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October-December 2019
Volume 13 | Issue 4
Page Nos. 601-699

Online since Monday, December 16, 2019

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REVIEW ARTICLE  

Critical analysis of guidelines for providing sedation to patients undergoing gastrointestinal endoscopy procedures Highly accessed article p. 601
Basavana Goudra, Preet Mohinder Singh
DOI:10.4103/aer.AER_135_19  PMID:32009702
In spite of growing numbers of gastrointestinal endoscopic procedures performed under deep sedation, guidelines are lacking. Hypoxemia and aspiration continue to be the main source of morbidity. Anesthesia providers have tried to address these concerns by modifying their technique and employing newer or improvised devices. In addition, preprocedural evaluation poses many challenges. In many centers, workload pressures determine the time available to perform such an evaluation. A comprehensive history and examination similar to a major surgical procedure is often not possible. As a result, a focused history and examination is essential. This should be followed by an appropriate explanation of risks before obtaining consent. A plan should be in place to manage complications such as aspiration. This paper provides a succinct review of the above aspects.
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ORIGINAL ARTICLES Top

Comparative evaluation of dexmedetomidine and pregabalin as premedication agent to attenuate adverse hemodynamic and stress response in patients undergoing laparoscopic cholecystectomy p. 608
Anshul Jain, Rajeev Sinha, Shivali Pandey, Vivek Sahu
DOI:10.4103/aer.AER_115_19  PMID:32009703
Background: Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. The goal of anesthetic management is to minimize stress response and early discharge. Dexmedetomidine, and pregabalin have been used successfully to attenuate laryngoscopy and intubation response in various surgical procedures. Aim: To compare efficacy of pregablin and dexmedetomidine in attenuating hemodynamic and stress response. Setting and Design: A prospective, double blind randomized trial comprising 130 ASA physical status class I and II patients posted for laparsoscopic cholecystectomy. Materials and Methods: Patients were randomized in to Group A and Group B. Group A received intravenous dexmedetomidine in a dose of 1ug.kg-1, through an infusion pump 20 min prior to induction of anaesthesia. Group B subjects received oral pregabalin 150 mg. Parameters observed were vitals, discharge time, cortisol level, side effects if any. Results: Post intervention heart rate got reduced significantly in Group A and it remained low in comparison to baseline during whole peri-operative period. In Group B, immediate post-pneumoperitoneum heart rate, and post exubation heart rate was higher than baseline. Blood pressure (BP) decreased significantly post intervention in Group A which persisted till pneumoperitoneum. In Group B there was statistically significant rise in systolic, diastolic and mean blood pressure postpneumoperitoneum as compared to baseline blood pressure. Post-operative cortisol level was significantly higher than baseline values and the level is more in Group B. Conclusion: Intravenous dexmedetomidine is more effective than oral pregabalin in attenuating perioperative stress response.
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Ultrasound-guided subclavian perivascular brachial plexus block using 0.5% bupivacaine with dexmedetomidine as an adjuvant: A prospective randomized controlled trial p. 615
Ramachandra R Avula, Nagendra N Vemuri, Swetha Puthi
DOI:10.4103/aer.AER_122_19  PMID:32009704
Background: Ultrasound guidance has dramatically improved the accuracy of nerve localization, and various adjuvants prolong the block and extend analgesia. Aims: This study aimed to evaluate the effects of dexmedetomidine added to 0.5% bupivacaine on the onset and duration of motor and sensory blockade and the duration of analgesia. Settings and Design: This is a prospective, randomized double-blind, study. Materials and Methods: Sixty adult patients aged 20–60 years of either sex undergoing orthopedic procedures on the forearm were randomly allocated into two groups of thirty each: Group BS (bupivacaine + saline) and Group BD (bupivacaine + dexmedetomidine). All patients were administered subclavian perivascular brachial plexus block under ultrasound guidance. Group BS: Patients in this group were administered 20-mL 0.5% bupivacaine + 0.75-mL saline. Group BD: Patients in this group were administered 20-mL 0.5% bupivacaine + 0.75-mL dexmedetomidine (75 μg). Statistical Analysis: Statistical analysis was performed with IBM SPSS software Version 21.0. Quantitative data were expressed as mean ± standard deviation. Independent sample t-test was used for comparisons between the two groups. P < 0.05 was considered statistically significant. Results: Demographic data and surgical characteristics were similar in both groups. The onset times for sensory and motor blocks were statistically significantly shorter in Group BD compared to Group BS (P < 0.01), whereas the duration of blocks and analgesia were statistically significantly longer (P < 0.01) in Group BD. Conclusion: The addition of dexmedetomidine to 0.5% bupivacaine for supraclavicular brachial plexus block shortens the onset time and prolongs both the duration of the block and analgesia.
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A comparative study of tramadol and clonidine as an additive to levobupivacaine in caudal block in pediatric patients undergoing perineal surgeries p. 620
Jyoti Rawat, Radhey Shyam, Dinesh Kaushal
DOI:10.4103/aer.AER_127_19  PMID:32009705
Background: Caudal block is a simple, safe procedure with fewer side effects to provide intraoperative and postoperative analgesia in pediatric patients. Many drugs were used as an additive to local anesthetics in caudal block. All these drugs had their own side effects. Aims: In this study, we compare the effects of tramadol and clonidine as an additive to levobupivacaine in caudal block in children undergoing perineal surgeries regarding hemodynamic changes, analgesic effects, and side effects. Settings and Design: This is a prospective, double-blind randomized, controlled study, conducted in Department of Paediatric Surgery, at King George's Medical University, Lucknow, Uttar Pradesh during 2017–2018. Materials and Methods: After informed consent and ethical clearance from institutional ethics committee, King Georges Medical University, Lucknow. Total 66 patients aged 1–10 year, planned for perineal surgery were randomly allocated according to computer-generated random number, into three groups. Group I - 0.25% levobupivacaine (1 mL.kg-1) alone, Group II - 0.25% levobupivacaine (1 mL.kg-1) with tramadol 1 mL.kg-1, and Group III - 0.25% levobupivacaine (1 mL.kg-1) with clonidine 1 μg.kg-1. Perioperative pain was the primary outcome. Hemodynamic parameters: heart rate, mean arterial pressure, and peripheral oxygen saturation were recorded. Postoperative pain assessed by Children and Infants Postoperative Pain Scale (CHIPPS), sedation by Ramsay sedation score and requirement of rescue analgesia were recorded at predetermined time intervals. Statistical Analysis: The values were represented in number (%) and mean ± standard deviation. Comparison of quantitative variables between the study groups was done using ANOVA test and Mann–Whitney U-test. Categorical data were analyzed using Chi-square test. Results: Postoperative analgesic effect was significantly longer in levobupivacaine with clonidine group as compared to tramadol with levobupivacaine group and levobupivacaine alone group. Conclusion: Clonidine in a dose of 1 μg.kg-1 when added to levobupivacaine in caudal block significantly prolongs the duration of analgesia as compared to tramadol with levobupivacaine and levobupivacaine alone without any clinically significant side effects. Thus, it is better to add additive like clonidine to enhance the effect of analgesia.
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Intravenous Fentanyl 4 μg per kg administered before scalp pin application is inferior to scalp block in preventing hemodynamic changes p. 625
S Arunashree, Pradeep Hosagoudar
DOI:10.4103/aer.AER_107_19  PMID:32009706
Background: Application of scalp pins for craniotomy surgeries is a noxious stimulus, causing tachycardia and hypertension, resulting in increased cerebral blood flow and elevated intracranial pressure, hence measures to attenuate this will have beneficial role. Aims: The aim is to compare the effectiveness of scalp block (SB) to 4 μg.kg-1 intravenous (i.v) fentanyl in attenuating hemodynamic response to scalp pin application in patients who underwent elective craniotomy under general anesthesia. Settings and Design: The study design involves prospective, randomized study conducted at Tertiary care center/hospital. Subjects and Methods: Forty-four American Society of Anesthesiologists physical status Classes l and II patients were randomly allocated into the following groups: Group-SB (n = 22) received SB using 0.25% injection bupivacaine and Group-F (n = 22) received 1 μg.kg-1 i.v fentanyl. Patient's heart rate (HR) and mean arterial pressure (MAP) were recorded from the application of pins till 60 min and rescue analgesic/anesthetic agents and their dosage were noted. Statistical analysis was performed comparing HR and MAP changes to application of scalp pins. Statistical Analysis: Software developed by the Centre for Disease Control, Atlanta, namely Epidemiological Information Package 2010 was used to derive statistical variables. Results: Patients were comparable in age, gender, hypertension as comorbidity, baseline HR, and MAP. Significant rise in HR was noted in Group-F till 20th min compared to Group-SB. MAP was high from application of pins till 60th min in Group-F compared to Group-SB. Requirement of rescue analgesics/anesthetics was high in Group-F compared to Group-SB. \Conclusion: SB effectively attenuates hemodynamic response to application of scalp pins in patients undergoing elective craniotomy and reduces requirement of rescue analgesic and/or anesthetics.
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Comparison of intraoperative glycemic levels in infants with the use of Ringer Lactate with supplemental 1% versus 2% dextrose as maintenance fluid p. 631
Pulak Tosh, Sunil Rajan, Kaushik Barua, Lakshmi Kumar
DOI:10.4103/aer.AER_128_19  PMID:32009707
Context: There is no consensus regarding the concentration of dextrose supplementation to be used in pediatric patients intraoperatively. Aims: The primary objective was to assess the effect of using Ringer lactate (RL) with 1% versus 2% dextrose as maintenance fluid in infants on intraoperative blood glucose levels. The secondary objectives included assessment of incidence of hyperglycemia and hypoglycemia in both groups. Settings and Design: This was a prospective randomized study conducted in a tertiary care teaching institute. Subjects and Methods: Forty infants undergoing cheiloplasty or palatoplasty were included. All patients fasted 6 h for solids and formula feeds, 4 h for breast milk, and 2 h for clear fluids and received general anesthesia as per standardized protocol. Patients belonging to Group 1 received RL with 1% dextrose supplementation, whereas Group 2 received RL with 2% dextrose added to it as an intraoperative maintenance fluid. Random blood sugar (RBS) was checked preoperatively and then at 60 min and 120 min after induction. Hypoglycemia was defined as RBS <70 mg/dL and hyperglycemia as RBS >150 mg/dL. Statistical Analysis Used: Independent sample ttest and Pearson's Chisquare test were used for statistical analysis. Results: Preoperative RBS was comparable in both groups. RBS at 60 and 120 min was significantly higher in Group 2 compared to Group 1. There was no incidence of hypoglycemia in both groups, and the incidence of hyperglycemia was similar in both groups. Conclusion: Use of RL with 2% dextrose as intraoperative maintenance fluid in infants resulted in significant increase in blood sugar levels as compared to addition of 1% dextrose although the incidence of hyperglycemia remained comparable in both groups.
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Dexmedetomidine compared to remifentanil infusion as adjuvant to sevoflurane anesthesia during laparoscopic sleeve gastrectomy p. 636
Jehan M E. Hamed, Hesham S.M. Refaat, Hamed Al-Wadaani
DOI:10.4103/aer.AER_126_19  PMID:32009708
Objectives: Evaluation of postoperative (PO) analgesic effects of intraoperative (IO) Dexmedetomidine (DEX) compared to remifentanil (REMI) infusions during sevoflurane anesthesia for laparoscopic gastric sleeve surgery. Patients and Methods: One hundred and thirty-two patients with body mass index >35 kg.m-2 and ASA Grades II or III were randomly divided into group R received REMI infusion (6–18 μg.kg-1.h-1) and Group D received DEX infusion (0.2–0.5 μg.kg-1.h-1) after tracheal intubation till before stoppage of inhalational anesthetic. Heart rate and mean arterial pressure were noninvasively monitored during and after surgery. Emergence time, time until postanesthetic care unit transfer, and total operating room (OR) time was recorded. PO shoulder-tip pain and wound pain scores were recorded and rescue analgesia was provided as 50 mg pethidine intramuscular injection. Occurrence of PO nausea and vomiting (PONV) and frequency of the need for antiemetic therapy were recorded. Primary study outcome was the ability of the study infusions to reduce consumption of PO pethidine down to one dose during 24-hr PO. Results: IO use of REMI or DEX infusion allowed hemodynamic control to surgical stresses with nonsignificant difference between both infusions. REMI infusion insured significantly rapid recovery and short OR times but required larger volume of sevoflurane during surgery and proper PO follow-up for pain and PONV. DEX infusion significantly improved control of PO pain with a larger number of patient requested rescue analgesia only once, reduced the dose of PO analgesia, reduced the frequency of PONV, and the need for antiemetic therapy. Conclusion: REMI or DEX infusion as IO adjuvant to general anesthesia is appropriate option to achieve hemodynamic control of surgical stresses and to improve perioperative outcomes. REMI infusion may be preferred for its induced rapid recovery and short OR time, whereas DEX infusion may be chosen for its improved control of PO pain and reduction of PO analgesia and frequency of PONV.
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Effect of combination of ketamine and propofol (ketofol) on cerebral oxygenation in neurosurgical patients: A randomized double-blinded controlled trial p. 643
Vishwanatha S Bhaire, Nidhi Panda, Ankur Luthra, Rajeev Chauhan, Deepak Rajappa, Hemant Bhagat
DOI:10.4103/aer.AER_119_19  PMID:32009709
Background: The effects of ketofol (a combination of ketamine and propofol) on systemic hemodynamics and requirement of opioids/Propofol have already been studied and published. However, there is paucity in the literature on the effects of ketofol on cerebral oxygenation. This study aims to compare the effects of ketofol (ketamine + propofol [1:5]) with propofol on cerebral oxygenation using jugular venous oxygen saturation (SjVO2), in patients undergoing surgical clipping of intracranial aneurysms. Materials and Methods: A total of 40 World Federation of Neurosurgeons I and II patients were randomized into ketofol (n = 20) and propofol (n = 20) groups. Postinduction, SjVO2 catheter was inserted, and anesthesia was maintained with propofol and fentanyl in the propofol group and ketofol and fentanyl in the ketofol group. Jugular venous oxygen saturation (SjVO2) was obtained at baseline, 1 h and 2 h intraoperatively, and at 6 h after the surgery. Intraoperative hemodynamics and brain relaxation scores were also noted. Results: Entire SjVO2 values in both groups were within the normal limits. Higher SjVO2 values were observed in ketofol group compared to propofol at 1 and 2 h after starting of the drug and at 6 h after surgery (P < 0.05). In propofol group, a significant fall in SjVO2 was recorded at 2 h after beginning the drug as compared to the baseline (P = 0.001). More than 20% fall in mean arterial pressure (MAP) compared to baseline MAP was noted in 75% of patients in propofol group and 15% of patients in ketofol group (P = 0.002). In propofol group, 55% of patients required rescue drug phenylephrine to treat hypotension, whereas only 15% of patients required it in ketofol group (P = 0.02). Fentanyl requirement in ketofol group was less as compared to the propofol group (P = 0.022). Brain relaxation scores were comparable in both the study groups (P = 0.887). Conclusion: Maintenance of anesthesia with ketofol provides better cerebral oxygenation and hemodynamic stability compared to propofol in neurosurgical patients.
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Bedside lung ultrasound for postoperative lung conditions in cardiothoracic intensive care unit: Diagnostic value and comparison with bedside chest roentgenogram p. 649
Kirubanand Senniappan, Rupa Sreedhar, MS Saravana Babu, Prasanta Kumar Dash, Shrinivas V Gadhinglajkar, Subin Sukesan
DOI:10.4103/aer.AER_125_19  PMID:32009710
Background: The postoperative settings in cardiothoracic intensive care unit (ICU) patients pose a certain risk with pulmonary dysfunction causing morbidity and mortality. Lung ultrasound (LUS) has a potential to supplant or replace Chest X-rays (CXR) in these subset of patients, who will require bed side pulmonary pathology diagnosis and interventions. Aims and Objectives: Aim of the study is to compare the diagnosis predicted from LUS to the diagnosis made from routine bedside CXR and to find the degree of agreement in diagnosis made by both modalities in different cardiopulmonary pathologies in ICUs. Materials and Methods: Prospective observational study involving 250 postoperative patients, admitted in cardio-thoracic and vascular ICU of a tertiary referral centre. LUS was done in the study patients after the scheduled CXR in the immediate postoperative period and postoperative day one. Findings of pulmonary pathologies by each imaging modality were independently interpreted by two different team of specialist investigators. The findings were evaluated for the degree of agreement between the two imaging modalities using Cohen's kappa statistical test. Results: CXR and LUS imaging showed substantial agreement in the diagnosing cardiopulmonary pathologies (κ = 0.652) in the immediate postoperative period as well as on the postoperative day one (κ = 0.740). For specific cardiopulmonary pathologies, the degree of agreement was moderate for pleural effusion (κ = 0.561), substantial for atelectasis (κ = 0.673) and interstitial edema (κ = 0.707) and perfect for pneumothorax (κ = 0.931). Conclusions: LUS can effectively replace CXR with reduction in radiation exposure in the immediate postoperative period and also in the follow up period. It can be used as a bedside diagnostic and monitoring tool in postoperative cardiothoracic and ICUs for diagnosing pneumothorax, pleural effusion, atelectasis and interstitial edema.
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Comparing effects of intrathecal adjuvants fentanyl and dexmedetomidine with hyperbaric ropivacaine in patients undergoing elective infraumbilical surgeries: A prospective, double-blind, clinical study p. 654
TK Shashikala, Sachinkumar S Sagar, Puttaiah Ramaliswamy, Vinod V Hudgi
DOI:10.4103/aer.AER_183_18  PMID:32009711
Background: Spinal anesthesia is most commonly used anesthesia technique for infraumbilical surgeries, and it is cost-effective with decreased hospital stay. Intrathecal isobaric ropivacaine has shorter duration of anesthesia than bupivacaine. By making, ropivacaine hyperbaric will help to achieve dense block with good postoperative analgesia. Materials and Methods: Ninety patients with American Society of Anesthesiologists physical status Classes I and II, aged between 18 and 60 years of either sex, undergoing for elective infraumbilical surgeries were randomly allocated into three groups 30 each (n = 30). Group Ropivacaine + Dexmedetomidine (RD) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + dexmedetomidine 10 μg (0.5 ml), Group Ropivacaine + Fentanyl (RF) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + fentanyl 25 μg (0.5 ml), and Group Ropivacaine + Normal saline (RC) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) +0.5 ml of normal saline. The onset, extent, and duration of sensory and motor block, duration of rescue analgesia, hemodynamic parameters, and side effects such as nausea, vomiting, pruritus, and shivering were recorded. Results: Time of onset early in RD (1.673 ± 0.567), in RF (1.73 ± 0.520), and in RC (1.763 ± 0.420) min (P = 0.783). Time to achieve maximum level of sensory block in RD (5.94 ± 1.88), in RF (3.86 ± 1.22), and RC (5.99 ± 0.46) min (P < 0.001). The total duration of analgesia in Group RD (356.67 ± 63.022), in RF (255.10 ± 35.626), and in RC (197.67 ± 37.605) min (P < 0.001). The time onset and duration of motor block in Group RD (1.59 ± 0.59, 319.57 ± 64.752), Group RF (1.59 ± 0.53, 236.83 ± 33.797), and Group RC (2.07 ± 0.20, 183.93 ± 35.252) min both are statistically highly significant (P < 0.001). Conclusion: Addition of glucose to ropivacaine makes the block dense. Addition of adjuvants such as dexmedetomidine and fentanyl further hastens the onset; prolong the postoperative analgesia with minimal hemodynamic and other side effects.
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Large dose bupivacaine 0.5% versus small dose in elective cesarean section p. 663
Hassan Mohamed Ali, Ahmed Abdelaziz Ismail
DOI:10.4103/aer.AER_131_19  PMID:32009712
Background and Aim: The spinal anesthesia in a cesarean section is still presenting a challenge to the anesthetist in the form of either severe hypotension from large bupivacaine dose or insufficient satisfactory anesthesia level conditions as a result of small bupivacaine dose. In this study, we tried to solve this challenge by increasing the dose of bupivacaine to achieve a proper spinal level accompanied by prolonged sitting up to avoid hypotension. Patients and Methods: We included 53 patients in this study whom were randomly divided into two groups, namely Group B and Group C. In Group B (25 patients), each patient received 3 mL of bupivacaine and left 5 min sitting up, whereas in Group C (28 patients), each patient received 2.5 mL of bupivacaine and was asked to lie supine immediately. Both groups were tested for hypotension, ephedrine dose, and sensory block level. Results: The present study showed a statistically significant lower dose of ephedrine which was given in Group B (7.2 ± 15.684 mg in Group B versus 27.86 ± 12.04 mg in Group C with P < 0.05). The proper anesthesia level was achieved equally in both groups. Conclusions: Large dose 15 mg of bupivacaine with the prolonged sitting position will lead to fewer incidences of hypotension and proper anesthesia block.
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Comparison of two supraglottic airway devices: I-gel airway and ProSeal laryngeal mask airway following digital insertion in nonparalyzed anesthetized patients p. 669
Ankur Luthra, Rajeev Chauhan, Amit Jain, Ishwar Bhukal, Shalvi Mahajan, Indu Bala
DOI:10.4103/aer.AER_132_19  PMID:32009713
Aims: The study is aimed to compare the efficacy of I-gel and ProSeal laryngeal mask airway (PLMA) in nonparalysed anesthetized individuals following manufacturer-recommended digital insertion. Materials and Methods: In this prospective randomized observational study, 40 American Society of Anesthesiologists I and II patients, aged 18–65 years scheduled for elective surgical procedures were allocated either to PLMA group (Group P, n = 20) or the I-gel group (Group I, n = 20). Following digital insertion of PLMA or I-gel, the following parameters were compared: insertion time, ease of insertion, number of attempts, failed insertion, airway reaction during insertion, oropharyngeal leak (OPL) pressure, and gastric insufflation on auscultation. Fiberoptic view of both the channels of the airway devices and ease of insertion of 12 F Ryle's tube through gastric drain channel were graded. Postoperative complications were also noted. Results: First attempt and overall insertion success were similar (PLMA, 85% and 100%; I-gel 80% and 100%, respectively). Mean (standard deviation) insertion times were similar (PLMA, 27.40 [11.51] s; I-gel 25.45 [9.03] s). Mean OPL pressure was 3.5 cm H2O higher with PLMA (P < 0.012). The passage of Ryle's tube was easier through I-gel than PLMA. Grade I glottic view (full view of the vocal cords) was visible in 17 (85%) patients who were managed with I-gel whereas only 9 (45%) patients had Grade I view in the PLMA group. Conclusion: The time required for digital insertion of PLMA and I-gel in nonparalyzed anesthetized patients is similar but PLMA forms a better oropharyngeal seal. I-gel is better positioned over the laryngeal framework and esophagus. I-gel allows easier passage of Ryle's tube through its drain channel than PLMA. The incidence and severity of postoperative sore throat and hoarseness was higher with PLMA.
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Comparison of continuous wound infusion versus continuous epidural infusion in upper abdominal surgery: Noninferiority randomized controlled trial p. 676
Arun Raja Thangavel, Sameer Sethi, Vikas Gupta
DOI:10.4103/aer.AER_133_19  PMID:32009714
Context: Wound catheter offers a less invasive alternative for postoperative analgesia in the abdominal surgery. Methods: We conducted a single-center, prospective, open-label noninferiority randomized controlled trial. A total of 40 patients who consented to this trial, undergoing upper abdominal surgery via an upper midline incision, were randomized into two groups. In the continuous wound infusion (CWI) group, the wound catheter was placed in the subcutaneous plane of the surgical incision; the continuous epidural infusion (CEI) group received thoracic epidural with a catheter placed. After the surgery, both the groups received 0.2% ropivacaine infusion at 10 mL/h following a 10 mL bolus for 48 h postsurgery. Postoperatively, the pain scores were noted at multiple time points, along with a record of morphine consumption and adverse effects. Results: There was no significant difference in pain scores both at rest and on movement between the two groups at all the time points assessed. The mean difference in numerical rating scale score 24 h postsurgery at rest (0.1, 95% confidence interval [CI] = −0.45, 0.65) and on movement (0.05, 95% CI = −0.73, 0.83), with 95% CI in both the groups, was within the noninferiority limit. Morphine consumption was less in the CEI group, though not significant. The time to appearance of bowel movement, time to ambulate, and length of hospital stay were significantly lower in the CWI group. The incidence of hypotension requiring intervention was higher in the CEI group. Conclusion: Hence, analgesia provided by continuous wound catheter infusion is not inferior to CEI with better preservation of hemodynamics and faster recovery.
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Safety and efficacy of dexmedetomidine versus propofol infusion as an adjunct to transtracheal block in ensuring patient immobility during general anesthesia without the use of muscle relaxants p. 683
Pulak Tosh, Sunil Rajan
DOI:10.4103/aer.AER_134_19  PMID:32009715
Background: In surgeries where nerve stimulation study is required intraoperatively, the use of long-acting muscle relaxants should be avoided. Aim of Study: This study aimed to assess the efficacy of dexmedetomidine versus propofol infusion as an adjunct to transtracheal block to ensure patient immobility during general anesthesia without the use of muscle relaxants and to compare hemodynamics in both the groups. Settings and Design: It was a prospective randomized controlled trial done at a tertiary care center. Subjects and Methods: Forty adult patients undergoing brachial plexus surgeries were included in the study and all patients received a transtracheal block just before the induction. After standardized induction and intubation, Group D received intravenous (i.v.) bolus of dexmedetomidine 0.5 μg.kg-1 body weight followed by infusion at 0.5 μg/kg/h intraoperatively. In Group B, the infusion of propofol was started at 1 mg/kg/h after induction. In both the groups, if the patient moved, bucked on endotracheal tube, or if there were signs of inadequate depth of anesthesia, bolus of propofol 0.5 mg.kg-1 i.v. was given and repeated as required. Statistical Tests Used: Mann–Whitney U-test and Fisher's exact test were used for the statistical analysis. Results: Number of times propofol bolus was required intraoperatively and hemodynamic parameters were comparable in both the groups at all-time points. Time to extubate was significantly higher in Group P compared to Group D (16.06 ± 5.78 vs. 9.61 ± 11.53 min). Conclusion: The use of dexmedetomidine infusion as an adjunct to transtracheal block is superior to propofol infusion in view of significantly shorter extubation time though both the agents provided comparable intraoperative hemodynamics and patient immobility.
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The comparative study of epidural anesthesia between isobaric ropivacaine 0.5% and isobaric bupivacaine 0.5% for lower abdominal surgery p. 688
Ashish Kumar, Rajesh Kumar, Rajnish Kumar, Alka Koshire
DOI:10.4103/aer.AER_142_19  PMID:32009716
Aim: The aim of the study was to compare the effectiveness of ropivacaine (0.5%) and bupivacaine (0.5%) in epidural neuraxial blockade for elective lower abdominal surgeries. Methods: The present study was conducted in sixty patients undergoing elective lower abdominal surgeries under epidural anesthesia who were included after satisfying the eligibility criteria. The patients were randomly divided into two groups. An epidural catheter was inserted in cephalad direction using Tuohy epidural needle at L2–L3 or L3–L4 with the help of loss of resistance to air technique. Twenty milliliter of the study drug was given, sensory blockade was tested using the pinprick method, and quality of motor blockade was assessed by the modified Bromage scale. Results: In our study, demographic data comparing age and sex show no statistically significant difference among both the groups. In our study, the mean time for the onset of sensory block consider at T10 in Group B was 10.05 ± 2.1 min and in Group R was 9.8 ± 1.8 min. Moreover, the mean time duration of sensory block in Group B was 5.56 ± 0.059 h and in Group R was 5.34 ± 0.073 h. The onset of motor block in Group B was 4.98 ± 1.07 min and in Group R was 5.28 ± 1.2 min, but the duration of motor block for Group B was 4.63 ± 0.39 h and for Group R was 3.53 ± 0.23 h, which is clinically and statistically significant. The maximum level of sensory blockade for Group B was T4 and for Group R was T5. The range of block in Group B was T10–T4 and in Group R was T10–T35. Conclusion: The onset of sensory block was comparable in both the group, but the duration of sensory block is shorter with ropivacaine compared to bupivacaine. The onset of motor blockade was comparable in both the groups, but the duration of motor blockade was also shorter and the degree of motor block was less intense with ropivacaine compared to bupivacaine.
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CASE REPORTS Top

Role of transnasal humidified rapid-insufflation ventilatory exchange therapy in the management of a twin pregnancy with H1N1 infection in early acute respiratory distress syndrome p. 692
Deepak Dwivedi, Jagdeep Singh Bhatia, Rabi Narayan Hota, Saurabh Sud
DOI:10.4103/aer.AER_124_19  PMID:32009717
Pregnancy with H1N1 infection presenting with early acute respiratory distress syndrome (ARDS) is a challenging situation, where the life of both mother and fetus are jeopardized. Morbidity and mortality in such a clinical situation are not uncommon; it may result in hypoxemic acute respiratory failure in a pregnant patient, leading to mechanical ventilation and poorer outcomes in neonates due to prematurity. An interdisciplinary approach involving obstetricians, respiratory physicians, neonatologist, and anesthesiologist is mandatory for a good outcome. This case report highlights the management strategy of the parturient infected with H1N1 in early ARDS with the Transnasal Humidified Rapid-Insufflation Ventilatory Exchange therapy, which completely obviated the requirement of the invasive ventilation.
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Utility of point-of-care ultrasonography in diagnosing submassive pulmonary thromboembolism in a trauma patient and subsequent anesthetic management: case report and literature review p. 695
Nitika Goel, Kajal Jain, Deepanshu Dhiman, K Gowtham
DOI:10.4103/aer.AER_120_19  PMID:32009718
Point-of-care ultrasonography is defined as ultrasonography brought to the patient's bedside and performed by the provider in real time. The clinician can use these real-time dynamic images immediately (rather than images recorded by a sonographer and interpreted later), allowing findings to be directly correlated with the patient's presenting signs and symptoms. Point-of-care ultrasonography is easily repeatable if the patient's condition changes. Over the past decade, the use of point-of-care ultrasonography has extended to emergency settings and intensive care units. The role of ultrasound in triage patients is not only limited to the Focused Assessment with Sonography for Trauma which includes assessment for hemoperitoneum and hemopericardium, it has also been used to detect the presence of hemothorax, pneumothorax, and intravascular filling status in a trauma patient. However, the use of ultrasonography in detecting pulmonary thromboembolism in trauma has not been commonly reported. We report a patient in whom submassive pulmonary embolism was detected by lung ultrasound and thereafter operated for bilateral open Grade III lower-limb fractures. The surgery was proceeded under bilateral ultrasound-guided femoral sciatic nerve block.
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OBITUARY Top

Prof. Mohamed Taha Al-jasser (1928–2019) p. 699
Mohamad S.M Takrouri
DOI:10.4103/aer.AER_140_19  
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