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   Table of Contents - Current issue
July-September 2019
Volume 13 | Issue 3
Page Nos. 403-600

Online since Friday, September 20, 2019

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Old meets new: Commentary on high volume, multilevel local anesthetics-epinephrine infiltration in kyphoscoliosis surgery: Blood conservation p. 403
Zeinab Ahmed Elseify
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High-volume, multilevel local anesthetics–epinephrine infiltration in kyphoscoliosis surgery: Blood conservation p. 405
Alaa Mazy, Alaa Eldin A. Elmaadawy, Mohamed Serry, Mohamed Kassem
Introduction: Scoliosis surgery is usually associated with severe bleeding. Various systemic strategies for blood conservation were applied, while the local techniques get less attention. The preemptive use of sufficient volume for proper tissue infiltration at two levels was applied. The local epinephrine may control bleeding without reliance upon deliberate hypotension, permitting a higher tissue perfusion. Materials and Methods: This prospective study included 46 patients scheduled for posterior spinal fusion for scoliosis correction. Patients were randomized into two groups. group I received a cocktail of high volume (100 ml/each 10 cm of wound length) of local anesthetics and epinephrine tumescent infiltration at the subcutaneous (SC) followed by intramuscular level bilaterally. Group C received saline infiltration in the same technique. Statistically, data were analyzed according to its distribution using the t-test, Mann–Whitney, and Chi-square tests as appropriate. Results: There was a significant reduction in blood loss (38%), reduced blood and fluid transfusion (36% and 23%), and reduced operative time (23%), with higher surgeon satisfaction. The surgical field visibility (Fromme's scale) was much better during SC and muscular dissection in Group I, while it was fair during the bony work. The satisfactory field in spite of higher mean blood pressure in Group I greatly omitted the reliance upon deliberate hypotension. Conclusion: The high-volume multilevel infiltration of epinephrine cocktail can provide a significant blood and operative time conservation in kyphoscoliosis surgery.
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Different analgesic routes of magnesium sulfate: Intravenous versus pectoralis II interfascial plane block for breast cosmetic surgeries p. 411
Maha A Abo-Zeid, Sameh Ghareeb, MM Abdelhalim
Purpose: The purpose of the study is to evaluate the most effective analgesic route of magnesium sulfate (MgSO4) either intravenous (i.v.) or pectoralis interfascial plane block. Patients and Methods: Fifty adult female patients were divided into two equal groups: i.v. MgSO4 and Pecs II block MgSO4(Pecs MgSO4) group. After general anesthesia, in i.v. MgSO4group, the local anesthetic (LA) for Pecs II block was prepared by adding 3 mL saline to 57 mL bupivacaine 0.25% divided equally for each side. A bolus i.v. solution of MgSO4 10% 0.5 diluted in saline in a total volume of 100 mL was given over 15 minutes. Then, the solution for continuous i.v. infusion; 30 mL MgSO4 10% and 70 mL saline was infused at the rate of 0.5 intraoperatively. For PecsMgSO4group, LA formed of 3 mL MgSO410% added to 57 mL bupivacaine 0.25%. Whereas, 100 mL saline was given as bolus i.v. followed by continuous infusion of 100 mL normal saline at the rate of 0.5 Results: In the group received MgSO4-bupivacaine Pecs II block, there was a nonsignificant decrease in postoperative morphine consumption compared to i.v. administration of MgSO4. The two groups were comparable in the intensity of pain and sedation scores. Conclusion: The use of bupivacaine Pecs II block enhanced with addition of MgSO4to pectoralis interfascial plane block or intravenously in patients underwent breast cosmetic surgeries under general anesthesia was associated with comparable results of the postoperative morphine requirements, intensity of postoperative pain, and extension of the duration of postoperative analgesia. The intraoperative hemodynamic effects i.v. MgSO4were superior to the pectoralis interfascial plane route of administration.
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Dexamethasone versus hyaluronidase as an adjuvant to local anesthetics in the ultrasound-guided hydrodissection of the median nerve for the treatment of carpal tunnel syndrome patients p. 417
Mohammed Awad Alsaeid
Background: Carpal tunnel syndrome (CTS) is one of the most common focal entrapment neuropathies. Although the exact etiology remains unclear, high-pressure-related intracarpal tunnel compression of the median nerve (MN), progressing ischemia, and mechanical strangulation are common mechanisms. The therapeutic managements for CTS depend on the disease severity, varying from a conservative treatment to surgical interventions. Conservative treatment is helpful for most of the patients with mild-to-moderate CTS. Hydrodissection is a minimally invasive procedure of injecting solutions into some anatomical spaces to facilitate dissection and adhesiolysis. Steroids as an anti-inflammatory drugs are used to treat chronic pain conditions. Hyaluronidase as an adhesolysis agent can also be used for epidural injections with local anesthetics (LAs) and steroids for control of chronic back pain. Aim of the Study: This study was carried out to compare the efficacy of hyaluronidase versus dexamethasone as adjuvants to the mixture of LAs in ultrasound (US)-guided hydrodissection of the median nerve in mild to moderate cases of carpal tunnel syndrome. Settings and Design: This study was a prospective randomized controlled double-blinded clinical study. Methods: 40 patients aged from 20 to 60 years old with clinical, electrophysiologic, and ultrasonographic evidence of mild to moderate CTS were included in this study. Each patient was assessed at the baseline (prior to injection) and at 1 week, 1 month, 3 months, and 6 months intervals after injection: (1) The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) which is a frequently used patient-based questionnaire for measurement of CTS. primary outcome. (2) Median motor and sensory nerve conduction studies (NCS) secondary outcome. (3) Median nerve ultrasonography. The ultrasound examination included measurement of the median nerve cross-sectional area (CSA) at the distal wrist crease (DWC). Also, the median nerve echogenicity, mobility, and vascularity at the DWC were assessed by US. Secondary outcome. All outcome assessments were assessed by single investigator who was blinded to the study details. All patients received US guided hydrodissection of the median nerve at the distal wrist crease. The selected patients were randomly allocated into 2 groups containing 20 patients each according to the study drugs; Group (D) received 5 mL (3 mL plain bupivacaine 0.5% and 2 mL (8 mg) dexamethasone), and Group (H) received 5 mL (3 mL plain bupivacaine 0.5% and 2 mL normal saline containing 300 international units (IU) hyaluronidase. Ultrasound-guided intracarpal injection using ultrasonography (Sono Scape A5; Shinzhen, China) with a 10-18-MHZ linear array transducer was performed by the same physician who was not aware of study groups, the MN was observed at the inlet of the carpal tunnel, 3 ml of solution was injected via the in-plane ulnar approach, to detach the MN from the transverse carpal ligament and an additional 2 ml was injected to separate the MN from underlying flexor tendons. All patients were observed for 30 minutes post injection for possible side effects before discharge. Normally distributed numerical data are presented as mean ± standard deviation, and differences between the groups were compared using the independent Student's t-test. Chi-square test was used for categorical data. Intragroup data at different follow up time points were evaluated using paired Student's t-test. All statistical tests were two-tailed, with P < 0.05 being considered statistically significant. Results: The demographic data of the patients in both groups were statistically insignificant (P-value >0.05). In the pre-injection time, there were no statistically significant differences between both groups as regards BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score). The comparison between both groups showed that measured parameters as regards BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score) were significantly improved in group H compared with group D in the follow up periods at 1 week, 1 month, 3 months and 6 months post-injection (P-value <0.05). The comparison within each group showed that in group D, the measured parameters; BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score) were statistically significantly improved at 1 week, 1 month and 3 months follow up post-injection times but they were not significantly improved at 6 months post-injection time compared with the pre-injection data (P-value >0.05). While in group H, these measured parameters were statistically significantly improved in the all follow up post-injection times; at 1 week, 1 month, 3 months and even at 6 months periods compared with the baseline pre-injection data (P-value < 0.05). Conclusion: In this study, it was concluded that MN hydrodissction using hyaluronidase (as an adhesolysis agent) significantly improved patients with mild to moderate CTS compared to steroid (as an anti-inflammatory agents) hydrodissection of MN as regards BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score) not only at 1 week, 1 month and 3 months follow up post-injection times but these parameters were also significantly improved at 6 months post-injection time in bupivacaine- hyaluronidase hydrodissection group compared to bupivacaine-steroid hydrodissection group.
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Esmolol infusion reduces blood loss and opiate consumption during fertility preserving myomectomy p. 423
Jehan Mohammad Ezzat Hamed, Walid Mamdouh Ataalla
Objectives: The objective of this study is to evaluate the effect of esmolol-induced hypotensive anesthesia (EIHA) on intra-operative (IO) bleeding during open myomectomy. Patients and Methods: Eighty-eight women were randomly divided into the study group received EIHA without uterine tourniquet and control group who received normotensive anesthesia with uterine tourniquet. EIHA was provided as priming dose of esmolol (0.5 before the induction of anesthesia and esmolol infusion (0.05-0.3 to maintain mean arterial pressure at 60–70 mmHg that was stopped on completion of myomectomy. Fentanyl was used as IO analgesia (loading dose: 1.0 μ then infusion of 0.2-0.4 μ All patients received 6% hydroxyethyl starch (HES; initially, 3 over 5-10 minutes and supplemental doses according to requirements) and Lactated Ringer's solution (LR; 5 Trigger for blood transfusion was hemoglobin concentration (HBC) <7 g.dL-1. Study outcomes included the extent of postoperative (PO) HBC deficit in relation to preoperative HBC, frequency of tourniquet application for the study patients, and total fentanyl consumption. Results: EIHA significantly reduced blood pressure measures since laryngoscopy and tracheal intubation till the end of surgery in the study group compared to control group. Eight study patients (18.9%) required tourniquet application for control of bleeding; however, amount of IO blood loss; total field visibility score and PO HBC deficit were non significantly lower in the study group. EIHA allowed significant reduction of the IO amount of LR and additional amounts of HES infusions. Study patients group consumed significantly lower IO fentanyl doses with significantly longer duration till the 1st PO request and the number of additional fentanyl, and lower numeric rating scale scores in study group compared to controls. Conclusion: Open myomectomy under EIHA is feasible and safe and allows fertility-sparing with minimal risk of blood transfusion. The applied procedure of EIHA allowed blunting of pressor reflexes secondary to LIT, surgical stresses and extubation, and allowed reduction of IO and PO opioid doses.
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Endotracheal intubation criteria and stress response: Airtraq versus macintosh laryngoscopes – A prospective randomized controlled trial p. 430
Sabry Ibrahim Abdallah, Khaled Mohamed Gaballah
Background: Airtraq® is a single-use video laryngoscope used to facilitate tracheal intubation in both expected and unexpected difficult airways. Aims: We hypothesized that Airtraq laryngoscope would facilitate better intubation criteria and lower stress response to laryngoscopy in comparison to the Macintosh laryngoscope. Materials and Methods: In this randomized, single-blinded, prospective study, 70 adult patients were randomly assigned to be intubated with either Airtraq (Group AT) or Macintosh (Group M) laryngoscope (35 patients in each). The primary outcomes involved intubation time, first-attempt success rate, time to best laryngoscopic view, and percentage of glottic opening (POGO) score. Other recorded parameters involved the hemodynamic and intraocular pressure (IOP) responses to laryngoscopy and intubation and complications during and after laryngoscopy and after extubation. Serum samples were collected before anesthesia induction and 2 min after intubation and analyzed for epinephrine, cortisol, and glucose. Results: Group AT had significantly higher POGO score and significantly shorter intubation time and time to best laryngoscopic view than Group M (P < 0.001). The first-attempt success rate was 97.1% in Group AT and 94.3% in Group M (P = 0.55). Postoperatively, laryngospasm and sore throat were encountered in 2.9% of Group M patients compared to 0% in Group AT (P = 1.00). The heart rate, mean arterial pressure, IOP, serum epinephrine, and cortisol were significantly increased in Group M than Group AT. Conclusion: In comparison to the Macintosh laryngoscope, Airtraq conferred significantly better intubation criteria and lesser stress response to laryngoscopy and intubation.
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Postoperative analgesic efficacy of sub-Tenon's block with levobupivacaine in retinal surgery under general anesthesia p. 437
Ola T Abdeldayem, Ghada F Amer, Mohamed G Abdulla
Background: Vitreoretinal surgery is associated with undesirable intraoperative and postoperative complications including pain, postoperative nausea and vomiting, and oculocardiac reflex (OCR). Systemic analgesics have side effects and are contraindicated in some cases. We hypothesized that the preoperative sub-Tenon's injection of levobupivacaine with general anesthesia would decrease postoperative pain and intraocular pressure as well as the incidence of complication. Methods: Eighty patients who were presented for vitreoretinal surgery, aged 30–60 years, were enrolled in the study. General anesthesia was administrated to all patients; then, they were randomized into two equal groups (40 each) – Group I: patients received 5 mL placebo solution for sub-Tenon's block and Group II: patients received 4 mL levobupivacaine 0.5% in 1 mL saline for sub-Tenon's block. Postoperative pain was evaluated using a verbal pain scale. Surgeon satisfaction, postoperative analgesic consumption, and perioperative hemodynamics were also reported. Results: Verbal rating pain scores were significantly lower at the first 6 h postoperative in Group II (sub-Tenon's levobupivacaine) compared to Group I (sub-Tenon's placebo). First analgesic rescue time and total dose of analgesic consumption were significantly reduced in Group II compared to Group I. There was a lower incidence of OCR with sub-Tenon's levobupivacaine (Group II), also surgeon satisfaction was significantly superior in the same group. Conclusion: The combination of general anesthesia with sub-Tenon's block using levobupivacaine in retinal surgery patients reduces pain scores after surgery; total analgesia requirement also decreases the incidence of OCR.
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Comparing efficacy of perineural dexmedetomidine with intravenous dexmedetomidine as adjuvant to levobupivacaine in supraclavicular brachial plexus block p. 441
Rayashettypura G Somsunder, Narayanappa B Archana, Gurulingaswamy Shivkumar, Kempegowda Krishna
Background: Prolonging postoperative analgesia using various adjuvants has become a trend in regional anesthesia practice. There are literally no studies where different routes of dexmedetomidine have been compared in supraclavicular block. We compared perineural dexmedetomidine and intravenous (i.v.) dexmedetomidine when used as an adjuvant with levobupivacaine using a nerve stimulator-guided supraclavicular block. Methodology: Sixty patients of either sex, aged between 18 and 60 years, belonging to the American Society of Anesthesiologists Physical Status Classes I and II posted for upper limb surgeries under supraclavicular brachial plexus block were enrolled for a prospective observational study. The patients were categorized into two groups: Group levobupivacine with perineural dexmedetomedine (LDP) received 20 mL of 0.5% levobupivacaine plus 10 mL of 2% lignocaine plus 1 μ dexmedetomidine perineurally, and Group levobupivacaine with intravenous dexmedetomedine (LDV) received 20 mL of 0.5% levobupivacaine plus 10 mL of 2% lignocaine and 1 μ dexmedetomidine in 50 mL of normal saline administered as infusion over 10 min and given 10 min before start of the supraclavicular block. Onset and duration of sensory and motor blocks, hemodynamic variables, adverse effects, and duration of analgesia were assessed. Results: Demographic profile, onset and duration of sensory and motor block, and duration of analgesia were comparable in both the groups. The incidence of hypotension was high in Group LDV compared to Group LDP, which was found to be statistically significant (LDP – 2, LDV – 11,P < 0.005). Twelve patients in LDV group had Ramsay sedation score >3 whereas In LDP group two patients had Ramsay Sedation score >3 which was statistically significant (LDP – 2, LDV – 12, P < 0.002). Conclusion: The i.v. dexmedetomidine is equally effective as compared to perineural dexmedetomidine with respect to onset and duration of block and duration of analgesia but has greater hemodynamic instability.
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Comparative study of effectiveness of tramadol and butorphanol as adjuvants to levobupivacaine for supraclavicular brachial plexus block p. 446
Anita Kumari, Himani Chhabra, Ruchi Gupta, Harmandeep Kaur
Background: Butorphanol and tramadol, the synthetic opioid analgesics, have been used alone or in combination with a local anesthetic in supraclavicular brachial plexus block. Aim: The aim of this study was to evaluate the sensory and motor block characteristics with the addition of tramadol (100 mg) and butorphanol (2 mg) to levobupivacaine for supraclavicular brachial plexus anesthesia. Settings and Design: This study was a prospective, randomized, double–blind, and comparative study. Materials and Methods: Patients were randomly allocated to three groups of 30 each. Group A received 0.5% levobupivacaine (25 mL) and saline in 5 mL, Group B received 0.5% levobupivacaine in 30 mL with 100 mg tramadol, and Group C received 0.5% levobupivacaine in 30 mL with 2 mg butorphanol. The duration of sensory block was evaluated as a primary outcome and other parameters as secondary outcomes. Statistical Tests: Statistical analyses were performed using Chi-square test for nonparametric data and analysis of variance for parametric data. Results: Onset time of sensory block was fast and comparable in both Group B and C as compared to Group A (P = 0.000). Group C had the longest duration of sensory block and duration of analgesia followed by Group B and Group A. Group C and Group B showed statistically longer duration of motor block as compared to Group A (P = 0.000). Hemodynamic derangements and adverse effects were comparable. Conclusion: Butorphanol (2 mg) as an adjuvant to levobupivacaine in supraclavicular block hastens the onset and prolongs the duration of the block as well as postoperative analgesia to a greater extent as compared to the addition of 100 mg tramadol.
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Survey of surgeons attitude to local anesthetics for postoperative pain relief p. 452
PL Narendra, Harihar V Hegde, K Chandrashekharappa, Vrinda V Tore, Preetish Endigeri, Mahesha Boodadi, Dayanand G Talikoti, Maroof Ahmad Khan
Background: There is no ideal postoperative pain management. Simple surgeon-delivered local anesthetic (LA) techniques such as wound infiltration and regional nerve blocks can play a significant role in the improvement of postoperative pain relief. Settings and Design: Administered paper questionnaires to delegates attending surgical society conferences. Methods: A 15-point questionnaire was administered to surgical delegates attending general surgey, orthopedic and gynecological conferences at different locations. Results: Response rate was 65.26%. 33% of surgeons used LA regularly, 31% occasionally, and 36% never used LA for postoperative analgesia. 50% of all surgeons used lignocaine for local anesthesia (P < 0.0001) and infiltration (65% of all surgeons) was the most common method (P < 0.0001). Only 30% surgeons knew the correct duration of action of bupivacaine infiltration (P < 0.0001) and only 4% surgeons knew that LAs are antimicrobial (P < 0.0001). 53% of orthopedic surgeons used combination of lignocaine and bupivacaine, while 46% of general and 73% gynecologists surgeons used lignocaine more commonly. Only <5% of all surgeons had used long-acting liposomal bupivacaine and almost 40% more were willing to use the liposomal LA drug only if more evidence is available. Conclusions: Although majority of surgeons were aware of the benefits of LA use for postoperative pain relief, reluctance, lack of knowledge of LA drugs and methods of LA use and fear of infection and wound healing are barriers for effective use of LA drugs for postoperative pain relief. Attending anesthesiologists must develop methods in the operating room to create awareness about the effectiveness of LA use for postoperative pain relief. Single-use vials or ampules of LA must be encouraged to LA use for postoperative analgesia, especially in the third-world countries.
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Comparison of the analgesic efficacy of a single dose of epidural dexmedetomidine versus fentanyl as an adjuvant to bupivacaine in abdominal surgery p. 465
Durga Prasad Sekhar, Lakshmi Kumar, Rajesh Kesavan, Shyamsundar Purushottaman, Zubair Umer Mohammed, Sunil Rajan
Background: Fentanyl as an epidural additive act on spinal opioid receptors, while dexmedetomidine has selective alpha-2 receptor agonist action enhancing analgesic effects. Aims: We aimed to compare the postoperative analgesic efficacy of single doses of dexmedetomidine against fentanyl as epidural adjuvant to 0.125% bupivacaine. Settings and Design: A prospective, randomized, controlled, double-blind trial was conducted in a tertiary care teaching institute. Patients and Methods: Forty-six patients undergoing abdominal surgery under general anesthesia with epidural analgesia were allocated into two groups to receive postoperative analgesia with single doses of 10 mL 0.125% bupivacaine with the addition of dexmedetomidine 0.5 μ (Group D) or fentanyl 0.5 μ (Group F). The primary outcome was the duration of postoperative analgesia between the two groups. The secondary outcomes were hemodynamic variations, vasopressor need, and motor blockade. Statistical Analysis: Chi-square test for static parameters and Student's t-test or Mann–Whitney test for continuous variables were used for analysis. Results: The duration of analgesia was longer in Group D (5.0 ± 2.0 h) versus Group F (2.9 ± 1.4 h), Sixteen patients in Group D versus seven patients in Group F needed vasopressors after the bolus to maintain the blood pressure (BP) within 20% of prebolus value (P = 0.018). Heart rate and mean and systolic BP were lower in Group D at various time points following bolus administration. Conclusion: A single dose of dexmedetomidine as an additive to epidural local anesthetic postoperatively prolongs the duration of analgesia in comparison to fentanyl but is associated with changes in hemodynamics, including the need for the administration of vasoactive drugs.
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Intrathecal 1% 2-Chloroprocaine with fentanyl in comparison with ropivacaine (0.5%) with fentanyl in day care perianal surgery: Prospective randomized comparative study p. 471
B Bhaskara, Sindhu A Prabhakar, Ramachandraiah Rangadhamaiah
Background: Spinal anesthesia is a reliable and safe technique for perianal surgeries; the changing trend of surgical practice from an inpatient to outpatient has urged us to use lower dose of local anesthetic providing segmental block with adjuvants such as opioids. Ropivacaine is a long acting; amide local anesthetic, with greater sensory motor differentiation. Chloroprocaine (CP) is an amino-ester local anesthetic with a very short half-life. This study was designed to compare CP with ropivacaine for spinal anesthesia in an elective ambulatory setting. Methods: This prospective, randomized, comparative study included 60 adult patients scheduled to undergo perianal surgeries under subarachnoid block with intrathecal 3.0 mL of 1% CP with 12.5 μg fentanyl (Group C) or 1.5 mL of 0.5% ropivacaine with 12.5 μg fentanyl (Group R). Statistical Analysis: Chi-square test used to assess significance for qualitative data, independent t-test for significance of the mean difference between two quantitative variables. Results: Meantime of onset of sensory block at T10 in both the groups were comparable (Group C – 4.7 min, Group R – 4.8 min). Maximum upper level of sensory block was at T8 in both the groups, time for regression of sensory level to L1 was significantly longer with ropivacaine (Group R – 135 min, Group C – 76 min, P < 0.0001), and the duration of motor blockade (Group C – 81 min, Group R – 145 min P < 0.0001) was significantly short in the Group C with early ambulation (160 min). Conclusion: CP provides adequate duration and depth of surgical anesthesia for short procedures with the advantages of faster block resolution and earlier hospital discharge compared with spinal ropivacaine.
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Comparison between position change after low-dose spinal anesthesia and higher dose with sitting position in elderly patients: Block characteristics, hemodynamic changes, and complications Highly accessed article p. 476
Mohammed A Alsaeid, Atef M Sayed
Background: Large numbers of patients are presenting for surgeries with aging-related pre-existing conditions that make them at higher risks of adverse outcomes. Hemodynamic instability due to high sympathetic nerve block largely limits the use of conventional dose spinal anesthesia in high risk elderly patients. Aims and Objectives: We aimed to compare the hemodynamic stability and the block characteristics in low dose spinal anesthesia (5 mg) with immediate position change into supine position versus higher dose of spinal anesthesia (10 mg) with maintaining patient position in sitting position for 3 minutes after the block in elderly high risk population. Settings and Design: This study was a prospective randomized controlled double-blinded clinical study. Materials and Methods: This study was carried on 70 patients of American Society of Anesthesiologists physical status classes I, II, and III aged 50 years old and above, who were scheduled for elective knee and below knee orthopedic surgeries expected to last for 40-60 minutes under spinal anesthesia. Patients were randomly allocated into two groups: group (A) Sitting group n= 35 patients that received 10 mg hyperbaric bupivacaine 0.5% in 2 mL volume intrathecal at level lumbar (L4-5) in sitting position and remained in this position for 3 minutes before turning supine. And, group (B) Supine group n = 35 patients received 5 mg (low dose) intrathecal hyperbaric bupivacaine in 2 mL volume (1 mL hyperbaric bupivacaine 0.5% diluted with 1 ml sterile distilled water) at L4-5in sitting position then turned supine immediately. The injection will be in the midline over 30 seconds by 25 gauge(G) Quincke needle. We measured the changes of mean arterial blood pressure, heart rate, O2saturation and the incidence of hypotension and bradycardia intraoperatively as a primary outcome. Also, we measured the characteristics and the duration of the sensory and motor blocks, the duration required till return of bladder function and the satisfaction levels of both the patients and the surgeons as secondary outcomes. Statistical Analysis Used: Student's t-test and Chi-square test were used for analysis. Results: As regards hemodynamics, mean arterial blood pressure and heart rate were significantly lower in group A compared to group B; P-value <0.05, during the intraoperative period, while MABP and HR were significantly decreasing in group A during the initial intraoperative period at 5 min, 10 min, 15 min, 20 min, 25 min, 30 min and 35 min, but in group B these parameters were statistically insignificant throughout the whole procedure P-value >0.05. As regards oxygen saturation, there were no significant differences between both groups or within the same group during the whole intraoperative period. Comparing sensory and motor blocks, sensory block was significantly higher and motor block was significantly dense in group A compared to group B during the first intraoperative period at 5 min, 10 min, 15 min, 20 min and 25 minutes. The recovery times from sensory and motor blocks were significantly longer in group A compared to group B (P-value <0.001). Also, the void recovery time was significantly longer in group A (129.29 ± 5.87 min) compared to group B (114.77 ± 8.24 min). In group B, patient satisfaction was significantly better (25 excellent/ 10 good) compared to group A (10 excellent/25 good). Also, surgeon satisfaction was statistically significantly better in group B (23 excellent/12 good) compared to group A (14 excellent/21 good). As regards side effects, in group A, 3 patients had to receive ephedrine due to significant reduction in MABP while no patients in group B had significant hypotension or bradycardia throughout the intra operative period. Conclusion: We concluded that the use of small dose of heavy bupivacaine 0.5% (5 mg) with immediate patient position changing to supine position provided good spinal block characteristics in elderly population without any hemodynamic side effects, also with better patient and surgeon satisfaction levels compared to higher doses of heavy bupivacaine (10 mg) even if we maintained patient position in the sitting position for 3 min after the block.
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Incidence and severity of postoperative pharyngolaryngeal complications following use of baska mask versus endotracheal intubation p. 481
Pulak Tosh, Sunil Rajan, Lakshmi Kumar
Background: Use of Baska Mask, since a supraglottic airway device, could result in low incidence of postoperative pharyngolaryngeal complications. Aims: The objectives were to compare the effect of Baska Mask versus endotracheal intubation on the incidence and severity of postoperative sore throat (POST), postoperative hoarseness of voice (POHV), and postoperative cough (POC). Settings and Design: This prospective randomized study was conducted in a tertiary care teaching institute in 120 patients undergoing short laparoscopic surgeries. Subjects and Methods: Airway was secured using with low-pressure, high-volume cuffed endotracheal tube in Group T and with Baska Mask in Group B. POST, POC, and POHV were assessed at 2, 6, 12, and 24 h after surgery. Those with Grade III score throat were managed by gargling with dispersible aspirin 75 mg. Statistical Analysis Used: Pearson's Chi-square test, Fisher's exact test, and independent sample t-test were used as applicable. Results: Group B patients required significantly more attempts at securing airway. Incidence of POST was significantly higher in Group T as compared to that Group B at 2, 6, 12, and 24 h after surgery. POC was significantly more in Group T at 2, 6, and 12 h. No patient in Group B had POC at 12 and 24 h. POHV showed significantly higher incidence in Group T at 2 and 6 h. No patient in Group B had hoarseness at 6, 12, and 24 h. Conclusion: Use of Baska Mask as compared to endotracheal intubation significantly reduces the incidence and severity of pharyngolaryngeal complications such as POST, POC, and POHV in patients undergoing short laparoscopic surgeries.
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Randomized open-labeled comparative evaluation of the efficacy of nitroglycerine, esmolol, and dexmedetomidine in producing controlled hypotension in spine surgeries p. 486
Rumani Ruku, Anju Jamwal, Naine Bhadrala, Smriti Gulati
Aim: This study was designed to evaluate the efficacy of nitroglycerine (NTG), esmolol, and dexmedetomidine (DEX) as hypotensive agents in decreasing intraoperative blood loss by producing controlled hypotension in posterior spine surgeries. Materials and Methods: Sixty patients aged 18–60 years, the American Society of Anesthesiologists physical status Classes I and II of either gender, were randomly assigned into three groups to receive either: NTG (0.01%) at the rate of 3–10 μ after positioning without a prior loading dose in Group N, esmolol 500μ loading dose over 1 min before induction of anesthesia followed by 50–300 μ infusion in Group E, and DEX 1 μ over 10 min before induction followed by 0.2–0.7 μ infusion in Group D to maintain mean arterial blood pressure (MAP) between 60 and 65 mmHg. The three groups were compared for the achievement of target MAP, intraoperative blood loss, reversibility of hypotensive state, quality of surgical field, emergence time, and postextubation sedation score. Statistical Analysis: Analysis of variance was used for intergroup analysis, and for multiple comparisons, Bonferroni post hoc test was applied. P < 0.05 was considered statistically significant. Results: Patients in Group D and Group E achieved the target MAP with better heart rate control as compared to Group N. The intraoperative blood loss was significantly lesser in Group D (P < 0.001). The time to hypotension reversal and emergence time was prolonged in Group D (P < 0.001). The mean quality of surgical field score was statistically insignificant among the three groups. The mean Ramsay Sedation Scores were significantly higher in Group D compared to Groups N and E at 20th and 40th min postextubation (P < 0.001) with no significant intergroup difference at 60th min postextubation (P = 0.130). Conclusion: Continuous infusion of DEX is an effective and safe method of producing controlled hypotension by achieving the target MAP, minimizing blood loss, and maintaining superior hemodynamics in comparison with NTG and esmolol in posterior spine surgeries.
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A Prospective, randomized, single-blind, comparative study of dexmedetomidine and propofol infusion for intraoperative hemodynamics and recovery characteristics in laparoscopic surgeries p. 492
Vasantha Kumar Janardhana, Vijayashree Thimmaiah
Background: Creation of pneumoperitoneum in laparoscopic surgeries with carbondioxide to intra-abdominal pressures higher than 10 mmHg induces significant alterations of hemodynamics. To counteract, propofol or dexmedetomidine was compared and postoperative recovery assessed. Aims: The aim of this study was to compare the efficacy of standard dose of propofol versus low-dose dexmedetomidine as infusions to limit hemodynamic instability with pneumoperitoneum and facilitate recovery. Settings and Design: This was a prospective, randomized, single-blind, comparative study. Materials and Methods: Seventy patients between 18 and 60 years belonging to the American Society of Anesthesiologists Physical Status Class 1 and 2 scheduled for laparoscopic surgeries were randomly divided – Group D: To receive dexmedetomidine 1 μg/kg over 10 min before and 0.2 μg/kg/h infusion after intubation till the end of pneumoperitoneum and Group P: To receive propofol 100 μg/kg/min after intubation till the end of pneumoperitoneum. Variables such as heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded at baseline, preinduction, after loading dose of dexmedetomidine, postinduction, postintubation, at pneumoperitoneum, every 15 min till the end of surgery, at extubation, and postoperatively for 2 h monitored with Ramsay Sedation Scale and modified Aldrete's score. Results: Hemodynamic stability was better maintained in Group D than Group P with significant attenuation of hemodynamic stress response to pneumoperitoneum in terms of HR (3% decrease vs. 18% increase), SBP (5% decrease vs. 12% increase), DBP (2%increase vs. 16% increase), and MAP (4% decrease vs. 7% increase). Postoperatively, significant sedation was noted till 90 min in Group D and recovery was better in Group P. Conclusion: With doses of test drug infusion used, there is better attenuation of hemodynamic stress response to pneumoperitoneum with dexmedetomidine and faster recovery with propofol.
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A comparative evaluation of hemodynamic response and ease of intubation using Airtraq and McCoy laryngoscope p. 498
Alok Kumar Sahoo, Kalpana Majhi, Indraprava Mandal
Background: Various airway gadgets have been devised to overcome difficult airway scenario in anesthesia practice. It includes simple rigid laryngoscope to complex fiber-optic intubating devices; however, there is weak evidence to support the superiority of one device over the other. Aims and Objective: The ease of intubation, time and the hemodynamic variability between two groups during intubation are considered as the primary outcome measures. Materials and Methods: In this prospective study, 60 patients of either sex undergoing elective surgery who required tracheal intubation were included. All the patients of age between 20 and 50 years with the American Society of Anesthesiologists Classes I and II were divided into the following two groups: Group AT (n = 30): the intubation was performed using AT laryngoscope and Group-MC (n = 30); the intubation was performed using MC laryngoscope. The following intubating parameters were recorded: ease of intubation (Grade-I–IV), mean time of laryngoscopy and intubation, Cormack–Lehane grade, and the percentage of glottis opening (POGO) score. The vital parameters such as heart rate (HR) and mean arterial blood pressure (MABP) were recorded only after premedication, and it was taken as the baseline value. These parameters were again recorded at 1 min, 3 min, 5 min, and 10 min after laryngoscopy and intubation. The incidences of sore throat were recorded just before discharge from the recovery room till 24 h of surgery. All these parameters were compared between these two groups using the Student's t-test and Chi-square test. Results: There was no significant difference in age, sex, weight, and Mallampati grading between the two groups. More than 30% of patients in Group AT were intubated without an external aid than the Group MC (P < 0.05). In Group AT, the mean time of intubation was 13.5 ± 5.72 s when compared to 15.63 ± 7.28 s in Group MC (P > 0.05). The Cormack–Lehane grade and POGO score were better in the AT group than that of the MC group. The HR at 1 min in Group AT was 101.83 ± 14.50 and in Group MC, it was 108.93 ± 12.86 (P < 0.05) and after 3 min, it was 98.66 ± 12.60 and 111.53 ± 11.67 (P < 0.05), respectively. The MABP was 107.17 ± 9.03 in Group AT compared to 116 ± 10.12 in Group MC (P < 0.05) at 1 min postintubation. The incidences of sore throat were similar in both the groups. Conclusion: The AT laryngoscope is better than MC in terms of the ease of intubation, better glottis view, and hemodynamic stability. However, the incidences of sore throat in both groups were comparable.
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Assessment of Anxiety in Surgical Patients:An Observational Study p. 503
Amit Kumar, Prakash K Dubey, Alok Ranjan
Context: Preoperative anxiety in surgical patients imposes stress and dissatisfaction. It results in altered neuroendocrine response and various perioperative complications. Aims: This study was conducted to determine the changes in anxiety level and need for information about the anesthetic and the surgical procedures at three different time points before surgery and evaluate the correlating factors. Settings and Design: A prospective observational study in a university hospital. Materials and Methods: Five hundred adults, American Society of Anesthesiologists Physical Status Class 1 and 2 patients were included in this study. Level of anxiety and need for information were assessed with the Amsterdam Preoperative Anxiety and Information Scale at three time points before the surgery: Evening before surgery in the ward (T1); on the day of surgery, in the preoperative holding area (T2); and in the operating room, after being positioned on the operating table (T3). T-test was applied to compare the mean between two groups, and the Chi-square test for independence of association between two categorical variables. Mann–Whitney–Wilcoxon test was applied to test the equality of distribution between two groups. Kruskal–Wallis test was applied for one-way analysis for comparing median score, and Friedman test was applied for two-way analysis of comparing score among three time points. Results: Total anxiety score recorded was significantly different over the time period (P = 0.023), with an increasing trend over the time. Need for information did not change significantly over time period. Conclusions: Preoperative anxiety continues to increase from ward to operation table. The factors responsible are nonmodifiable.
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The influence of different degrees of temperature of intrathecal levobupivacaine on spinal block characteristics in orthopedic surgeries: A prospective randomized study p. 509
Reem Abdelraouf Elsharkawy, Medhat Mikhail Messeha, Adham Abdelraouf Elgeidi
Background and Aims: The temperature of the local anesthetics may affect the distribution of spinal anesthesia. The aim of the current study is to compare the effects of different degrees of intrathecal levobupivacaine 0.5% on the spinal anesthesia characteristics and shivering in orthopedic surgery. Materials and Methods: A randomized, prospective, and controlled trial was conducted on 120 patients aged 40–70 years with American Society of Anesthesiologists Classes I and II and who scheduled for orthopedic surgery; they were randomly distributed into three groups: Group 1 (L 24°C) – levobupivacaine 0.5% warmed to 24°C; Group 2 (L 30°C) – levobupivacaine 0.5% warmed to 30°C; and Group 3 (L 37°C) – levobupivacaine 0.5% warmed to 37°C. Every patient had received 3 mL of 0.5% levobupivacaine intrathecally. Sensory blockade was tested using the loss of pinprick sensation, whereas the motor block was tested using the modified Bromage scale. The onset and grading of shivering after spinal anesthesia were recorded. Results: The use of intrathecal levobupivacaine 0.5% warmed to either 30°C or 37°C resulted in a significant acceleration of the onset of either sensory or motor blockade with a significant prolongation in the duration in addition to significant delay in the onset of shivering and the time of the first analgesia requirement in comparison to those of spinal anesthesia with levobupivacaine at room temperature (24°C). Notably, a nonsignificant difference in the spinal block characteristics and shivering was observed between Group L 30°C and Group L 37°C. Conclusion: The increasing the temperature of levobupivacaine 0.5% to 30 °C attains more rapid onset of sensory and motor blocks ,with prolongation of the onset of shivering. It could be considered as effective equivalent to warming levobupivacaine 0.5%to 37°C in spinal anesthesia.
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Comparative evaluation of the effects of pregabalin, dexmedetomidine, and their combination on the hemodynamic response and anesthetic requirements in patients undergoing laparoscopic cholecystectomy: A randomized double-blind prospective study p. 515
Naveen K Vijayan, Vandana Talwar, Madhu Dayal
Background: In this study, we evaluated the efficacy of premedication with dexmedetomidine, pregabalin, and dexmedetomidine-pregabalin combination for attenuating the haemodynamic stress response to laryngoscopy and intubation and pneumoperitoneum (primary outcome), and for reducing anaesthetic requirement (secondary outcome) in patients undergoing laparoscopic cholecystectomy. Methods: Ninety ASA physical status classes I-II patients, between 18 to 65 years of age, of either sex, scheduled to undergo laparoscopic cholecystectomy were included in this randomised double blind study. Morbidly obese patients and those with history of hypertension, cardiac, renal, hepatic, endocrine or pulmonary dysfunction were excluded. Patients were randomized to three groups – Group P- received oral pregabalin (150 mg) one hour before induction and 100 mL of i.v normal saline (0.9%) over 10 minutes, 10 minutes before induction; Group D- received i.v dexmedetomidine (1 μ−1) prepared in 100 mL of 0.9% normal saline and given over 10 minutes, 10 minutes before induction, and an oral placebo tablet one hour before induction; and Group C-received a combination of oral pregabalin 75 mg one hour before induction, and IV dexmedetomidine (0.5 μ−1) prepared in 100 mL of 0.9% normal saline over 10 minutes, 10 minutes before induction. Results: Dexmedetomidine significantly attenuated the stress response to laryngoscopy and intubation and pneumoperitoneum and reduced anaesthetic requirement as compared to the other two groups. Dexmedetomidine was associated with significantly lower mean arterial pressures and higher sedation score in the preoperative and postoperative period and significantly lower heart rate and arterial pressures and reduced anaesthetic requirement in the intraoperative period as compared to the other groups. Conclusion: Dexmedetomidine is a valuable adjunct to the technique of balanced anaesthesia for maintaining haemodynamic stability.
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Efficacy of adding midazolam to bupivacaine for transversus abdominis plane block on postoperative analgesia after hysterectomy: A randomized controlled study p. 522
Samah El Kenany, Mohamed Eslam Elshehawi, Ahmed Mohamed Farid, Mohamed Ibrahem Eid
Background and Aim: Different adjuncts have been utilized to promote the quality and prolong the duration of local anesthetics for a variety of regional block techniques. This study aimed to assess the effects of midazolam coadministered with bupivacaine in transversus abdominis plane (TAP) block on the 24-h morphine consumption, the postoperative analgesia duration and adverse effects. Settings and Design: A prospective, randomized, controlled double-blind trial that was carried out at a university hospital. Patients and Methods: Eighty-two females subjected to open total abdominal hysterectomy under general anesthesia were involved in this trial. Participants were allocated randomly to either of two groups (41 each). Control group: received TAP block with 20 mL of 0.25% bupivacaine or midazolam group: received TAP block using the same volume of bupivacaine plus 50 μg/kg midazolam/side. Postoperative cumulative 24-h morphine consumption, analgesia duration, pain score, sedation score, and adverse events were recorded. Statistical Analysis: Student's t-test, Mann–Whitney U-test, and Chi-square test were used. Results: Patients in the midazolam group had a lower cumulative 24-h morphine consumption [median doses (interquartile range): 15 (10–19.50) mg compared to 25 (17.50–37) mg, P < 0.001], lower postoperative pain score at rest at the 4th, 6th, and 12th h (P = 0.01, 0.02, and 0.02, respectively) and on movement at 2, 4, 6, and 12 h (P < 0.001), longer time till the first postoperative demand for rescue analgesia (430.11 ± 63.02 min) compared to 327.78 ± 61.99 min (P < 0.001), and less sedation, nausea and/or vomiting, and pruritus. Conclusions: Adding midazolam as a bupivacaine adjuvant for TAP block reduces the 24-h morphine consumption, extends the postoperative analgesia duration, and decreases the incidence of adverse effects following abdominal hysterectomy.
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Vasopressin continuous infusion improves intracranial pressure and patient outcomes after surgical clipping or endovascular coiling of cerebral aneurysm p. 528
Ahmed Said Elgebaly, Mohamed Samir Abd El Ghafar, Sameh Mohamed Fathy, Mohamad Nasar Shaddad
Background: Hypertensive therapy prevents vasospasm-related delayed ischemic neurologic deficit and infarcts. New alternatives would include vasopressin which has vasoconstrictive effects and positive influence on cerebral perfusion pressure (CPP) and intracranial pressure (ICP). Aims: The aim of this study is to demonstrate the value of vasopressin intravenous infusion (IVI) in decreasing ICP and preventing vasospasm following surgical clipping or endovascular coiling. Settings and Design: A triple-blind prospective randomized controlled study. Subjects and Methods: Thirty patients, 25–60 years, both genders, had undergone surgical clipping or endovascular coiling for a cerebral aneurysm, World Federation of Neurosurgical Societies (WFNS) grade 1–3 (15 patients in each); Group I (Vasopressin): 0.1–0.4 unit/min and Group II (Norepinephrine): 5–20 ug/min with target systolic blood pressure 160–180 mmHg. Statistical Analysis: SPSS version 25 software was used for analysis. Results: Invasive mean arterial pressure (MAP) showed the insignificant difference between the two groups, but ICP showed a significant decrease in Group V from hour 24 to 168 hence calculated CPP showed a significant increase in Group V at most times from hour 36 to 168. Glasgow Coma Scale showed a significant decrease in Group N from hour 138 due to the occurrence of vasospasm. The incidence of vasospasm, mechanical ventilation, and 28-day mortality were significantly lower in Group V with 81% risk reduction of vasospasm and better survival. Conclusion: Vasopressin IVI improved ICP, MAP, CPP and patient outcomes safely by reducing the incidence of cerebral vasospasm, and 28-day mortality after clipping or coiling of the cerebral aneurysm.
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Comparison of laryngoscopic view obtained by conventional head rise to that obtained by horizontal alignment of external auditory meatus and sternal notch p. 535
Laba Kumar Nayak, Dilip Chandar Desingh, Neeraj Narang, Ashish Sethi
Aims: The aim of this study was to determine the effect of change of patients' position during laryngoscopy on laryngoscopic view and to evaluate the effect of body mass index (BMI) and neck circumference on laryngoscopic view in both the positions. Methodology: A prospective, unblinded observational study was done with patients and laryngoscopists acting as their own controls. The study included 300 patients of ASA classes I and II aged more than 18 years who were scheduled to undergo general anesthesia. Detailed airway assessment including neck circumference and BMI of the patients was done. Initially, the patients were placed in the Head-Elevated Laryngoscopic Position (HELP) on the operating table. After proper intravenous induction, an experienced anesthesiologist did direct laryngoscopy with a suitable size Macintosh blade and assessed the C and L grades (HELP score). Immediately, the patients were repositioned to conventional sniff position and the C and L grades reassessed (sniff score). Both the scores were compared later on. Results: HELP provided a view better than or equal to sniff in 94% cases, whereas in only 6% of the cases, sniff provided a view better than HELP. HELP provided better view for laryngoscopy. Moreover, neck circumference as a parameter was more helpful in predicting difficult laryngoscopy compared to BMI. Conclusion: HELP should be the ideal intubating position in all patients irrespective of ages and sexes with or without predilections for difficult airway.
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A comparative study of midazolam alone or in combination with dexmedetomidine or clonidine for awake fiberoptic intubation p. 539
Noor Bano, Pooja Singh, Dheer Singh, Tallamraju Prabhakar
Background: Awake fiberoptic intubation (AFOI) is the gold standard technique for managing patients with anticipated difficult airway. Conscious sedation is desirable, not only to make the procedure more tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Ideal sedation regime for AFOI should provide comfort, cooperation, hemodynamic stability, and amnesia along with maintenance of spontaneous respiration. Several sedative agents have been assessed over the past two decades for this purpose but α2 agonists appear to be the favorable choice owing to its sedative, analgesic, amnestic, and sympatholytic properties along with good hemodynamic profile. Aims: The present study has been aimed to recognize the characteristics of dexmedetomidine, clonidine, and midazolam and to compare their efficacy in providing optimal intubating conditions as well as hemodynamic stability during AFOI. Settings and Design: prospective double-blind randomized study done in tertiary care hospital. Materials and Methods: Sixty patients of American Society of Anesthesiologists physical status Classes I and II aged 18–60 years with anticipated difficult airway were randomly allocated into three groups. All the patients received injection midazolam bolus followed by sedation infusion of midazolam, dexmedetomidine, and clonidine according to the allocated group. Primary outcome includes the time to achieve Ramsay Sedation Score (RSS) ≥2, time taken in intubation, intubation score, comfort score for fiberoptic insertion and intubation, and patient tolerance after intubation. The secondary outcome was hemodynamic, and respiratory variables include changes in heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and respiratory rate during the procedure. Statistical Analysis: All data were recorded, summarized, tabulated, and statistically analyzed using SPSS 16.0 version (Chicago, Inc., USA). The data were presented in mean ± standard deviation. P < 0.05 was considered as statistically significant. Results: All the three groups were comparable in terms of demographic profile. Time to achieve RSS ≥2 and mean intubation time was significantly less in Groups D and C as compared to Group M (P < 0.001). Among groups, Group D took least time to achieve RSS ≥2 (5.53 ± 0.74) and mean intubation time (4.53 ± 0.91). Similarly, overall intubation score, comfort, and patient tolerance score were significantly more in Group M as compared to Groups D and C (P < 0.001). Among the groups, Group D achieved least intubation score (3.80 ± 0.67) and comfort score (2.53 ± 0.74). Although Groups D and C have a lower mean HR and MAP during the procedure and intubation compared to Group M, the incidence of SpO2is most frequent with clonidine. Conclusions: Patients who received α2 agonist were calmer and cooperative with less pain and discomfort than the patients who received midazolam. Dexmedetomidine allows better endurance, stable hemodynamics, and patent airway as compared to clonidine.
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Fascia iliaca block as an anesthetic technique for: Acute lower limb ischemia p. 547
Maha Ahmed Abo-Zeid, Reem Abdelraouf Elsharkawy, Mohamed Farag, Sameh Hany Emile
Purpose: The purpose of this study is to evaluate the efficacy of preoperative fascia iliaca block (FIB) as a sole anesthetic technique in transfemoral thromboembolectomy of unilateral acute lower limb ischemia compared to unilateral spinal anesthesia (SA) as a primary outcome. Hemodynamic variation, postoperative pain score, and the first demand for analgesia with the total postoperative analgesic required in the 1st postoperative day were considered as the secondary outcome. Patients and Methods: This prospective randomized controlled study included two groups of patients aged between 40 and 70 years, who underwent transfemoral thrombectomy for acute unilateral lower limb ischemia. Patients in the spinal group (SA) (n = 56): underwent unilateral SA using 10 mg bupivacaine 0.5% and patients in the group FIB (n = 56): received FIB with 30 mL of 0.25% bupivacaine. Sensory block was evaluated over the incisional area with 3-point scale. If the sensory block did not reach zero grade after 30 min, the patient received general anesthesia. Results: The incidence of the successful block was 100% in the SA group compared to 80.35% in the FIB group. There was a significant decrease in recorded heart rate and mean blood pressure within the SA group at 3, 10, and 20 min and 3, 20, and 45 min, respectively. Values of visual analog scale decreased significantly in SA group compared to that of the FIB group immediately and 1 h postoperative. However, the time for the first postoperative analgesic requirement and morphine consumption was comparable between the groups. Conclusion: Preoperative FIB could be considered as a promising alternative anesthetic technique to SA with better hemodynamic parameters in patients undergoing transfemoral thrombectomy for acute lower limb ischemia. It could be also due to limited precautions considered the first choice over SA for patients on perioperative anticoagulants.
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Patient transportation delays and effects on operation theatres' efficiency: A study for problem analysis and remedial measures p. 554
Rudrashish Haldar, Devendra Gupta, Hemchandra Pandey, Shashi Srivastava, Prabhakar Mishra, Anil Agarwal
Background and Aims: Delay in patients' transportation to the operating theater (OT) is a globally recognized phenomenon, leading to delay in the subsequent processes (anesthesia induction, surgery, and patient turnover). This observational study was conducted to evaluate the common reasons for delay in transporting patients to the neurosurgery OT complex and its consequent effects and how the elimination of these reasons by application of feasible measures can influence the after effects. Settings and Design: This was an anesthesiologist-based audit of transportation process of patients to the OT complex of a tertiary care teaching hospital to identify the impediments and effects of delay, suggest and implement remedial measures, and assess the outcomes. Materials and Methods: The movement process of successive 551 patients was studied. In the evaluation phase, common reasons for transportation delays were identified. The incidences of consequent effects such as second-case cancellations and overrunning of OTs beyond scheduled hours were noted. In the implementation phase, corrective measures were instituted and the incidences of delays and the consequent effects were again noted. Statistical Analysis: Statistical analysis was performed using SPSS 17.0. Results: In the evaluation phase (303 patients), common reasons for delays included porter-associated delays (15), unavailable lifts (7), and pediatric patients (6). The incidences of case cancellation (20) and overrunning of OTs (9) were high. In the implementation phase, after remedial measures were enforced, the incidences of delays due to porter, lifts, and pediatric patients dropped to 1, 6, and 0, respectively. Simultaneously, a decrease in second-case cancellation (2) and overrunning of OTs (7) also reduced. As an additional finding, a significant reduction in OT turnover times was also observed (16.31 ± 9.29 min vs. 11.70 ± 5.78 min). Conclusions: Analysis of common reasons of patient transportation delays and removal of these impediments can markedly improve the efficiency in OT functioning.
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Efficacy of epidural dexamethasone combined with intrathecal nalbuphine in lower abdominal oncology operations p. 560
Mohamed Ghanem, Mona Gad, Ahmed Abdallah, Mosab Shetiwy, Mohamed Shetiwy
Background: Dragging pain during lower abdominal surgeries under intrathecal anesthesia is a common problem. Epidural steroid seemed to be effective in reducing intra and postoperative pain. Kappa receptor agonist like nalbuphine helps in reduction of visceral pain. Hence, this study was designed to detect the efficacy of epidural steroid dexamethasone with intrathecal Kappa opioid as a sole anesthetic technique in patients subjected to lower abdominal oncology operations. Patients and Methods: Patients were randomly allocated into two groups; epidural placebo group–control group (Group P) – Intrathecal injection of 20 μg fentanyl followed by intrathecal injection of (15 mg) of hyperbaric bupivacaine 0.5%, then (epidural injection placebo 15 mL volume of sterile saline 0.9%). Epidural dexamethasone group–study group (Group D) – Intrathecal injection of 0.6 mg nalbuphine followed by intrathecal injection of (15 mg) of hyperbaric bupivacaine 0.5% then (epidural injection of 8 mg dexamethasone in 15 mL total volume using sterile saline 0.9%). Results: Group D recorded significantly longer times to 1st analgesic request, sensory regression to S1 and modified bromage Score 0 with significant lower number of patients that had abdominal dragging pain in comparison with Group P. Visual analog score in the first four postoperative hours, total postoperative nalbuphine dose in 1st 24 h and incidence of nausea and vomiting were significantly lower in Group D. Heart rate and mean arterial pressure were comparable in both groups. Postoperative headache incidence was comparable in both groups. Both patient and surgeon satisfaction were significantly higher in Group D compared to Group P. Conclusion: Combined epidural dexamethasone with intrathecal nalbuphine as a sole anesthetic technique during lower abdominal oncology operations could be an efficient anesthetic technique that offered better block characteristics, with more analgesia and as a result it gained better patient and surgeon satisfaction.
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Effectiveness of different techniques of ethyl chloride spray for venepuncture-induced pain: A randomised controlled trial p. 568
Parnandi Bhaskar Rao, Chitta Ranjan Mohanty, Neha Singh, Manisha Mund, Anamika Patel, Alok Kumar Sahoo
Background: Venepuncture is an essential component of anaesthesia services. However, this invites pain generating the first negative experience with anaesthesia. Hence, relief of this pain carries considerable importance. Efficacy of ethyl chloride spray although studied, there is no consensus for the best way of application. Objectives: The present study was conducted to find an effective technique/method of ethyl chloride spray application to reduce venepuncture pain. Methods: Adult patients posted for different anaesthesia procedures were randomised into three groups. Venepuncture was done either after installation of distilled water or spray of ethyl chloride either once to twice. Venepuncture pain was assessed with a 0-100 Numeric Rating Scale. Results: The analysis showed significant differences among the groups (F [2,96] = 66.27, P < 0.05). The twice sprayed group experienced the least pain ([mean ± standard deviation [SD] 16.67 ± 10.21), lower in the once spray group ([mean ± SD] 27.58 ± 13.24), and the controls had the highest pain score ([mean ± SD] 49.09 ± 11.28). Post hoc Tukey's tests showed all the three groups differed significantly. The effect size was large, and the variability of the spray on the reduction of pain scores is 58% (η2 = 57.99). Conclusion: Ethyl chloride spray effectively reduces the pain on venepuncture, especially when the vapocoolant is sprayed twice each over 5 s, and from a distance of 5 cm perpendicular to the skin.
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Comparison of three different methods of attenuating postoperative sore throat, cough, and hoarseness of voice in patients undergoing tracheal intubation p. 572
Kamal Kajal, Divya Dharmu, Ishwar Bhukkal, Sandhya Yaddanapudi, Shiv Lal Soni, Mukesh Kumar, Ankush Singla
Context: Postoperative sore throat (POST) is a frequent and undesirable complication after general anesthesia with endotracheal intubation. Various pharmacological and non-pharmacological methods with variable success rate are used for attenuating POST. However, no single drug has been universally accepted. Aims: To compare the effect of betamethasone gel, ketamine gargles and intravenous dexamethasone on the incidence and severity of POST. Settings and Design: Prospective randomized controlled single-blinded trial conducted at a tertiary care centre. Materials and Methods: A total of 100 patients of age 18 to 70 yr, ASA class I and II, scheduled for elective surgeries under general anaesthesia were included and divided randomly in betamethasone, dexamethasone, ketamine and control groups. Endotracheal tubes were lubricated with 0.05% betamethasone gel in betamethasone group, 0.2 mg/kg of dexamethasone was administered intravenously before induction of anaesthesia in dexamethasone group, 40 mg of ketamine gargles mixed with 30 ml of saline was given 5 minutes prior to induction in ketamine group. In the control group, none of the above agents were used. During the 24 hr after the operation, we noted the occurrence and severity of POST, cough and hoarseness. Statistical Analysis Used: The demographic data, surgical time and intubation among the groups were analyzed using one-way analysis of variance. Incidence and severity of POST, cough and hoarseness of voice among the groups were analyzed utilizing Chi-square test. Results: Incidence of POST at one hour was found to be significantly less in betamethasone group (16%) and dexamethasone group (20%) in comparison to the control group (48%). The incidence of POST at 4 hours and 24 hours were found to be comparable. The frequency of hoarseness and cough at 1 hour, 4 hour and 24 hours were similar in all the groups. Conclusions: Prophylactic betamethasone gel application and intravenous dexamethasone administration before induction of anaesthesia resulted in clinically important and statistically significant decreases in the incidence of POST only in early postoperative period.
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Analysis of neonatal outcome with supplemental oxygen to mother during elective cesarean section under spinal anesthesia: A prospective randomized controlled trial p. 577
Jhuma Biswas, Arpita Choudhury, Shyamashis Das, Purnava Mukhopadhyay, Anirban Pal, Dipan Jana
Background: Many questions have arisen on benefits of routine use of supplemental oxygen during elective cesarean section (CS) under spinal anesthesia. Aims: The aim of this randomized controlled study was to evaluate neonatal outcome in immediate postpartum period with or without supplemental oxygen to mother, undergoing elective CS under spinal anesthesia. Materials and Methods: One hundred and thirty-four nonlaboring term pregnant women were allocated randomly into two groups to breathe room air (air group) or oxygen (oxygen group). Times from starting oxygen supplementation to delivery interval, skin incision to delivery (I-D) interval, and uterine incision to delivery (U-D) interval were recorded. APGAR scores were assessed at 1 min and 5 min after delivery. Umbilical cord blood gas analysis was done immediately to measure pH, oxygen partial pressure, carbon dioxide partial pressure (PCO2), and bicarbonate. Statistical Analysis: Statistical comparisons were performed using either Student's t-test or Mann–Whitney U-test. Results: For oxygen group versus air group, In Oxygen group, proportion of fetal acidosis was significantly less; umbilical arterial (UA) blood pH (7.22 ± 0.05 vs. 7.19 ± 0.05, P = 0.001) as well as umbilical venous (UV) blood pH (7.26 ± 0.05 vs. 7.22 ± 0.06, P < 0.001) were significantly higher and UA PCO2 (55.4 ± 9.9 vs. 62.9 ± 6.9, P = 0.001) and UV PCO2 (51.4 ± 8.2 vs. 54.3 ± 7.2, P = 0.036) were significantly lower compared to air group. APGAR scores were similar between the groups. Conclusions: Supplemental oxygen has potential benefits as demonstrated by less proportion of FA in mothers receiving supplemental oxygen.
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Evaluation of arterial to end-tidal carbon dioxide pressure differences during laparoscopic renal surgery in the lateral decubitus position p. 583
Shalvi Mahajan, Rajeev Chauhan, Ankur Luthra, Indu Bala, Neerja Bharti, Ashish Sharma
Background: End-tidal carbon dioxide (PEtCO2) is a noninvasive reliable technique to measure arterial partial pressure of carbon dioxide (PaCO2) in the body under general anesthesia. However, gradient between PaCO2and PEtCO2(P[a-Et] CO2) is influenced by many factors. Aims: In the present study, we evaluated the changes in P (a-Et) CO2for laparoscopic donor nephrectomy in lateral decubitus position (LDP). Settings and Design: This was an observational, double-blinded, tertiary care center-based study. Methods: Thirty-one American Society of Anesthesiologists Class I and Class II patients of either sex undergoing laparoscopic donor nephrectomy in LDP under general anesthesia were included. An arterial cannula was inserted, PaCO2was measured at eight predesignated time intervals, and PEtCO2was also noted at the corresponding time period. Statistical Analysis: Data were analyzed using a two-way analysis of variance for repeated measurements using one dependent variable and one within-subject factor (time). Quantitative data were presented as mean ± standard deviation or median and interquartile range, as appropriate. Results: The mean P (a-Et) CO2gradient was 5.67 ± 1.36 mmHg 10 min after induction of anesthesia in the supine position (T1a). Ten minutes after LDP, P (a-Et) CO2gradient was 7.38 ± 1.45 mmHg (T1b) and was higher than T1a. The P (a-Et) CO2values 10 min after release of pneumoperitoneum and 10 min after making the patient supine were significantly higher than the T1a value. The highest value of P (a-Et) CO2gradient was at 30 min after creation of pneumoperitoneum (T30), i.e., 9.99 ± 1.70 mmHg. Pearson's correlation coefficient showed that the degree of correlation varied considerably during surgery due to interindividual variability (R2 T1a vs. T60 was 0.61 vs. 0.17). Conclusions: PEtCO2does not reliably predict PaCO2in healthy patients scheduled for laparoscopic renal surgery in LDP.
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Self-extubation in patients with traumatic head injury: Determinants, complications, and outcomes p. 589
Saeed A Mahmood, Omaima S Mahmood, Ayman A El-Menyar, Mohammad M Asim, Ahmed Abdel-Aziz Abdelbari, Talat Saeed Chughtai, Hassan A Al-Thani
Background: Self-extubation is a common clinical problem associated with mechanical ventilation in trauma patients worldwide. Objectives: This study aimed to evaluate the predisposing factors, complications, and outcomes of self-extubation in patients with head injury. Methods: This was a retrospective cohort study. Settings: The study was conducted in a trauma intensive care unit (TICU). Patients: All intubated patients with head injury admitted to TICU between 2013 and 2015 were included in the study. Interventions: Planned compared to selfextubation during weaning from sedation. Measurements: Risk, predictors, and outcomes of self-extubation were measured. Main Results: A total of 321 patients with head injury required mechanical ventilation, of which 39 (12%) had self-extubation and 12 (30.7%) had reintubation. The median Glasgow Coma Scale, head abbreviated injury score, and injury severity score were 9, 3, and 27, respectively. The incidence of self-extubation was 0.92/100 ventilated days. Self-extubated patients were more likely to be older, develop agitation (P = 0.001), and require restraints (P = 0.001) than those who had planned extubation. Furthermore, self-extubation was associated with more use of propofol (P = 0.002) and tramadol (P = 0.001). Patients with self-extubation had higher Ramsay sedation score (P = 0.01), had prolonged hospital length of stay (P = 0.03), and were more likely to develop sepsis (P = 0.003) when compared to the planned extubation group. The overall in-hospital mortality was significantly higher in the planned extubation group (P = 0.001). Age-adjusted predictors of self-extubation were sedation use (adjusted odds ratio [aOR]: 0.06; P = 0.001), restraint use (aOR: 10.4; P = 0.001), and tramadol use (aOR: 7.21; P = 0.01). Conclusions: More than one-tenth of patients with traumatic head injury develop self-extubation; this group of patients is more likely to have prescribed tramadol, develop agitation, and have longer hospital length of stay and less sedation use. Further prospective studies are needed to assess the predictors of self-extubation in TICU.
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Microcuff pediatric endotracheal tubes: Evaluation of cuff sealing pressure, fiber-optic assessment of tube tip, and cuff position by ultrasonography p. 596
Srinivasan Ramachandran, Sandeep Kumar Mishra, Hemavathi Balachander, Prasanna Udupi Bidkar, Savitri Velayudhan, Satyen Parida, Muthapillai Senthilnathan
Background: Use of uncuffed tubes causes lots of morbidity, and there is a surge in the use of microcuff pediatric endotracheal tubes. These tubes are not evaluated in the Indian population. Aims: The study aimed to evaluate the pediatric microcuff endotracheal tubes in terms of cuff sealing pressure, fiber-optic assessment of tube tip, and cuff position to assess postextubation airway morbidity. Settings and Design: Study design involves follow-up analytical study. Subjects and Methods: Thirty-four children in the age group of 2–12 years were studied. Patients with leak pressure >20 cm H2O were exchanged with smaller size tube and excluded. Cuff pressure, fiber-optic assessment of tube tip to carina distance in neutral and flexion, ultrasound assessment of cuff position, and postextubation airway morbidity were assessed. Statistical Analysis Used: Parameters expressed as the median with the interquartile range. Nonparametric data were analyzed using the Wilcoxon signed-rank test. Results: The tracheal leak pressure was <20 cm H2O (median 14.5 cm H2O) in 30 children. Tube exchange was required in four patients. A complete seal was achieved in 30 patients with cuff pressures ranging from 6 to 8.25 cm of H2O (median 8 cm of H2O). The median caudal displacement is 0.8 cm (0.47–1.22 cm) with flexion. There was no airway-related morbidity in any of these patients. Conclusions: The microcuff pediatric endotracheal tubes when used according to the age-based formula had a higher tube exchange rate in our study population. However, in children in whom the tube size was appropriate, the tubes provided good sealing without increasing airway morbidity. Further studies with a larger sample size might be required to confirm the findings.
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