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January-March 2019
Volume 13 | Issue 1
Page Nos. 1-192

Online since Thursday, March 7, 2019

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ORIGINAL ARTICLES  

Peritubal infiltration of fentanyl compared to dexmedetomidine with ropivacaine in percutaneous nephrolithotomy: A randomized comparative analysis p. 1
Sumit Soni, Kalpesh Parmar, Shyam Meena Charan, Sameer Sethi, Naveen B Naik
DOI:10.4103/aer.AER_1_19  
Context: Dexmedetomidine has been found as an effective adjuvant in various nerve blocks. Despite several studies on dexmedetomidine with ropivacaine, there is no study on comparing with fentanyl in peritubal infiltration in percutaneous nephrolithotomy (PCNL). Aims: The aim of this study was to compare the effect of the addition of dexmedetomidine or fentanyl in peritubal local anesthetic infiltration on pain scores and analgesic consumption in patients who underwent PCNL. Settings and Design: This was a prospective, randomized, double-blind, tertiary care center-based study. Subjects and Methods: A total of 60 American Society of Anesthesiologists Class I, II, and III patients were selected and randomly divided into two groups: Group RF ropivacaine and fentanyl (n = 30) and Group RD ropivacaine and dexmedetomidine (n = 30). Balanced general anesthesia was given. After completion of the surgery, peritubal infiltration was given at 6 and 12 O'clock positions under fluoroscopic guidance. Postoperative pain was assessed using the visual analog scale and dynamic visual analog scale rating 0–10 for initial 48 h. Postoperative sedation was assessed using five-point sedation score. Time to first rescue analgesic, number of doses of tramadol, and total consumption of tramadol required in 48 h were noted. Statistical Analysis Used: Descriptive data were expressed in mean and standard deviation for between-group comparisons; the Chi-square and Fisher's exact tests were used for categorical variables, whereas t-test and Mann–Whitney U-test were used to compare continuous variables between two groups. Results: Duration of analgesia in group RD (12.87 ± 3.85) is more prolonged than group RF (8.13 ± 3.28) h. Total dose of rescue analgesia required in 48 h in group RF was higher as compared to group RD. Conclusions: Addition of dexmedetomidine to ropivacaine is more effective than fentanyl in terms of prolongation of analgesic efficacy of local anesthetic in peritubal block along with short-lived mild sedation.
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Intra-articular morphine versus dexmedetomedine for knee arthroscopy under local anesthesia p. 7
Doaa Galal Diab, Alaaeldin Adel Elmaddawy, Abdelrahman Elganainy
DOI:10.4103/aer.AER_154_18  
Background: Knee arthroscopy has both diagnostic and therapeutic applications which can be performed under general, regional, or local anesthesia. Morphine is used as an additive to local anesthetics. Dexmedetomedine, the highly selective alpha-2 (α2)-adrenoceptor agonist with the sedative and analgesic effect can be used also to augment local anesthetic effect. Patients and Methods: Sixty patients submitted for elective knee arthroscopy whose age between 25 and 45 years, of either sex, the American society of anethesiologists physical status Classes I and II at a university hospital were enrolled in this study. Patients were classified into two groups. Morphine Group (M) (n = 30): Patients received 20 ml of 0.5% bupivacaine plus 5 ml of 0.2% lidocaine with epinephrine 1:200,000 plus 1 mg morphine. Dexmedetomedine Group (D) (n = 30): Patients received 20 ml of 0.5% bupivacaine plus 5 ml of 0.2% lidocaine with epinephrine 1:200,000 plus 1 μg/kg dexmedetomedine. Results: Demographic data of patients showed no significant difference among the studied groups. Heart rate (HR) was significantly lower in (D) Group compared to that of (M) Group 5 min from the start of procedure to immediately postoperatively. Moreover, (D) Group showed a significant decrease in HR 10 min up to 35 min intraoperatively compared to the basal value. Furthermore, mean arterial blood pressure (MBP) was significantly lower in (D) Group compared to that of (M) Group 15 min from the start of surgery up to 1 h postoperatively. Furthermore, (D) Group showed a significant decrease in MBP 15 min intraoperative up to 2 h postoperatively compared to the basal value. While there was no significant difference in (visual analogue score [VAS], onset and total consumption of ketorolac, surgeon and patients' satisfaction, side effects in (D) Group compared to (M) Group, respectively. Conclusion: Addition of either morphine or dexmedetomidine to bupivacaine intraarticularly improved both intraoperative anesthesia and postoperative analgesia with minimal side effects or complications in knee arthroscopy, with superiority of dexmedetomidine compared to morphine on hemodynamic stability.
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A comparison of stress response between insertion of gastro-laryngeal tube and endotracheal intubation in patients undergoing upper gastrointestinal endoscopic procedures for endoscopic retrograde cholangiopancreatography p. 13
Josemine Davis, Deepak Kumar Sreevastava, Deepak Dwivedi, Siddaramesh Gadgi, Saurabh Sud, Puja Dudeja
DOI:10.4103/aer.AER_9_19  
Background: Complex gastrointestinal (GI) endoscopic procedures like endoscopic retrograde cholangiopancreatography (ERCP) require deep sedation or general anesthesia. Comorbidities with the poor physiological condition warrant endotracheal intubation to prevent hypoxia and aspiration. The gastro-laryngeal tube (GLT), a new supraglottic airway device with a separate channel for endoscope looks promising. Aims: The aim of the study is to compare the stress response during insertion of GLT and endotracheal intubation (ETT) in patients undergoing upper GI endoscopic procedures like ERCP. Subjects and Methods: This control versus comparison study comprised two groups with 30 patients each who underwent ETT and GLT insertion. The standard general anesthesia technique was used. In GLT group, the device was inserted without neuromuscular blocker. In ETT group, injection atracurium 0.5 mg/kg intravenous was administered as muscle relaxant for aiding endotracheal intubation. Hemodynamic parameters and time taken for the insertion of GLT/ETT were recorded. Statistical Analysis: Data were analyzed using SPSS version 20. Student's t-test was used to compare quantitative data between the groups. ANOVA test was applied for intragroup comparisons between GLT and ETT groups. Categorical variables were analyzed using the Chi-square test. Results: Heart rate and mean arterial pressure increased from baseline in ETT group, following laryngoscopy and endotracheal intubation as well as with GLT insertion. However, the stress response caused by endotracheal intubation was significantly greater than that caused by GLT insertion. Conclusion: GLT as an airway device is a safe alternative with decreased stress response compared to endotracheal intubation for upper GI endoscopy procedures.
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The effect of forced-air warmer, ondansetron or their combination on shivering in pregnant women coming for elective cesarean section under spinal anesthesia: A prospective, randomized controlled comparative study p. 19
KS Ram Kiran, Kalyani Surya Dhana Lakshmi Sangineni
DOI:10.4103/aer.AER_198_18  
Context: Perioperative shivering can occur in up to 85% of patients undergoing cesarean section under spinal anesthesia. It has many detrimental effects and disrupts early mother-child bonding. Therefore, it should ideally be prevented by either pharmacologic or nonpharmacological means. Aims: The primary aim of this study was to evaluate the efficacy of intraoperative forced-air warming, ondansetron or their combination in preventing perioperative shivering in patients undergoing elective cesarean section under spinal anesthesia. Settings and Design: A prospective randomized controlled comparative study done at the tertiary care center. Subjects and Methods: A total of 120 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to three groups. Group O received ondansetron 4 mg intravenously (i.v.) after giving block with no forced air warming. Group W received forced-air warming intraoperatively. Group C received ondansetron 4 mg i.v. after giving block plus intraoperative forced-air warming. Core temperature (tympanic membrane) and the arm skin temperature were measured and shivering was graded simultaneously. Statistical Analysis Used: Parametric data were analyzed using one-way ANOVA and Student's paired t-test where ever appropriate. Nonparametric data were analyzed using the Kruskal–Wallis and the Chi-square test. Values of P < 0.05 were considered statistically significant. Results: Shivering incidence was higher in Group O and Group W being 17.5% and 20%, respectively, and least in Group C being 5%. The incidence of Grade ≥3 shivering requiring rescue drug was lower in Group C (2.5%) compared to that of the Groups W (5%) and O (10%) but was not statistically significant (P = 0.21). Conclusions: Combined use of ondansetron and forced- air warmer was more effective in reducing the incidence of shivering in pregnant women during elective cesarean section than when used individually.
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Efficacy of dexmedetomidine as an adjunct in aiding video laryngoscope-assisted assessment of vocal cord movements at extubation following total thyroidectomy Highly accessed article p. 25
Santhosh Djearadjane, Sunil Rajan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/aer.AER_150_18  
Background: Assessment of vocal cord movements following total thyroidectomy diagnoses recurrent laryngeal nerve injury. Use of videoscope along with sedatives may blunt hemodynamic responses seen with the conduct of direct laryngoscopy for assessing vocal cord mobility. Aims: The primary objective of this study was to assess changes in mean arterial pressure (MAP) during vocal cord assessment following total thyroidectomy using video laryngoscope, with and without the use of dexmedetomidine as an adjunct. Secondary objectives included assessment of changes in heart rate (HR), patient reactivity score along with ease of laryngoscopy and vocal cord visibility. Settings and Design: This randomized, prospective, unblinded study was conducted in 54 patients at a tertiary care center. Materials and Methods: Group D received dexmedetomidine 0.5 μg/kg, once the thyroid was removed. Group S did not receive dexmedetomidine. Hemodynamic response at extubation, patient reactivity, ease of laryngoscopy, and ease of vocal cord assessment were noted. Statistical Analysis Used: Chi-square test and Independent t-test. Results: Baseline HR, systolic blood pressure (SBP), and MAP were comparable between the groups. However subsequently, Group D had significantly lower HR and SBP at the time of extubation and at 3 and 6 min later. MAP at extubation and at 3 min later was comparable, but at 6 min, Group D had significantly lower values. In both groups, patient reactivity scores, ease of laryngoscopy, and vocal cord visibility were comparable (P > 0.05). Conclusion: Dexmedetomidine 0.5 μg/kg when used as an adjunct clinically improved conditions for assessing vocal cord mobility with significant attenuation of associated hemodynamic responses.
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A prospective study of comparison of analgesic efficacy of dexamethasone as an adjuvant in supraclavicular block with intravenous dexamethasone after supraclavicular block in patients undergoing forearm surgeries p. 31
Madhavi Rahul Godbole, Seema Shreepad Karhade, Priya P Parihar
DOI:10.4103/aer.AER_11_19  
Context: Brachial plexus block is a preferred anesthesia technique for upper limb surgeries below the shoulder joint. Drugs used as adjuvants in block enhance the postoperative analgesia significantly. Aim: We aimed to evaluate the analgesic efficacy, of perineural dexamethasone used as an adjuvant to supraclavicular block as against systemic dexamethasone after supraclavicular block. Time for rescue analgesia was also noted in both groups. Subjects and Methods: In our randomized study, 60 patients belonging to the American Society of Anesthesiologist physical status Classes I and II were randomly allocated in two groups of thirty. Group BD received supraclavicular block with local anesthetic and dexamethasone 0.05 mg/kg as an adjuvant. Group BI received supraclavicular block with local anesthetic and intravenous (IV) dexamethasone 0.05 mg/kg after the block. In both groups, the comparison of postoperative analgesia and time for first rescue analgesic was noted. Statistical Analysis Used: Data analysis was done using SPSS version 20.0. Demographic data and continuous variables were analyzed by independent sample t-test. Categorical data were analyzed by unpaired t-test. Results: Group BD showed significantly prolonged postoperative analgesia as compared to Group BI. Time for rescue analgesic in Group BD was (15.8 ± 2.6) H as compared to Group BI (10.3 ± 1.07) H. Conclusions: Dexamethasone, when used in supraclavicular block significantly, prolongs the duration of analgesia as against IV dexamethasone after supraclavicular block.
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A prospective crossover study evaluating the efficacy of king vision video laryngoscope in patients requiring general anesthesia with endotracheal intubation p. 36
Ramachandra R Avula, Nagendra Nath Vemuri, Rambabu Tallapragada
DOI:10.4103/aer.AER_165_18  
Background: Direct laryngoscopy used for tracheal intubation requires aligning the pharyngeal, laryngeal and oral axes to achieve a line of sight. Video laryngoscopy provides a better view of the glottis without the need for aligning the three axes. Aims: To evaluate the effectiveness of King vision laryngoscope over Macintosh laryngoscope in visualizing the glottis and intubating the trachea, when used on a same patient as in a cross over manner. Settings and Design: Department of Anaesthesia, Mediciti Institute of Medical Sciences, prospective crossover study conducted over a period of six months. Subjects and Methods: Sixty adult patients belonging to ASA physical status class I-II, requiring tracheal intubation were randomly assigned to intubation by King vision or Macintosh laryngoscope. Improvement, if any, in the Cormack-Lehane grading using the King vision scope, following initial grading with the Macintosh blade in the same patient was analyzed. Statistical Analysis: Mean and Standard deviation were calculated for different parameters under the study. Where appropriate, results were analyzed using the Mc Nemar χ2 test. A ‘p’ value less than 0.05 was considered statistically significant. Results: In the King Vision group, Cormack and Lehane grade improved in the majority (9/12) of patients in whom the initial Cormack and Lehane grade was >1 using the Macintosh blade. Conclusions: The use of the King vision blade significantly improved the laryngoscopic view over the Macintosh blade but the time for intubation was prolonged.
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A comparative study between the efficacy of fentanyl, antihistamines, and dexmedetomidine in suppressing photic sneeze reflex during peribulbar block p. 40
Karim YK Hakim, Mohammed Awad Alsaeid
DOI:10.4103/aer.AER_174_18  
Background: The photic sneeze reflex (autosomal dominant) is a condition that causes sneezing in response to numerous stimuli, such as looking at bright lights or periocular (surrounding the eyeball) injection. Unexpected or sudden sneezing during injection can be a dangerous side effect in periocular injection, in which abrupt head movement may cause globe injury. Aims: We intended to evaluate the efficacy of adding fentanyl, dexmedetomidine, and antihistamines on the incidence of the sneeze reflex associated with propofol sedation during periocular local anesthesia injections. Settings and Design: Our study was a randomized, prospective, double-blinded and controlled clinical study. Patients and Methods: This study was conducted in Ain Shams and Fayoum university hospitals at the ophthalmic surgery department. After obtaining approval from our universities ethical committee and written informed valid consents from the patients, 90 patients were included in this study. The study population included patients of both sex, ASA grade 1 and 2, in the age ranging from 18-65 years. Patients were scheduled for cataract extraction surgeries and received peribulbar block. Then patients were randomly divided into three groups (30 patients each) using a computer- generated table of random numbers. Patients were preoxygenated with supplemental oxygen by nasal cannula, all 90 patients received intravenous propofol 1mg.kg- 1 bolus for sedation and were randomized to receive adjunctive drug 2 to 4 minutes prior to propofol injection: 30 patients received intravenous fentanyl 1 μmg.kg-1 (Group F), 30 patients received dexmedetomidine 1μmg.kg-1 (Group D), and 30 patients received antihistamine (pheniramine 22.75 mg) (Group H). The same local anesthetic admixture, consisting of 5 mL 2% lidocaine with 90 IU hyaluronidase, combined with 5 mL 0.5% plain bupivacaine in a 10-mL syringe at room temperature was administered to all patients using peribulbar block technique. A masked observer (surgeon or anesthesia assistant) recorded whether the patient had a sneezing event. Continuous cardiorespiratory monitoring was performed intraoperatively. Intraoperative and postoperative medication side effects were recorded including bradycardia (HR <55 beats/min), hypotension (MAP <50 mmHg sustained for >10 min), oxygen desaturation (SpO2<90%), nausea, vomiting and prolonged sedation using Ramsay Sedation Score (RSS). Statistical Analysis Used: Student's t-test and Chi-square test were used for analysis. Results: The demographic data of the three study groups revealed non-significant differences between the three study groups as regards age, sex distribution, and the duration of surgery. No patient was excluded after inclusion to the study. All patients were able to complete the entire study and their data were included in the final analysis. Five events of sneezing had occurred in 90 patients. Two in (D) group and three in (H) group with is no statistically significant difference between the three groups as regard sneezing. Bradycardia, hypotension and sedation had occurred significantly in group (D) compared to group (F) and group (D). No patient suffered from nausea, vomiting or oxygen desaturation in all studied groups. No statistically significant difference as regards patient satisfaction between the three studied groups. Conclusion: Fentanyl, dexmedetomidine and antihistamines with propofol sedation suppress photic sneeze reflex during peribulbar block.
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Evaluation of neuromuscular blockade with vecuronium during general anesthesia with oxygen, nitrous oxide, isoflurane versus oxygen, air, isoflurane: A randomized controlled study p. 44
Vishanth Boddu, Srinivasan Swaminathan, Hemavathy Balachander, Ranjith Kumar Sivakumar
DOI:10.4103/aer.AER_2_19  
Background: The use of air oxygen mixture with isoflurane has become more common in the place of nitrous oxide, especially in laparoscopic and abdominal surgeries. With a varied mixture of gases and isoflurane used in general anesthesia, the exact dosing requirement and time duration of action have not been precisely studied with vecuronium when given as a bolus, as is given routinely. Purpose: This study was undertaken to evaluate and compare the neuromuscular effect of vecuronium during anesthesia with oxygen, nitrous oxide and isoflurane versus oxygen, air and isoflurane. Methodology: The study was a prospective, randomized controlled trial on 70 patients allocated into two groups as follows: Group N (nitrous oxide group) and Group A (medical air group). The primary objective was to measure and compare the posttetanic count (PTC1) – train of four (TOF1) interval, to evaluate the time taken for recovery from the intense blockade in both groups. The secondary objectives were to compare time duration for twitch height depression to be 30% of baseline after administering vecuronium, time duration from vecuronium administration to appearance of the first PTC1, PTC (n) at the reappearance of the 1st twitch, time interval between TOF1 and TOF3 and time from vecuronium administration to appearance of TOF3 in both the groups. Results: There is no significant difference between both the groups with reference to the block onset time using 30% depression of single twitch and recovery time from neuromuscular blockade using PTC, PTC1-TOF1 and TOF1-TOF3 time intervals. Conclusion: Measuring and comparing neuromuscular transmission monitoring parameters such as the onset time(ST depression to 30%), and recovery using PTC, PTC1-TOF1 and TOF1-TOF3 time intervals, it is concluded that the character of neuromuscular block with vecuronium is unaffected and not prolonged with or without nitrous oxide when used with isoflurane.
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Evaluation of ultrasound-guided erector spinae plane block and oblique subcostal transversus abdominis plane block in laparoscopic cholecystectomy: Randomized, controlled, prospective study p. 50
Serkan Tulgar, Mahmut Sertan Kapakli, Halil Cihan Kose, Ozgur Senturk, Onur Selvi, Talat Ercan Serifsoy, David Terence Thomas, Zeliha Ozer
DOI:10.4103/aer.AER_194_18  
Background: Oblique subcostal transversus abdominis plane block (OSTAP) is a recently described regional anesthetic technique used in upper abdominal surgeries such as laparoscopic cholecystectomy (LC). Erector spinae plane block (ESPB) has also been reported for postoperative analgesia in LC. Aim: We aimed to compare the effectiveness of OSTAP and ESPB in providing postoperative analgesia in patients undergoing these surgeries. Setting and Design: This study was designed as a double-blinded, prospective, randomized, efficiency study in a tertiary university hospital, postoperative recovery room, and ward. Materials and Methods: A total of 72 patients were recruited and 60 patients were randomized into three equal groups (ESPB, OSTAP, and control group). Pain intensity between groups was compared using Numeric Rating Scale (NRS) scores. In addition, consumption of paracetamol and tramadol and additional rescue analgesic requirement were measured. Standard multimodal analgesia was performed in all groups, while ESPB block was also performed in Group ESPB and OSTAP block was also performed in group OSTAP. Statistical Analysis Used: Descriptive statistics were expressed as mean ± standard deviation. Independent t-test, Mann–Whitney U-test, Chi-square test, Fisher's exact test, Shapiro–Wilk test, one-way ANOVA, and post hoc Tukey's analysis were used for statistical analysis. Results: NRS was lower in block groups during the first 3 h. There was no difference in NRS scores at other hours. Analgesic consumption and rescue analgesic requirement were lower in groups ESPB and OSTAP when compared to those of control group. Block groups were similar. Conclusion: Bilateral ultrasound-guided ESPB and OSTAP performed at the end of LC lead to akin analgesia requirement and improve the quality of multimodal analgesia.
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Dexmedetomidine as bolus or low-dose infusion for the prevention of emergence agitation with sevoflurane anesthesia in pediatric patients p. 57
Uzma Begum, Prem Raj Singh, Bhavya Naithani, Vinita Singh, GP Singh, Tanmay Tiwari
DOI:10.4103/aer.AER_177_18  
Background: This study was designed to compare the prevention of emergence agitation (EA) of sevoflurane anesthesia by an intraoperative bolus or low-dose infusion of dexmedetomidine in pediatric patients undergoing lower abdominal surgeries. Materials and Methods: Forty-eight patients, aged 2–12 years, undergoing lower abdominal surgeries with sevoflurane anesthesia were enrolled in this study. Patients were randomly assigned to receive either intravenous bolus over 10 min. 0.4 μg/kg dexmedetomidine (Group I, n = 24) or low-dose infusion 0.4 μg/kg/h of dexmedetomidine (Group II, n = 24) after intubation. Heart rate and mean arterial pressure were recorded before induction, at induction and every 5 min after induction. Observational pain scores (OPS), pediatric anesthesia emergence delirium (PAED) scores, and Ramsay sedation scores (RSS) were recorded on arrival to the postanesthesia care unit and at 5, 10, 15, 30, 45, 60 min thereafter. Extubation time, emergence time, and time to reach Aldrete score ≥9 were recorded. Results: OPS and PAED scores and percentage of patients with OPS ≥4 or PAED scale ≥10 were significantly higher in Group II as compared to Group I. RSS score, extubation time, emergence time, and time to reach Aldrete score ≥9 did not show any significant difference. Conclusion: Both bolus or low-dose infusion of dexmedetomidine was effective for the prevention of EA with sevoflurane anesthesia, but bolus dose of dexmedetomidine was more effective.
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Effect of single-dose dexmedetomidine on intraoperative hemodynamics and postoperative recovery during pediatric adenotonsillectomy p. 63
Kiran Sharma, Mritunjay Kumar, Ranju Gandhi
DOI:10.4103/aer.AER_178_18  
Background: In children undergoing adenotonsillectomy, smooth recovery from anesthesia without any respiratory compromise and excessive sedation or pain is always desirable. In this placebo-controlled study, we examined the effect of single dose of dexmedetomidine on intraoperative hemodynamics and postoperative recovery profile such as emergence agitation (EA), pain, and sedation in children undergoing adenotonsillectomy. Methods: Sixty American Society of Anesthesiologists I or II children in the age group of 5–10 years, undergoing adenotonsillectomy were randomly assigned to receive dexmedetomidine 1 μg/kg (Group D) or volume-matched saline (placebo) (Group C), 10 min before induction of anesthesia. Intraoperative heart rate (HR) and mean blood pressure (MBP), duration of surgery, time to extubation, EA using Paediatric Anaesthesia Emergence Delirium (PAED) scale, level of sedation in postanesthesia care unit using Ramsay sedation score (RSS), and postoperative visual analog score (VAS) for pain were recorded and compared. Results: Dexmedetomidine group had lower HR and stable MBP, compared to the control group (P < 0.05). Postoperatively, the agitation score (PAED scale score) was statistically lower in Group D compared to Group C (13.84 ± 1.39; median 14 in Group C vs. 9.37 ± 1.33; median 9.5 in Group D; P < 0.001). All patients in Group C had PAED scale score >12, while only 6.67% of patients in Group D had PAED scale score of 12. The patients in Group D had higher RSS (2.62 ± 0.49 in Group D vs. 1.60 ± 0.50, P= 0.004); none of the patients were excessively sedated or had RSS >3. No significant difference was found in VAS score of the groups at all times, except at 0 h (P = 0.002). Time to extubation was significantly longer in the dexmedetomidine group (7.70 ± 1.62 min in Group D vs. 5.23 ± 1.91 min in Group C; P= 0.001). Conclusion: Premedication of dexmedetomidine at the dose of 1 μg/kg in children undergoing adenotonsillectomy resulted in favorable effect on intraoperative hemodynamics, significant decrease in postoperative EA without causing any excessive sedation, desaturation, or any other drug-related adverse events.
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Postoperative nausea and vomiting prophylaxis: A comparative study of ramosetron and palonosetron in patients undergoing laparoscopic cholecystectomy – A prospective randomized trial p. 68
G Sowmya Reddy, B Manjusruthi, G Jyothsna
DOI:10.4103/aer.AER_192_18  
Background: In spite of the availability of several antiemetic drugs, postoperative nausea and vomiting (PONV) is very common following laparoscopic surgery. Selective 5-hydroxytryptamine type 3 receptor antagonists are considered first-line agents for prophylaxis for PONV. Aims: In this study, we investigated and compared the efficacy of ramosetron and palonosetron in preventing PONV following laparoscopic cholecystectomy. Settings and Design: This was a randomized, prospective, double-blinded, observational clinical study. Methods: A total number of 80 patients, undergoing elective laparoscopic cholecystectomy surgeries under general anesthesia, were randomly assigned to one of the two equal groups to receive either of the following: Group R – received injection ramosetron 0.3 mg and Group P – received injection palonosetron 0.075 mg intravenous bolus immediately before the induction of anesthesia. The incidence of PONV, adverse effects of the study drugs, and need for rescue antiemetics were recorded over the next 48 h. Primary outcome was the incidence of PONV. Secondary outcomes were adverse effects of the study drugs and need for rescue. Statistical Analysis: The data were analyzed with Student's t-test and Chi-square test.Results: The incidence of a complete response (no PONV and no rescue medication) during 0–3 h in the postoperative period was 82.5% with ramosetron and 90% with palonosetron; the incidence during 3–24 h postoperatively was 80% with ramosetron and 87.5% with palonosetron. During 24–48 h, the incidence was 65% and 90%, respectively (P < 0.05). The incidences of adverse effects were statistically insignificant between the groups. Conclusion: Prophylactic therapy with palonosetron is more effective than ramosetron for long-term prevention of PONV following laparoscopic cholecystectomy.
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Efficacy of adding low-dose ketamine to dexmedetomidine versus low-dose ketamine and propofol for conscious sedation in patients undergoing awake fiber-optic intubation p. 73
Reem Abdelraouf El Sharkawy
DOI:10.4103/aer.AER_181_18  
Background and Aims: Conscious sedation is the key for successful AFOI. This trial was conducted to compare the effectiveness of dexmedetomidine and low dose of ketamine against propofol and low dose ketamine. Materials and Methods: Sixty patients subjected for general anesthesia were invited to participate in the study and randomly allocated into two equal groups: D-K (n = 30) had been received a bolus dose of both ketamine 0.5mg /kg and dexmedetomidine 1ug/kg over 10 min. Then continuous infusion of ketamine 0.5mg /kg and dexmedetomidine 1ug/kg. The second group (P-K group) (n = 30): had been received a bolus dose of both ketamine 0.5mg/kg and propofol 1mg/kg over 10 min. Then continuous infusion of ketamine 0. 5mg/kg and propofol 1mg/kg. Results: The intubation time was statistically significant shorter within the D-K group (58.9 ± 6.1) versus P-K group (63.4 ± 5.3) with p-value 0.02. The shorter time needed to achieve the OAA/S score = 2 was in the D-K group (2.25 ± 0.75) versus (2.9 ± 0.79) in P-K group with (P-value 0.004).The intubation scores were insignificant different between both groups except vocal cord opening which was statistical better among D-K group with P-value 0.03.The significant hypotensive recorded data were among P-K group while the decreased heart rate were recorded in D-K group. Eighty percentages of patients had excellent score of satisfaction within the D-K gp against 47% among the patients within P-K gp with P-value 0.01. Conclusion: The concomitant administration of low dose of ketamine with dexmedetomidine had better intubation time and sedation scores with higher patient satisfaction scores than the combination of propofol and low dose of ketamine.
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Does perioperative use of noradrenaline affect free flap outcome following reconstructive microvascular surgeries? A retrospective analysis p. 79
Sunil Rajan, Manu Sudevan, Dilesh Kadapamannil, Anish Mohan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/aer.AER_193_18  
Background: Over concerns of vasoconstriction leading to free flap failure, it has been a common practice to avoid vasopressors for the maintenance of blood pressure during reconstructive microvascular surgeries. Aims: The aim of this study was to assess the impact of use of noradrenaline in the perioperative period on outcome of free flaps in patients who underwent reconstructive surgeries as compared to those who did not receive noradrenaline. Settings and Design: Retrospective analysis was conducted at a tertiary care institute. Materials and Methods: A total of 120 patients who underwent free flap surgeries were included in the study, of which 102 patients who did not require noradrenaline perioperatively formed the control group (Group C), whereas those who required noradrenaline infusion constituted the study group (Group N). Data regarding flap outcome at discharge, intraoperative hemodynamics and temperature were documented. Statistical Test Used: Chi-square test, Mann–Whitney test, Independent sample t-test, and paired t-test were used for statistical analysis. Results: Out of 120 patients, 15% (n = 18) patients required noradrenaline (Group N). In Group N, 27.78% (n = 5) patients and in Group C, 22.55% (n = 23) were re-explored. Four patients in Group C and none in Group N had a poor flap outcome (3.92% vs. 0%). There was no significant difference in surgical duration and the volume of crystalloids received in both groups. Preoperative hemoglobin levels were lower in Group N; intraoperatively, they were more hypothermic and needed more colloids, blood, and plasma. Conclusion: Perioperative use of noradrenaline did not adversely affect free flap survival in patients who underwent microvascular reconstructive surgeries. Although re-exploration rate was marginally increased with use of noradrenaline, the final flap outcome was unaffected.
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Comparative study between preemptive and postoperative intra-articular injection of levobupivacaine and tramadol for control of postoperative pain p. 84
Ayman Anis Metry, Ramy M Wahba, George M Nakhla, Fady A Abdelmalek, Milad Z Ragaei, Neven G Fahmy
DOI:10.4103/aer.AER_20_19  
Background: This study had been formulated to evaluate and compare the analgesic effect of preemptive (PE), postoperative (PO), and combined knee intra-articular injection (IAI) of levobupivacaine and tramadol after knee arthroscopy. Materials and Methods: A total of 220 patients assigned for therapeutic knee arthroscopy were divided into four equal groups. Patients in Group C received IAI of 20 mL (0.5%) levobupivacaine preoperative, meanwhile patients in Group PE received IAI of 18 mL (0.5%) levobupivacaine with 100 mg tramadol (2 mL). Patients in Group PO received IAI of 18 mL (0.5%) levobupivacaine with 100 mg tramadol (2 mL) postoperatively, whereas patients in Group PE/PO received IAI of 19 mL (0.25%) levobupivacaine with 50 mg tramadol (1 mL) preoperatively and postoperatively. Numeric rating scale (NRS) had been used to assess pain sensation. Duration till the first request of rescue analgesia and number of requests were recorded. Results: NRS scores were significantly higher in Group C compared to other groups and in Group PE in comparison to PO and PE/PO groups. Frequency of rescue analgesia requests was significantly higher in Group C with significantly higher mean times of requests, while was significantly lower in Group PE/PO with significantly lower mean times of requests when compared to groups PE and PO. Conclusions: PE levobupivacaine and tramadol IAI provided satisfactory level of PO analgesia after therapeutic arthroscopy. However, combined PE and PO levobupivacaine and tramadol IAI of half dose provided PO analgesia superior to that provided by either PE or PO full-dose IAI.
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Safety of pediatric peripheral blood stem cell harvest in daycare setting: An institutional experience p. 91
Melvin Alex Abraham, Anup J Devasia, Sajan Philip George, Biju George, Tunny Sebastian
DOI:10.4103/aer.AER_5_19  
Introduction: Children serving as a donor for their siblings will require anesthesia or sedation. In view of shortage of time and space in operating room setting, peripheral blood stem cell (PBSC) harvest is performed as a daycare procedure. Aim: This study aims to find out whether performing PBSC harvest in hematology blood collection area as a daycare procedure is safe or not. Settings and Design: This secondary analysis included 164 pediatric PBSC harvest (154 pediatric donors, of which 10 had repeat harvesting done) donors, performed under anesthesia, in the Department of Hematology, between January 2009 and June 2017. Materials and Methods: Donors were examined, informed consent was obtained, and adequate premedications were ensured. Induction was intravenous for cooperative donors or inhalational sevoflurane followed by intravenous maintenance infusion using either face mask or a laryngeal mask airway (LMA). During the procedure, vitals are monitored with a noninvasive monitor. Normal hemodynamics were ensured before transferring the children to the ward. Statistical Analysis:Statistical analysis was performed using SPSS 16.0 statistical software. Descriptive statistics and frequencies were used for the data description. Results: A total of 137 donors (median age of 5 years) were induced with sevoflurane and LMA was used in 84 children and face mask in 53. Twenty-seven children cooperated for intravenous induction. Various combinations of propofol, dexmedetomidine, and ketamine were used with respiratory and hemodynamic stability. The median duration of anesthesia was 250 (165–375) min. The recovery from anesthesia was smooth with a median wake-up time of 20 (5–60) min. Conclusion: This retrospective analysis demonstrates that nonoperating room anesthesia for pediatric age group for PBSC harvest can be safely and successfully accomplished outside the operation room setting by a consultant anesthesiologist.
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Oral pregabalin as premedication on anxiolysis and stress response to laryngoscopy and endotracheal intubation in patients undergoing laparoscopic cholecystectomy: A randomized double-blind study p. 97
Dheer Singh, Jaybrijesh Singh Yadav, Birendra Kumar Jamuda, Pooja Singh
DOI:10.4103/aer.AER_12_19  
Background: Direct laryngoscopy and tracheal intubation lead to increase in heart rate and blood pressure. This can cause serious complications in patients with coronary artery disease, reactive airways, or intracranial neuropathology. Preoperative anxiety is associated with greater level of postoperative pain. Attenuation of anxiety and hemodynamic response to laryngoscopy and intubation are cornerstone of better anesthetic outcome. Gabapentinoids (gabapentin and pregabalin) have been known to possess anxiolytic, analgesic, and anticonvulsant properties. Aim: The aim of this study is to determine the effects of oral pregabalin on anxiolysis and attenuation of stress response to laryngoscopy and endotracheal intubation. Study Design: This was a prospective randomized double-blind placebo controlled study. Materials and Methods: A total of 60 patients ASA physical status Class I and II, undergoing elective laparoscopic cholecystectomy, were randomly allocated into two groups receiving either oral placebo or oral pregabalin 150 mg, 60 min before induction of anesthesia. Visual analog scale (VAS) for anxiety was recorded before, and 60 min after giving the drug. Hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) were recorded before, and 60 min after giving drug, during and 2, 4, 6, 8, and 10 min after intubation. Results: During preinduction, pregabalin showed a decrease in VAS and attenuation of stress response to laryngoscopy and intubation compared to that of placebo. The premedicated patients were hemodynamically stable perioperatively without side effects. Conclusion: Pregabalin is effective in attenuating preoperative anxiety and stress response to endotracheal intubation.
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Efficacy of clonidine as an additive on the duration of action of brachial plexus block performed under ultrasound and nerve locator guidance: A prospective randomized study p. 105
Ajay Prasad Hrishi, Gurudutt Rao, Karen Ruby Lionel
DOI:10.4103/aer.AER_6_19  
Background: Clonidine, an alpha2agonist, when added to local anesthetics in different regional and neuraxial blocks reduces the onset time, improves the efficacy, and increases the duration of postoperative analgesia. Aims: This study evaluated the effect of bupivacaine clonidine combination in ultrasound and nerve locator-guided supraclavicular brachial plexus block for upper limb surgeries. Settings and Design: This was a prospective, randomized, controlled, double-blind study carried out in a tertiary care center in South India on 50 patients with American Society of Anesthesiologists (ASA) physical status classes I and II undergoing elective upper limb surgery under supraclavicular brachial plexus block. Materials and Methods: Eligible participants were randomized equally to either Group B who received 20 ml of bupivacaine and 7 mL of 2% lignocaine or Group C who received 20 ml of bupivacaine, 7 ml of 2% lignocaine, and 100 μg of clonidine. Statistical Analysis: Continuous outcome variables were tested for statistical significance using Student's t-test, and Mann–Whitney U-test was used for outcomes that were nonnormally distributed. Categorical variables were compared using Fisher's exact test.P <0.05 was considered as statistically significant. Results: The onset of sensory and motor blockade was significantly faster (P < 0.05) in Group C compared to Group B. The duration of sensory and motor block and the duration of analgesia were significantly longer in Group C (P < 0.001). The sedation in Group C patients was significantly more (P < 0.05) when compared to Group B, but none of the sedation scores exceeded 3 on the Ramsay sedation score. Hemodynamic parameters did not differ between groups (P > 0.05). Conclusion: The inclusion of 100 μg of clonidine with bupivacaine in ultrasound-guided supraclavicular brachial plexus blocks prolongs both sensory and motor blockade. It also provides significant postoperative analgesia and mild sedation which is beneficial in the immediate stressful postoperative period.
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Evaluation and comparison of fentanyl versus nalbuphine for attenuation of hemodynamic response to laryngoscopy and endotracheal intubation in general anesthesia p. 111
Shoiab Bashir Khanday, Aabid Hussain Mir, Khalid Pervaiz Sofi, Abdul Qayoom Lone, Areeba Noor Shah
DOI:10.4103/aer.AER_16_19  
Background: General anesthesia administration involves laryngoscopy and endotracheal intubation which are associated with the pressor response and can lead to tachycardia, hypertension, and arrhythmias, which can be deleterious in compromised patients and hence, this response needs to be suppressed. Aims: The aim of the study is to compare the effectiveness of intravenous (i.v) fentanyl and nalbuphine on the suppression of hemodynamic response in patients undergoing surgery under general anesthesia. Setting and Design: This prospective comparative study was conducted in the department of anesthesiology of a tertiary care center, and patients posted for elective surgery under general anesthesia were included. Methods: A total of 100 patients of either sex in the age group of 20–50 years, belonging to the American Society of Anesthesiologists physical status classes I and II undergoing surgery under general anesthesia, were divided into two groups: Group N (n = 50) – who received injection nalbuphine 0.2 mg/kg diluted in 10 mL normal saline i.v and Group F (n = 50) – who received injection fentanyl 2 μg/kg diluted in 10 mL of normal saline i.v over 1 min, 5 min prior to intubation. Technique of anesthesia was standardized for all the patients in the study. Heart rate (HR), blood pressure (systolic, diastolic, and mean arterial pressure [SBP, DBP, and MAP]), and oxygen saturation were recorded at baseline, induction, and at 1, 3, 5, and 10 min after intubation. Statistical Analysis: Descriptive statistics were done using mean with standard deviation for quantitative variables, and categorical variables were presented in frequencies along with respective percentages. The statistical comparisons for quantitative variables were done using Student's t-test and for categorical variables, Chi-square was used according to the data. All statistical analyses were performed using SPSS software (Version 22, SPSS Inc., Chicago, IL, USA). All analyses were two tailed, and results were discussed on 5% level of significance, i.e., P < 0.05 was considered statistically significant. Results: The demographic characteristics were comparable in both groups. HR was statistically insignificant between the two groups at all intervals. Comparing SBP, DBP, and MAP between the two groups, there was a significant increase in nalbuphine group than fentanyl group postintubation and was statistically significant at all intervals of time. Maximum rise in SBP, DBP, and MAP was 5.49%, 6.03%, and 5.80% for fentanyl group and 12.88%, 9.37%, and 10.86% for nalbuphine group, respectively. Comparison of oxygen saturation in two groups was statistically insignificant. Conclusion: Fentanyl is better than nalbuphine in blunting the pressor response of laryngoscopy and endotracheal intubation.
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Effect of fentanyl and nalbuphine for prevention of etomidate-induced myoclonus p. 119
Megha Bisht, Abhimanyu Singh Pokhriyal, Gurjeet Khurana, Jagdish P Sharma
DOI:10.4103/aer.AER_188_18  
Background: Etomidate is a potent intravenous inducing agent with known undesirable side effects such as myoclonus and pain on injection in nonpremedicated patients. Aims: The aim of this study is to compare the effect of fentanyl and nalbuphine in the prevention of etomidate-induced myoclonus. Settings and Design: Randomized double-blind, placebo-controlled, and prospective comparative study. Materials and Methods: A total of 120 patients were randomly allocated to one of the three groups containing 40 patients each for intravenous administration of fentanyl 2 μg/kg diluted in 10 mL normal saline (NS) (Group 1), nalbuphine 0.3 mg/kg diluted in 10 mL NS (Group 2), and only 10 mL NS (Group 3) over 10 min. All groups subsequently received 0.3 mg/kg etomidate by intravenous bolus injection over 15–20 s and were assessed for the severity of pain using Grade IV pain scale and observed for myoclonus for 2 min and graded according to clinical severity. Serum creatinine phosphokinase (CPK) levels were obtained prior and postetomidate injection. Statistical Analysis: Statistical analysis was performed by the SPSS program version 17.0 for Windows. Tests used are Shaipro–Wilk test, ANOVA, Tukey's multiple comparison test, Tamhane's T2, and the Chi-square test. For all statistical tests,P < 0.05 was considered statistically significant with 5% level of significance (α). Results: The incidence of myoclonus in Group 1 and 2 was 52.5% and 17.5%, respectively, whereas it was 92.45% in Group 3. There was no pain observed in 70%, 92.5%, and 50% of patients in Group 1, 2, and 3, respectively. There was a statistically significant difference in mean CPK level after induction among three groups (P < 0.001). Conclusion: Nalbuphine is more effective than fentanyl in the prevention of etomidate-induced myoclonus and pain with the minimum rise in CPK levels.
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Evaluation of ultrasound-guided transversus abdominis plane block for postoperative analgesia in patients undergoing intraperitoneal onlay mesh repair p. 126
Swati Jain, Sumit Kalra, Bimla Sharma, Chand Sahai, Jayashree Sood
DOI:10.4103/aer.AER_176_18  
Introduction: Ventral hernia is a commonly performed surgical procedure in adults. Laparoscopic intraperitoneal onlay mesh repair (IPOM) of ventral hernia is procedure of choice. IPOM of ventral hernia is associated with significant pain. Hence, our aim was to study the efficacy of instilling preemptive local analgesia for reducing postoperative pain in patients undergoing laparoscopic ventral hernia repairs. Objective: To study the role of local infiltration of 10 ml of 0.5% ropivacaine in the anterior abdominal wall preoperatively to improve pain scores compared to conventional intravenous systemic analgesia. Materials and Methods: The study pool consists of two groups of patients (25 in each group) admitted for laparoscopic uncomplicated ventral hernia repair. Analysis was performed by the SPSS program (Company – International Business Machines Corporation, headquartered at Armonk, New York, USA) for Windows, version 17.0. Normally distributed continuous variables were compared using ANOVA. Categorical variables were analyzed using the Chi-square test. Results: Both groups were matching in terms of demographic features. Postoperatively, pain assessment was performed every 30 min for the first 2 h and was followed up for a period of 24 h at intervals (4, 6, 12, and 24 h). Postoperatively, patients were also assessed for time of ambulation, time of return of bowel sounds at 6, 12, and 24 h, and length of hospital stay. Side effects and complication were noted. Conclusion: Our study demonstrated that supplementing US-guided transversus abdominis plane (TAP) block to conventional systemic analgesics resulted in decreased VAS scores and decreased requirement of rescue analgesics. The patients ambulated early had earlier appearance of bowel sounds and decreased length of hospital stay. There was also decreased incidence of nausea and vomiting. TAP block for laparoscopic IPOM surgery significantly decreases postoperative pain and opioid requirement in patients.
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Hepatic protective effect of dexmedetomidine after partial hepatectomy surgery: A prospective controlled study p. 132
Hani I Taman, Emad Elhefnawy
DOI:10.4103/aer.AER_106_18  
Background: Inflow occlusion of the portal triad is a common blood loss-reducing method during hepatectomy which may induce ischemic-reperfusion injury of the remaining parts of the liver. Dexmedetomidine is used for reducing ischemic-reperfusion injury in hepatectomy. Aim: The aim of this study was to assess the protective effect of dexmedetomidine on liver after partial hepatectomy using inflow occlusion. Setting and Design: This prospective controlled, double-blinded, randomized study included any patients of either sex with age between 20 and 70 years, those in physical status American Society of Anesthesiologists Classes I and II, and those who were planned for partial hepatectomy. Patients and Methods: Patients with elective hepatectomy were randomized into dexmedetomidine group, which received dexmedetomidine at 0.3 mg/kg/h, and control group, which received a placebo. Statistical Analysis: Statistical analysis was performed using IBM SPSS software version 18. Data were tested using Kolmogorov–Smirnov test, independent t-test or Mann–Whitney U-test, and Chi-square or Fisher's exact test. The statistical significance was considered at P < 0.05. Results: Serum albumin, aspartate aminotransferase, alanine aminotransferase, prothrombin time were higher in control group in comparison to dexmedetomidine group. Hypotension duration was lower in control group in comparison to dexmedetomidine group. Vasoconstrictor usage, amount of blood loss, and colloid, crystalloid, and blood given to patients were higher in control group in comparison to the study group. Conclusions: Dexmedetomidine can protect the liver during hepatic resection surgery with inflow occlusion with decreasing blood loss and need for blood transfusion.
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Study of attenuation of hemodynamic response to laryngoscopy and endotracheal intubation using intra-oral ivabradine p. 138
Vishal Arora, Gunjan Awasthi, Raj Bahadur Singh, Vivek Singh
DOI:10.4103/aer.AER_175_18  
Context: Endotracheal intubation is one of the most commonly performed procedures, where rapid and dramatic hemodynamic changes which adversely affect the patient may occur during the perioperative period. Various strategies have been applied to attenuate these responses in high-risk individuals. Ivabradine is a very unique cardiotonic drug in the medical literature which reduces the heart rate without jeopardizing hemodynamics in unhealthy, compromised patients. Aims and Objective: The aim of this study is to evaluate the effect of oral ivabradine on the hemodynamics during laryngoscopy and endotracheal intubation in patients undergoing surgical procedure under general anesthesia and to note the side effects and complications. Settings and Design: This was a prospective, randomized, and double-blind controlled study. Subjects and Methods: A total of 50 American Society of Anesthesiologists physical status I patients between 20 and 50 years age comparable in demographic variables of either sex, undergoing surgery under general anesthesia were randomized into two groups, namely, Group T and Group C of 25 each. Group T (test group) received tablet ivabradine 5 mg 1 h before intubation. Group C (control group) received placebo 1 h before intubation. The pulse rate, systolic and diastolic blood pressures, and mean arterial pressure were recorded for around 10 min and surgery was not allowed to commence. These hemodynamic variables were measured preoperatively, at intubation, after 1 min, 5 min, 8 min and 10 min postintubation. Statistical Analysis Used: The Chi-square test and ANOVA test using INDOSTAT software for hemodynamics were used in this study. Results: There was an increase in all parameters in the control group during and postintubation and was undisturbed in the test group as compared to base line. The increase was constant up to 3 min and got settled within 5 min in the control group. Conclusion: Ivabradine had better patient compliance in terms of blunting laryngoscopic pressor.
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Comparison of subcostal transversus abdominis block with intraperitoneal instillation of levobupivacaine for pain relief after laparoscopic cholecystectomy: A prospective study p. 144
Hariom Khandelwal, Kumar Parag, Ashutosh Singh, Nidhi Anand, Nishith Govil
DOI:10.4103/aer.AER_3_19  
Background: There are several methods employed in the management of postoperative pain after laparoscopic cholecystectomy such as conventional systemic analgesics, including paracetamol, non-steroidal anti-inflammatory drugs, systemic opioids, and thoracic epidural analgesia with all having its limitations and side effects. Aims: The present study aims to compare ultrasound-guided subcostal transversus abdominis (STA) block with intraperitoneal instillation of levobupivacaine in reducing postoperative pain, total analgesic consumption, nausea and vomiting, and recovery time in patients after elective laparoscopic cholecystectomy. Settings and Design: A prospective study was conducted between January 2017 and December 2017 in 80 patients undergoing elective laparoscopic cholecystectomy after approval of the Institutional Ethical Committee (Reference No: SGRR/IEC/05/16). Materials and Methods: Patients were randomly divided into two equal-sized (n = 40) study groups. Group 1 patients received ultrasonography-guided STA block with 0.25% levobupivacaine both sides and Group 2 patients received 0.25% levobupivacaine through intraperitoneal route. Statistical Analysis: Quantitative data were expressed in mean and standard deviation. Qualitative data were expressed in proportion and percentages. Independent t-test was applied to compare the means of quantitative data and the Chi-square test was used to compare categorical data. P < 0.05 was considered to be statistically significant. Survival curve was drawn using the log-rank test for comparing two groups. Results: Patient characteristics regarding age, gender, and weight were comparable in the two groups. The mean Numerical Rating Scale scores were less in Group 1 than in Group 2 in the first 6 h, which was found to be statistically significant. There was no significant difference noted in pain scores after 6 h up to 24 h in postoperative area among the two groups. Pain scores for shoulder tip pain were lower in Group 2 as compared to Group 1 in the first 24 h, which was not significant statistically. Conclusion: STA block is a better modality for analgesia compared to intraperitoneal instillation in patients undergoing elective laparoscopic cholecystectomy.
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Ultrasound-guided inter-scalene brachial plexus block with superficial cervical plexus block compared with general anesthesia in patients undergoing clavicular surgery: A comparative analysis p. 149
Swarna Banerjee, Ranjita Acharya, Bhavna Sriramka
DOI:10.4103/aer.AER_185_18  
Background: General anesthesia is preferred for clavicular surgeries. With the advent of ultrasound-guided technology, interscalene brachial plexus block with superficial cervical nerve block has become a new option for providing intraoperative anesthesia and postoperative analgesia for surgeries of the clavicle. Aims and Objectives: The present study compares the ultrasound-guided interscalene brachial plexus nerve block combined with superficial cervical nerve block to general anesthesia in clavicular surgery. Settings and Design: This study was a randomized controlled trial in a tertiary care setting. Materials and Methods: A total of 60 patients between 18 and 60 years who were scheduled for clavicular surgeries were randomly and equally divided into Group B and Group G. Group B received ultrasound-guided interscalene brachial plexus block with superficial cervical nerve block. Group G received general anesthesia. Time duration between start of anesthesia to the incision time, intraoperative vitals, and time spent in postanesthesia care unit, postoperative pain scores, postoperative analgesic consumption, and complications were noted and compared. Statistical Analysis: Statistical analyses were done using SPSS software 20.0. Normality tests were applied, and accordingly, parametric and nonparametric tests were used to calculate the results. Results: The demographic data were comparable in both the groups. Time duration between start of anesthesia to the incision time was significantly more in Group B than in Group G. The time spent in postanesthesia care unit and postoperative pain scores were significantly more in Group G than Group B. Total postoperative opioid consumption was significantly less in Group B than in Group G. Conclusion: Ultrasound-guided interscalene brachial plexus block combined with superficial cervical nerve block is a safe and effective mode of anesthesia in comparison to general anesthesia for clavicle surgeries.
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Comparison of heparin quick penetrating solution and diclofenac quick penetrating solution for the prevention of superficial thrombophlebitis caused by peripheral venous cannulation: A randomized double-blind study p. 155
Akhileshwar , Swati Singh
DOI:10.4103/aer.AER_189_18  
Background and Aims: The association of superficial thrombophlebitis (ST) with deep-venous thrombosis varies between 6% and 44%. Thus, prevention of ST is important. The aim of this study was to compare the efficacy of topical quick penetrating solution (QPS) of heparin 1000 IU/mL versus diclofenac QPS for prevention of postinfusion ST. Settings and Design: This is a randomized, controlled, double-blind study. Materials and Methods: The study was done after ethical clearance and Clinical Trial Registry- India registration to compare 100 patients for the prevention of ST with application of heparin QPS and diclofenac QPS at regular intervals. Patients were randomized into two groups (Group H [control group] – heparin QPS group and Group D – diclofenac QPS group) and the assigned treatment was applied four times daily. The appearance of thrombophlebitis was graded on the basis of infusion nursing society scale. The site of venous cannulation was inspected every 6 h for any changes for the next 5 days. Statistical Analysis: The parametric data were analyzed using Student's t-test and nonparametric data were analyzed by Kruskal–Wallis test. Results: Of 98, only 10 patients developed thrombophlebitis and all belonged to Group D (23%). No patient belonging to Group H developed thrombophlebitis (0%). This difference was statistically significant (P = 0.034). Conclusion: The QPS formulation of heparine and diclofenac was effective in preventing thrombophlebitis. Heparine QPS is more effective than diclofenac QPS for the same.
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Post extubation airway conditions after direct laryngoscopic biopsy: A comparative evaluation between lignocaine nebulization and lignocaine lozenges - A randomized trial p. 158
Kanika Sachdeva, Veena Asthana, Divya Gupta, Sampan S Bist
DOI:10.4103/aer.AER_195_18  
Context: Postextubation airway complications are one of the most undesired side effects of airway manipulation. Pharmacological and nonpharmacological measures have been utilized for minimizing the morbidity. Lignocaine lozenges, a new modality, used to reduce post-extubation airway complications is an area yet to be explored. Aims: The aim of this study is to evaluate and compare the effects of lignocaine nebulization versus lignocaine lozenges in decreasing immediate postextubation airway complications in patients presenting for direct laryngoscopic biopsy. Settings and Design: This randomized study was conducted at tertiary care teaching hospital in northern state of India. Subjects and Methods: A total of 90 patients, 40–70 years, the American Society of Anesthesiologists (ASA) physical status Classes I, II, and III of either sex, posted for elective direct laryngoscopic biopsy, requiring general anesthesia with endotracheal intubation were included and randomly divided into groups (n = 30) to receive lignocaine nebulization (Group A), lignocaine lozenge (Group B), control (Group C). The patients were assessed for a cough after extubation after 5 min then every 10 min up to 30 min postextubation. Statistical Analysis Used: Categorical variables were compared using the Chi-square test or Fisher's exact test and continuous variables by using one-way Analysis of variance and Kruskal–Wallis test, respectively. Results: Comparison of a cough at various time intervals starting from extubation up to 30 min in post-extubation period was highly significant in between groups. Among Group A (lignocaine nebulization) 33% of patients had a decrease in the severity of a cough within the first 5 min; although among Group B (Lignocaine Lozenges), the decrease in the severity of a cough (40%) was more as compared to that of Group A. Similar decrease in the severity of a cough was observed through various time interval from 10 min to 30 min postextubation. After 30 min, 73% of patients in Group A and 76% of patients in Group B had an incidence of a decrease in the severity of cough. Conclusions: Lignocaine Lozenges have been found to have a better result.
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A comparative clinical study of ultrasonography-guided perivascular and perineural axillary brachial plexus block for upper limb surgeries p. 163
Vinuta Vidyanand Vastrad, Sridevi Mallanna Mulimani, Dayanand Gurubasappa Talikoti, Vijaya M Sorganvi
DOI:10.4103/aer.AER_184_18  
Background: Axillary brachial plexus block (ABPB) is safest among other methods of brachial plexus block because of its ease and reliability. The two approaches of ultrasonography-guided ABPB are perivascular (PV) and perineural (PN). Aims: This study was conducted to compare primary outcomes such as performance time, onset of the block, number of needle passes, block success rate, duration of sensory and motor block, and complications between ultrasound-guided PV and PN ABPB in patients posted for upper limb surgeries. Settings and Design: This prospective randomized study was conducted on 106 patients American Society of Anesthesiologists Class I and II posted for forearm, wrist, and hand surgeries, who were allotted into Group PV and Group PN 53 each. Materials and Methods: In both methods, 20 mL of the drug was used. To start with, musculocutaneous nerve was blocked with 5 mL of the drug. In the PV technique, remaining 15 mL of the drug was deposited anterior and posterior to axillary artery, and in PN technique, 5 mL of the drug was injected around radial, ulnar, and median nerve. Statistical Analysis: Mann–Whitney and Chi-square test were used for statistical analysis. Results: Significant difference was observed between the two groups in performance time (PV – 8.647 ± 0.54 min and PN – 14.53 ± 0.20 min), onset time (PV – 19.48 ± 2.83 min and PN – 13.86 ± 1.81 min), and number of needle passes (PV – 2.30 ± 0.50 and PN – 4.91 ± 0.66). Other parameters were comparable in both the groups. Conclusions: Ultrasound-guided PV axillary plexus block is better than PN axillary plexus block with respect to performance time and number of needle passes; but onset time was shorter in PN block, with precaution eliminating the risk of complications.
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Intraperitoneal ropivacaine with dexmedetomidine or fentanyl for postoperative analgesia following laparoscopic cholecystectomy: A comparative randomized trial p. 169
B Lakshmi Praveena, B Bharathi, VR Sahana
DOI:10.4103/aer.AER_191_18  
Background: Intraperitoneal local anesthetic is an effective analgesic approach following laparoscopic cholecystectomy. Aims: The aim of the present study was to compare the antinociceptive effects of intraperitoneal ropivacaine plus fentanyl with ropivacaine plus dexmedetomidine in patients undergoing laparoscopic cholecystectomy. Settings and Designs: This was randomized, prospective, double-blinded, observational clinical study. Methods: A total of 80 patients, undergoing elective laparoscopic cholecystectomy under general anesthesia were randomly assigned to one of the two equal groups to receive either of the following: Group RF (n = 40) were given 30 mL of 0.2% ropivacaine combined with 1 μg/kg fentanyl (diluted in 2 mL normal saline) and Group RD (n = 40) were given 30 mL of 0.2% ropivacaine combined with 1 μg/kg dexmedetomidine (diluted in 2 mL normal saline) through trocars. The quality of analgesia was assessed using visual analog scale score (VAS). Time to the first request of analgesia, the total dose of analgesic in the first 24 h and adverse effects were noted. Statistical Analysis: The data were analyzed with the Students' t-test and Chi-square test. Results: VAS score at different time intervals, overall VAS in 24 h was significantly lower (1.68 ± 0.46 vs. 4.47 ± 0.94), time to first request of analgesia (min) was longest (122.7 ± 24.5 vs. 89.3 ± 13.2) and total analgesic consumption (mg) was lowest (95.3 ± 15.6 vs. 135.7 ± 75.1) in RD group than in RF group. Conclusion: The antinociceptive effect of the intraperitoneal instillation of ropivacaine in combination with dexmedetomidine is superior to ropivacaine combined with fentanyl.
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Supraclavicular brachial plexus block: Comparison of varying doses of butorphanol combined with levobupivacaine – A double-blind prospective randomized trial p. 174
B Bharathi, B Lakshmi Praveena, K Neela Krishnaveni
DOI:10.4103/aer.AER_190_18  
Background: The ideal dose of butorphanol for brachial plexus block is not well known. Aims: This study was carried out to evaluate 1 mg and 2 mg of butorphanol added to 0.375% levobupivacaine, with regard to the duration of analgesia. Our study also sought to assess the onset and duration of sensorimotor blockade, hemodynamic effects, sedation, and adverse effects. Settings and Design: This study was a prospective, randomized, double-blinded, and comparative study. Methods: Eighty adult patients of either sex undergoing upper limb surgeries under supraclavicular brachial plexus block were randomly allocated into two groups. Group LB1 received 29 ml of 0.375% levobupivacaine plus 1 mg of butorphanol diluted in 1 ml of normal saline. Group LB2 received 29 ml of 0.375% levobupivacaine plus 2 mg of butorphanol diluted in 1 ml of normal saline. The onset and duration of sensorimotor blockade, level of sedation, duration of analgesia, and adverse effects were assessed. Statistical Analysis: The data were analyzed with Student's t-test and Chi-square test. Results: The onset of sensory (P = 0.032) and motor block (P = 0.026) was earlier in Group LB2 than in Group LB1. The duration of analgesia was significantly prolonged in Group LB2 (643.55 ± 131.6 vs. 511.73 ± 128.6 min; P = 0.001). The incidence of sedation was observed in more number of patients in Group LB2 (P = 0.01). Furthermore, the incidence of nausea, vomiting, and pruritus were observed in more number of patients in Group LB2 (P < 0.05). Conclusion: Higher dose of butorphanol in brachial plexus block hastens the onset and prolongs the duration of sensorimotor blockade and analgesia but is associated with a higher incidence of sedation which requires intense monitoring.
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Transversus abdominis plane block: Comparison of efficacy of varying doses of clonidine combined with levobupivacaine – A double-blind randomized trail p. 179
B Manju Sruthi, G Sowmya Reddy, G Jyothsna
DOI:10.4103/aer.AER_179_18  
Background: Transversus abdominis plane block (TAP) has an evolving role in postoperative analgesia following laparoscopic-assisted vaginal hysterectomy (LAVH). Aims: This study was carried out to evaluate 75 μg and 150 μg of clonidine added to 0.25% levobupivacaine, with regard to the duration of analgesia. Our study also sought to assess the hemodynamic effects, sedation, and adverse effects. Settings and Design: This was a prospective, randomized, double-blinded, comparative study. Methods: A total number of 80 patients undergoing elective LAVH surgery under general anesthesia were randomly assigned to one of the two equal groups to receive either of the following: Group LC75 – 29 ml of 0.25% levobupivacaine plus 75 μg of clonidine diluted in 1 ml of normal saline (total 30 ml) and Group LC150 – 29 ml of 0.25% levobupivacaine plus 150 μg of clonidine diluted in 1 ml of normal saline (total 30 ml). Duration of analgesia was the primary outcome. Hemodynamic variables, sedation score, and adverse effects were secondary outcomes. Statistical Analysis: The data were analyzed with Student's t-test and Chi-square test. Results: The duration of analgesia was significantly prolonged in Group LC150 (609.18 ± 6.59 vs. 410.52 ± 7.18 min; P = 0.001). The visual analog scale score in patients who received clonidine 150 μg Group LC150 as an adjunct was significantly lower than who received 75 μg Group LC75. Significantly higher sedation score was observed in Group LC150. The incidence of bradycardia was also significant between two groups. Significantly fewer patients in Group LC150 required rescue analgesia. Conclusion: The 150 μg dose of clonidine in TAP block prolongs the duration of analgesia but with higher incidence of sedation.
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CASE REPORTS Top

Spontaneous bilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema following intracranial aneurysm clipping under general anesthesia p. 184
Yuanyuan Wang, Bo Shi, Yanhui Li, Na Wang
DOI:10.4103/aer.AER_167_18  
A 64-year-old male smoker who was previously healthy underwent intracranial aneurysm clipping after subarachnoid hemorrhage. Thoracic computerized tomography which was taken a day before the surgery revealed small bullae and low attenuation area in bilateral lower lobes. Soon after the completion of the surgery, the patient began to breathe, and then developed cough, 5 min later oxygen saturation decreased, and diminished breath sounds were detected in the left lung. Tube thoracostomy was performed and eventually resolved the complication. Bilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema were confirmed by computerized tomography later. Early recognition and intervention of perioperative pneumothorax and pneumomediastinum can improve the patient's outcome.
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Serotonin syndrome induced by combined use of sertraline and linezolid p. 188
Ramesh Hasani, Jahnabee Sarma, Sudha Kansal
DOI:10.4103/aer.AER_173_18  
Serotonin syndrome is a potentially fatal increase in serotonergic activity in both the central nervous system and peripheral nervous system. The etiology can vary from therapeutic drug use, deliberate overdose, or drug interactions that all lead to an increase in serotonin activity. There are some drugs from different classes that can cause serotonin syndrome either alone at high doses or when combined. We present here a case of an 82-year-old female who presented to the emergency room with high-grade fever, loose stools, burning micturition, and tachycardia. Her current medications included sertraline for depression. She was initially treated on the floor for urosepsis and subsequently managed with antibiotic therapy consisting of cephalosporins. She did not improve so her antibiotics were modified and she was then started on linezolid. Within the first 24 h of taking linezolid, the patient had a rapid clinical deterioration manifesting as restlessness, diaphoresis, tremor, shivering, myoclonus, and high fever (40°C). She also had an acute decompensation of her mental status with disorientation and confusion. As a result, she was transferred to intensive care unit. On clinical examination, she had rigidity and hyperreflexia all the four limbs. Babinski sign was positive. Laboratory test results were unremarkable for sepsis. Sertraline and linezolid were stopped. Within 24 h, the patient's mental status had improved. By the 2nd day on this treatment regimen, the patient's function returned to baseline, and she was discharged from the hospital. Nevertheless, in our case, the administration of sertraline did not reveal any symptomatic interaction, as the serotonin syndrome was induced only after the addition of linezolid to the treatment regimen. This patient was diagnosed with serotonin syndrome.
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LETTER TO EDITOR Top

The analgesic efficacy of transversus abdominis plane block combined with femoral branch of genitofemoral nerve block for femoral endarterectomy p. 191
Vincenzo Romano, Corrie Burke, Jian Hou, Jeff L Xu
DOI:10.4103/0028-3886.253606  
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