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   2015| October-December  | Volume 9 | Issue 4  
    Online since September 16, 2015

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Conflicts in operating room: Focus on causes and resolution
Joginder Pal Attri, Gagandeep Kaur Sandhu, Brij Mohan, Neeru Bala, Kulwinder Singh Sandhu, Lipsy Bansal
October-December 2015, 9(4):457-463
DOI:10.4103/1658-354X.159476  PMID:26543468
The operation theater (OT) environment is the most complex and volatile workplace where two coequal physicians share responsibility of one patient. Difference in information, opinion, values, experience and interests between a surgeon and anesthesiologist may arise while working in high-pressure environments like OT, which may trigger conflict. Quality of patient care depends on effective teamwork for which multidisciplinary communication is an essential part. Troubled relationships leads to conflicts and conflicts leads to stressful work environment which hinders the safe discharge of patient care. Unresolved conflicts can harm the relationship but when handled in a positive way it provides an opportunity for growth and ultimately strengthening the bond between two people. By learning the skills to resolve conflict, we can keep our professional relationship healthy and strong which is an important component of good patient care.
  5,720 276 7
Dexmedetomidine as an adjunct in postoperative analgesia following cardiac surgery: A randomized, double-blind study
Shio Priye, Sathyanarayan Jagannath, Dipali Singh, S Shivaprakash, Durga Prasad Reddy
October-December 2015, 9(4):353-358
DOI:10.4103/1658-354X.154715  PMID:26543448
Objectives: The purpose of this study was to determine analgesic efficacy of dexmedetomidine used as a continuous infusion without loading dose in postcardiac surgery patients. Settings and Design: A prospective, randomized, double-blind clinical study in a single tertiary care hospital on patients posted for elective cardiac surgery under cardiopulmonary bypass. Interventions: Sixty-four patients who underwent elective cardiac surgery under general anesthesia were shifted to intensive care unit (ICU) and randomly divided into two groups. Group A (n = 32) received a 12 h infusion of normal saline and group B (n = 32) received a 12 h infusion of dexmedetomidine 0.4 μg/kg/h. Postoperative pain was managed with bolus intravenous fentanyl. Total fentanyl consumption, hemodynamic monitoring, Visual Analogue Scale (VAS) pain ratings, Ramsay Sedation Scale were charted every 6 th hourly for 24 h postoperatively and followed-up till recovery from ICU. Student's t-test, Chi-square/Fisher's exact test has been used to find the significance of study parameters between the groups. Results: Dexmedetomidine treated patients had significantly less VAS score at each level (P < 0.001). Total fentanyl consumption in dexmedetomidine group was 128.13 ± 35.78 μg versus 201.56 ± 36.99 μg in saline group (P < 0.001). A statistically significant but clinically unimportant sedation was noted at 6 and 12 h (P < 0.001, and P = 0.046 respectively). Incidence of delirium was less in dexmedetomidine group (P = 0.086+). Hemodynamic parameters were statistically insignificant. Conclusions: Dexmedetomidine infusion even without loading dose provides safe, effective adjunct analgesia, reduces narcotic consumption, and showed a reduced trend of delirium incidence without undesirable hemodynamic effects in the cardiac surgery patients.
  5,307 435 18
Anesthetic consideration in a patient with giant bilateral lung bullae with severe respiratory compromise
Rajendra Kumar Sahoo, Abhijit S Nair, Venugopal Kulkarni, RaviKiran Mudunuri
October-December 2015, 9(4):493-495
DOI:10.4103/1658-354X.165128  PMID:26543479
  4,732 136 -
Comparison of dexmedetomidine and clonidine as an adjuvant to ropivacaine for epidural anesthesia in lower abdominal and lower limb surgeries
Sruthi Arunkumar, VR Hemanth Kumar, N Krishnaveni, M Ravishankar, Velraj Jaya, M Aruloli
October-December 2015, 9(4):404-408
DOI:10.4103/1658-354X.159464  PMID:26543457
Background: The quality and duration of analgesia is improved when a local anesthetic is combined with alpha 2 adrenergic agonist. Though, the effects of clonidine on local anesthetics have been extensively studied, there are limited studies demonstrating the effects of epidural dexmedetomidine on local anesthetics. The aim of our study is to compare the effect of clonidine and dexmedetomidine when used as an adjuvant to epidural ropivacaine in lower abdominal and lower limb surgeries. Materials and Methods: Patients were randomized into two groups-group ropivacaine with clonidine (RC) received 15 ml of 0.75% ropivacaine with 1 μg/kg clonidine and group ropivacaine with dexmedetomidine (RD) received 15 ml of 0.75% ropivacaine with 1 μg/kg dexmedetomidine epidurally. Onset of sensory analgesia using cold swab, onset of motor blockade using Bromage scale, time to 2 dermatome regression of sensory level, time to first demand for analgesia, sedation using Ramsay sedation scale, intra operative hemodynamic parameters and complications were assessed. Results: The onset (RD-8.53 ± 1.81, RC-11.93 ± 1.96) and duration of sensory blockade (RD-316 ± 31.5, RC-281 ± 37, sedation were found to be significantly better in the dexmedetomidine group. No significant difference was found in terms of onset of motor blockade and hemodynamic changes. Conclusion: Dexmedetomidine at doses of 1 μg/kg is an effective adjuvant to ropivacaine for epidural anesthesia, which is comparable to clonidine.
  3,998 377 2
Perioperative management in a case of glucose-6-phosphate dehydrogenase deficiency undergoing orthopaedic surgery
Chaula M Doshi, Sushama R Tandale, Shubha N Mohite, Anisha Nagaria
October-December 2015, 9(4):490-491
DOI:10.4103/1658-354X.159485  PMID:26543477
  4,028 172 -
The effects of dexmedetomidine on attenuation of hemodynamic changes and there effects as adjuvant in anesthesia during laparoscopic surgeries
Kalpana S Vora, Ushma Baranda, Veena R Shah, Manisha Modi, Geeta P Parikh, Bina P Butala
October-December 2015, 9(4):386-392
DOI:10.4103/1658-354X.159461  PMID:26543454
Background: As an anesthetic adjuvant dexmedetomidine has been shown to provide good perioperative hemodynamic stability with minimum alveolar concentration sparing effect on inhalational anesthetic agents during laparoscopic surgeries performed under general anesthesia. Aim: The study was planned to investigate the effects of dexmedetomidine on attenuation of hemodynamic changes and requirements of intra-operative analgesic and inhalational anesthetic during laparoscopic surgeries and its postoperative side effects. Materials and Methods: A total of 70 patients scheduled for elective laparoscopic surgeries were randomized to receive bolus infusion of dexmedetomidine (group D) or saline (group S) 1 mcg/kg/h, followed by continuous infusion of the same, at the rate of 0.5 mcg/kg/h. Anesthesia was maintained with nitrous oxide in oxygen, muscle relaxant and isoflurane. Supplementation with end-tidal isoflurane was considered when heart rate (HR) and mean arterial blood pressure (BP) exceeded 20% of the baseline value. Hemodynamics, end-tidal isoflurane concentration and adverse events were recorded. Results: Intra-operative mean HR and mean BP in group D were lower than group S (P < 0.05) throughout the laparoscopy surgery. Requirement of intra-operative fentanyl, end-tidal isoflurane and postoperative tramadol were significantly more in group S compared to group D (P < 0.05) Statistically significant nausea and vomiting were noted in group S. Undue sedation and other adverse effects are comparable in both the groups. Conclusion: Dexmedetomidine as an adjuvant in general anesthesia for laparoscopic surgeries provided a stable hemodynamic profile in the perioperative period and effectively blunted pressor response to intubation and extubation, leading to minimal requirements for additional analgesics and potent inhalational agents. There were less adverse events.
  3,832 351 4
Spinal anesthesia using Taylor's approach helps avoid general anesthesia in short stature asthmatic patient
Amarjeet Dnyandeo Patil, Manasi Bapat, Sunita A Patil, Roshan Lal Gogna
October-December 2015, 9(4):474-476
DOI:10.4103/1658-354X.159481  PMID:26543472
The case history of a 35-year-old female patient with short stature is presented. She was posted for rectopexy in view of rectal prolapse. She was a known case of bronchial asthma. She had crowding of intervertebral spaces, which made administration of spinal anesthesia via the normal route very difficult. Taylor's approach for administration of the same was tried and proved successful, thus saving the patient from receiving general anesthesia in the presence of bronchial asthma, for a perineal surgery. The possible cause for the difficulty in administration of spinal anesthesia and the Taylor's approach are discussed, and reports of similar cases reviewed.
  3,954 169 3
Hemodynamic response to endotracheal intubation using C-Trach assembly and direct laryngoscopy
Jayita Sarkar, Tanuja Anand, Sunil Kant Kamra
October-December 2015, 9(4):343-347
DOI:10.4103/1658-354X.154702  PMID:26543446
Purpose: Our objective was to study the pressor response to endotracheal intubation through laryngeal mask airway C-Trach and compare it to the hemodynamic response to intubation with direct laryngoscopy (DL). Materials and Methods: After obtained approval from institutional ethical committee, 100 patients of American Society of Anesthesiologists physical Status I, aged 14-65 years, posted for elective surgery were enrolled in the trial. They were randomly divided into two groups of each 50 patients. Anesthesia technique was standardized and patients of Group I were intubated using DL, while patients of Group II were intubated with the help of C-Trach assembly. Hemodynamic parameters, systemic blood pressure (systolic and diastolic) and heart rate were recorded before and after induction of anesthesia and every minute up to 5 min after intubation. Results: Patients of Group II recorded a minimal rise in peak systolic blood pressure (SBP) (1.8%) and diastolic blood pressure (10.6%). In comparison patients of Group I recorded a significant sustained rise in peak SBP (20.3%) and diastolic blood pressure (21.4%). However heart rate changes recorded in the two groups were of equal measure (peak rise of 22.9% in Group I vs. 22.4% in Group II). Conclusion: We conclude that intubation through C-Trach generates a lower pressor response to intubation in comparison to intubation using DL.
  3,805 297 3
Effect of ondansetron on prevention of post-induction hypotension in elderly patients undergoing general anesthesia: A randomized, double-blind placebo-controlled clinical trial
Mohammad Golparvar, Mahmoud Saghaei, Mohammad Ali Saadati, Shadi Farsaei
October-December 2015, 9(4):365-369
DOI:10.4103/1658-354X.159455  PMID:26543450
Background: Elderly patients are susceptible to post-induction hypotension. Volume loading and vasopressors for prevention of hypotension in elderly patients may increase perioperative cardiovascular risks. Ondansetron by blocking Bezold-Jarisch reflex (BJR) through inhibition of serotonin receptors has been effective in the prevention of post-spinal hypotension, and bradycardia. Bradycardia frequently accompanies post-induction hypotension in elderly patients, which signifies a possible preventing role for ondansetron. No previous study has evaluated the prophylactic effects of ondansetron for the prevention of post-induction hypotension. Materials and Methods: In this randomized placebo-controlled clinical trial, ondansetron 4 mg was given intravenously to 65 elderly patients, 20 min before induction of general anesthesia, and the rate of post-induction hypotension defined as 25% or more reduction in mean arterial blood pressure, compared with a placebo groups. Results: A total of 114 patients completed the study (58 in ondansetron and 56 in the placebo group). Proportions of post-induction hypotension were 9 (16%) and 25 (45%) in ondansetron and placebo groups, respectively, (P = 0.001). Forty-five patients (40%) developed bradycardia. Rates of bradycardia were not significantly different between two groups. Conclusions: The results of this study show the effectiveness of intravenous ondansetron for prevention of post-induction hypotension in elderly patients. The mechanism of this effect largely is unknown. Role of ondansetron for prevention of post-induction hypotension may not fully understandable by its interaction with BJR, as has been shown in post-spinal hypotension.
  3,593 365 1
Stellate ganglion pulsed radiofrequency ablation for stretch induced complex regional pain syndrome type II
Shiv Pratap Singh Rana, Mary Abraham, Varun Gupta, Shubhashish Biswas, Manish Marda
October-December 2015, 9(4):470-473
DOI:10.4103/1658-354X.159480  PMID:26543471
Complex regional pain syndrome (CRPS) following injury or nerve damage, as its name signifies, is a challenging entity, and its successful management requires a multidisciplinary approach. It not only manifests as severe pain, but also gives rise to functional disability, lack of sleep, lack of enjoyment of life and poor quality of life. Various pain interventional techniques have been described in the literature for the management of CRPS ranging from sympathetic blocks to spinal cord stimulator. A 34-year-old liver transplant donor, who developed position-induced right upper limb neuropathic pain suggestive of CRPS type II was managed initially with medications and later with stellate ganglion block under fluoroscopic guidance at cervical C7 position. Following an initial significant improvement in pain and allodynia, which was transient, a pulsed radiofrequency ablation of stellate ganglion was performed successfully to provide prolonged and sustained pain relief, which persisted up to 14 months of follow-up.
  3,602 160 4
Success rates and complications of awake caudal versus spinal block in preterm infants undergoing inguinal hernia repair: A prospective study
Mahin Seyedhejazi, Abdolnaser Moghadam, Behzad Aliakbari Sharabiani, Samad E. J. Golzari, Nasrin Taghizadieh
October-December 2015, 9(4):348-352
DOI:10.4103/1658-354X.154704  PMID:26543447
Background: Inguinal hernia is a common disease in preterm infants necessitating surgical repair. Despite the increased risk of postoperative apnea in preterm infants, the procedure was conventionally performed under general anesthesia. Recently, regional anesthesia approaches, including spinal and caudal blocks have been proposed as safe and efficient alternative anesthesia methods in this group of patients. The current study evaluates awake caudal and spinal blocks in preterm infants undergoing inguinal hernia repair. Materials and Methods: In a randomized clinical trial, 66 neonates and infants (weight <5 kg) undergoing inguinal hernia repair were recruited in Tabriz Teaching Children Hospital during a 12-month period. They were randomly divided into two equal groups; receiving either caudal block by 1 ml/kg of 0.25% bupivacaine plus 20 μg adrenaline (group C) or spinal block by 1 mg/kg of 0.5% bupivacaine plus 20 μg adrenaline (group S). Vital signs and pain scores were documented during operation and thereafter up to 24 h after operation. Results: Decrease in heart rate and systolic blood pressure was significantly higher in group C throughout the study period (P < 0.05). The mean recovery time was significantly higher in group S (27.3 ± 5.5 min vs. 21.8 ± 9.3 min; P = 0.03). Postoperative need for analgesia was significantly more frequent in group S (75.8% vs. 36.4%; P = 0.001). Failure in anesthesia was significantly higher in group S (24.4% vs. 6.1%; P = 0.04). Conclusion: More appropriate success rate, duration of recovery and postoperative need of analgesics could contribute to caudal block being a superior anesthesia technique compared to spinal anesthesia in awaked preterm infants undergoing inguinal hernia repair.
  3,473 204 5
Combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study
Waleed Abdalla, Mona Ahmed Ammar, Ayman Ibrahim Tharwat
October-December 2015, 9(4):433-438
DOI:10.4103/1658-354X.159470  PMID:26543463
Background: Satisfactory analgesia is of great importance in the labor. The clinical efficacy and side effects of remifentanil in the management of labor pain had been evaluated. Dexmedetomidine (DMET) demonstrates an antinociceptive effect in visceral pain conditions. Aims of the study were to assess whether the combination of DMET with remifentanil would produce a synergistic effect that results in lower analgesic requirements. Furthermore, whether this combination would have less maternal and neonatal adverse effects. Patients and Methods: Sixty American Society of Anesthesiologists physical status I-II pregnant women had been enrolled into this study. All were full term (37-40 weeks' gestation), singleton fetus with cephalic presentation in the first stage of spontaneous labor. They were divided into two groups group (I) Patient-controlled IV remifentanil analgesia (bolus dose 0.25 μg/kg, lockout interval 2 min) increased by 0.25 μg/kg to a maximum bolus dose 1 μg/kg in addition to a loading dose of DMET 1 μg/kg over 20 min, followed by infusion at 0.5 μg/kg/h group (II) Patient-controlled IV remifentanil analgesia (PCA) (bolus dose 0.25 μg/kg, lockout interval 2 min) increased by 0.25 μg/kg to a maximum bolus dose 1 μg/kg in addition to a the same volume of normal saline as a loading dose, followed by a continuous saline infusion. Visual analog scale score, maternal, and fetal complications and patients' satisfaction were recorded. Results: Patients receiving a combination of PCA remifentanil and DMET had a lower pain score compared with remifentanil alone in the second stage of labor (P = 0.001). The Total consumption of remifentanil was reduced by 53.3% in group I. There was an increased incidence of maternal complications and a lower patient satisfaction score in group II. Conclusion: DMET has an opioid sparing effect; a combination of DMET and remifentanil produces a synergistic effect that results in lower analgesic requirements and less maternal and neonatal adverse events.
  3,470 193 4
Comparative study between paracetamol and two different doses of pregabalin on postoperative pain in laparoscopic cholecystectomy
Ibrahim M Esmat, Hanan M Farag
October-December 2015, 9(4):376-380
DOI:10.4103/1658-354X.159459  PMID:26543452
Background: Postoperative pain is the primary reason for prolonged hospital stay after laparoscopic cholecystectomy. This study compared the effect of a single oral preoperative administration of paracetamol (1 g) with 2 different doses of pregabalin (150 or 300 mg) for attenuating postoperative pain and analgesic consumption. Materials and Methods: Seventy-five patients, aged 18-60 years, American Society of Anesthesiologists' physical status I and II undergoing elective laparoscopic cholecystectomy were included in this randomized controlled study. Patients were divided into three groups, 25 each to receive either oral paracetamol 1 g (group I, control group) or pregabalin 150 (group II) or 300 mg (group III), 2 h before surgery. Postoperative pain was evaluated based on visual analog scale over a period of 6 h and 1 st time for rescue analgesia. Postoperative sedation, hemodynamic changes, serum cortisol level, and side effects were also evaluated. Results: There was a significant decrease in mean heart rate, mean systolic blood pressure, sedation score, pain score, and delayed the first request for analgesics postoperatively in group (II) and group (III) compared to group (I) 2 h postoperatively. There was no significant difference in group (III) compared to group (II) postoperatively. The incidence of postoperative side effects was more in group (III). Conclusion: The single oral preoperative dose administration of pregabalin had significant opioid-sparing effect in the first 6 h after surgery, whereas side effects were more common with administration of pregabalin 300 mg.
  3,341 303 4
Articaine and mepivacaine buccal infiltration in securing mandibular first molar pulp anesthesia following mepivacaine inferior alveolar nerve block: A randomized, double-blind crossover study
Giath Gazal, Abdullah Muteb Alharbi, Khalid HidayatAllah Al-Samadani, Mohammad Dib Kanaa
October-December 2015, 9(4):397-403
DOI:10.4103/1658-354X.159463  PMID:26543456
Aims: A crossover double-blind, randomized study was designed to explore the efficacy of 2% mepivacaine with 1:100,000 adrenaline buccal infiltration and 4% articaine with 1:100,000 adrenaline buccal infiltration following 2% mepivacaine with 1:100,000 adrenaline inferior alveolar nerve block (IANB) for testing pulp anesthesia of mandibular first molar teeth in adult volunteers. Materials and Methods: A total of 23 healthy adult volunteers received two regimens with at least 1-week apart; one with 4% articaine buccal infiltration and 2% mepivacaine IANB (articaine regimen) and another with 2% mepivacaine buccal infiltration supplemented to 2% mepivacaine IANB (mepivacaine regimen). Pulp testing of first molar tooth was electronically measured twice at baseline, then at intervals of 2 min for the first 10 min, then every 5 min until 45 min postinjection. Anesthetic success was considered when two consecutive maximal stimulation on pulp testing readings without sensation were obtained within 10 min and continuously sustained for 45 min postinjection. Results: In total, the number of no sensations to maximum pulp testing for first molar teeth were significantly higher after articaine regimen than mepivacaine during 45 min postinjection (267 vs. 250 episodes, respectively, P < 0.001), however, both articaine and mepivacaine buccal infiltrations are equally effective in securing anesthetic success for first molar pulp anesthesia when supplemented to mepivacaine IANB injections (P > 0.05). Interestingly, volunteers in the articaine regimen provided faster onset and longer duration (means 2.78 min, 42.22 min, respectively) than mepivacaine regimen (means 4.26 min, 40.74 min, respectively) for first molar pulp anesthesia (P < 0.001). Conclusions: Supplementary mepivacaine and articaine buccal infiltrations produced similar successful first molar pulp anesthesia following mepivacaine IANB injections in volunteers. Articaine buccal infiltration produced faster onset and longer duration than mepivacaine buccal infiltration following mepivacaine IANB injections.
  3,335 195 3
Efficacy of the methoxyflurane as bridging analgesia during epidural placement in laboring parturient
Jamil S Anwari, Laith Khalil, Abdullah S Terkawi
October-December 2015, 9(4):370-375
DOI:10.4103/1658-354X.159457  PMID:26543451
Background: Establishing an epidural in an agitated laboring woman can be challenging. The ideal pain control technique in such a situation should be effective, fast acting, and short lived. We assessed the efficacy of inhalational methoxyflurane (Penthrox™) analgesia as bridging analgesia for epidural placement. Materials and Methods: Sixty-four laboring women who requested epidural analgesia with pain score of ≥7 enrolled in an observational study, 56 of which completed the study. The parturients were instructed to use the device prior to the onset of uterine contraction pain and to stop at the peak of uterine contraction, repeatedly until epidural has been successfully placed. After each (methoxyflurane inhalation-uterine contraction) cycle, pain, Richmond Agitation Sedation Scale (RASS), nausea and vomiting were evaluated. Maternal and fetal hemodynamics and parturient satisfaction were recorded. Results: The mean baseline pain score was 8.2 ± 1.5 which was reduced to 6.2 ± 2.0 after the first inhalation with a mean difference of 2.0 ± 1.1 (95% confidence interval 1.7-2.3, P < 0.0001), and continued to decrease significantly over the study period (P < 0.0001). The RASS scores continuously improved after each cycle (P < 0.0001). Only 1 parturient from the cohort became lightly sedated (RASS = −1). Two parturients vomited, and no significant changes in maternal hemodynamics or fetal heart rate changes were identified during treatment. 67% of the parturients reported very good or excellent satisfaction with treatment. Conclusion: Penthrox™ provides rapid, robust, and satisfactory therapy to control pain and restlessness during epidural placement in laboring parturient.
  3,376 145 -
Endotracheal intubation without muscle relaxants in children using remifentanil and propofol: Comparative study
Freshteh Naziri, Hakimeh Alereza Amiri, Mozaffar Rabiee, Nadia Banihashem, Farhad Mohammad Nejad, Ziba Shirkhani, Sedigheh Solimanian
October-December 2015, 9(4):409-412
DOI:10.4103/1658-354X.159465  PMID:26543458
Introduction: Endotracheal intubation is essential during general anesthesia and muscle relaxant drugs provide ideal conditions for this purpose. The objective of this study was to evaluate the intubating condition of remifentanil combined with propofol without muscle relaxant. Materials and Methods: In this prospective randomized study, 60 children aged 3-12 years, American Society of Anesthesiologists physical status I and II were included. All the children were premedicated with 0.05 mg/kg midazolam and 1.5 mg/kg lidocaine 5 min before the induction of anesthesia with 3 mg/kg propofol. Then, they were allocated randomly to receive either 2 μg/kg remifentanil (group R) or 1.5 mg/kg succinylcholine (group S). Tracheal intubation was attempted 90 s after the administration of propofol. The quality of intubation was assessed by using Copenhagen score based on jaw relaxation, ease of laryngoscopy, position of vocal cord, coughing and limb movement. Heart rate and blood pressure were recorded before and after induction, and 1, 3, 5 min after intubation. Results: There was no significant difference in intubating condition between the two groups (P = 0.11). Intubation condition was excellent in 26 of 30 (86.7%) patients in the group R compared with 30 (100%) patients in the group S. We observed significant difference in heart rate and systolic blood pressure over time between two groups (P = 0.02, P = 0.03 respectively). After intubation, we had higher heart rate and systolic blood pressure with a significant difference in group S compared with group R (P = 0.006, P = 0.018). None of the children had a chest rigidity, laryngospasm, and hypoxia. Conclusions: In premedicated children, propofol-remifentanil combination provides adequate conditions for tracheal intubation that is comparable with succinylcholine. Hemodynamic response to laryngoscopy and tracheal intubation was controlled better in group R.
  3,254 191 3
Effect of preinduction low-dose ketamine bolus on intra operative and immediate postoperative analgesia requirement in day care surgery: A randomized controlled trial
Khalid Maudood Siddiqui, Fauzia Anis Khan
October-December 2015, 9(4):422-427
DOI:10.4103/1658-354X.159468  PMID:26543461
Background: Availability of narcotics is an issue in developing countries, and low-dose ketamine offers an alternative to these drugs. Objective: The objective of this study is to evaluate the effect of a preemptive dose of low-dose ketamine on intra operative and the immediate postoperative analgesic requirements. Design: Randomized double-blind control trial. Settings: This study has been performed in the operating rooms and postanesthesia care unit at Aga Khan University Hospital, Karachi, Pakistan. Materials and Methods: Totally, 60 adult American Society of Anesthesiologists I and II patients undergoing day care surgery were randomly allocated into two groups, Group A (ketamine group) and Group B (saline group). Intervention: All patients underwent general anesthesia. Propofol 2 mg/kg was used as an induction agent; laryngeal mask airway (size 3 for females and 4 for males) was inserted. Following induction patients in Group A received ketamine 0.3 mg/kg and Group B saline bolus in a blinded manner. All patients were administered injection fentanyl 1 μg/kg as an analgesic and anesthesia was maintained with oxygen 40%, nitrous oxide 60% and isoflorane 1-2 minimum alveolar concentration. Patients breathed spontaneously on Lack circuit. Postoperatively rescue analgesia was provided with intravenous morphine 0.1 mg/kg when patient complained of pain. Main Outcome Measures: We observed analgesic effects of low-dose ketamine intra operatively and narcotic requirements in immediate postoperative period for day care surgeries. Results: There was no significant difference in demographic data in between groups. Saline group required more rescue analgesia (morphine) postoperatively (P < 0.001). No significant psychotomimetic symptoms were noted in either group. Conclusion: Low-dose ketamine 0.3 mg/kg provided adequate co-analgesia with fentanyl 1 μg/kg and was effective in a reduction of morphine requirement in the postoperative phase with minimal adverse effects.
  2,851 545 2
Etomidate in pediatric anesthesiology: Where are we now?
Joseph D Tobias
October-December 2015, 9(4):451-456
DOI:10.4103/1658-354X.159475  PMID:26543467
Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.
  3,185 185 1
Femoral nerve block for acute pain relief in fracture shaft femur in an emergency ward
Mukesh Somvanshi, Archana Tripathi, Naval Meena
October-December 2015, 9(4):439-441
DOI:10.4103/1658-354X.159471  PMID:26543464
Background: Analgesia in patients with fracture shaft femur is usually insufficient as physician usually relies on parental analgesia in such situations. Local anesthetic blockade of femoral nerve to provide analgesia in fracture shaft femur is an under-used technique. We conducted a study to evaluate the efficacy of femoral nerve block (FNB) with 0.5% ropivacaine for acute pain relief in patients with fracture shaft femur. Materials and Methods: A total of 50 patients were studied as they present in an emergency ward. All patients received an FNB with 15 ml of 0.5% ropivacaine. The onset of block, duration of analgesia, patient's acceptance after 24 h together with the effect of block were assessed. Results: The onset of analgesia occurred in 5.34 ± 1.10 min after the block. Pain scores decreased significantly from 9.12 ± 0.9, preblock visual analog scale (VAS) score to 1.84 ± 1.25, VAS score at 10 min after the block (P < 0.001). The quality of analgesia did not change when patient underwent radiological examination (38.9 ± 5.22 min after block) and traction application (69.4 ± 8.98 min after block). The duration of analgesia observed was 227 ± 63.99 min. Patient acceptance after 24 h of FNB was good in 86% patients. There were no side effects. Conclusions: It was concluded that in the emergency ward, rapid, effective, and long lasting analgesia can be achieved by safe and simple FNB in patients with fracture shaft femur.
  3,038 213 3
Low tracheal tumor and airway management: An anesthetic challenge
Richa Saroa, Satinder Gombar, Sanjeev Palta, Usha Dalal, Varinder Saini
October-December 2015, 9(4):480-483
DOI:10.4103/1658-354X.159483  PMID:26543474
We describe a case presenting with tracheal tumor wherein a Microlaryngeal tube was advanced into the trachea distal to the tumor for primary airway control followed by cannulation of both endobronchial lumen with 5.5 mm endotracheal tubes to provide independent lung ventilation post tracheal transection using Y- connector attached to anesthesia machine. The plan was formulated to provide maximal surgical access to the trachea while providing adequate ventilation at the same time. A 32 yrs non smoker male, complaining of cough, progressive dyspnea and hemoptysis was diagnosed to have a broad based mass in the trachea on computed tomography of chest. Bronchoscopy of the upper airway confirmed presence of the mass at a distance of 9 cms from the vocal cords, obstructing the tracheal lumen by three fourth of the diameter. The patient was scheduled to undergo the resection of the mass through anterolateral thoracotomy. We recommend the use of extralong, soft, small sized microlaryngeal surgery tube in tumors proximal to carina, for securing the airway before the transection of trachea and bilateral endobronchial intubation with small sized cuffed endotracheal tubes for maintenance of ventilation after the transection of trachea in patients with mass in the lower trachea.
  3,035 162 6
The rapid response team in outpatient settings identifies patients who need immediate intensive care unit admission: A call for policy maker
Mariam A Alansari, Eyad A Althenayan, Mohammed H Hijazi, Khalid A Maghrabi
October-December 2015, 9(4):428-432
DOI:10.4103/1658-354X.159469  PMID:26543462
Background: Caregivers in the ambulatory care setting with differing clinical background could encounter a patient at high risk of deterioration. In the absence of a dedicated acute care team, the response to an unanticipated medical emergencies in these settings is likely to have a poor outcome. Objective: To describe our experience in implementing an intensivist-led rapid response team (RRT) in the outpatient settings that identified patients who needed immediate Intensive Care Unit (ICU) admission. The effect on in hospital arrests, mortality, and ICU outcome is not the scope of this study. Materials and Methods: This retrospective descriptive study was performed from January 1, 2009 to December 31, 2011 in a tertiary hospital. Data from hospital records were used (none from patients' records). Consent was not needed. Measurements: Direct ICU admissions from the outpatient areas. Results: There were 90 patients cared for by RRT in the outpatient's settings, 76 adult, and 14 pediatric patients. A total of12 adult patients were transferred directly to ICU. Among the patient who were transferred to the emergency department, additional four patients required to be transferred to ICU (total 16 patients [17.7%], 15 adult, and one pediatric patient). Follow-up at 24 h in the ICU showed death of one adult oncology patient (6.25%), and discharge of two patients (12.5%). Nine patients (81%) were still sick to require longer ICU stay. Conclusion: Intensivist-led RRT in outpatient settings identifies patients who are critically ill and in need of immediate ICU admission. Thus, an intensivist-led RRT policy in the outpatient settings needs to be implemented hospital wide.
  3,070 118 2
Anesthetic management of an elderly patient with kyphoscoliosis and dilated cardiomyopathy posted for abdominal hysterectomy and salpingo-oophorectomy
Suvidha Sood, Manjunath R Kamath, Anil S Shetty
October-December 2015, 9(4):464-466
DOI:10.4103/1658-354X.154736  PMID:26543469
A 76-year-old kyphoscoliotic female patient presented with severe pain and sudden acute abdominal distension for 1-week and was diagnosed to have right-sided massive twisted ovarian cyst. The patient was a known case of hypertension, dilated cardiomyopathy with low 20% cardiac ejection fraction. Though very few incidences of multiple co-morbid conditions existing together in a single elderly patient have been reported in the past, it is important to titrate the dosage, type of anesthetic agents and their routes of administration in high risk patients.
  2,956 168 -
A prospective study to evaluate and compare laryngeal mask airway ProSeal and i-gel airway in the prone position
Susheela Taxak, Ajith Gopinath, Savita Saini, Teena Bansal, Mangal Singh Ahlawat, Manju Bala
October-December 2015, 9(4):446-450
DOI:10.4103/1658-354X.159473  PMID:26543466
Background: Prone position is commonly used to provide surgical access to a variety of surgeries. In view of the advantages of induction of anesthesia in the prone position, we conducted a randomized study to evaluate and compare ProSeal laryngeal mask airway (LMA) and i-gel in the prone position. Materials and Methods: Totally, 40 patients of either sex as per American Society of Anesthesiologists physical status I or II, between 16 and 60 years of age, scheduled to undergo surgery in prone position were included in the study. After the patients positioned themselves prone on the operating table, anesthesia was induced by the standard technique. LMA ProSeal was used as an airway conduit in group 1 while i-gel was used in group 2. At the end of surgery, the airway device was removed in the same position. Results: Insertion of airway device was successful in first attempt in 16, and 17 cases in ProSeal laryngeal mask airway (PLMA) and i-gel groups, respectively. A second attempt was required to secure the airway in 4 and 3 patients in PLMA and i-gel groups, respectively. The mean insertion time was 21.8 ± 2.70 s for group 1 and 13.1 ± 2.24 s for group 2, the difference being statistically significant (P < 0.05). The mean seal pressure in group 1 was 36 ± 6.22 cm H 2 O and in group 2 was 25.4 ± 3.21 cm H 2 O. The difference was statistically significant (P < 0.05). 13 patients in group 1 had fiberoptic bronchoscopy (FOB) grade 1 while it was 6 for group 2. The remaining patients in both groups had FOB grade 2. Conclusion: Insertion of supraglottic airways and conduct of anesthesia with them is feasible in the prone position. The PLMA has a better seal while insertion is easier with i-gel.
  2,906 159 1
Stress response in shoulder surgery under interscalene block, randomized controlled study comparing ultrasound guidance to nerve stimulation
Hossam A Elshamaa
October-December 2015, 9(4):359-364
DOI:10.4103/1658-354X.159454  PMID:26543449
Background: Shoulder surgeries are known to cause moderate to severe pain. Many techniques have been used successfully to minimize that stress response including interscalene block. Ultrasound guided techniques are becoming widely spread and commonly used for regional anesthesia. The objective of the present randomized controlled study is to compare the ultrasound guidance with nerve stimulation for interscalene brachial plexus block (IBPB) regarding the effect on stress response. Patients and Methods: 50 patients, American Society of Anesthesiologists physical status I, II, and III, undergoing shoulder surgery were enrolled in the current study. Group U patients (n = 25) received ultrasound guided IBPB and Group N patients (n = 25) received IBPB using nerve locator. IBPB was done under ultrasound guidance using the linear 13-6 MHz transducer of the SonoSite M-Turbo ultrasonic device. In both groups, venous blood samples to measure cortisol level and assess stress response as a primary outcome were collected. Results: The current study demonstrated that the stress response, as indicated by the cortisol level in blood, showed no significant difference in the preoperative blood level between Group U and Group N, as well as blood level after block and before skin incision. However, it differed significantly between the two groups postoperatively. Conclusion: The current study concluded that the use of ultrasound guidance for IBPB in shoulder surgeries offered a significant suppression of the stress response intraoperatively and postoperatively as indicated by the low cortisol level with less complications and easier technique compared to nerve location.
  2,760 155 1
Comparative study of preoperative use of oral gabapentin, intravenous dexamethasone and their combination in gynaecological procedure
Neha Agrawal, Chandrashekhar Chatterjee, Mamta Khandelwal, Rama Chatterjee, Madan Mohan Gupta
October-December 2015, 9(4):413-417
DOI:10.4103/1658-354X.159466  PMID:26543459
Background: We studied the effects of oral gabapentin and intravenous (I.V.) dexamethasone given together or separately 1 h before the start of surgery on intraoperative hemodynamics Postoperative analgesia and postoperative nausea vomiting (PONV) in patients undergoing gynaecological procedure. Materials and Methods: Patients were randomly divided into three groups: Group 1 (gabapentin, n = 46) received 400 mg gabapentin, Group 2 (dexamethasone, n = 46) received 8 mg dexamethasone and Group 3 (gabapentin plus dexamethasone, n = 46) received both 400 mg gabapentin and 8 mg dexamethasone I.V. 1 h before the start of surgery. Standard induction and maintenance of anesthesia were accomplished. Visual analog scale for pain was recorded for 12 h. Side effects were noted. Results: Hemodynamics at various time interval (0, 5, 10, 15, 20, 25 and 30 min) of laryngeal mask airway insertion and PONV were found significantly lower in Group 3 than in Group 1 and Group 2 (P < 0.05). The average time to first postoperative analgesic requirement at (visual analogue score >3) was significantly longer in Group 3 (510.00 ± 61.64 min) than in Group 1 (352.83 ± 80.61 min) and in Group 2 (294.78 ± 60.76 min), (P < 0.05). Conclusion: The present study concludes that the combination of oral Gabapentin and I.V. dexamethasone has significantly less hemodynamic changes, better postoperative analgesia and less incidence of PONV than individual administration of each drug.
  2,712 145 3
Evaluating the quality of intravenous regional anesthesia following adding dexamethasone to lidocaine
Ebrahim Hassani, Alireza Mahoori, Mir Mousa Aghdashi, Habibollah Pirnejad
October-December 2015, 9(4):418-421
DOI:10.4103/1658-354X.159467  PMID:26543460
Objectives: The quality of anesthesia in intravenous regional anesthesia (IVRA) has been evaluated in many studies so far. This study was designed to evaluate the effects of adding the dexamethasone to lidocaine on the quality of IVRA. Materials and Methods: A double-blind clinical trial was set up involving 50 hand surgery candidates, 20 to 55 years old, and with American Society of Anesthesiologists class of I and II. Patients were randomly allocated into two groups of 25 cases and received either 3 mg/kg of lidocaine (control group) or 3 mg/kg of lidocaine plus 8 mg of dexamethasone (study group). The onset and recovery times from sensory and motor blocks, the starting time of tourniquet pain, the amount of narcotics needed during patients' recovery, and probable side-effects were all compared between the two groups. Results: No significant differences were detected concerning age, gender, length of surgery and the mean time of starting of tourniquet pain between the two groups. The mean times of both sensory (P = 0.002) and motor (P = 0.004) blocks onset were significantly shorter in the study group. The mean time of recovery from sensory block was significantly longer in the study group (P = 0.01). The average amount of narcotics needed during the recovery was significantly lower in the study group (P = 0.01). No side-effect was detected. Conclusion: We conclude that adding the dexamethasone to lidocaine can improve the quality of anesthesia in IVRA.
  2,486 153 -
Midazolam as an adjuvant to intrathecal lignocaine: A prospective randomized control study
Venkatesh Selvaraj, Tapan Ray
October-December 2015, 9(4):393-396
DOI:10.4103/1658-354X.159462  PMID:26543455
Context: Unfortunately in the past decade, phenomenon of transient neurologic symptoms (TNS) cast doubts on the use of lignocaine for spinal anesthesia. Intrathecal midazolam has been proved to have its role in relieving neuropathic pain. We attempted to study the role of midazolam as an adjuvant to intrathecal lignocaine. Aims: The primary objective of the study was to evaluate the effect of intrathecal midazolam as an adjuvant to spinal lignocaine in terms of quality and duration of spinal sensory blockade. The secondary objectives are to study the effect on hemodynamics and the incidence of TNS. Settings and Design: A prospective randomized control double-blinded study in American Society of Anesthesiology I and II surgical population. Materials and Methods: Hundred healthy adult patients scheduled for elective infraumbilical surgery were randomly assigned to group A patients received spinal anesthesia with 1.5 ml of 5% lignocaine heavy with 0.4 ml of 0.9% saline and group B (control group) received spinal anesthesia with 1.5 ml of 5% heavy lignocaine with 0.4 ml of preservative-free 0.5% midazolam. Statistical Analysis Used: Z test for study parameters and analysis of variance was used for hemodynamic parameters in the same group. P < 0.05 was considered statistically significant. Results: Midazolam resulted in improved quality of sensory blockade in terms of early onset, increased duration of effective analgesia, and delayed two segment regression time and also decreases the incidence of TNS with intrathecal lignocaine. Conclusions: Midazolam is an effective adjuvant to intrathecal lignocaine.
  2,424 157 -
Anesthetic management for bronchoscopy and debulking of obstructing intratracheal tumor
B Uma, Anjali Kochhar, UC Verma, RS Rautela
October-December 2015, 9(4):484-488
DOI:10.4103/1658-354X.165129  PMID:26543475
Primary tracheal tumors comprise a rare group of benign and malignant tumors. Bronchoscopy is required for diagnosis and staging of tracheal neoplasms as well as debulking of the tumor. The management of anesthesia for rigid bronchoscopy in a patient with tracheal neoplasm presents with many challenges to the anesthetist. We present anesthetic management of an 18-year-old female who presented with orthopnea. Computed tomography scan of the thorax revealed a polypoidal lesion in the trachea proximal to carina and consolidation in the right middle lobe. The patient was scheduled for rigid bronchoscopy and debulking of the tumor. Case was successfully managed by providing positive pressure ventilation and oxygenation during rigid bronchoscopy using manual ventilation through the side port of the rigid bronchoscope. The procedure was uneventful, and patient improved symptomatically in the immediate postoperative period. The successful management of this case demonstrates the airway management in a patient with tracheal tumor for rigid bronchoscopy.
  2,382 140 1
"Amber in chamber" an enigmatous right atrial mass in a neonate
Sanjay Kumar, Jai Prakash Sharma, Saurabh Saigal, Ritika Dhurwe
October-December 2015, 9(4):477-479
DOI:10.4103/1658-354X.159482  PMID:26543473
The incidence of fungal infection is increasing worldwide. Although fungal infection is common in adults, few cases have been reported in the neonatal population. We report a case of the preterm neonate of 34 weeks who developed respiratory distress on 2 nd day and was initiated on mechanical ventilation. Treatment was instituted for sepsis, but the patient continued to deteriorate. Two-dimensional echocardiography revealed a large right atrial mass, which eventually turned out to be fungal ball. Intense surgical and medical management led to a speedy recovery of the patient. We stress on the early use of echocardiography in atypical presentation of neonatal septicemia along with routine investigations to help in early recognition of source of infection. This can be of great value in initiating definitive management and improving survival rate in such patients.
  2,417 86 -
Perioperative analgesic requirements in severely obese adolescents and young adults undergoing laparoscopic versus robotic-assisted gastric sleeve resection
Anita Joselyn, Tarun Bhalla, Christopher McKee, Victoria Pepper, Karen Diefenbach, Marc Michalsky, Joseph D Tobias
October-December 2015, 9(4):442-445
DOI:10.4103/1658-354X.159472  PMID:26543465
Purpose: One of the major advantages for patients undergoing minimally invasive surgery as compared to an open surgical procedure is the improved recovery profile and decreased opioid requirements in the perioperative period. There are no definitive studies comparing the analgesic requirements in patients undergoing two different types of minimally invasive procedure. This study retrospectively compares the perioperative analgesic requirements in severely obese adolescents and young adults undergoing laparoscopic versus robotic-assisted, laparoscopic gastric sleeve resection. Materials and Methods: With Institutional Review Board approval, the medication administration records of all severely obese patients who underwent gastric sleeve resection were retrospectively reviewed. Intra-operative analgesic and adjuvant medications administered, postoperative analgesic requirements, and visual analog pain scores were compared between those undergoing a laparoscopic procedure versus a robotic-assisted procedure. Results: This study cohort included a total of 28 patients who underwent gastric sleeve resection surgery with 14 patients in the laparoscopic group and 14 patients in the robotic-assisted group. Intra-operative adjuvant administration of both intravenous acetaminophen and ketorolac was similar in both groups. Patients in the robotic-assisted group required significantly less opioid during the intra-operative period as compared to patients in the laparoscopic group (0.15 ± 0.08 mg/kg vs. 0.19 ± 0.06 mg/kg morphine, P = 0.024). Cumulative opioid requirements for the first 72 postoperative h were similar in both the groups (0.64 ± 0.25 vs. 0.68 ± 0.27 mg/kg morphine, P = NS). No difference was noted in the postoperative pain scores. Conclusion: Although intraoperative opioid administration was lower in the robotic-assisted group, the postoperative opioid requirements, and the postoperative pain scores were similar in both groups.
  2,401 100 -
ED50 of sevoflurane for I-Gel removal in anesthetized children in cataract surgeries using subtenon block
Sameer Sethi, Babita Ghai, Dipika Bansal, Jagat Ram
October-December 2015, 9(4):381-385
DOI:10.4103/1658-354X.159460  PMID:26543453
Objective: The aim of this study was to determine the minimum concentration of sevoflurane required for I-Gel removal in 50% children undergoing elective cataract surgery. Design: A prospective observational study. Setting: A single tertiary care surgical center. Materials and Methods: Our study enrolled 20 American Society of Anesthesiologists I and II children aged 2-10 years, undergoing elective cataract surgery. Anesthesia was induced with sevoflurane and oxygen/nitrous oxide mixture and a size 2 I-Gel was inserted. A subtenon block was administered in all children before surgical incision. Sevoflurane was used for maintenance of anesthesia. Predetermined end-tidal concentration of sevoflurane was maintained for 10 min at the end of surgery before I-Gel removal was attempted. End-tidal concentrations were increased/decreased using the Dixon up-down method (with 0.2% as a step size) in the next patient depending on the previous patient's response. Patient responses to I-Gel removal were classified as "movement" or "no movement". Results: Minimum concentration of sevoflurane required for successful removal of a I-Gel in 50% (ED50) and 95% (ED95) of children was 0.44% (95% confidence interval [CI], 0.34-0.52%) and 0.77% (95% CI, 0.63-1.2%), respectively. Conclusion: A very low end-tidal concentration of sevoflurane (ED50 of 0.44% ED95 of 0.77%) is required for I-Gel removal in children in cataract surgery with the supplementation of subtenon block.
  2,312 93 -
Cardiac arrest following tourniquet release: Needs attention!
Kewal Krishan Gupta, Amanjot Singh
October-December 2015, 9(4):489-490
DOI:10.4103/1658-354X.159484  PMID:26543476
  2,126 109 -
Sonopathology: An onco-intensivist in active search of serendipity
Mayank Gupta, Priyanka Gupta
October-December 2015, 9(4):491-493
DOI:10.4103/1658-354X.159486  PMID:26543478
  1,859 62 -
Comments on "combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study"
José Ramón Ortiz-Gómez
October-December 2015, 9(4):341-342
DOI:10.4103/1658-354X.159453  PMID:26543445
  1,499 138 -
Anesthetic management of craniosynostosis repair in patient with Apert syndrome: Erratum

October-December 2015, 9(4):496-496
DOI:10.4103/1658-354X.165486  PMID:26543480
  1,511 72 -
Transient bladder and fecal incontinence following epidural blood patch
Miguel Angel Palomero-Rodríguez, Francisco J Palacio-Abinzada, Sara Chacón Campollo, Yolanda Laporta-Báez, Jose Carlos Mendez Cendón, Andres López-García
October-December 2015, 9(4):467-469
DOI:10.4103/1658-354X.159478  PMID:26543470
Epidural blood patch (EBP) is the currently accepted treatment of choice for postdural puncture headache because of its high initial success rates and infrequent complications. Many authors recommended a small volume (10-20 mL) of blood to be delivered for an effective EBP. Here, we report an obstetric patient who developed a transient bladder and fecal incontinence after 19 mL of blood EBP at L 1 -L 2 level. Since the magnetic resonance image did not demonstrate any definitive spinal cord lesion, the exact mechanism remains unclear. We suggest that accumulation of blood performed at L 1 to L 2 level in a closed relationship with the sacral cord, may have trigger a significant pressure elevation of the epidural space at this level, resulting in a temporal spinal cord-related injury in the sacral cord.
  1,330 54 -