A plain X-ray was taken that showed two radio-opaque shadows in the urinary bladder corresponding to vesical calculi reported on the USG. Along with that there were two serpentine radio-opaque shadows on each side of the urinary bladder (figure 1). The primary care physician thought these shadows to be ureteric calculi/calcification and referred the patient to our centre for further workup and management. On carefully reviewing the X-ray we immediately recognised that the serpentine radio-opaque shadows were nothing but bilaterally calcified vas deferens. The shadow on the left also had a characteristic pattern of loop that the vas makes during its course towards the inguinal canal. The patient was non-diabetic and...
https://ift.tt/2ualRup
A case of posterior reversible encephalopathy syndrome associated with sepsis
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterised by parieto-occipital vasogenic oedema seen on MRI. Infection and sepsis has been reported as a possible cause for this disorder.
We present a 19-year-old immunocompetent Caucasian man with known type 1 diabetes mellitus who presented to the emergency department with acute onset of bilateral visual loss, headaches and hypertension; he had been discharged 2 weeks ago for severe diabetic ketoacidosis and Staphylococcus aureus bacteraemia. Initial CT scan of the head was negative, but MRI showed findings suggestive of PRES. He was treated with nicardipine drip for strict blood pressure management and symptoms resolved within 4 days. PRES is a rare disease that has been increasingly reported as MRI becomes more commonplace. Usually associated with immunological disease, pre-eclampsia and cytotoxic therapies but an association with sepsis due to gram-positive bacteria.
https://ift.tt/2ukOzbz
Gluten-free diet: a possible treatment for chronic diarrhoea in common variable immunodeficiency
Gastrointestinal disorders are frequent in common variable immunodeficiency (CVID). Clinical symptoms and histological alterations in CIVD can resemble celiac disease. Usually, patients with chronic diarrhoea associated with CVID do not improve with a gluten-free diet. The authors present a case of a male patient who was diagnosed with CVID at age 33 and had chronic diarrhoea which resolved after initiating a gluten-free diet. Clinical relapse occurred after gluten reintroduction. The main objective of this case report is to alert clinicians to implement a gluten-free diet in patients with CVID with chronic diarrhoea.
https://ift.tt/2u7o3TC
Unusual surgical emergency in a patient of dengue haemorrhagic fever: spontaneous rectus sheath haematoma leading to abdominal compartment syndrome
Abdominal compartment syndrome (ACS) is an uncommon complication of dengue haemorrhagic fever (DHF), described so far only in association with fluid refractory shock and high-volume resuscitation. We describe an unusual case of ACS in a patient of DHF where raised intra-abdominal pressure was due to spontaneous rectus sheath haematoma causing external compression. Early recognition of the haematoma, constant vigilance and timely decision for surgical intervention could salvage the patient with complete recovery of organ function.
https://ift.tt/2zoj5XN
A novel cause of postmenopausal bleeding in an immunosuppressed patient
Malakoplakia is a rare histiocytic disease first described in 1902 by Michaelis and Gutmann. It is associated with host immunocompromise including chronic inflammatory conditions, infectious conditions or malnutrition. Here, we report the case of uterine malakoplakia as a rare cause of postmenopausal bleeding in an immunocompromised patient.
https://ift.tt/2u7LlZl
A novel mutation in Wiskott-Aldrich gene manifesting as macrothrombocytopenia and neutropenia
Wiskott-Aldrich syndrome (WAS) is a rare X-linked disorder, described as a clinical triad of microthrombocytopenia, eczema and recurrent infections. Different mutations in WAS gene have been identified, resulting in various phenotypes and a broad range of disease severity, ranging from classic WAS to X-linked thrombocytopenia and X-linked neutropenia. WAS in some cases can be fatal without haematopoietic stem cell transplantation early in life. In this particular case, we present a novel mutation with a unique presentation. An 18-year-old man incidentally found to have macrothrombocytopenia and neutropenia at 16 years of age later found to be hemizygous for c. 869T>C (p.Ile290Thr) mutation in WAS gene. The late presentation, absence of other manifestations of WAS and presence of macrothrombocytopenia, rather than microthrombocytopenia, which is usually a characteristic finding in WAS, misled the initial diagnosis. On review of literature, this mutation has not been reported as causing WAS.
https://ift.tt/2zpBKSO
Rectus sheath haematoma causing ureteric obstruction
Rectus sheath haematoma is an uncommon condition. However, its incidence is increasing, attributed to greater use of anticoagulant therapy. We present the case of an 83-year-old woman on therapeutic enoxaparin for a prior pulmonary embolus who underwent elective right hemicolectomy and developed a rectus sheath haematoma 13 days postoperatively. Her extensive haematoma compressed retroperitoneal structures including the right ureter. She was successfully managed conservatively.
https://ift.tt/2u7o220
Rare but life-threatening complication of fecalith
Description
A 78-year-old woman with history of Addison's disease, hypothyroidism, hypertension and recent hospital admission for asthma exacerbation requiring hospitalisation for steroid pulse presented to the emergency department with 1 day of significant epigastric and right lower quadrant pain. Her pain steadily worsened and was associated with nausea and clear emesis. She was on a steroid taper for her recent asthma exacerbation, and she is normally on baseline low-dose steroids for her Addison's disease.
On evaluation in the emergency department, the patient was noted to be tachycardic in the 100s but otherwise haemodynamically stable. Her abdomen was distended, and she endorsed moderate to severe tenderness over her right lower quadrant with guarding but no rebound. Her labs were notable for white cell count of 31.6x109/L and a lactate of 4.5 mmol/L.
The patient was promptly fluid resuscitated, given intravenous antibiotics and analgesics. Given concern for bowel ischaemia, an abdominopelvic CT angiogram was...
https://ift.tt/2zoiRjp
Giant abdominal metastasis from cardiac liposarcoma
Description
The patient was a 58-year-old man. His history began 6 years before the admission to our hospital because of a syncopal episode. MRI showed a 2 cm lesion at the confluence of the left pulmonary veins. It was surgically removed and the histopathological diagnosis was of 'pleomorphic liposarcoma'. The postoperative course was regular.
Since the patient lived in a rural area, he was not treated in a high-volume reference centre for sarcoma and follow-up was not managed by a dedicated multidisciplinary team. Three years later, for the onset of an intestinal occlusion, he underwent emergency laparotomy. An ileo-ileal invagination due to a little ileal lesion was treated with a 30 cm intestinal resection. The histopathological response was again of liposarcoma. Chemotherapy was not performed.
One year later, a thoracoabdominal CT scan showed a heart recurrence and an enormous abdominal mass involving many ileal loops with intestinal subocclusion. The patient...
https://ift.tt/2u6feJU
When a patient with depression is feeling sleepy, be aware of sleep apnoea
A 67-year-old man was referred to an outpatient clinic of geriatric psychiatry because of persistent symptoms of depression and anxiety, accompanied by sleepiness. The latter had been evaluated multiple times in the general practice over several years; each time it was considered to be a symptom of depression. After referral, the patient was diagnosed with severe obstructive sleep apnoea (OSA), comorbid to a depressive and anxiety disorder. Retrospectively, we conclude that affective symptoms accompanying OSA and sleepiness were wrongfully interpreted as depression, but after having led to problems at work, they have triggered psychiatric comorbidity. Treatment of OSA in addition to the psychiatric disorders resulted in a full recovery over time. The delayed diagnosis of OSA has certainly diminished the patient's quality of life and might have precipitated the depressive disorder. Moreover, OSA poses patients at an increased risk of cardiovascular disease, hypertension, stroke and traffic accidents.
https://ift.tt/2uffEg6
Mixed extragonadal germ cell tumour of the prostate
Extragonadal germ cell tumours (EGGCTs) originated in prostate are extremely rare, with <20 cases described in the literature. We report a case of a patient with a primary prostatic mixed EGGCT. A 47-year-old man presenting severe low urinary tract symptoms and signs of prostatic enlargement, with no malignancy suspicion, underwent transurethral resection of the prostate. The histopathological evaluation suggested the diagnosis of a retroperitoneal sarcoma. The patient underwent neoadjuvant chemotherapy and then was submitted to radical cystoprostatectomy. Histology revealed a mixed EGGCT of the prostate with yolk sac tumour and seminoma components. No testicular abnormalities were identified on the postoperative scrotal ultrasound. The patient went through four cycles of chemotherapy with bleomycin, etoposide and cisplatin. After 12 months of follow-up, the patient is alive and free of recurrence.
https://ift.tt/2u6dEYs
Recurrent minor strokes/TIA with a right to left shunt
A patient came to our institution for evaluation and closure of suspected patent foramen ovale actively manifesting as cerebrovascular accident. Through further studies, we found the presence of a pulmonary arteriovenous fistula, which was subsequently and successfully closed through non-invasive percutaneous selective segmental pulmonary artery embolisation.
https://ift.tt/2zoiJAr
Empirical treatment of tuberculosis: TB or not TB?
Of the 8.6 million new cases of tuberculosis (TB) that occur globally each year, a quarter occur in India. We describe the case of a 38-year-old Indian woman who presented with symptoms of hepatitis after being treated empirically with anti-TB therapy for five months. The patient was suspected to have TB after having recurrent episodes of coughing which would improve briefly before her respiratory symptoms returned, which led to her being treated at various healthcare clinics and hospitals. We highlight the challenges the patient faced due to the lack of centralised medical records which would have prevented unnecessary investigations and treatment.
https://ift.tt/2u6fdFQ
Cold agglutinin-mediated autoimmune haemolytic anaemia associated with diffuse large B cell lymphoma
Cold agglutinin-mediated autoimmune haemolytic anaemia is associated with the development of autoantibodies that can agglutinate red blood cells at cold temperatures. While primary cold agglutinin disease is an idiopathic lymphoproliferative disorder, secondary cold agglutinin syndrome (CAS) complicates other diseases such as infections, autoimmune diseases and cancers, mostly low-grade lymphomas. Early recognition, treatment of CAS and treatment of its associated underlying diseases are crucial to a successful outcome. We report a case of CAS in a setting of diffuse large B cell lymphoma, in which the treatment course was complicated by worsened anaemia due to chemotherapy-induced myelosuppression. We reviewed previously reported cases and discussed diagnosis and treatment strategies, including novel complement inhibitors, as potential future therapy.
https://ift.tt/2zsNyUo
Postoperative diffuse alveolar haemorrhage: insidious negative pressure or sevoflurane induced?
Negative pressure pulmonary oedema is well described in the literature as an uncommon but recognised complication of general anaesthe sia; negative pressure diffuse alveolar haemorrhage is a rarer consequence. We report a case of massive haemoptysis following elective general anaesthesia using a laryngeal mask airway device and sevoflurane anaesthetic maintenance. The patient had no obvious signs of laryngospasm or other cause of upper airway obstruction perioperatively. We explore the possibility that the haemoptysis was caused by clinically unapparent negative pressure generation, but also ask whether the anaesthetic agent should be considered as a culprit.
https://ift.tt/2u8P218
Comparison of ketamine with midazolam versus ketamine with fentanyl for pediatric extracorporeal shock wave lithotripsy procedure: A randomized controlled study
Anesthesia: Essays and Researches 2018 12(2):459-464
Objectives: To compare the effects of ketamine-fentanyl (KF) and ketamine-midazolam (KM) combinations on hemodynamic parameters, recovery properties, pain, and side effects in pediatric patients undergoing extracorporeal shock wave lithotripsy (ESWL) procedure. Methodology: In this double-blinded, randomized trial, 60 pediatric patients aged between 1 and 13 years with American Society of Anesthesiologists physical status Classes I and II, who scheduled for ESWL procedure, were included in the study. Patients were randomly divided into two groups: Group KM received 0.1 mg/kg of midazolam +1–1.5 mg/kg of ketamine and Group KF received 1 μg/kg of fentanyl +1–1.5 mg/kg of ketamine intravenously. Results: There were similar demographic properties, recovery, and discharge times between groups. No statistically significant difference was found in peripheral oxygen saturation, mean and diastolic blood pressure, Ramsey sedation scores, modified Aldrete recovery scores, side effects, and recovery times (Group KM, 16.067 ± 1.2 min; Group KF, 19.46 ± 0.86 min) between groups (P > 0.05). Conclusion: KF combination offers better hemodynamic properties, less side effects with lower visual analog scores, and face, legs, activity, cry, and consolability scores than KM in the pediatric ESWL procedure.
https://ift.tt/2NFtykr
Geriatric patients with hip fracture: Frailty and other risk factors affecting the outcome
Anesthesia: Essays and Researches 2018 12(2):546-551
Background: Hip fracture is a devastating health-care problem in a geriatric patient, leading to high mortality and morbidity. Preoperative risk assessment in the geriatric patient is often inexact because of the difficulty in measuring their poor physiologic reserves. Aims: The primary objective was to find the association of modified frailty index (MFI) with 90-day mortality in geriatric patients who received anesthesia for fractured hip. Secondary objectives were to assess the association of preoperative waiting time with the 90-day mortality and the correlation of preexisting medical conditions with poor functional outcome among the survivors. Settings and Designs: This prospective, observational study was conducted at a tertiary care institution. Subjects and Methods: In this prospective observational study, done over a period of 1 year, 60 geriatric patients aged ≥65 years who received anesthesia for fractured hip and fulfilled selection criteria were recruited. The association of MFI with 90-day mortality and the correlation of preexisting comorbidities with poor functional outcome among the survivors were assessed. Statistical Analysis Used: Independent sample t-test, Mann–Whitney test, and odds ratio were used as applicable. Results: Total 60 patients were available for analysis as two patients dropped off from final 62 on follow up, fifty three patients survived after 90 days. MFI and 90-day mortality showed a significant direct correlation with P < 0.0001. However, no association was found between the preoperative waiting time and 90-day mortality. Preexisting medical conditions showed a significant association of dementia with total dependence afterward with a P = 0.02. Conclusion: There is significant statistical correlation of MFI with the 90-day mortality in the geriatric hip-fractured patients undergoing surgery.
https://ift.tt/2Jbj2Ov
Assessment of job satisfaction and quality of life among practicing Indian anesthesiologists
Anesthesia: Essays and Researches 2018 12(2):302-308
Introduction: Anesthesiologists are exposed to extreme level of stress from beginning of career. With evolution of super-specialty branches, level of stress faced has also raised. Prolonged working hours, poor hospital facilities and dependencies on surgeon are main contributing factors. Stress and unsatisfactory remuneration may lead to decrease in job satisfaction. One should have a good quality of life, but high level of stress may itself compromise quality of life. This study aims at assessment of stress, quality of life spent, job satisfaction, and health issues. Aim: The aim is to study stress level, job satisfaction, and quality of life of practicing Indian anesthesiologists. Setting and Design: This was an online survey, descriptive study. Subjects and Methods: An online survey consisting of 21 questions was sent to Indian anesthesiologists by E-mail using SurveyMonkey platform. The responses were collected and analyzed. Results: Out of 1219 anesthesiologists, 81% were satisfied being anesthesiologist, but 58% are unsatisfied with remuneration. More than one role was played by 47.7% of anesthesiologists. Nearly 83% of anesthesiologists agreed that the stress is highest among anesthesiologist compared to other medical professionals. Stress does reduce with the presence of another anesthesiologist while managing cases. Most anesthesiologists practiced various stress reduction methods of which spending time with the family was most popular method. Conclusion: This study divulges working pattern, job satisfaction, level of stress faced, methods to alleviate stress, and quality of life of anesthesiologists in India. A balanced family and professional life with proper utilization of leisure will reduce the stress.
https://ift.tt/2NFthxV
Epidural analgesia during labor: Attitudes among expectant mothers and their care providers
Anesthesia: Essays and Researches 2018 12(2):501-505
Introduction: Varying levels of knowledge and attitudes among parturients and physicians toward epidural analgesia result in its low utilization. We aimed to assess the knowledge, attitude, and practice of parturients, obstetricians, and anesthesiologists regarding epidural labor analgesia. Methodology: We surveyed obstetricians, anesthesiologists, and parturients availing care and later delivered at our hospital from July 1, 2017, to December 31, 2017. Knowledge, attitude, and practice regarding epidural analgesia were collected using a semi-structured predesigned questionnaire. Data were described as frequencies and analyzed for association between parity and various beliefs and attitudes using Chi-square or Fisher's exact test. Results: About 33% of the parturients knew that delivery is possible without labor pains, but only 18% were satisfied with the procedure. Timely epidural anesthesia could not be availed by 83% of the parturients due to unavailability of service. Among the obstetricians, 64% preferred epidural analgesia and thought that epidural analgesia prolongs the duration of labor, and 55% thought that it would increase the incidence of lower uterine segment cesarean section (LUSCS). In our survey, 48% of all anesthesiologists thought that epidural analgesia would lead to an increase in the incidence of instrumental delivery, 52% required intravenous analgesics with epidural, and 63% thought that it would not increase the incidence of LUSCS. Fear of labor and delivery pain, knowledge status, unwillingness and demand for epidural analgesia, satisfaction level, and reasons for not undergoing the procedure were significantly associated with the gravid status. Conclusion: Wide gap between desire for labor analgesia and its availability exists. A collaborative approach between anesthesiologists and obstetricians is required to disseminate correct information regarding epidural analgesia.
https://ift.tt/2J7tdDO
Clonidine as a sole epidural adjuvant in combined spinal-epidural: Clinical study
Anesthesia: Essays and Researches 2018 12(2):309-312
Background and Aims: Clonidine has been used as an epidural adjuvant along with local anesthetics; however, its use as a sole epidural adjuvant in combined spinal-epidural (CSE) anesthesia has not been explored; thus, this study aimed to assess the effects of clonidine as a sole epidural adjuvant in CSE on sensory and motor characteristics of 0.5% hyperbaric bupivacaine given by subarachnoid route. Methodology: A total of 60 patients belonging to the American Society of Anesthesiologists Classes I and II aged 18–60 years were randomized in two groups; group G300 and group GNS. G300 group received 300 mg clonidine and GNS received normal saline through epidural route followed by 15 mg of 0.5% hyperbaric bupivacaine as subarachnoid block. Onset of sensory block (time to T10) and motor block (time to Bromage 3), level of sedation (using Modified Ramsay Sedation Score), and hemodynamic changes were recorded. Two-segment regression, duration of analgesia (time for 1st rescue analgesia), and motor block (time to Bromage 0) were recorded. Student's t-test (two-tailed, independent) and Chi-square/Fisher's exact probability test were used for statistical analysis. Results: The demographic data were comparable between the groups. The onset of sensory and motor block was significantly faster in G300 (sensory-71.63 ± 4.51 s, motor-55.63 ± 2.54 s) as compared to GNS (sensory-90.13 ± 4.88 s, motor-118.43 ± 9.50 s) (P < 0.001 and < 0.001, respectively). The two-segment regression was 199.33 ± 19.11 min and 79 ± 9.77 min in G300 and GNS, respectively, (P < 0.001). Duration of analgesia was 317.90 ± 15.32 min and 207 ± 20.66 min for G300 and GNS, respectively (P < 0.001), and duration of motor block was 409.9 ± 34.87 min and 204 ± 22.79 min for G300 and GNS, respectively (P < 0.001). The side effects such as hypotension and bradycardia were statistically and clinically not significant. Conclusion: Clonidine used as a sole epidural adjuvant in dose of 300 mg, for infraumbilical surgeries, has significantly faster onset of sensory and motor block with prolonged duration of analgesia and motor blockade and no significant side effects on a conventional subarachnoid block performed with 0.5% hyperbaric bupivacaine.
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A comparison of acute physiology and chronic health evaluation III and simplified acute physiology score II in predicting sepsis outcome in Intensive Care Unit
Anesthesia: Essays and Researches 2018 12(2):592-597
Context: Acute Physiology and Chronic Health Evaluation (APACHE) III and Simplified Acute Physiology Score (SAPS) II are frequently used to predict the outcome of Intensive Care Unit (ICU) patients of sepsis. Aim: The aim of the study was to compare the predictability of outcome with APACHE III and SAPS II score in ICU patients of sepsis, severe sepsis, and septic shock and the 28-day mortality. Settings and Design: This study was an observational, prospective cohort study. Materials and Methods: A total of 100 consecutive patients of sepsis were studied over 20 months. The worst physiological and biochemical parameters during the first 24 h were recorded for the scores and the patient's 28-day outcome followed up. Statistical Analysis Used: Continuous data were expressed as mean ± standard deviation or median. Receivers operating characteristic (ROC) curve was used to find the cutoff value, area under the curve, sensitivity and specificity of APACHE III score, and SAPS II score. Binary logistic regression with response variable as the outcome was utilized. P < 0.05 was considered statistically significant. Results: The mean APACHE III score in the survivor group was 66.49 ± 18.56 as opposed to 80.67 ± 19.03 for nonsurvivors. The mean SAPS II score for the survivor group was 43.32 ± 13.02 as against the nonsurvivor group at 51.92 ± 12.34. The area under the ROC curve for APACHE III was 0.711 with 95% confidence interval as against 0.686 for SAPS II. The best cutoff value obtained for mortality prediction using the ROC curve was 69 for APACHE III while that for SAPS II was 49. Conclusions: APACHE III was found to be a better predictor of mortality as compared to SAPS II though the margin of difference in mortality prediction was not high.
https://ift.tt/2J9bgEN
The effect of single-dose intravenous dexamethasone on postoperative pain and postoperative nausea and vomiting in patients undergoing surgery under spinal anesthesia: A double-blind randomized clinical study
Anesthesia: Essays and Researches 2018 12(2):313-317
Background: The use of neuraxial anesthesia has dramatically increased. Acute postoperative pain is an undesirable outcome that can delay functional recovery for patients undergoing surgery. Nausea and vomiting in the postoperative period occurs in 20%–30% of the patients and together are the second-most common complaint reported (pain is the most common). Efficacy of glucocorticoids for reducing pain and inflammation after surgery is being explored. Glucocorticoids are strong anti-inflammatory agents, which can be used for a short-time postoperative pain control in various surgeries. Dexamethasone is a glucocorticoid with little mineralocorticoid effect commonly used perioperatively to reduce postoperative nausea and vomiting (PONV) and has a beneficial role in postoperative analgesia. Dexamethasone has also an antiemetic effect, in addition to its anti-inflammatory and analgesic effects. Aim: The main purpose of this study is to evaluate the effect of administration of single-dose intravenous (i.v.) dexamethasone on postoperative pain and PONV in patients undergoing surgery under spinal anesthesia. Settings and Design: A double-blind randomized clinical study was performed in our institute between November 2014 and October 2015 after obtaining clearance from the ethical committee. Materials and Methods: A double-blind randomized clinical study was performed on 60 patients posted for surgery under spinal anesthesia. Patients were randomly assigned into two groups: A (study: 2 ml [8 mg] dexamethasone) and B (control: 2 ml saline). In both the groups, variables such as mean arterial blood pressure (MAP), heart rate (HR), respiratory rate, severity of pain (based on visual analog scale), and other symptoms such as nausea and vomiting were recorded at different time points during the first 24 h after surgery. Statistical methods using Student t-test (two-tailed, independent) and Fischer's exact test were used for analyzing the data. Results: Between-group comparisons indicated significant differences in terms of severity of postoperative pain and PONV (P < 0.001), MAP (P = 0.063), and HR (P = 0.071), which in the study group were lower than the control group. Conclusion: i.v. dexamethasone is efficient in reducing postoperative pain, requirement of rescue analgesia on the first postoperative day, and incidence of PONV with no significant changes in vital signs.
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Would “suction above cuff” be a better option than the “standard” endotracheal tube for the prevention of ventilator-associated pneumonia: A randomized study in postoperative neurological patients
Anesthesia: Essays and Researches 2018 12(2):480-483
Context: Ventilator associated pneumonia is one the most common nosocomial infection encountered in the ICU patients. Despite of the implementation of the VAP prevention bundle, the incidence remains high. This can be attributed to the peritubal leak and the aspiration of the oropharyngeal secretions. The secretions further forms a nidus for the growth of organisms in the lower respiratory tract. In this study, a specialised tube, named 'suction above cuff endotracheal tube' is used, which has an additional suction port opening above the cuff. This is to facilitate timely aspiration of the secretion which pent-up above the cuff and gradually trickles down the trachea resulting in pneumonia. Aim: to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurological post-operative patients and its impact on clinical outcome. Settings and Design: 60 patients of post-operative neurological cases aged ≥ 18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. Results: In this study involving neurological population, there was no significant difference in incidence of clinical and microbiological VAP between SETT and SACETT group, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.
https://ift.tt/2J9MAMC
Correlation between weight of the baby and the level of sensory blockade in spinal anaesthesia for caesarean section: An observational study
Anesthesia: Essays and Researches 2018 12(2):318-321
Background: The spread of local anaesthetics during spinal anaesthesia is affected by various factors and can be unpredictable especially in parturients undergoing caesarean section. Factors like abdominal girth, symphysis fundal height etc have to studied to know their impact on level of sensory blockade. We hypothesized a study to find any correlation between weight of the baby and the level of sensory blockade. Methods: 46 parturients posted for elective caesarean section belonging to American Society of Anaesthesiologists (ASA) physical status 1 and 2 were included in the study. Maternal height and weight were noted down before entering operation theatre. All patients were instituted subarachnoid block with 2 cc of 0.5% of hyperbaric bupivacaine in sitting position. Level of sensory blockade was assessed with pin prick along midline of the patient every min till 5th minute and 5 minutes till 15th minute. The birth weight of baby was recorded soon after delivery. Results: The weight of the baby and height of the mother were correlated with the sensory blockade of T4. The number of babies weighing more than 3.5 kgs were 3 in our study out of which 2 babies were associated with maximum sensory blockade at 15th minute. It amounts to 66.7% when compared with 14.7% in babies weighing 2.5 to 3.5 kgs which is suggestive of significance ('P' value of 0.093). Conclusion: There is no statistically significant correlation between weight of the baby and the level of sensory blockade.
https://ift.tt/2NEDzON
Prevention of emergence delirium in children – A randomized study comparing two different timings of administration of midazolam
Anesthesia: Essays and Researches 2018 12(2):522-527
Background: Emergence delirium (ED) is a distressing side effect of sevoflurane anesthesia in children. Midazolam is a widely studied drug for the prevention of ED with conflicting results. Aim, Settings and Design: We designed this prospective randomized double-blind study to compare the effect of 0.03 mg/kg midazolam administered at induction and the same dose administered 10 min before the end of surgery in the prevention of ED in children undergoing sevoflurane anesthesia and also the effect on the time to recovery in both groups. Materials and Methods: Eighty children between 2 and 8 years belonging to patient physical status American Society of Anesthesiologist Classes 1 and 2 undergoing infra-umbilical surgeries under general anesthesia were randomly allocated to receive 0.03 mg/kg midazolam at induction (Group A) and 10 min before the end of surgery (Group B). Caudal block was administered for analgesia after induction. The primary outcome, the incidence of ED was evaluated using the Paediatric Anaesthesia Emergence Delirium Scale from the time of extubation till 30 min postsurgery. The secondary outcome measured was the time to recovery (time from discontinuation of sevoflurane to the time of extubation) and the results were statistically analyzed. Results: The incidence of ED was comparable between the groups (30%, 10%, 5%, and 2.5% at 5, 10, 15, and 20 min, respectively in Group A and 25%, 10%, 5%, and 2.5% of children at 5, 10, 15, and 20 min, respectively in Group B). Recovery was significantly prolonged in Group B (42.5% of patients in Group A recovered within 6 min of discontinuation of sevoflurane in Group A compared to only 20% of patients in Group B). Conclusion: There is no difference in the reduction of incidence of ED following sevoflurane anesthesia when midazolam is administered at induction or the end of surgery. However, the time to recovery was longer when the drug was administered at the end of the surgery.
https://ift.tt/2J9ubiT
Comparison of palonosetron, dexamethasone, and palonosetron plus dexamethasone as prophylactic antiemetic and antipruritic drug in patients receiving intrathecal morphine for lower segment cesarean section
Anesthesia: Essays and Researches 2018 12(2):322-327
Background: Intrathecal morphine is commonly used for postcesarean analgesia. Its use is frequently associated with opioid-induced nausea, vomiting, and pruritus. Palonosetron (0.075 mg) combined with dexamethasone (8 mg) is postulated to have an additive effect over each drug alone. The study, therefore, compared the effect of intravenous (i.v.) palonosetron, dexamethasone, and palonosetron with dexamethasone combination in preventing intrathecal morphine-induced postoperative vomiting and pruritus in lower segment cesarean section (LSCS) patients. Settings and Design: Randomized, prospective, double-blinded, observational clinical study. Methods: Ninety pregnant women, American Society of Anesthesiologists physical status class I undergoing LSCS were included in the study. They were randomly assigned to three groups – Group P received 0.075 mg palonosetron i.v., Group D received dexamethasone 8 mg i.v., and Group PD received palonosetron 0.075 mg along with dexamethasone 4 mg i.v., just after spinal anesthesia with bupivacaine 2.2 ml (12 mg) and 150 μg morphine. The incidence of pruritus, nausea, vomiting, and need for rescue drug were recorded for 24 h. Statistical Analysis: Statistical analysis was performed using Student's t-test for categorical variables and Chi-square test for noncategorical variables. Results: The incidence of nausea, vomiting was significantly more in Group D (40%) than Group P (27%) and Group PD (20%) in 24 h. The incidence of pruritus was significantly more in Group D (6%) than Group P and PD (3%). The need of rescue antiemetic was more in Group D (30%) than Group P (6%) and Group PD (3%). No difference in three groups requiring rescue antipruritic drug. Conclusion: Prevention of intrathecal morphine-induced vomiting and pruritus was more effective with palonosetron alone or with dexamethasone combination than dexamethasone alone. Combination of palonosetron and dexamethasone proved no better than palonosetron alone.
https://ift.tt/2NEDsml
Therapeutic efficacy of two different doses of dexmedetomidine on the hemodynamic response to intubation, the intubating conditions, and the effect on the induction dose of propofol: A randomized, double-blind, placebo-controlled study
Anesthesia: Essays and Researches 2018 12(2):566-571
Context: The hemodynamic response associated with laryngoscopy and tracheal intubation is a common concern for the anesthesiologist, especially in high-risk patients. The use of dexmedetomidine has found favor in obtunding this response, in addition to providing better intubating conditions and reducing the dose of other anesthetic drugs. Most of the current literature states a loading dose of 1 μg/kg dexmedetomidine to be superior to lower doses in this regard. However, using a lower dose may be advantageous by reducing incidence of adverse effects such as hypotension and bradycardia which are likelier with the use of higher dose, in addition to being more cost-effective. Aims: The aim of the study was (1) to evaluate and compare the effect of loading doses of 1 μg/kg and 0.5 μg/kg dexmedetomidine on attenuation of hemodynamic response to laryngoscopy and intubation and (2) to evaluate the efficacy of dexmedetomidine in reducing the induction dose of propofol for achieving better intubating conditions. Materials and Methods: A randomized, double-blind, placebo-controlled study was planned on ninety American Society of Anesthesiologists I and II patients scheduled for elective surgery under general anesthesia. Patients were divided into three groups. Two groups received different loading doses of dexmedetomidine infusion before induction and the third group was a control group. The induction dose of propofol required to abolish the verbal response was noted and compared in all the three groups. All patients were assessed for the intubating conditions and hemodynamic response. Statistical Analysis: Nonparametric data were compared using the Chi-square test and parametric data were compared using Student's t-test using SPSS 16.0 software. Results: Both the loading doses of 1 μg/kg and 0.5 μg/kg dexmedetomidine were equally effective in reducing the induction dose of propofol, improving the intubating conditions and blunting the hemodynamic response to laryngoscopy and intubation. The incidence of adverse effects such as hypotension and bradycardia was lesser with the loading dose of 0.5 μg/kg. Conclusions: Dexmedetomidine when used as infusion in the loading dose of 0.5 μg/kg is therapeutically as effective as when used in the dose of 1.0 μg/kg not only in reducing the induction dose of propofol but also in providing good intubating conditions and blunting the hemodynamic response to intubation. A lower dose is associated with a lesser incidence of adverse effects such as hypotension and bradycardia.
https://ift.tt/2L3zC4B
Intrathecal bupivacaine with neostigmine and bupivacaine with normal saline for postoperative analgesia: A cost-effective additive
Anesthesia: Essays and Researches 2018 12(2):328-332
Context: In day-to-day practice, subarachnoid block remains the most common type of anesthesia. Bupivacaine is commonly used local anesthetic of neuraxial blockade, though earlier 5% xylocaine and now ropivacaine and levobupivacaine are also used. Additives such as opioids and α2agonists are also used. We are using neostigmine as an additive with bupivacaine to see the duration of postoperative analgesia. Aims: To compare the efficacy of intrathecal hyperbaric bupivacaine with neostigmine when compared to hyperbaric bupivacaine with normal saline with regard to time of onset and duration of sensory and motor blockade, time to two-segment regression. Settings and Design: Randomized, double-blinded study. Subjects and Methods: One hundred patients admitted for lower abdominal and lower limb surgeries done under spinal anesthesia (SA) during the period of February 2015–August 2016. Statistical Analysis Used: Data were entered into Microsoft excel data sheet and analyzed using SPSS 22 version. Categorical data were represented in the form of frequencies and proportions. Chi-square was used as a test of significance. Continuous data were represented as a mean and standard deviation. Independent t-test was used as a test of significance to identify the mean difference between two groups. Results: Mean onset of sensory blockade with neostigmine group was 174.1 ± 107.1 s and in normal saline group 171 ± 35.6 s. Mean onset of motor blockade with neostigmine group was 197.4 ± 111.6 s and in normal saline group was 219.4 ± 73.2 s. Mean two-segment regression with neostigmine group was 110.6 ± 22.7 s and in normal saline group was 71.5 ± 17.1 min. Duration of analgesia with neostigmine group was 336.3 ± 54.5 min and in normal saline group was 188.8 ± 18.4 min. Conclusions: Intrathecal neostigmine is associated with significantly prolonged sensory, motor blockade, and effective postoperative analgesia.
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Incident reporting of adverse drug reaction to intravenous ranitidine in an emergency department
Anesthesia: Essays and Researches 2018 12(2):605-606
https://ift.tt/2L4uKwj
A comparative study of three vasopressors for maintenance of blood pressure during spinal anesthesia in lower abdominal surgeries
Anesthesia: Essays and Researches 2018 12(2):333-337
Introduction: Subarachnoid block, although being highly efficient with lesser drug doses, often has limitation such as hypotension, continues to be a matter of concern to the anesthetist. The present study was aimed to compare the use of phenylephrine, ephedrine, and mephentermine bolus for maintenance of blood pressure during spinal anesthesia in lower abdominal surgeries. Subjects and Methods: In a randomized, prospective study, 90 adult patients of either sex who developed hypotension during surgery under subarachnoid block were allocated into three groups to receive bolus phenylephrine, ephedrine, and mephentermine. The number of boluses and time taken to recover from hypotension was noted. Occurrence of adverse effects in the perioperative and postoperative period was also noted. Results: Results were analyzed by Student's paired t-test and Chi-square test. The ANOVA test was used to compare the group variances among the study groups. P < 0.05 was considered statistically significant. Thirty-four hypotensive events (average 1.03 events/patient) took place in mephentermine group. In phenylephrine group, a total of 53 hypotensive events took place. On an average, the group had a total of 1.61 hypotensive events per patient. No hypotensive event took place in ephedrine group after the first bolus of drug (average 1 event/patient). Mean heart rate in phenylephrine group was significantly lower as compared to the other two groups (P < 0.001). Conclusion: Mephentermine and ephedrine were similar in performance, offered a better hypotensive control, and had lower recurring events as compared to phenylephrine.
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Comparison of two doses of dexmedetomidine for supraclavicular brachial plexus block: A randomized controlled trial
Anesthesia: Essays and Researches 2018 12(2):470-474
Background: Dexmedetomidine is commonly used as an additive in supraclavicular brachial plexus block (SBPB). Due to its adverse effects such as bradycardia and hypotension, finding the appropriate dose of dexmedetomidine is the question. Aims: We aimed to compare two commonly used doses of dexmedetomidine (1 μg/kg and 2 μg/kg) added to levobupivacaine in ultrasound-guided SBPB in terms of its effect on duration of analgesia, hemodynamics, and associated adverse effects. Settings and Design: This randomized, double-blinded prospective study was conducted over a period of 1.5 years in our tertiary care hospital. Materials and Methods: Clearance from the Institutional Ethical Committee and Clinical Trial Registry of India was taken. Ninety patients' physical status American Society of Anesthesiologists Classes I and II undergoing upper limb surgeries under SBPB were included in this study. Patients in Group I received 1 μg/kg dexmedetomidine, whereas patients in Group II received 2 μg/kg dexmedetomidine added to 20 cc levobupivacaine. The primary outcome measure was the duration of analgesia after administering the block. Secondary outcomes included effect on hemodynamics, duration of blockade, and adverse effects. Statistical Analysis: Statistical analysis was carried out using Stata Version 10. Unpaired t-test and Chi-square test were used. Results: The duration of analgesia and sensory and motor blockade were similar in both the groups. The heart rate (HR) and mean arterial pressure were statistically lower in Group II. The incidence of bradycardia and hypotension was more in Group II. Conclusions: Increasing the dose of dexmedetomidine does not prolong the duration of analgesia, but it is associated with lower HR and blood pressure. Incidence of hypotension and bradycardia is also more. Hence, a lower dose of 1 μg/kg dexmedetomidine added to 0.5% levobupivacaine is a good balance between safety and efficacy.
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Comparison of effect of airway nebulization with lignocaine 2% versus ropivacaine 0.25% on intubation and extubation response in patients undergoing surgery under general anesthesia: A randomized double-blind clinical trial
Anesthesia: Essays and Researches 2018 12(2):338-343
Context: Both intubation and extubation are associated with pressor response. Aims: We aimed to evaluate if ropivacaine 0.25% nebulization would prevent hemodynamic and cough responses to intubation and extubation and compared it with lignocaine 2% and saline group. Settings and Design: This was a randomized double-blind clinical trial. Materials and Methods: A total of 75 patients classified as the American Society of Anaesthesiologists physical status Classes I and II belonging to 18–60 years were included in the randomized double-blind trial and divided into three groups; Group 1: received 5 ml of normal saline, Group 2: received 5 ml of 0.25% ropivacaine, Group 3: received 5 ml of 2% lignocaine through nebulization before the induction. Patients were then administered general anesthesia. Mean arterial pressure (MAP), heart rate (HR), and saturation were recorded at baseline (T1), at intubation (T2), upon anesthetic withdrawal (T3), upon eye opening (T4), upon extubation (T5), and 2 min after extubation (T6). Cough response was recorded at emergence and extubation. Statistical Analysis Used: Repeated measures analysis of variance were used to compare hemodynamic variables and Chi-square test to compare the grades of cough between the two groups. Results: The drug ropivacaine was found to be effective in reducing the hemodynamic responses to both intubation and extubation when compared to saline (P < 0.05). At extubation, though the mean values of HR and MAP were lower in ropivacaine compared to lignocaine group, the difference did not achieve statistical significance (P = 0.103 and 0.153 respectively). Only 40% of patients who received ropivacaine had cough at extubation (P < 0.001). Conclusion: Ropivacaine when used through nebulization preinduction effectively reduced both intubation and extubation responses when compared to saline. However, there was no significant difference between the ropivacaine and lignocaine on extubation response.
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The comparison of the efficacy and safety of midazolam, ketamine, and midazolam combined with ketamine administered nasally for premedication in children
Anesthesia: Essays and Researches 2018 12(2):489-494
Background: In this prospective, randomized study, we evaluated the intranasal administration of Midazolam ketamine combination, midazolam, and ketamine in premedication for children. Material and Methods: We studied 60 American Society of Anesthesiology physical status Classes I and II children aged between 1 and 10 years undergoing ear nose throat operations. All cases were premedicated 15 min before operation with intranasal administration of 0.2 mg/kg midazolam in Group M, 5 mg/kg Ketamine in Group K, and 0.1 mg/kg Midazolam + 3 mg/kg ketamine in Group MK. Patients were evaluated for sedation, anxiety scores, respiratory, and hemodynamic effects before premedication, 5 min interval between induction and postoperative period. Results: There was no difference with respect to age, sex, weight, the duration of the operation, and for mask tolerance. Sedation scores were significantly higher in Group MK. There was no statistically difference between the groups for heart rate, oxygen saturation, and respiratory rate. Conclusion: We concluded that intranasal MK combination provides sufficient sedation, comfortable anesthesia induction with postoperative recovery for pediatric premedication.
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Inter scalene block: Revisiting old technique
Anesthesia: Essays and Researches 2018 12(2):344-348
Background and Aims: The technique of percutaneous brachial plexus block has persisted in many variations since first such block given by Hirsheli in 1911.[1] Both supraclavicular and infraclavicular approaches have been described. Consequent to perivascular technique (Winnie and Collins 1964), Winnie described interscalene block (ISB) in 1970.[2],[3] Winnie's was a single deposit block which relied upon volume for its success. It is nearly 50 years that ISB has stood the test of time and has evolved from single to multiple deposits Block. In mid-90s, ultrasound guidance was first explored by anesthetists for regional anesthesia in University of Vienna.[3] As ultrasound guidance is becoming popular and is increasingly available to budding anesthetist, popularity of old technique has started waning. In this study, old technique of ISB was revisited with a view to assess its success rate with established drugs and examine if in light of ultrasound guidance, this technique has become irrelevant for anesthetist today. Methods: A retrospective study, a survey with high response rate, was done on success rate of three variations of old technique of ISB in 100 patients. In variation-1, thirty patients received two deposits of local anesthetic in interscalene groove. In variation-2, thirty patients received four deposits of local anesthetic in interscalene groove. In variation-3, forty patients received six deposits of local anesthetic in interscalene groove along with infiltration of both scalene muscles. In none of the variations, paraesthesia was sought or peripheral nerve stimulator (PNS) or imaging gadget was used. Demographic data in three variations were compared statistically using Chi-square and one-way ANOVA test. Success rate among variations was analyzed by Fisher's exact test. Results: In variation-1, 17 out of 30, in variation-2, 23 out of 30, and in variation-3, 37 out of 40 blocks were successful. Conclusion: Success of ISB given without PNS or ultrasound guidance is directly proportional to the number of deposits of local anesthetic made in interscalene groove.
https://ift.tt/2NECXbX
Minimum alveolar concentration of desflurane for maintaining BIS below 50 in children and effect of caudal analgesia on it
Anesthesia: Essays and Researches 2018 12(2):512-516
Context: Neuraxial techniques have sedative properties secondary to decreased inputs from sensory and motor afferents. We hypothesized that caudal analgesia decreases the requirement of desflurane as measured by bispectral index (BIS). Aims: This study aims to determine the minimum alveolar concentration (MAC) of desflurane for maintaining BIS below 50 (MACBIS50) in children undergoing infraumbilical surgeries with laryngeal mask airway (LMA) and study the effect of caudal analgesia on the same. Settings and Design: This is prospective and observational study. Subjects and Methods: Thirty-nine American Society of Anesthesiologists physical status Classes I and II children in between 1 and 8 years of age undergoing elective infraumbilical surgery under general anesthesia were allocated randomly into two groups (Group C and Group D) after induction with sevoflurane and LMA insertion. In Group C, caudal block was performed with 0.75 mL/kg of 0.25% bupivacaine and BIS values were recorded after 10 min for 1 min at 10 s intervals. In Group D, BIS was recorded for desflurane for 1 min at 10 s intervals followed by a caudal block with the same dose. Statistical Analysis Used: Dixon up-down method with a step size of 0.5%, and probit analysis were used for analysis. Results: A total of 39 patients were enrolled. MAC of desflurane for maintaining MACBIS50was 5.57 (95% confidence interval [CI] 5.22–5.95) in Group D and 4.31 (95% CI 3.12–5.08) in Group C. The use of caudal anesthesia lowered the MAC of desflurane for maintaining MACBIS50 in children by 22.36% (P < 0.001). Conclusions: The use of caudal analgesia significantly reduced MAC of desflurane for maintaining MACBIS50in children undergoing infraumbilical surgeries using LMA.
https://ift.tt/2Je9HFS
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