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   Table of Contents - Current issue
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April-June 2019
Volume 13 | Issue 2
Page Nos. 193-402

Online since Tuesday, May 28, 2019

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REVIEW ARTICLE  

Root cause analysis of blunders in anesthesia Highly accessed article p. 193
Ayman Aly Rayan, Sherif Essam Hemdan, Ayman Mohamed Shetaia
DOI:10.4103/aer.AER_47_19  PMID:31198229
The frequency of blunders perioperative because of anesthesia is expanding, and the precise occurrence is significantly thought little of practically due to underreporting. Root cause analysis of majority of anesthesia errors due to lack of knowledge, unfollow the patient procedures and guidelines, medications errors and lack of communication between the members of anesthesia team leading to morbidity or even mortality. The cornerstone in the operating room environment is the communication, especially the patient's data are accumulated and changed continuously during a patient's anesthesia. Continuous attempts for establishing Iideal strategies to reduce the incidence and chance of anesthesia errors. The advancement of a nonaccuse condition where mistakes are transparently revealed and talked about, and guidelines for naming the medication holders, vials, and ampoules are focused. All endeavors ought to be made in the revealing and anticipation of medical drug errors. It is time to incorporate electronic and digital concepts to encourage the evolution of anesthesia-related drug delivery system.
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ORIGINAL ARTICLES Top

Opioid-free total intravenous anesthesia improves postoperative quality of recovery after ambulatory gynecologic laparoscopy Highly accessed article p. 199
Karim Youssef Kamal Hakim, Wahba Zakaria Bekhet Wahba
DOI:10.4103/aer.AER_74_19  PMID:31198230
Background: Gynecological laparoscopic surgery is commonly performed on an ambulatory basis under general anesthesia. The postoperative quality of recovery (QOR) should be considered one of the principal endpoints after ambulatory surgery. Total intravenous anesthesia (TIVA) with opioids is known to improve postoperative QOR after ambulatory surgery. However, opioids can be associated with an increased incidence of postoperative complications, which can affect postoperative QOR. The primary aim of this study was to compare the patient recovery using the QOR-40 at 24 h postoperative in ambulatory gynecological laparoscopy between opioid-free (OF) TIVA and opioid-based TIVA. Settings and Design: A prospective, randomized, controlled, comparative study was conducted at the day surgery center. Patients and Methods: Eighty females were included in the study. They were randomized into two equal groups: OF TIVA group with dexmedetomidine and propofol or opioid-based TIVA (O) group with fentanyl and propofol. The primary outcome was QOR-40 at 24 h postoperative, and the secondary outcomes were postoperative numerical rating scale (NRS), time to first rescue analgesia, number of rescue tramadol analgesia, and the incidence of postoperative nausea and vomiting. Results: A statistically significant difference in total QOR-40 score at 24 h postoperative was observed between the groups (median [range] QOR-40 of 182.0 [164.0–192.0] in the OF TIVA group and 170.0 [156.0–185.0] in the O group; P = 0.03). OF group had significantly lower time to first rescue analgesia, maximum NRS pain scores, number of rescue tramadol analgesia, and ondansetron use. Conclusions: OF TIVA significantly improves postoperative QOR in patients undergoing ambulatory gynecological laparoscopic surgery.
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Comparing the ease of mask ventilation, laryngoscopy, and intubation in supine and lateral position in infants with meningomyelocele p. 204
Saraswathi Nagappa, Raghavendra Biligiri Sridhara, Sandhya Kalappa
DOI:10.4103/aer.AER_41_19  PMID:31198231
Background: The biggest anesthetic challenge in infants with thoracolumbar /sacral meningomyelocele is securing the airway. For securing the airway, most of the anesthesiologist's practices supine position with doughnut or head ring placed around the swelling to prevent rupture, which has got disadvantages like risk of rupture, infection and damage to neural structure. Left lateral position has been recommended previously for tracheal intubation in post-tonsillectomy hemorrhage. Several studies have shown successful ventilation in lateral position using laryngeal mask airway and intubation using video laryngoscopes. Aims and Objectives: Primary objective is to compare the time taken for intubation, number of attempts required for intubation. Secondary objective is to compare ease of mask ventilation, Cormack Lehane grading and Backwards Upward Rightwards Pressure [BURP] manoeuvre. Materials and Methods: A comparative, prospective randomized, controlled trial of 60 infants undergoing thoracolumbar/sacral meningomylocele repair. Infants were allocated to one of two groups of 30 patients each, by computer-generated randomization into Group S: mask ventilation, laryngoscopy and intubation in supine position and Group L: mask ventilation, laryngoscopy and intubation in lateral position. Statistical Methods: Chi-square/Fisher Exact test was used to find the significance of study parameters on categorical scale between two or more groups. Results: Mean intubation time of sixteen seconds were clinically acceptable and comparable in each of the two positions P = 0.145. Ten patients in the left lateral position, eight patients in the supine position required second intubation attempts before the airway was secured. Only 8.3% of our patients required third intubation attempts. Conclusion: Anesthesiologist should pay more attention to the safety and quality of mask ventilation, laryngoscopy and intubation in meningomylocele infants. Both supine and lateral position were comparable.
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Effect of local anesthesia and general anesthesia using I-gel laryngeal mask airway in diabetic patients undergoing cataract surgery: comparative study p. 209
Ghada Fouad Amer, Ola T Abdeldayem, Fatma MF Lahloub
DOI:10.4103/aer.AER_68_19  PMID:31198232
Background: Cataract surgery is one of the most commonly performed ophthalmic procedures. On choosing the appropriate method of anesthesia for diabetic patients with cataract whether regional or general, one should consider a technique that is associated with less stress response, minimal effect on hemodynamic and essentially associated with a good intraoperative glycemic control. This is yet to be determined. Aims: The aim of this study is to evaluate the use of I-gel as an alternative to local anesthesia (LA) in diabetic patients undergoing cataract surgery. Patients and Methods: This study was conducted on 60 controlled insulin-dependent diabetic patients undergoing cataract surgery. They were randomized to receive either LA by sub-Tenon's block (LA group n = 30) or general anesthesia (GA) using I-gel (GA group n = 30). Mean arterial blood pressure (MBP) and heart rate were monitored. Furthermore, blood glucose level and plasma cortisol level were measured at basal level, after induction of anesthesia or local block, after nuclear extraction, at the end of surgery, and 30, 60, 120, and 240 min postoperative. Results: There was no significant difference in either blood glucose or cortisol levels in both groups. Blood glucose level increased with induction of anesthesia in both groups. The use of I-gel was not associated with increase heart rate or MBP compared to the LA group. Conclusion: Both local and GA using I-gel are relatively safe without marked changes in hemodynamics, blood glucose, or cortisol level in insulin-dependent diabetic patients.
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Correlation of symphysiofundal height and abdominal girth with the incidence of hypotension in cesarean section under spinal anesthesia using bupivacaine with fentanyl as adjuvant: A clinical study p. 214
Prabha Parthasarathy, Rashmi R Aithal, RS Raghavendra Rao, Shreyavathi Raghuram, R Ramesh, Anis Nazneen
DOI:10.4103/aer.AER_36_19  PMID:31198233
Background and Aims: A decreased lumbosacral subarachnoid space volume is a major factor in cephalad intrathecal spread of local anesthetic in term parturients due to compressive effect of the gravid uterus. The aim of this study was to assess the relationship of symphysiofundal height (SFH) and abdominal girth (AG) with the incidence of hypotension and the highest level of sensory blockade. Settings and Design: This study was a prospective observational study. Materials and Methods: Ninety parturients under the American Society of Anesthesiologists physical status class II within the age range of 20–30 years, weighing between 60 and 65 kg, and height between 150 and 155 cm were studied, and the SFH and AG of all parturients had been measured just before spinal anesthesia. Hyperbaric bupivacaine 9 mg with 12.5 μg intrathecal fentanyl was administered for subarachnoid block. The incidence of hypotension and the highest level of sensory block were assessed. Statistical Analysis: Correlation analysis (Spearman's rank test) was applied to analyze the data, and P < 0.05 was considered to be statistically significant. Results: The incidence of hypotension was higher with increasing SFH (16.9% with SFH of 30–35 cm, 78.37% with SFH of 36–40 cm; correlation coefficient Ρ =0.338) and with increasing AG (5.3% with AG between 85 and 89 cm, 35.7% with AG 90–94 cm, 62.8% with AG 95–99 cm; Ρ =0.341), and both were statistically significant (P < 0.001). There was a statistically significant correlation between increasing SFH and maximum sensory block achieved (Ρ =0.157, P < 0.001). There was increased level of sensory blockade with increased AG but was not statistically significant (Ρ =0.011, P = 0.32). Conclusion: In term parturients undergoing cesarean section under spinal anesthesia, the SFH has a significant positive correlation with the incidence of hypotension and ascent of spinal anesthesia. AG also has a positive correlation with the incidence of hypotension but is not significant with the ascent of spinal anesthesia.
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Evaluation of renal function with administration of 6% hydroxyethyl starch and 4% gelatin in major abdominal surgeries: A pilot study p. 219
Meera Mohanan, Sunil Rajan, Rajesh Kesavan, Zubair Umer Mohamed, Sundaram K Ramaiyar, Lakshmi Kumar
DOI:10.4103/aer.AER_25_19  PMID:31198234
Background: Synthetic colloids, both starches and gelatins, are commonly used as intravascular fluid replacements on account of increased vascular persistence. The safety on renal outcomes during perioperative use is poorly understood. Aims: We evaluated renal outcomes of hydroxyethyl starch 6% (HES) and gelatins 4% (G) in patients undergoing elective abdominal surgery. The primary outcome was serum creatinine measurements at baseline, 12 h, 36 h, and 1 week postoperatively (T0, T12, T36, and D7). The secondary outcomes were measurements of prothrombin time (PT), international normalized ratio (INR), fibrinogen, and activated partial thromboplastin time (aPTT) at baseline, 12 h, and 36 h postoperatively. Setting and Design: A prospective randomized study was conducted at a tertiary care institute. Materials and Methods: Seven-five adult patients received either HES (Group H) or gelatin (Group G) at 20-ml/kg body weight or only crystalloids (Group C) during surgery. Statistical tests used were one-way ANOVA, Student's t-test, Pearson correlation method, and Chi-square test. Results: Serum creatinine assessed at T0, T12, T36, and D7 was comparable between the three groups. PT/INR and aPTT showed no significant increase in values of T12 and T36 in comparison to T0. Fibrinogen level was significantly higher in Group C at T12 and T36. Intraoperative vasopressor use, need for product transfusion, length of intensive care unit stay, and return of bowel function were similar between the three groups. Conclusions: Intraoperative use of HES (130/0.4) or gelatin (4%) at 20-ml/kg body weight was not associated with renal dysfunction or altered PT and aPTT in adult patients undergoing elective abdominal major surgeries.
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Efficacy of intra-articular dexmedetomidine versus buprenorphine for postoperative analgesia following knee arthroscopy: A comparative study p. 225
Pulin Bihari Das, Soumya Samal
DOI:10.4103/aer.AER_33_19  PMID:31198235
Background: Arthroscopic knee surgery is most commonly performed minimally invasive surgical procedure in orthopaedics. Postoperative pain relief is must for early mobilisation that reduces patient's morbidity and improves postoperative recovery. Aims and Objectives: We sought to compare analgesic efficacy of intraarticular buprenorphine with dexmedetomidine following arthroscopic surgery of knee. Settings and Design: A prospective , randomized controlled double blinded study was conducted involving 60 patients undergoing arthroscopic knee surgery. Materials and Methods: Patients were allocated into group B (n = 30) and group D (n = 30) receiving 100 μg of intraarticular buprenorphine and 100 μg 0f intraarticular dexmedetomidine respectively. Parameters observed were the time to first rescue analgesia , the number of patients requiring rescue analgesia with in next 24 hours, Visual analogue scale (VAS) at rest and on mobilization at 1st, 2nd, 4th, 8th, 12th and 24th hour. Statistical Analysis: Quantitative data were analyzed by unpaired student's t test and categorical data by Fisher's exact test. A P < 0.05 was considered to be significant. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS 19.0, SPSS Inc., Chicago, IL, USA). Results: Time to first rescue analgesia was significantly longer in patients receiving in group B. VAS scores at rest were comparable between the groups at 1st, 2nd, 4th and 8th hour but significantly low with intraarticular buprenorphine than intraarticular dexmedetomidine at 12th and 24th hour. VAS scores on ambulation were comparable at 1st, 2nd and 4th hour but significantly higher in dexmedetomidine group as compared to buprenorphine at 8th, 12th and 24th hour. Conclusion: Intraarticular buprenorphine 100 μg provides longer duration of analgesia with decreased postoperative rescue analgesic requirement as compared to 100 μg intraarticular dexmedetomidine.
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The effect of adding dopamine infusion to noradrenaline infusion combined with restrictive hydration on renal function and tissue perfusion during open abdominal surgeries p. 229
Ayman Anis Metry, Adham F Tawfik, George M Nakhla, Rami M Wahba, Milad Z Ragaei, Fady A Abdelmalek
DOI:10.4103/aer.AER_34_19  PMID:31198236
Objectives: This study was designed to assess the effect of adding dopamine infusion in addition to restrictive hydration combined with noradrenaline infusion on intraoperative renal function and serum lactate levels in comparison to restrictive hydration combined with noradrenaline infusion only and standard hydration during open abdominal surgeries. Patients and Methods: One hundred and twenty patients were randomly assigned into three equal groups undergoing major open abdominal procedures. In Group I, dopamine infusion in addition to norepinephrine infusion were administered with restrictive hydration. In Group II, norepinephrine infusion was started before the induction of anesthesia with restrictive hydration. In Groups I and II, Ringer's solution was infused at a fixed rate of 2 mL.kg-1.h-1 until the end of surgery. In Group III, the conventional fluid replacement was introduced according maintenance, fluid deficit and third space loss. The outcome to be assessed was serial measurements of creatinine and serum lactate levels preoperatively, intraoperatively, and just postoperatively in addition to after 24 h. Results: Serum lactate level was significantly low in Groups I and II than that in Group III intraoperatively and postoperatively. In addition, urine output was significantly more in Group I and Group III than in Group II. Creatinine level was higher with significance in Group II than in Group I and III 24 h postoperatively.Conclusion: Dopamine infusion, when added to norepinephrine infusion combined with restricted hydration, improved urine output and creatinine level. Tissue perfusion as indicated by serum lactate level was more adequate in Groups I and II than that in Group III.
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Comparative study between different modes of ventilation during cardiopulmonary bypass and its effect on postoperative pulmonary dysfunction p. 236
Noha Sayed Hussain, Ayman Anis Metry, George Mikhail Nakhla, Rami Mounir Wahba, Milad Zakery Ragaei, John Nader Bestarous
DOI:10.4103/aer.AER_48_19  PMID:31198237
Background: Postoperative pulmonary dysfunction is a prevalent complication after cardiac surgery; it has many contributing considerations due to either the surgery itself, anomalies to gas exchange or maybe as a result of alterations in lung mechanics. The aim of this study was to compare pressure-controlled ventilation versus volume-controlled ventilation in the presence of no ventilation group as a control group during cardiopulmonary bypass and its effect on postoperative pulmonary dysfunction. Patients and Methods: Sixty-six patients going through open-heart surgeries were included in the study. They divided into three groups (Group P: Pressure-controlled ventilation, Group V: Volume-controlled ventilation, and Group C: Control group with no ventilation) in accordance with the mode of ventilation. Patients studied for chest X-ray, lung ultrasound, arterial oxygen partial pressure to fractional inspired oxygen ratio, alveolar–arterial oxygen gradient, static lung compliance, and dynamic lung compliance, taken after induction of anesthesia, 1-h post-CPB, and 1 h after arrival to cardiac surgical unit. Results: There was no significant difference regarding the chest X-ray and lung ultrasonography results among the three groups of the study. Regarding arterial oxygen partial pressure to fractional inspired oxygen ratio, alveolar–arterial oxygen gradient, static lung compliance, and dynamic lung compliance, the results showed lower values in the postbypass period, and the postoperative period compared to the postinduction period among the three groups of the study with no significant difference. Conclusions: The evidence of clear benefits of maintaining ventilation alone during cardiopulmonary bypass is inconsistent. More studies are required to determine the precise role of different lung protective strategies during cardiopulmonary bypass.
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Abdominoplasty under spinal anesthesia: A feasibility study p. 243
Ayman Anis Metry, George M Nakhla, Wahba Z Wahba, Rami M Wahba, Ibrahim H Kamel
DOI:10.4103/aer.AER_69_19  PMID:31198238
Objectives: Abdominoplasty is a very common surgery nowadays and mainly performed as an office-based procedure. Spinal anesthesia is assumed to be safer than general anesthesia in such operations. The aim of this study is to compare between spinal and general anesthesia for abdominoplasty. Patients and Methods: Two hundred patients undergoing abdominoplasty, American Society of Anesthesiologists physical status classes I and II, were enrolled in this randomized prospective study. One hundred patients were operated upon under general anesthesia (Group G) and another one hundred patients under spinal anesthesia (Group S). Any intraoperative complications such as hypotension, bradycardia, pain, shivering, nausea, and vomiting related to anesthesia were managed and recorded. Visual analog scale was used to assess postoperative pain severity and the need for analgesia to be administered till 12 h postoperatively. Results: There was no significant difference as regards patient's satisfaction in both groups although it was lower in Group G than in Group S. There were significant differences in between both groups as regards postoperative nausea and vomiting, early demand for analgesic and total dose of pain killer consumed in 12 h postoperatively which were higher in Group G than in Group S. Conclusion: Spinal anesthesia can be an effective anesthetic technique for office-based abdominoplasty with less postoperative complications when compared with general anesthesia for short procedures with no extensive dissection and positioning.
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Efficacy of stroke volume variation, cardiac output and cardiac index as predictors of fluid responsiveness using minimally invasive vigileo device in intracranial surgeries p. 248
Zareena Shaik, Santhi Sree Mulam
DOI:10.4103/aer.AER_10_19  PMID:31198239
Introduction: Functional hemodynamic monitoring using dynamic parameters such as stroke volume variations (SVVs) based on pulse contour analysis is considered more accurate than central venous pressure and mean arterial pressure (MAP) in predicting fluid responsiveness. New device, i.e., Vigileo system, allows automatic and continuous monitoring of cardiac output (CO) based on pulse contour analysis and respiratory stroke volume. Aim: The study aims to test the above hypothesis using graded volume loading step (VLS) to assess the accuracy of SVV as a predictor of fluid responsiveness in patients undergoing intracranial surgery. Materials and Methods: After taking ethical committee approval and informed consent, 60 patients aged between 18 and 55 years belonging to the American Society of Anesthesiologists physical status Class I and II, of either sex, scheduled for brain surgery were included in the study. In this study, 5 min after intubation, with stable hemodynamics, patients received volume loading in successive steps (VLS) of 200 ml of lactated Ringer's solution until the stroke volume increased to <10%. Blood pressure (BP), heart rate (HR), stroke volume (SV), and SVV were measured before and after each VLS. Optimal preload augmentation required by each patient was measured by the number of VLS after which an increase in SV was <10%. Results: There was a significant decrease in the baseline BP and SV in responsive and nonresponsive groups for the first VLS, but there is no change in HR statistically. There was a significant change in SV after first VLS. Receiver operating characteristic analysis showed a larger area under the curve of 0.758 for SVV compared to other measured variables. The median number of VLS administered were 2 per patient equating to a mean ± SD requirement of 368 ± 176 ml of crystalloid per patient as the optimal preoperative infusion volume. Conclusion: SVV is a better predictor of preload responsiveness measured with third-generation Vigileo device when compared to BP and HR.
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Efficacy of adding dexmedetomidine to intra-articular levobupivacaine on postoperative pain after knee arthroscopy p. 254
Mohamed Maher El Baz, Tamer El Metwally Farahat
DOI:10.4103/aer.AER_23_19  PMID:31198240
Background and Aims: Intrarticular ingection of local anesthetics in the knee joint decreases postoperative pain after knee arthrosopy. Dexmedetomidine an α2agonist has sedative and analgesic effects and decreases postoperative pain after knee arthroscopy when injected intraarticulary. Levobubivacaine is a long acting local anesthetic with less toxicity than bubivacaine. We compared the analgesic effects of dexmedetomidine when added to intraarticular levobupivacaine in patients posted for knee arthroscopy. Methods: Data were first tested for normality by Kolmogorov–Smirnov test. Study was done on 90 patients. Patients were divided into 3 groups 30 patients each. Group (C) received 50 ml saline only as a control group. Group (L) received 50 ml 0.25% levobupivacaine. Group (L/D) received 50 ml 0.25% levobupivacaine and dexmedetomidine 1μg.kg-1. (VAS) score was used to assess postoperative pain. Time of first pethidine demand and total dose of pethidine in the first 24 h were recorded, also postoperative complications such as pruritis, nausea and vomiting. SPSS version 16 was used for data analysis. P < 0.05 was considered significant. Results: Postoperative VAS sore at different intervals was less in Group LD than Group L than Group C, time to the first pethedine injection in (min) was longer (39 ± 6, 31 ± 7, 21 ± 6), and total pethedine dose given (mg) was lower (36 ± 9.8, 64 ± 19, 102 ± 24) in Group LD than Group L than Group C respectively. Conclusion: Adding dexmedetomidine to intraarticular levobupivacaine in patients undergoing knee arthroscopy provides more analgesic effect with lower pain scores than levobupivacaine alone with less use of postoperative analgesics during the first 24 h.
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Safety of inhalational anesthesia in patients with multiple drug allergies presenting for major surgeries under general anesthesia p. 259
Sunil Rajan, Jacob Mathew, Pulak Tosh, Manu Sudevan
DOI:10.4103/aer.AER_28_19  PMID:31198241
The prevalence of perioperative anaphylaxis is 1 in 1250–20,000 anesthetics. Inhalational anesthesia is considered safe in patients with multiple drug allergies, as there have been no reports of anaphylaxis to volatile inhalational agents. Anesthetic management of six patients with documented allergy to all commonly used anesthetic drugs who underwent major surgeries under general anesthesia is described as a case series. The plan of anesthesia in these patients was an anesthetic gas-based general anesthesia without using muscle relaxants but with the use of intravenous fentanyl if patient was not allergic to it. Sevoflurane 8% in oxygen was used for induction. Following cessation of breathing and on attaining an end-tidal concentration of >4% sevoflurane, direct laryngoscopy and intubation were performed. Anesthesia was maintained with sevoflurane in nitrous oxide and oxygen mixture maintaining a lower end-tidal carbon dioxide. Hypotension and/or bradycardia were managed with intermittent intravenous boluses of adrenaline 20 μg. At the end of surgery, all anesthetic gases were cutoff, and patients were extubated when awake. No muscle relaxant was used in any of the cases. Two patients received fentanyl before induction, whereas others were given oral paracetamol 2 h before induction. Postoperative analgesia was provided with oral paracetamol which was given 2–4 h after surgery. Intraoperative period was uneventful for these patients. In patients with multiple drug allergies, inhalational agent-based general anesthesia can be considered as a safe alternative to regular anesthetic practice involving polypharmacy, with a reduced risk of perioperative adverse events.
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Lumbar plexus block as an effective alternative to subarachnoid block for intertrochanteric hip fracture surgeries in the elderly p. 264
Z Aejaz Ahamed, Melveetil S Sreejit
DOI:10.4103/aer.AER_39_19  PMID:31198242
Background and Aims: Elderly patients with hip fractures pose a medical challenge for the anesthesiologist and are often associated with a high incidence of perioperative morbidity and mortality. We aimed to compare the efficacy of lumbar plexus block (LPB) with subarachnoid block (SAB) in elderly patients undergoing closed reduction and internal fixation for hip fractures. Methods: In this observational study, 50 patients with femoral intertrochanteric fracture were divided into LPB group and SAB group of 25 each by convenient sampling. Patients in the LPB group were given 20–25 ml of 0.5% bupivacaine to block the ipsilateral lumbar plexus with nerve stimulator assistance, whereas the patients in the SAB group received 0.5% bupivacaine intrathecally. Student's t-test was used for comparing the time for performing block, the time to achieving block, the time to the first request for analgesia, and the hemodynamic variables. Results: Lumbar plexus blockade took a longer time for performing and achieving block (P < 0.001). The time for the first request for analgesia was significantly longer in the LPB group (P < 0.001). A statistically significant reduction in blood pressures was noted in the SAB group. Conclusions: Lumbar plexus blockade offered more stable intraoperative hemodynamics and longer duration of postoperative analgesia in elderly patients undergoing hip fracture surgery.
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Blind tracheal intubation through the Air-Q intubating laryngeal airway in pediatric patients: Reevaluation – A randomized controlled trial p. 269
El-Sayed M El-Emam, Enas A. Abd El motlb
DOI:10.4103/aer.AER_42_19  PMID:31198243
Context: Some pediatric supraglottic airway devices have not been evaluated in a large perspective for blind intubation although they are validated as a conduit for fiberoptic-guided intubation. Objective: The objective of this study was to compare the success rate of blind technique with correction maneuvers versus fiberoptic-guided intubation through the air-Q laryngeal airway in pediatric patients. Patients and Methods: One hundred and twenty-six pediatric patients undergoing elective surgery under general anesthesia were randomized into two equal groups. The air-Q was placed in all patients as a conduit for tracheal intubation. Group B patients underwent blind intubation with correction maneuvers. Group F patients underwent fiberoptic-guided intubation. Results: There was no significant difference between the groups regarding the success rate of intubation or postextubation complications. Group F patients showed a significantly longer time to intubation and total time of the trial. Furthermore, Group F patients showed a significantly higher level of pre- and postintubation heart rate compared to Group B patients. Conclusion: Blind tracheal intubation in pediatric patients through the air-Q with correction maneuvers could be a good alternative for fiberoptic-guided intubation with stable hemodynamics and shorter time till intubation.
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Ultrasound-guided erector spinae versus ilioinguinal/iliohypogastric block for postoperative analgesia in children undergoing inguinal surgeries p. 274
El-Sayed M El-Emam, Enas A. Abd El motlb
DOI:10.4103/aer.AER_81_19  PMID:31198244
Context: Erector spinae plane (ESP) block is a promising technique in the field of pediatric postoperative analgesia considering its safety and simplicity. Objective: The objective of the study is to compare the efficacy of ultrasound (US)-guided ilioinguinal/iliohypogastric nerve (IIN) block and ESP block for postoperative analgesia after pediatric unilateral inguinal hernia repair. Patients and Methods: Sixty patients randomized into two equal groups. ESP group received US-guided ESP block, and IIN group received US-guided IIN block. Block in both groups was done with 0.5 mL/kg 0.125 bupivacaine + fentanyl 1 μg/mL injectate. Primary outcome is to compare both groups regarding time to first analgesic request. Secondary outcomes include evaluation of postoperative FLACC score, number of patients requiring rescue analgesic, number of rescue analgesic doses, parental satisfaction, incidence of postoperative vomiting, and motor weakness. Results: IIN group showed a significantly higher FLACC score at 4 and 6 h, significantly higher number of rescue medication doses and number of patients needed rescue analgesia. The ESP group carries a significantly higher parental satisfaction and a significantly longer time to first rescue analgesic compared to IIN group. Conclusion: The findings suggest that US guided ESP block resulted in a more effective and longer duration of postoperative analgesia following a pediatric unilateral inguinal hernia repair compared to IIN block.
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Effect of perineural and intravenous dexamethasone on duration of analgesia in supraclavicular brachial plexus block with bupivacaine: A comparative study p. 280
Rony Mathew, Korumbil Raghavan Radha, Vadakkoot Raghavan Hema
DOI:10.4103/aer.AER_15_19  PMID:31198245
Background: Perineural dexamethasone has been shown to improve analgesia in single injection supraclavicular block. Systemic mechanism of action of dexamethasone along with safety concerns of perineural route of administration has prompted the investigation of intravenous route as an alternative. Aims: We aim to compare the effects of dexamethasone as an additive to local anesthetic when used via perineural and intravenous route in terms of duration of analgesia and onset of motor and sensory block. Settings and Design: The study was done as a prospective comparative observational study conducted in a tertiary care hospital in India among 50 patients during a period of 1 year. Materials and Methods: Twenty-five patients aged 18–60 years, belonging to the American Society of Anesthesiologists physical status Classes I and II, receiving supraclavicular block with 0.5% bupivacaine and perineural dexamethasone were compared with similar number of patients receiving the block along with intravenous dexamethasone. Duration of analgesia, onset of sensory block, and onset of motor block were studied. Statistical Analysis: The results were analyzed using Chi-square test for qualitative variables and unpaired t-test for quantitative variables. Results: The duration of analgesia in the group receiving perineural dexamethasone (Group DP) 817.2 ± 88.011 min was comparable to the group receiving intravenous dexamethasone (Group DI) 858.00 ± 86.168, with a P = 0.104. Time to onset of sensory block in Group DP (10.20 ± 1.443 min) was significantly faster than that of Group DI (11.60 ± 1.443) with a P = 0.001. Time to onset of motor block in Group DP (13.92 ± 1.754 min) was significantly earlier than that of Group DI (14.96 ± 1.274 min) with a P = 0.02. Conclusion: It is concluded from this study that intravenous and perineural dexamethasone equally prolongs the duration of analgesia in supraclavicular block. However, perineural dexamethasone resulted in a faster onset of motor and sensory blockade.
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An exact localization of adductor canal and its clinical significance: A cadaveric study p. 284
Muthu Kumar Thiayagarajan, Singaram Vijaya Kumar, S Venkatesh
DOI:10.4103/aer.AER_35_19  PMID:31198246
Background and Objectives: Adductor canal block is a regional anesthetic block procedure commonly employed for knee surgeries. This study aims at locating the adductor canal precisely which will be of great use for the surgeons operating on knee. Materials and Methods: Forty cadaveric lower limbs fixed with formalin were utilized for the study. The length of the lower limb from anterior superior iliac spine to the base of patella is measured, and the midpoint between the two is marked. Adductor canal is dissected and the distance between proximal foramen and the midpoint of thigh, the length of the adductor canal, and the distance between the distal foramen and the base of the patella are measured. Results: The mean value of the adductor canal is about 10.5 cm. The average distance from anterior superior iliac spine to proximal foramen is 25 cm. The average distance from base of patella to distal foramen is 8.5 cm. In 36 (90%) lower limbs, the proximal foramen is 3 cm distal to the midpoint of the thigh. Interpretation and Conclusion: This study suggests that a point more than 3 cm below the midpoint of thigh will be the ideal location for the approach of adductor canal block.
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Postprocedure intravenous patient-controlled analgesia compared to epidural patient-controlled analgesia use after uterine fibroid embolization: Aclinical audit p. 287
Karen N Tran-Harding, Qiong Han, Shelly C Ferrell, Driss Raissi
DOI:10.4103/aer.AER_27_19  PMID:31198247
Purpose: Postprocedure epidural analgesia has a proven benefit over intravenous(i.v.) analgesia for pain management, but has not yet been demonstrated for uterine fibroid embolization(UFE). The objectives of this clinical audit were to determine if epidural patient-controlled analgesia(PCA) was beneficial to patient outcome as compared to i.v. PCA in decreasing parenteral opioid requirements and its associated side effects and determine if there is a difference in required oral opioids after the PCA is stopped. Materials and Methods: This manuscript audited postprocedural pain management of 51patients after UFE was performed. 20patients received an i.v. PCA for post-UFE pain control and 31 received an epidural PCA for post-UFE pain control. Total hydromorphone dose, the frequency of anti-nausea medication use, the frequency of anti-pruritus medication use, and patient pain satisfaction data was collected. Results: Total hydromorphone dose administered to patients post-UFE using epidural PCA was significantly less than patients using an i.v. PCA(P=0.001). However, the frequency of nausea and pruritus between the two groups did not achieve statistical significance with(P=0.663) and(P=0.639) respectively. Conclusion: Our clinical audit found that parenteral opioid requirements administered after UFE can be significantly reduced by using epidural PCA instead of i.v. PCA. However, we found no statistically significant difference in medication related side effects or oral opioid use thereafter.
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Efficacy of a bolus dose of esmolol and bolus dose of lignocaine for attenuating the pressor response to laryngoscopy and endotracheal intubation in general anesthesia: A comparative study p. 292
Sridevi Mallanna Mulimani, Dayanand Gurubasappa Talikoti, Vinuta Vidyanand Vastrad, Vijaya Manjunath Sorganvi
DOI:10.4103/aer.AER_31_19  PMID:31198248
Context: Laryngoscopy and endotracheal intubation result in an increase in heart rate and blood pressure; they evoke life-threatening complications. The esmolol is short-acting cardioselective beta-blocker and brings advantages to the perioperative management of tachycardia and hypertension. Aims: The aim of this study was to compare the efficacy of a bolus dose of esmolol and bolus dose of lignocaine for attenuation of the pressor response to laryngoscopy and intubation. Settings and Design: Sixty patients of both sex, aged 20–50 years, belonging to the American Society of Anesthesiologists physical Status I and II randomly allocated into two groups (n = 30). Materials and Methods: The study drugs diluted in 10-ml normal saline. Group I received esmolol 1.5 mg/kg and Group II received lignocaine 1.5 mg/kg 2 min before inducing the patients with thiopentone 5 mg/kg and suxamethonium 1.5 mg/kg. The heart rate, systolic blood pressure, and diastolic blood pressure were measured at basal, during intubation, and 1, 2, 3, and 5 min after intubation, and based on these values, the mean arterial pressure (MAP) and rate pressure product (RPP) was calculated. Statistical Analysis Used: The Student's t-test and data were represented by mean standard deviation and graphs. Results: The mean pulse rate, mean of MAP, and mean of RPP at intubation and at 1, 2, 3, and 5 min after intubation in lignocaine group showed a significant rise in these values but in esmolol group it remained nearer to or less than baseline values. Conclusions: Esmolol 1.5 mg/kg is effective in attenuating the pressor response in comparison with lignocaine 1.5 mg/kg during laryngoscopy and intubation.
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Comparative evaluation of dexmedetomidine versus midazolam as premedication to propofol anesthesia in endoscopic retrograde cholangiopancreatography p. 297
Geetanjali Pushkarna, Pankaj Sarangal, Varun Pushkarna, Ruchi Gupta
DOI:10.4103/aer.AER_62_19  PMID:31198249
Background: Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreaticobiliary diseases. It is a potentially uncomfortable procedure that needs to be performed under conscious sedation. Safe and effective sedation protocol is the need of an hour. Aims: This study aims to evaluate the requirement of propofol using midazolam and dexmedetomidine as premedication for ERCP. The degree of comfort experienced by endoscopist and the patients was also assessed. Materials and Methods: A total of sixty patients were enrolled in a randomized, assessor-blinded study in the age group of 40–80 years, American Society of Anesthesiologists physical class II–III undergoing elective ERCP procedures. They were divided into two groups of 30 each. Group D (n = 30): Dexmedetomidine (100 μg/mL + 18 mL saline) loading dose at 1 μg/kg intravenous (IV) over 10 min followed by 0.5 μg/kg/h infusion, and Group M (n = 30): Midazolam at 0.05 mg/kg IV bolus over 10 min followed by normal saline infusion under hemodynamic monitoring. Satisfaction scores, total propofol requirement, and complications such as gagging, restlessness, agitation, postoperative nausea and vomiting were noted and analyzed statistically. Statistical Analysis: Statistical analysis was performed using SSPS 17.0 software (SPSS Inc., 233 South Wacker Drive, Chicago, USA). The Chi-square test was applied for nonparametric data and parametric numerical data, unpaired t-test for intergroup comparison, and repeated measures ANOVA for intragroup comparison. Results were expressed as a mean ± standard deviation. Value of P < 0.05 was considered statistically significant and <0.001 as highly significant. Results: Surgeons and patients were more satisfied and comfortable along with less requirement of propofol in the dexmedetomidine group. The incidence of complications was also less in the dexmedetomidine group as compared to that of midazolam group. Conclusion: Both dexmedetomidine and midazolam can be safely administered as an anesthetic adjuvant to propofol for short procedures like ERCP's. Dexmedetomidine provided intense and better sedation quality along with lesser requirement of propofol doses. Moreover, it provided stable hemodynamic conditions and good recovery characteristics as compared to midazolam group.
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Analysis of changes in right ventricular systolic function by point-of-care ultrasound in patients undergoing corrective surgeries for femur fracture p. 303
I Joseph Raajesh, N Pratheeba, Ravindra R Bhat, R Remadevi
DOI:10.4103/aer.AER_67_19  PMID:31198250
Background: Fat embolism syndrome (FES) following major orthopedic injuries and surgeries is a well-known phenomenon where acute depression of right ventricular (RV) systolic function is a potential possibility. Clinical presentation of FES may vary from mild self-limiting nature to severe life-threatening multiorgan dysfunction syndrome with pulmonary manifestations being most common. Aims: This study was aimed to know whether perioperative assessment of RV function by measuring tricuspid annular plane systolic excursion (TAPSE) with point-of-care transthoracic echocardiogram will identify patients at risk of developing FES and its sequelae. Settings and Design: This was a prospective observational study. Materials and Methods: This study was carried out in 142 patients with femur fractures posted for correction surgeries of both genders who require intramedullary (IM) reaming. TAPSE was recorded four times perioperatively. Time taken for IM reaming was also recorded. Statistical Analysis Used: Recorded data were analyzed using professional statistics package Epi Info 7.0 version for Windows. Descriptive data were represented as mean ± standard deviation for numeric variables, percentages, and proportions for categorical variables. Repeated-measure ANOVA was applied to assess the changes in TAPSE from baseline to immediate postoperative, after 6-h postoperative, and after 24-h postoperatively. Pearson's correlation was utilized to be applied to assess the relationship between TAPSE and other numerical variables. Results: All four readings of TAPSE were well above 17 mm (mean of 19.06, 19.05, 19.04, and 19.04, respectively). Mean reaming time was found to be 6.92 min. None of the patients developed any postoperative pulmonary complications. Conclusion: Assessment of RV function can be done with relative ease using TAPSE as a noninvasive method without any complications. Reaming time not exceeding 12 min did not produce any changes in RV function as measured by TAPSE as well as any postoperative pulmonary complications.
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Hemodynamic Response to Orotracheal Intubation: Comparison between Macintosh, McCoy, and C-MAC Video Laryngoscope p. 308
Hiteshi Aggarwal, Sarvjeet Kaur, Naresh Baghla, Satinderjit Kaur
DOI:10.4103/aer.AER_7_19  PMID:31198251
Background: The most commonly used devices for direct visualization of the larynx and tracheal intubation are Macintosh and McCoy laryngoscopes. C-MAC video laryngoscope, based on the principles of indirect laryngoscopy, has been introduced into clinical practice in recent years. Video laryngoscope may be useful in difficult tracheal intubation situations. Aim: We aimed at comparing the McCoy and C-MAC video laryngoscope with conventional Macintosh laryngoscope for hemodynamic responses of orotracheal intubation among adults receiving general anesthesia for elective surgeries. Settings and Design: This was a hospital-based randomized, double-blind, comparison, done between June 2015 and October 2016 after permission of institutional ethical committee. Materials and Methods: One hundred and fifty patients with normal airways undergoing elective general anesthesia were randomly allocated to undergo intubation using either Macintosh (Group A), McCoy (Group B), or C-MAC video laryngoscope (Group C). Hemodynamic changes associated with intubation were recorded immediately before and after laryngoscopy and intubation, every minute for 5 min and at 10 min after intubation by an independent observer. The time taken to perform endotracheal intubation and Cormack and Lehane score were also noted in all three groups. Statistical Analysis: Data were compiled, and statistical analysis was performed using SPSS 17.0 version. Results: Hemodynamic response after intubation was least in Group B (McCoy) as compared to Group A (Macintosh) and Group C (C-Mac) (P = 0.001). Ninety-two percentage patients were in Cormack and Lehane score Class I in Group C in comparison to 52% in Group A and 48% in Group B (P = 0.000). Time for intubation taken in Group A, Group B, and Group C was 15.53 ± 1.53 min, 18.65 ± 0.44 min, and 22.82 ± 1.323 min, respectively (P = 0.000). Conclusion: The McCoy laryngoscope provided better attenuation of hemodynamic responses to laryngoscopy and intubation than the Macintosh and C-Mac video laryngoscope whereas more appearance of Cormack and Lehane score Class I was seen with the C-MAC video laryngoscope. Furthermore, the time taken to perform endotracheal intubation was the longest with the C-MAC video laryngoscope.
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Comparison of nebulized ketamine and ketamine with clonidine in postoperative sore throat p. 313
Shashank Shekhar, Ankesh Gupta, Gunjan , Sonali Gupta, Kunal Singh
DOI:10.4103/aer.AER_19_19  PMID:31198252
Background: Various nonpharmacological and pharmacological trials have been used for attenuating postoperative sore throat (POST) with no proven single modality. Ketamine has been used as a gargle or nebulization in the attenuation of POST by its action on peripheral N-methyl-D-aspartate receptors. Topical administration of clonidine elicits antinociception through α2-adrenoceptors without producing undesirable side effect. Aim: This study aims to compare between nebulized ketamine and ketamine with clonidine in POST. Materials and Methods: The effects of nebulized ketamine and ketamine with clonidine in POST have been compared in 100 patients. Patients were divided into two groups: Group K patients were nebulized with ketamine 1 mL (50 mg) plus normal saline 3 mL and Group KC patients were nebulized with ketamine 1 mL (50 mg) plus clonidine 1 mL (50 mg) plus normal saline 2 mL. Online statistical software was used for analysis of the data. Results: At 4 h, seven patients experienced sore throat in Group K while no incidence was reported in group KC (0%). At 8 h, 12 (85.7%) patients experienced sore throat in Group K and 2 (14.28%) patients in Group KC. At 12 h, 13 (81.25%) patients experienced sore throat in Group K and 3 (18.75%) patients of Group KC. At 24 h, 6 (85.71%) patients experienced sore throat in Group K and 1 (14.28%) patient in Group KC. Patients in both groups remained hemodynamically stable with no complaint of nausea, vomiting, sedation, laryngospasm, or any other side effect. Conclusion: Nebulization with ketamine plus clonidine preoperatively is more effective in reducing POST with no adverse effects as compared to preoperative nebulization with ketamine.
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Comparison of Palonosetron and Dexamethasone with Ondansetron and Dexamethasone to Prevent Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Cholecystectomy p. 317
Kumar Rajnikant, Ishwar Bhukal, Narender Kaloria, Shiv Lal Soni, Kamal Kajal
DOI:10.4103/aer.AER_21_19  PMID:31198253
Background: Laparoscopic cholecystectomy (LC) is associated with high risk of postoperative nausea and vomiting (PONV) if no prophylactic antiemetic is used. Aims: The study compared prophylactic palonosetron and dexamethasone with ondansetron and dexamethasone in patients undergoing LC. Setting and Design: This prospective, double-blinded, randomized, controlled study was conducted at a tertiary care center. Materials and Methods: The study was carried out in 86 patients who underwent LC. The patients were randomly assigned to following study groups: Group 1 who received palonosetron (0.75 mg) with dexamethasone (8 mg) and Group II who received ondansetron (4 mg) with dexamethasone (8 mg). Patients were observed for nausea with visual analog scale and vomiting episode during 48 h postoperative follow-up. Statistical Analysis Used: Data were analyzed as mean, standard deviation, percentage, and number. The following statistical tests were used: paired or unpaired t-test, Mann–Whitney test, Chi-square test, and repeated ANOVA test. Results: There was no statistically significant difference in heart rate, mean arterial pressure, and oxygen saturation from baseline. During 48 h follow-up, the incidence of nausea, vomiting, and PONV was higher in Group II, but the difference was not statistically significant. The total dose of rescue antiemetic was 2.14 ± 4.15 mg in Group I and 5.00 ± 8.62 mg in Group II patients (P = 0.058). Headache was present in three patients in Group I and two patients of Group II. Conclusion: The palonosetron with dexamethasone is comparable to ondansetron with dexamethasone in the prevention of PONV in patients undergoing LC.
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Intraoperative comparison and evaluation of intrathecal bupivacaine combined with clonidine versus fentanyl in children undergoing hernia repair or genital surgery: A prospective, randomized controlled trial p. 323
Kumar Parag, Madhuri Sharma, Hariom Khandelwal, Nidhi Anand, Nishith Govil
DOI:10.4103/aer.AER_24_19  PMID:31198254
Background: Nowadays, spinal anesthesia is commonly being used in infants and children for infraumblical surgeries. Intrathecal adjuvants such as clonidine and fentanyl are used with local anesthetics for additive effects. Aim: The present study aims to assess and compare the effects of adding clonidine versus fentanyl to bupivacaine intrathecally in terms of propofol consumption, hemodynamic profile, adverse events, and complications intraoperatively in pediatric patients. Settings and Design: A prospective randomized controlled trial was conducted between June 2016 and October 2018 in pediatric patients aged 3–8 years undergoing hernia repair or genital surgery under spinal anesthesia after approval of the Institutional Ethical Committee (Reference No: SGRR/IEC/04/16). Materials and Methods: Patients were randomly divided into two equal sized (n = 42) study groups, while analysis was done in (n = 40) each group. Group 1 (BC) received clonidine 1 μg/kg with 0.5% bupivacaine (heavy) and Group 2 (BF) received fentanyl 0.5 μg/kg with 0.5% bupivacaine (heavy). 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 Chi-square test was used to compare categorical data. P < 0.05 was considered statistically significant. Results: Patient characteristics regarding age, weight, and surgical time were comparable in the two groups. The maintenance dose and bolus dose of propofol consumed during surgery were less in Group 1 than that in the Group 2 and were found to be statistically insignificant. The values of hemodynamic parameters such as heart rate, systolic blood pressure, and diastolic blood pressure were less in Group 1 and were statistically significant at different time intervals. Sedation scores were comparable in both groups. Intraoperative incidence of bradycardia, systolic hypotension, and diastolic hypotension were high in Group 1, whereas the incidence of desaturation was high in Group 2. Intraoperative complications such as apnea and respiratory obstruction were high in Group 2, but were statistically insignificant. Conclusion: We conclude that intrathecal adjuvant fentanyl maintains a better hemodynamic profile in terms of adverse events such as bradycardia, systolic hypotension, and diastolic hypotension. Intrathecal clonidine maintains a better sedation level requiring less propofol for sedation. Complications such as apnea and respiratory obstruction can be attributed more to the deep sedation caused by bolus of propofol rather than the inherent properties of intrathecal adjuvant clonidine or fentanyl.
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Comparison of prolongation of spinal anesthesia produced by intravenous dexmedetomidine and midazolam: A randomized control trial p. 330
Swetha N Sivachalam, Nitu Puthenveettil, Sunil Rajan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/aer.AER_38_19  PMID:31198255
Context: Various intravenous (i.v.) adjuvants have been used along with spinal anesthesia to delay the onset of postoperative pain. Aims: To compare effects of i.v. dexmedetomidine with midazolam on duration of spinal anesthesia. Settings and Design: This prospective randomized control trial was conducted in a tertiary care institution. Subjects and Methods: Forty-three patients presenting for elective infraumbilical surgery under spinal anesthesia were randomly allocated into two groups. Group A received a loading dose of 0.5 μg/kg followed by 0.5 μg/kg/h of i.v. dexmedetomidine. Group B received a loading dose of 0.03 mg/kg followed by 0.03 mg/kg/h of i.v. midazolam. Two dermatomal regressions, regression to S1level, and sedation score were noted. Statistical Analysis Used: To test the statistical significance of duration of sensory blockade, Mann–Whitney U-test was applied. The incidence of bradycardia and hypotension was analyzed using Pearson's correlation coefficient test. Results: The mean time for two dermatomal regressions was significantly prolonged in Group A (2.3 ± 0.4 h) than Group B (1.6 ± 0.5 h, P = 0.001). Mean time for sensory regression to S1dermatome was also prolonged in Group A (5.2 ± 0.83 h) than in Group B (4.4 ± 0.87 h, P = 0.01). Glycopyrrolate was administered in 45% of patients in Group A and 21% in Group B, which was statistically significant (P = 0.039). Conclusion: Conscious sedation with i.v. dexmedetomidine at a loading dose of 0.5 μg/kg followed by 0.5 μg/kg/h prolongs duration of spinal anesthesia than i.v. midazolam at a loading dose of 0.03 mg/kg followed by 0.03 mg/kg/h in patients undergoing infraumbilical surgeries. However, dexmedetomidine is associated with higher incidence of hemodynamic instability.
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Ultrasound-guided erector spinae plane block compared to modified pectoral plane block for modified radical mastectomy operations Highly accessed article p. 334
Mona Gad, Khaled Abdelwahab, Ahmed Abdallah, Mohamed Abdelkhalek, Mahmoud Abdelaziz
DOI:10.4103/aer.AER_77_19  PMID:31198256
Background: Modified radical mastectomy (MRM) is the most common surgery for cancer breast that is associated with marked postoperative pain. Effective control of this pain suppresses the surgical stress response and decreases the opioids and general anesthetics' needs. This study compared the erector spinae plane (ESP) block and the pectoral plane (PECS) block effects on the opioid consumption postoperatively, stress response, fentanyl needs intraoperatively, pain scores, and incidence of complications in female patients subjected to MRM surgery. Patients and Methods: Fifty patients were allocated randomly and divided into two groups. Forty-seven patients were included in the final analysis after exclusion. ESP block group (E group, n = 24) received 20 mL of 0.25% levobupivacaine plus 0.5 μ/kg dexmedetomidine that was injected in-between erector spinae muscle and transverse process. PECS block group (P group, n = 23) received 30 mL of 0.25% levobupivacaine plus 0.5 μg/kg dexmedetomidine divided into 10 mL that was injected between the two pectoralis muscles in the interfascial plane and the other was 20 mL injected between the serratus anterior and the pectoralis minor. Results: Postoperative morphine consumption and stress hormone level in P group were significantly lower than E group. The pain scores and number of patients requested analgesic postoperatively showed significantly higher values in E group. Hemodynamic parameters, fentanyl needed intraoperatively and the incidence of postoperative complications recorded no significant difference between the two groups. Conclusion: The current study demonstrated that PECS block provides better quality of analgesia than ESP block in patients subjected to MRM operations.
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Effect of intravenous ondansetron on spinal anesthesia-induced hypotension and bradycardia: A randomized controlled double-blinded study p. 340
Chandra Mouli Tatikonda, Geetha C Rajappa, Prapti Rath, Mohammad Abbas, Vishnu S Madhapura, Nori Venu Gopal
DOI:10.4103/aer.AER_22_19  PMID:31198257
Background: Spinal anesthesia is a safe anesthetic technique commonly practiced. However, it is associated with hypotension (33%), bradycardia (13%), and shivering which are induced by hypovolemia, sympathetic blockade, and Bezold–Jarisch reflex through intracardiac serotonin (5HT3) receptors and vagus nerve. Aim: To study the effect of intravenous (i.v.) ondansetron on hypotension and bradycardia induced by spinal anesthesia. Setting and Design: This was a randomized controlled double-blinded study done in a tertiary care teaching hospital. Methods: Of 140 patients, 70 in Group A received 2 mL of i.v. ondansetron 4 mg and 70 in the Group B received 2 mL of i.v. normal saline. 3 mL of 0.5% hyperbaric bupivacaine was injected intrathecally. Measurements of blood pressure and heart rate (HR) were taken every 3 min for 30 min after spinal anesthesia was performed. Mean arterial pressure (MAP) drop more than 20% was considered as incidence of hypotension and ephedrine 6 mg i.v. was given. HR drop >20% was regarded as bradycardia and atropine 0.5 mg i.v. was given. Statistical Tests: Quantitative data were analyzed using ANOVA test and qualitative data were analyzed using Chi-square test. Results: Both groups are comparable in demographic data. Four (5.7%) patients in Group B and no patients in Group A had incidence of bradycardia and atropine requirement (P = 0.120). There was no statistically significant difference in systolic blood pressure, diastolic blood pressure, and MAP. 19 (27%) patients in Group A and 33 (47.1%) in Group B required ephedrine with P = 0.029. 12 (17.1%) in Group B and no patients in Group A had shivering with P = 0.0001. Conclusion: Our study indicates that prophylactic use of ondansetron before spinal anesthesia significantly reduces the requirement of ephedrine and shivering.
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Pressure-controlled ventilation with volume guarantee compared to volume-controlled ventilation with equal ratio in obese patients undergoing laparoscopic hysterectomy p. 347
Mona Gad, Khaled Gaballa, Ahmed Abdallah, Mohamed Abdelkhalek, Abdelhady Zayed, Hanan Nabil
DOI:10.4103/aer.AER_82_19  PMID:31198258
Background: Laparoscopic hysterectomy operations especially for obese patients necessitate Trendelenburg position and pneumoperitoneum with carbon dioxide, which could affect cardiac and pulmonary functions. The present study aimed to compare the impact of pressure-controlled ventilation with volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) with equal ratio ventilation (ERV), i.e., I: E ratio of 1:1 on hemodynamics, respiratory mechanics, and oxygenation. Patients and Methods: Eighty females with body mass index (BMI) >30 kg/m2 and with physical status American Society of Anesthesiologists Classes I and II undergoing laparoscopic hysterectomy were allocated randomly to either PCV-VG (Group P) or VCV with ERV (Group V). The ventilation parameters, hemodynamics, and arterial blood gases (ABGs) analysis were recorded at four times: (T1): after the anesthetic induction while in supine position by 10 min, (T2 and T3): after the CO2 pneumoperitoneum and Trendelenburg positioning by 30 and 60 min, respectively, and (T4): after desufflation and resuming the supine position. Results: The peak inspiratory pressure in Group P recorded significant lower values than in Group V while the dynamic compliance was greater significantly in Group P than in Group V. No significant differences were reported as regards the ABG analysis, oxygenation, and hemodynamic data between both groups. Conclusion: In obese females undergoing laparoscopic hysterectomy surgeries, PCV-VG was superior to VCV with ERV as it provided higher dynamic compliance and lower peak inspiratory pressure that could be preferable, especially in those patients in whom cardiopulmonary function could be more susceptible to impairment.
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Comparative evaluation of dexamethasone and dexmedetomidine as adjuvants for bupivacaine in ultrasound-Guided infraorbital nerve block for cleft lip repair: A prospective, randomized, Double-Blind study p. 354
El-Sayed M. El-Emam, Enas A. Abd El motlb
DOI:10.4103/aer.AER_14_19  PMID:31198259
Purpose: To compare dexamethasone (DA) to dexmedetomidine (DE) as adjuvants for bupivacaine during infraorbital nerve block (IONB) in a randomized clinical trial. Patients and Methods: One hundred patients were randomized into two equal groups. By the guidance of ultrasound, the IONB was performed bilaterally in all patients, using 1 mL of the solution on each side. In DA group, 1 mL of 0.5% bupivacaine was added to 0.1 mg.kg−1 DA and diluted to 2 mL in DE group; 1 mL of 0.5% bupivacaine was added to 0.5 μg.kg−1 DE and diluted to 2 mL. The primary outcome was time to first rescue analgesic. The secondary outcomes included face legs activity cry consolability (FLACC) score rating during the first 24 h, hemodynamic variables, the incidence of postoperative vomiting, sedation score, and parent satisfaction. Results: During the first 24 h postoperatively, the DE group showed a significantly lower FLACC score and a longer time to first analgesic request compared to DA group. Sedation and parent satisfaction scores were significantly higher while heart rate and mean blood pressure were significantly lower in DE group compared to DA group. There were no differences in other secondary outcomes. Conclusion: The use of DE as an adjuvant to bupivacaine in IONB for cleft lip repair resulted in lower pain score and more prolonged duration of analgesia compared to DA.
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Effect of cricoid pressure on the glottic view and intubation with king vision® video laryngoscope p. 359
M Manjuladevi, Vikram M Shivappagoudar, Shilpa Bhimasen Joshi, Pramod Kalgudi, Santu Ghosh
DOI:10.4103/aer.AER_186_18  PMID:31198260
Context: To establish the usefulness of King Vision® video laryngoscope (KVL) in patients with rapid sequence anesthesia. Aims: This study aims to compare the role of KVL on glottic visualization, intubation time and associated sympathetic response in routine intubations to those intubations done with cricoid pressure (CP). Settings and Design: Randomized controlled study in a tertiary care hospital. Methodology: Seventy-six patients intubated with KVL were randomized to two groups – Group C (who did not receive any CP) and Group CP – who received CP. The percentage of glottic opening (POGO), intubation time, subjective assessment, and number of attempts taken to introduce KVL and endotracheal tube (ETT) were noted. The saturation, end-tidal carbon dioxide concentration and hemodynamic response (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and rate pressure product) in the peri-intubation period were also recorded. Results: The demographics, airway, and technical characteristics of insertion of KVL and ETT were comparable between the groups (P > 0.05). POGO score was 100% in both groups. The significant time in insertion of KVL (Group C 29.87 ± 11.64 s and Group CP 40.68 ± 18.93 s, P = 0.004) and ETT (Group C 17.53 ± 8.71 s and Group CP 22.42 ± 10.77 s, P = 0.033) contributed to prolonged overall intubation time in CP (Group C 41.11 ± 11.65 s and Group CP 51.05 ± 17.31 s, P = 0.005). The intergroup and intragroup hemodynamic variables did not show any statistical significance (P > 0.05) over time. Conclusion: Although overall intubation time with KVL is prolonged in patients with CP, it provides excellent glottic view, eases intubation, and causes insignificant hemodynamic variation.
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Comparison of oral triclofos and oral midazolam as premedication in children undergoing elective surgery p. 366
Ankesh Gupta, Gunjan , Shashank Shekhar, Sonali Gupta, Ajit Gupta
DOI:10.4103/aer.AER_13_19  PMID:31198261
Background: Children who have experienced previous hospital admission, operation, procedures, and needle pricks are more reactive to subsequent anesthetic procedures. Many sedative agents have been used for the purpose of premedication, but few of them can be given orally, thus avoiding the pricks. Midazolam, being one such choices, can be given orally, intranasally, and parenterally but has unpredictable response. Triclofos, available as sweet syrup, is a phosphorylated derivative of chloral hydrate, has been proven to be effective within 30 min in doses of 25–75 mg/kg. Hence, this study compares triclofos hydrochloride with midazolam oral to know the efficacy of both the drugs as premedication. Aim: This study aims to assess sedation score, level of anxiety/resistance, and behavior of the child in the preoperative period. Settings and Design: After parental and institutional approval, a total of 70 children were studied based on computer-generated randomization and divided into groups M and T of 35 each. Materials and Methods: Group M patients received oral midazolam 0.5 mg/kg. Group T patients received commercially available triclofos syrup containing 100 mg/ml of drug in dose of 75 mg/kg. The response of children to taste of premedication was noted, whether completely ingested or not. In case of vomiting, the child was excluded from further study. Statistical Analysis: Numerical variables were analyzed using Student's paired t-test and other variables using Mann–Whitney U-test, Fisher exact test, and Friedman ANOVA. Results: Sedation score at 5 min interval from 0 to 30 min showed P = 0.54, 0.71, 0.65, 0.92, 0.29, 0.42, and 0.15; none were statistically significant. Anxiety score during parental separation, intravenous cannulation, and mask application were also similar in both the groups. Conclusion: data obtained, it can be concluded that parenteral formulation of either midazolam or triclofos can be safely used as premedicant in children.
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Comparative study of oral midazolam syrup and intranasal midazolam spray for sedative premedication in pediatric surgeries p. 370
Imran Mehdi, Shirin Parveen, Sanjay Choubey, Asim Rasheed, Prachi Singh, Mohammad Ghayas
DOI:10.4103/aer.AER_182_18  PMID:31198262
Introduction: Midazolam is a water-soluble benzodiazepine which is frequently administered by intravenous and oral routes. Its nasal spray has become recently available. Materials and Methods: In this study, after obtaining clearance from the ethical committe, 66 patients between the age group of 4 and 10 years comparable in demographic variables were randomly allocated into two groups of 33 each. Group “O” received oral midazolam (0.5 mg/kg) 20 min before induction. Group “N” received intranasal midazolam (0.2 mg/kg) 20 min before induction. The heart rate and blood pressure (systolic, diastolic, and mean) and oxygen saturation (SPO2) were recorded.Statistical Analysis Used: The statistical analysis was done using SPSS (Statistical Package for the Social Sciences) version 15.0 software. The values were represented in number (%) and mean±sd. Results: Satisfactory sedation scores were better in nasal spray group than oral group. Satisfactory ease of induction scores, recovery times, and postanesthesia recovery scores were better in the nasal spray group than in the oral group. Conclusion: Nasal midazolam spray is acceptable and is a good alternative to oral midazolam as premedication in the pediatric population.
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Comparison between the effects of sumatriptan versus naratriptan in the treatment of postdural puncture headache in obstetric patients: A randomized controlled trial p. 376
Joseph Makram Botros, Atef Mohammed Sayed
DOI:10.4103/aer.AER_17_19  PMID:31198263
Background: Postdural puncture headache (PDPH) in the obstetric anesthesia practice is one of the most annoying, common, and important problems. Aim: This comparative study was designed to assess the efficacy of naratriptan in relieving PDPH in parturients who gave birth by cesarean section under intrathecal anesthesia and to compare its efficacy with sumatriptan. Settings and Design: One hundred and eighty-nine adult parturients who complained of PDPH in the first 3 days postpartum period were enrolled in this study. They were divided into three equal parallel groups of 63 each. Materials and Methods: Group-1 controlled (C-group) received multivitamin tablets, Group-2 sumatriptan (S-group) received sumatriptan tablets and Group-3 naratriptan (N-group) received naratriptan tablets. The efficacy of naratriptan in relieving PDPH was studied and compared with that of sumatriptan. Incidences of complications of both drugs were also noted. Statistical Analysis: The collected data were organized, tabulated, and statistically analyzed using SPSS software statistical computer package version 18 (SPSS Inc., USA). Results: After the first 6 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.0001 and 0.001), respectively, and the difference between Group S and Group N was statistically significant (P = 0.004). After 12 h, there were statistically significant differences between Groups S and N from one side and the control group from the other side (P < 0.0001) and the difference between Group S and Group N was statistically significant (P = 0.002). After 72 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.001 and 0.009), respectively. The difference was nonsignificant between S and N group (P = 0.717). Conclusion: The study revealed that anti-migraine drug naratriptan in combination with supportive treatment was effective in relieving PDPH in parturients.
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Nonpneumatic anti-shock garment versus intermittent sequential compression device for prevention of postspinal hypotension in patients undergoing cesarean section: A randomized controlled study p. 383
Abhay Tyagi, Ashok Kumar Sethi, Rashmi Salhotra, Asha Tyagi
DOI:10.4103/aer.AER_83_19  PMID:31198264
Context: Postspinal hypotension remains a frequent complication of subarachnoid block during cesarean section causing further maternal and fetal adverse effects. Aims: This study aims to evaluate and compare a continuous pressure nonpneumatic anti-shock garment (NASG) and an intermittent sequential compression device (SCD) with a control group for prevention of postspinal hypotension in women undergoing elective cesarean section. Settings and Design: A randomized, observer blind, controlled study at single university hospital. Subjects and Methods: Ninety singleton term parturients between 18 and 35 years of age undergoing cesarean section with spinal anesthesia were randomly assigned to be applied with NASG, SCD, or no device; n = 30 in each group. A standardized protocol for cohydration and anesthetic technique was followed. The primary outcome measure was incidence of hypotension defined as a decrease in systolic blood pressure of more than 20% from baseline or an absolute value <100 mmHg, whichever was higher. The secondary outcome measures were median dose of ephedrine required, incidence of maternal nausea and vomiting, and neonatal Apgar scores. Statistical Analysis Used: Results were expressed as mean (±standard deviation), median (range), or number (%) as appropriate. Nominal data were compared using Chi-square/Fischer's exact test. Continuous data were compared using ANOVA one-way test. Nonparametric data were compared using Kruskal–Wallis test. Results: In Groups NASG, SCD, and C, incidence of hypotension was 60%, 83%, and 90%, respectively (P = 0.021), with significant reduction in incidence of hypotension in Group NASG versus Group C (P < 0.001, odds ratio 0.17, 95% confidence interval 0.04–0.68). Median (interquartile range) dose of ephedrine required was significantly less in Group NASG compared with Groups SCD and C, respectively (P = 0.002, P < 0.001). Conclusions: NASG proved to be a more effective device for prevention of postspinal hypotension when compared with application of SCD or no device.
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A comparative clinical study between clonidine and tramadol with bupivacaine in caudal epidural for postoperative analgesia in pediatric surgery p. 389
S Amitha, Vidyadhar Metri, Thejeswini Mahadevaiah, Yoganarasimha
DOI:10.4103/aer.AER_37_19  PMID:31198265
Context: Adjuvants to bupivacaine for single shot caudal block in children. Aims: This study entitled was conducted to compare the effects of addition of tramadol to bupivacaine over addition of clonidine to bupivacaine as a single shot caudal block in children. Settings and Design: Sixty children of ASA grade I and II in the age group of 2-12 years coming for various infra-umbilical surgeries were included. Materials and Methods: They were divided into two groups of 30 each. Group BC received caudal bupivacaine 0.25% 0.5ml/kg with clonidine 2 mcg/kg Group BT received caudal bupivacaine 0.25% 0.5 ml/kg with tramadol 2 mg/kg. The main parameters studied were hemodynamic changes, duration of post-operative analgesia and incidence of adverse effects. Statistical Analysis Used: The results of continuous variables are given as mean ± SD and proportion as percentage. The difference between the two groups was assessed by student's – t test and chi-square test Results: The mean duration of post-operative analgesia in group BT was statistically significant (P<0.001), reducing the requirement of analgesics in group BT. There was no difference in sedation score, nausea, vomiting, urinary retention between the two groups. Conclusions: The present study demonstrated that caudal administration of bupivacaine 0.25% 0.5 ml/kg with tramadol 2 mg/kg resulted in superior analgesia with longer duration of action and reduced requirement of analgesics in first 24 hours postoperatively when compared with 0.25% bupivacaine 0.5 ml/kg with clonidine 2 mcg/kg.
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Pregnancy-induced low back pain in Indian women: Prevalence, risk factors, and correlation with serum calcium levels p. 395
Ashok Kumar Saxena, Geetanjali T Chilkoti, Anshul Singh, Gaurav Yadav
DOI:10.4103/aer.AER_196_18  PMID:31198266
Background: Pregnancy-induced low back pain (LBP) is a common problem during the pregnancy which usually begins between the 20th and the 28th weeks of gestation, and the exact duration varies. Aims: The aim of this study is to determine the prevalence of LBP including pelvic girdle pain (PGP) and its various aspects such as nature, intensity, character, radiation, circadian pattern, and its correlation with serum calcium levels. Setting and Design: This was a cross-sectional survey conducted in a tertiary care hospital in the capital of Delhi. Materials and Methods: In this cross-sectional study, 200 pregnant women completed a questionnaire and also underwent clinical examinations if PGP is suspected. The clinical examination included various pain provocation tests including active straight leg raise test. Venous blood samples were drawn to evaluate the serum calcium levels in pregnant women complaining of back pain. Possible associating factors were studied by nonparametric tests and logistic regression analysis. Statistical Analysis: Bivariant correlation of serum calcium levels, total duration of pain, and Visual Analog Scale score was done with various factors such as parity, socioeconomic status, and nature of pain. Results: The point prevalence of LBP was found to be 80% with a significantly lower prevalence of PGP, i.e., 2%, when compared to the international figures. Majority of women graded their pain as dull aching type (47.5%) and moderate to severe in intensity. The circadian rhythm of back pain was observed in 56% of the patients, and out of that, insomnia was complained by 33% of the patients. Limitation of physical activity was observed in 62.5% of the patients. Conclusion: A negative correlation was observed between the serum calcium levels and parity; however, a positive correlation between the intensity of pain and parity was observed.
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