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   2016| April-June  | Volume 32 | Issue 2  
    Online since May 10, 2016

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Intravenous sub-anesthetic ketamine for perioperative analgesia
Andrew W Gorlin, David M Rosenfeld, Harish Ramakrishna
April-June 2016, 32(2):160-167
DOI:10.4103/0970-9185.182085  PMID:27275042
Ketamine, an N-methyl-d-aspartate antagonist, blunts central pain sensitization at sub-anesthetic doses (0.3 mg/kg or less) and has been studied extensively as an adjunct for perioperative analgesia. At sub-anesthetic doses, ketamine has a minimal physiologic impact though it is associated with a low incidence of mild psychomimetic symptoms as well as nystagmus and double vision. Contraindications to its use do exist and due to ketamine's metabolism, caution should be exercised in patients with renal or hepatic dysfunction. Sub-anesthetic ketamine improves pain scores and reduces perioperative opioid consumption in a broad range of surgical procedures. In addition, there is evidence that ketamine may be useful in patients with opioid tolerance and for preventing chronic postsurgical pain.
  14,146 3,494 56
Brain death and care of the organ donor
Lakshmi Kumar
April-June 2016, 32(2):146-152
DOI:10.4103/0970-9185.168266  PMID:27275040
Brain death has specific implications for organ donation with the potential for saving several lives. Awareness on maintenance of the brain dead has increased over the last decade with the progress in the field of transplant. The diagnosis of brain death is clinical and can be confirmed by apnea testing. Ancillary tests can be considered when the apnea test cannot be completed or is inconclusive. Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death. Adequate care for the donor targeting hemodynamic indices and lung protective ventilator strategies can improve graft quality for donation. Hormone supplementation using thyroxine, antidiuretic hormone, corticosteroid and insulin has shown to improve outcomes following transplant. India still ranks low compared to the rest of the world in deceased donation. The formation of organ sharing networks supported by state governments has shown a substantial increase in the numbers of deceased donors primarily by creating awareness and ensuring protocols in caring for the donor. This review describes the steps in the establishment of brain death and the management of the organ donor. Material for the review was collected through a Medline search, and the search terms included were brain death and organ donation.
  12,639 3,404 24
Amniotic fluid embolism
Kiranpreet Kaur, Mamta Bhardwaj, Prashant Kumar, Suresh Singhal, Tarandeep Singh, Sarla Hooda
April-June 2016, 32(2):153-159
DOI:10.4103/0970-9185.173356  PMID:27275041
Amniotic fluid embolism (AFE) is one of the catastrophic complications of pregnancy in which amniotic fluid, fetal cells, hair, or other debris enters into the maternal pulmonary circulation, causing cardiovascular collapse. Etiology largely remains unknown, but may occur in healthy women during labour, during cesarean section, after abnormal vaginal delivery, or during the second trimester of pregnancy. It may also occur up to 48 hours post-delivery. It can also occur during abortion, after abdominal trauma, and during amnio-infusion. The pathophysiology of AFE is not completely understood. Possible historical cause is that any breach of the barrier between maternal blood and amniotic fluid forces the entry of amniotic fluid into the systemic circulation and results in a physical obstruction of the pulmonary circulation. The presenting signs and symptoms of AFE involve many organ systems. Clinical signs and symptoms are acute dyspnea, cough, hypotension, cyanosis, fetal bradycardia, encephalopathy, acute pulmonary hypertension, coagulopathy etc. Besides basic investigations lung scan, serum tryptase levels, serum levels of C3 and C4 complements, zinc coproporphyrin, serum sialyl Tn etc are helpful in establishing the diagnosis. Treatment is mainly supportive, but exchange transfusion, extracorporeal membrane oxygenation, and uterine artery embolization have been tried from time to time. The maternal prognosis after amniotic fluid embolism is very poor though infant survival rate is around 70%.
  8,954 2,419 19
Intrathecal buprenorphine versus fentanyl as adjuvant to 0.75% ropivacaine in lower limb surgeries
Arvinder Pal Singh, Ravinder Kaur, Ruchi Gupta, Anita Kumari
April-June 2016, 32(2):229-233
DOI:10.4103/0970-9185.182107  PMID:27275055
Background and Aims: This study aims to compare the anesthesia characteristics between buprenorphine and fentanyl when added as an adjuvant to intrathecal ropivaciane in an attempt to prolong the duration of spinal anesthesia. Material and Methods: The present prospective double-blind study was undertaken on ninety American Society of Anesthesiologist I and II patients between 18 and 60 years of age undergoing subarachnoid block for lower limb surgery. Group I (n = 30) patients were administered 3 ml of intrathecal solution (2.8 ml of 0.75% ropivacaine + 0.2 ml of isotonic sodium chloride), while Groups II and III patients (n = 30 each) received 2.8 ml 0.75% ropivacaine + 0.2 ml buprenorphine (60 μg) and 2.8 ml 0.75% ropivacaine + 0.2 ml fentanyl (10 μg), respectively. Following parameters were observed: Onset times and duration of sensory and motor block, time to first analgesic use, total dose of rescue analgesia, intra- and post-operative pain scores based on visual analog scale, sedation scores, hemodynamic parameters, and side effects if any. Data were analyzed by appropriate statistical tests and P < 0.05 were considered significant. Results: Time to onset of sensory and motor block in all the three groups was comparable. However, duration of sensory block was significantly prolonged in Groups II and III in comparison to Group I (P < 0.05) and it was the longest in Group II (P < 0.05). The duration of motor blockade was similar in all the three groups. The time to first analgesic dose was also significantly prolonged in Groups II and III as compared to Group I (P < 0.05) but was comparable between Groups II and III. Intra- and post-operative hemodynamic parameters, as well as side effects, were comparable. Conclusion: Addition of buprenorphine and fentanyl as adjuvants to intrathecal 0.75% ropivacaine prolongs postoperative pain relief without causing any increase in the duration of motor blockade but buprenorphine is better as compared to fentanyl in prolonging the duration of sensory block and achieving a better outcome in terms of pain relief.
  5,231 792 3
The efficacy and safety of epidural dexmedetomidine and clonidine with bupivacaine in patients undergoing lower limb orthopedic surgeries
Safiya I Shaikh, Sarala B Mahesh
April-June 2016, 32(2):203-209
DOI:10.4103/0970-9185.182104  PMID:27275050
Background and Aims: Alpha (α-2) adrenergic agonists have both analgesic and sedative properties when used as an adjuvant in regional anesthesia. A prospective randomized double-blind study was carried out to evaluate the efficacy of epidural route and to compare the efficacy and clinical profile of dexmedetomidine and clonidine as an adjuvant to bupivacaine with special emphasis on their quality of analgesia, sedation and the ability to provide the smooth intra-operative and postoperative course. Material and Methods: The study was conducted in prospective, randomized and double-blind manner. It included 60 American Society of Anesthesiologists Class I and II patients undergoing lower limb surgery under epidural anesthesia. Patients were randomly divided into Group A receiving 0.5% isobaric bupivacaine 15 ml with dexmedetomidine 1 μg/kg and Group B receiving 0.5% isobaric bupivacaine 15 ml with clonidine 2 μg/kg epidurally. Onset and duration of sensory and motor blocks, duration of analgesia, sedation, and adverse effects were assessed. Results: Demographic data, surgical characteristics cardio-respiratory parameters, side-effect profile were comparable and statistically not significant in both the groups. However, sedation scores with dexmedetomidine were better than clonidine and turned out to be statistically significant. The onset times for sensory and motor blocks were significantly shorter in Group A as compared to Group B. The duration of analgesia and motor block was significantly longer in A Group as compared to Group B. Conclusion: Dexmedetomidine is a superior neuraxial adjuvant to bupivacaine when compared to clonidine for early onset of analgesia, superior intra-operative analgesia, stable cardio-respiratory parameters, prolonged postoperative analgesia and providing patient comfort.
  4,249 757 13
Effect of magnesium sulfate nebulization on the incidence of postoperative sore throat
Monu Yadav, Nitish Chalumuru, Ramachandran Gopinath
April-June 2016, 32(2):168-171
DOI:10.4103/0970-9185.173367  PMID:27275043
Background: Postoperative sore throat (POST) is a well-recognized complication after general anesthesia (GA). Numerous nonpharmacological and pharmacological measures have been used for attenuating POST with variable success. Aims and Objectives: The present study was conducted to compare the efficiency of preoperative nebulization of normal saline and magnesium sulfate in reducing the incidence of POST following GA. Materials and Methods: Following institutional ethical committee approval and written informed consent, a prospective randomized double-blinded study was conducted in 100 cases divided into two equal groups. Patients included in the study were of either gender belonging to American Society of Anesthesiologist (ASA) status 1 or 2 undergoing elective surgery of approximately 2 h or more duration requiring tracheal intubation. Patients in Group A are nebulized with 3 ml of normal saline and the patients in Group B are nebulized with 3 ml of 225 mg isotonic nebulized magnesium sulfate for 15 min, 5 min before induction of anesthesia. The incidence of POST at rest and on swallowing and any undue complaints at 0, 2, 4, and 24 h in the postoperative period are evaluated. Results: There is no significant difference in POST at rest during 0th, 2nd and 4th h between normal saline and MgSO4. Significant difference is seen at 24th h, where MgSO4lessens POST. There is no significant difference in POST “on swallowing” during 0th and 2nd h between normal saline and MgSO4. Significant difference is seen at 4th h, where MgSO4has been shown to lessen POST. Conclusions: MgSO4significantly reduces the incidence of POST compared to normal saline.
  4,122 824 4
Effect of dexamethasone in low volume supraclavicular brachial plexus block: A double-blinded randomized clinical study
Arun Kumar Alarasan, Jitendre Agrawal, Bhanu Choudhary, Amrita Melhotra, Satyendre Uike, Arghya Mukherji
April-June 2016, 32(2):234-239
DOI:10.4103/0970-9185.182108  PMID:27275056
Background and Aims: With the use of ultrasound, a minimal effective volume of 20 ml has been described for supraclavicular brachial plexus block. However achieving a long duration of analgesia with this minimal volume remains a challenge. We aimed to determine the effect of dexamethasone on onset and duration of analgesia in low volume supraclavicular brachial plexus block. Material and Methods: Sixty patients were randomly divided into two groups of 30 each. Group C received saline (2 ml) + 20 ml of 0.5% bupivacaine and Group D received dexamethasone (8 mg) + 20 ml of 0.5% bupivacaine in supraclavicular brachial plexus block. Hemodynamic variables and visual analog scale (VAS) score were noted at regular intervals until 450 min. The onset and duration of sensory and motor block were measured. The incidence of "Halo" around brachial plexus was observed. Student's t-test and Chi-square test were used for statistical analysis. Results: The onset of sensory and motor block was significantly earlier in dexamethasone group (10.36 ± 1.99 and 12 ± 1.64) minutes compared to control group (12.9 ± 2.23 and 18.03 ± 2.41) minutes. The duration of sensory and motor block was significantly prolonged in dexamethasone group (366 ± 28.11 and 337.33 ± 28.75) minutes compared to control group (242.66 ± 26.38 and 213 ± 26.80) minutes. The VAS score was significantly lower in dexamethasone group after 210 min. "Halo" was present around the brachial plexus in all patients in both the groups. Conclusion: Dexamethasone addition significantly increases the duration of analgesia in patients receiving low volume supraclavicular brachial plexus block. No significant side-effects were seen in patients receiving dexamethasone as an adjunct.
  4,114 686 10
Postoperative analgesia in children: A comparison of three different doses of caudal epidural morphine
Neha Baduni, Manoj Kumar Sanwal, Homay Vajifdar, Radhika Agarwala
April-June 2016, 32(2):220-223
DOI:10.4103/0970-9185.182106  PMID:27275053
Background and Aims: Caudal epidural block is the most commonly used neuraxial block in children. Morphine has been used as a caudal additive for more than three decades. The aim of our study was to evaluate the efficacy and duration of analgesia of three different doses of caudal epidural morphine (CEM), and to find out the incidence of side effects. Material and Methods: This study was conducted on 75 patients of American Society of Anesthesiologists grades I and II, aged 2-12 years, undergoing lower abdominal and urogenital surgeries. Patients were randomly allocated to one of the three groups according to the dose of morphine. Group I received 30 μg/kg, group II 50 μg/kg, and group III 70 μg/kg. Heart rate, blood pressure, oxygen saturation, electrocardiogram, pain score, sedation score, duration of analgesia, and side-effects were noted. Results: The mean duration of analgesia was 8.63 h in group I, 13.36 h in group II and 19.19 h in group III. Respiratory depression was noted in three patients in group III. One patient in group I had itching. One patient each in groups I, II, and III had nausea/vomiting. Conclusion: CEM significantly prolongs the duration of analgesia, though with a higher dose the risk of respiratory depression should always be kept in mind.
  4,075 566 4
Comparative efficacy of intravenous dexmedetomidine, clonidine, and tramadol in postanesthesia shivering
Shikha Sahi, Mirley Rupinder Singh, Sunil Katyal
April-June 2016, 32(2):240-244
DOI:10.4103/0970-9185.182109  PMID:27275057
Background and Aims: Postanesthesia shivering continues to be a major challenge in the perioperative care. We compared the efficacy of tramadol, clonidine, and dexmedetomidine in preventing postoperative shivering and its potential adverse effects in patients undergoing laparoscopic cholecystectomy under general anesthesia. Material and Methods: One hundred and twenty American Society of Anesthesiologists I and II patients scheduled for elective laparoscopic cholecystectomy under general anesthesia were divided into four equal groups. Group 1 received clonidine 2 μg/kg, Group 2 received tramadol 1 mg/kg, Group 3 received dexmedetomidine 1 mcg/kg all intravenous diluted in NS to 5 ml, and Group 4 received NS intravenous 5 ml. Parameters analysed included postoperative blood pressure (BP), pulse rate, respiratory rate (RR), arterial saturation, and tympanic membrane temperature. Patients were observed for shivering episodes, sedation, pain, respiratory depression, nausea, and vomiting. Analysis of variance, Tukey's post-hoc comparison, Chi-square test and Bonferroni post-hoc comparison test were performed using SPSS (Statistical analysis by Statistical Package of Social Sciences of Microsoft Windows) Statistics (version 16.0). Results: The incidence of shivering was 10, 3.3, 13.3 and 40% in Groups 1, 2, 3, and 4 respectively. Patients who were given tramadol had significantly less shivering than patients in clonidine and dexmedetomidine groups (P < 0.01). Conclusion: All the three drugs were effective in preventing postoperative shivering. However, tramadol has been found to be more efficacious in preventing postoperative shivering.
  3,837 768 6
Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation
Sukhminder Jit Singh Bajwa, Jasleen Kaur, Ashish Kulshrestha, Rudrashish Haldar, Rakesh Sethi, Amarjit Singh
April-June 2016, 32(2):192-197
DOI:10.4103/0970-9185.173325  PMID:27275048
Background and Aim: Induced hypotension limits intra-operative blood loss to provide better visibility of the surgical field and diminishes the incidence of major complications during functional endoscopic sinus surgery (FESS). We aimed at comparing nitroglycerine, esmolol and dexmedetomidine for inducing controlled hypotension in patients undergoing FESS. Material and Methods: One hundred and fifty American Society of Anesthesiologists physical status I or II adult patients undergoing FESS under general anesthesia were randomly allocated to three groups of 50 patients each. Group E received esmolol in a loading and maintenance dose of 1 mg/kg over 1 min and 0.5-1.0 mg/kg/h, respectively. Group D received a loading dose of dexmedetomidine 1 μg/kg over 10 min followed by an infusion 0.5-1.0 μg/kg/h, and group N received nitroglycerine infusion at a dose of 0.5-2 μg/kg/min so as to maintain mean arterial pressure (MAP) between 60 and 70 mmHg in all the groups. The visibility of the surgical field was assessed by surgeon using Fromme and Boezaart scoring system. Hemodynamic variables, total intra-operative fentanyl consumption, emergence time and time to first analgesic request were recorded. Any side-effects were noted. The postoperative sedation was assessed using Ramsay Sedation Score. Result: The desired MAP (60-70 mmHg) could be achieved in all the three study groups albeit with titration of study drugs during intra-operative period. No significant intergroup difference was observed in Fromme's score during the intra-operative period. The mean total dose of fentanyl (μg/kg) used was found to be significantly lower in group D compared to groups E and N (1.2 ± 0.75 vs. 3.6 ± 1.3 and 2.9 ± 1.1 respectively). The mean heart rate was significantly lower in group D compared to groups E and N at all times of measurement (P < 0.05). The MAP was found to be significantly lower in group D compared to groups E and N after infusion of study drugs, after induction, just after intubation and 5 min after intubation (P < 0.05). The Ramsay Sedation Scores were significantly higher in group D (score 3 in 46%) when compared to group E (score 2 in 50%) and group N (score 2 in 54%) (P < 0.001). The emergence time was significantly lower in group E and group N compared to group D. Time to first analgesic request was significantly longer in group D. Conclusion: Dexmedetomidine and esmolol provided better hemodynamic stability and operative field visibility compared to nitroglycerin during FESS. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.
  3,703 764 18
Intravenous dexmedetomidine versus propofol for intraoperative moderate sedation during spinal anesthesia: A comparative study
Pratibha Jain Shah, Kamta Prasad Dubey, Kamal Kishore Sahare, Amit Agrawal
April-June 2016, 32(2):245-249
DOI:10.4103/0970-9185.168172  PMID:27275058
Background and Aims: There has been a paradigm shift of focus toward quality of spinal anesthesia with sedation being an integral aspect of this regional anesthesia technique. Thus, this study was designed to compare efficacy of intravenous dexmedetomidine and propofol for moderate sedation during spinal anesthesia. Material and Methods: A total of 120 patients of age group 18-60 years of American Society of Anesthesiologists grade I & II, posted for surgeries under spinal anesthesia were randomly divided in to three groups (n = 40 each); Group D received infusion of dexmedetomidine 1 μg/kg over 10 min followed by maintenance infusion of 0.5 μg/kg/h. Group P received infusion of propofol 6 mg/kg/h for 10 min followed by the infusion maintenance of 2.5 mg/kg/h. Group C (control group) received normal saline. Level of sedation (using observer's assessment of alertness/sedation score), pain intensity (by visual analogue scale), onset and recovery from sedation, hemodynamic changes, and overall patient's satisfaction were assessed. Results: The onset and recovery from sedation were significantly earlier with propofol (15.57 ± 1.89 min vs. 27.06 ± 2.26 min; P < 0.001) however intraoperative sedation (level 4), and overall patient's satisfaction was significantly better with dexmedetomidine group (p < 0.05). Duration of postoperative analgesia was significantly prolonged with dexmedetomidine (225.53 ± 5.61 min vs. 139.60 ± 3.03 min; P = 0.0013). Mean heart rate and blood pressure were significantly lower in the propofol group (P < 0.05). Conclusion: Dexmedetomidine with its stable cardio-respiratory profile, better sedation, overall patient's satisfaction, and analgesia could be a valuable adjunct for intraoperative sedation during spinal anesthesia.
  3,560 759 8
Dexmedetomidine: The game changer or a team player?
Rakhee Goyal
April-June 2016, 32(2):144-145
DOI:10.4103/0970-9185.182084  PMID:27275039
  3,110 713 3
Thoracic combined spinal epidural anesthesia for laparoscopic cholecystectomy: A feasibility study
Nandita Mehta, Mohd Reidwan Dar, Shikha Sharma, Kuldeep Singh Mehta
April-June 2016, 32(2):224-228
DOI:10.4103/0970-9185.173384  PMID:27275054
Background and Aims: The use of regional anesthesia for laparoscopic cholecystectomy has been reserved for patients who are at high-risk under general anesthesia (GA). The aim of this study was to assess whether thoracic combined spinal epidural (CSE) anesthesia is a feasible option for American Society of Anesthesiologists (ASA) physical status I and II patients undergoing elective laparoscopic cholecystectomy. Material and Methods: Thirty ASA physical status I and II patients undergoing elective laparoscopic cholecystectomy received thoracic CSE anesthesia at T9-T10 or T10-T11 interspinous space using the midline approach. Two ml of isobaric levobupivacaine 0.5% with 25 μg of fentanyl was given intrathecally. Results: Surgery was conducted successfully in all except one patient. Thoracic CSE was performed at T9-T10 interspace in 25 patients and T10-T11 interspace in five patients. Paresthesia occurred in two patients (6.6%) transiently on Whitacre needle insertion that disappeared spontaneously. Dural puncture on epidural needle insertion occurred in one patient, and intrathecal placement of epidural catheter occurred in one. Ten patients (33%) complained of shoulder pain. Conversion to GA was done in one patient due to severe shoulder pain and anxiety. Hypotension occurred in 11 patients (36%) and all responded to single dose of mephenteramine 6 mg and fluid bolus. Bradycardia occurred in six patients (20%) which was managed in all with a single dose of atropine. Conclusion: Thoracic CSE anesthesia can be used effectively for ASA I and II patients undergoing laparoscopic cholecystectomy with significant postoperative benefits.
  2,915 638 -
Incidence of hemidiaphragmatic paresis after peripheral nerve stimulator versus ultrasound guided interscalene brachial plexus block
Poonam Sachin Ghodki, Noopur Dasmit Singh
April-June 2016, 32(2):177-181
DOI:10.4103/0970-9185.168263  PMID:27275045
Background and Aims: We compared interscalene brachial plexus block (ISBPB) using peripheral nerve stimulation (PNS) and ultrasound (US) techniques. The primary outcomes were the incidence of hemidiaphragmatic paresis (HDP) and the duration of the block. Secondary outcomes were the block success rate, time to conduct the block, onset of sensory block, and dermatomal spread, postoperative pain by Numeric Rating Scale (NRS), duration of postoperative analgesia and incidence of complications. Material and Methods: We conducted a prospective, randomized, and observer-blinded study in 60 patients undergoing shoulder arthroscopy under block plus general anesthesia. ISBPB was performed with 10 ml of 0.5% bupivacaine using either PNS (Group PNS, n = 30) or US (Group US, n = 30). Hemidiaphragmatic function, the primary outcome, was assessed by ultrasonographic evaluation of diaphragmatic movement and pulmonary function tests using a bedside spirometer (forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate). General anesthesia was administered to all the patients for surgery. P < 0.05 test was considered to be statistically significant. Results: Twelve patients in Group PNS had HDP and none in Group US (P < 0.0001). PFTs were also significantly reduced in Group PNS (P < 0.0001). The time to conduct the block and sensory onset time both were less in Group US (P < 0.05). The groups did not differ in block success rate, duration of analgesia, and NRS. Other complications like incidence of Horner's syndrome and vascular puncture were comparable in both the groups. Conclusions: PNS guided ISBPB with 10 ml of 0.5% bupivacaine is associated with a higher incidence of HDP as compared to US guided ISBPB. There is no significant difference in quality or duration of analgesia in the two groups.
  2,980 567 9
Outcomes associated with stroke volume variation versus central venous pressure guided fluid replacements during major abdominal surgery
Lakshmi Kumar, Sunil Rajan, Ramasubramanian Baalachandran
April-June 2016, 32(2):182-186
DOI:10.4103/0970-9185.182103  PMID:27275046
Background and Aims: There is limited data on the impact of perioperative fluid therapy guided by dynamic preload variables like stroke volume variation (SVV) on outcomes after abdominal surgery. We studied the effect of SVV guided versus central venous pressure (CVP) guided perioperative fluid administration on outcomes after major abdominal surgery. Material and Methods: Sixty patients undergoing major abdominal surgeries were randomized into two equal groups in this prospective single blind randomized study. In the standard care group, the CVP was maintained at 10-12 mmHg while in the intervention group a SVV of 10% was achieved by the administration of fluids. The primary end-points were the length of Intensive Care Unit (ICU) and hospital stay. The secondary end points were intraoperative lactate, intravenous fluid use, requirement for inotropes, postoperative ventilation and return of bowel function. Results: The ICU stay was significantly shorter in the intervention group as compared to the control group (2.9 ± 1.15 vs. 5.4 ± 2.71 days). The length of hospital stay was also shorter in the intervention group, (9.9 ± 2.68 vs. 11.96 ± 5.15 days) though not statistically significant. The use of intraoperative fluids was significantly lower in the intervention group than the control group (7721.5 ± 4138.9 vs. 9216.33 ± 2821.38 ml). Other secondary outcomes were comparable between the two groups. Conclusion: Implementation of fluid replacement guided by a dynamic preload variable (SVV) versus conventional static variables (CVP) is associated with lesser postoperative ICU stay and reduced fluid requirements in major abdominal surgery.
  2,858 623 9
The effects of intravenous dexmedetomidine premedication on intraocular pressure and pressor response to laryngoscopy and intubation
Alka Chandra, Reena Ranjan, Jay Kumar, Ashima Vohra, Vijay Kumar Thakur
April-June 2016, 32(2):198-202
DOI:10.4103/0970-9185.173354  PMID:27275049
Background and Aims: Penetrating eye injuries are a challenge for the anesthesiologists in emergency due to increase in intraocular pressure (IOP). The aim of this study was to evaluate the effects of intravenous dexmedetomidine premedication on changes in IOP and hemodynamic response following laryngoscopy and tracheal intubation. Material and Methods: Hundred patients aged 18-60 years undergoing elective nonophthalmic surgery were divided into two groups of 50 each. Group D received a bolus dose of dexmedetomidine (0.4 μg/kg) diluted to 20 ml normal saline and Group C received normal saline (0.4 ml/kg) over 10 min as premedication. Heart rate (HR), systolic blood pressure (SBP) and IOP were measured and recorded before premedication (T1), 5 and 10 m after premedication (T2, T3), immediately after induction, intubation and then 1, 3, 5 min after intubation (T4, 5, 6, 7, 8). Results: HR was comparable in both groups at preoperative level, but it was significantly low in the drug group when compared with the control group at T4-T8 (P = 0.034, P < 0.001, 0.001, 0.036 and 0.001, respectively). The SBP was comparable in both the groups at baseline and till before induction. At T4-T8 there was a fall in SBP in Group D compared to the Group C (P = 0.045, P = 0.007, 0.001, 0.001 and 0.001, respectively). The baseline IOP was comparable in both the groups (P = NS). There was a significant fall in the IOP in Group D, 5 min after the drug infusion compared to Group C, which was sustained till 5 min after intubation (T8) (P < 0.001 at all intervals). Conclusion: Dexmedetomidine premedication in the dose of 0.4 μg/kg lowers the IOP and attenuates the pressor response to laryngoscopy and intubation.
  2,938 525 6
Evaluation of low-dose dexmedetomidine and neostigmine with bupivacaine for postoperative analgesia in orthopedic surgeries: A prospective randomized double-blind study
Ashima Sharma, Naresh J Kumar, Mohammad Azharuddin, Lalith C Mohan, Gopinath Ramachandran
April-June 2016, 32(2):187-191
DOI:10.4103/0970-9185.173355  PMID:27275047
Background and Aims: Neuraxial adjuants to local anesthetics is an effective technique of improving the quality and duration of postoperative analgesia. The safety and efficacy of drugs like dexmedetomidine and neostigmine as epidural medications have been sparsely investigated. Material and Methods: Combined spinal-epidural anesthesia was performed in 60 American Society of Anesthesiologists I and II patients who required lower limb surgeries of ≤3 h duration. The epidural drug was administered at the end of surgery with patients randomized into three groups. Group I, II and III received 6 ml of 0.25% bupivacaine alone, with 1 ug/kg of neostigmine and with 0.5 ug/kg of dexmedetomidine + 1 ug/kg of neostigmine, respectively. The patients were prescribed 50 mg tramadol intravenous as rescue analgesic. Patients were assessed for hemodynamic parameters, pain scores, duration of analgesia, rescue analgesic requirements and the incidence of side-effects over the next 10 h. Data was analyzed using SPSS ® version 17.0 (Chicago, IL, USA). P < 0.05 was considered as statistically significant. Results: Patients in Group III had significantly longer mean duration of analgesia (273.5 min) compared to Group II (176.25 min) and Group I (144 min). There was increased requirement of fluids to maintain blood pressures in Group III. Neostigmine did not cause significant incidence of gastrointestinal side effects. Conclusions: Epidurally administered dexmedetomidine and neostigmine exhibit synergism in analgesic action. The incidence of drug-related side-effects was low in our study.
  2,856 551 5
Intraperitoneal pre-insufflation of 0.125% bupivaciane with tramadol for postoperative pain relief following laparoscopic cholecystectomy
Aslam Jamal, Hammad Usmani, Mohd Mozaffar Khan, Amjad Ali Rizvi, Mohd Masood Hussain Siddiqi, Mohammad Aslam
April-June 2016, 32(2):257-260
DOI:10.4103/0970-9185.173402  PMID:27275060
Background and Aims: Laparoscopic cholecystectomy is associated with a fairly high incidence of postoperative discomfort which is more of visceral origin than somatic. Studies have concluded that the instillation of local anesthetic with opioid around gall bladder bed provides more effective analgesia than either local anesthetic or opioid alone. Material and Methods: The study included 90 American Society of Anesthesiologists I-II patients of age 16-65 years scheduled for laparoscopic cholecystectomy under general anesthesia. The patients received the study drugs at the initiation of insufflation of CO 2 in the intraperitoneal space by the operating surgeon under laparoscopic camera guidance over the gallbladder bed. Patients in Group T received tramadol 2 mg/kg in 30 ml normal saline, in Group B received bupivacaine 30 ml of 0.125% and in Group BT received tramadol 2 mg/kg in 30 ml of 0.125% bupivacaine intraperitoneally. Postoperative pain assessment was done at different time intervals in the first 24 h using Visual Analog Scale of 0-10 (0 = No pain, 10 = Worst pain imagined). Time to first dose of rescue analgesic and total analgesics required in the first 24 h postoperatively were also recorded. The incidence of side effects during the postoperative period was recorded. Results: Reduction in postoperative pain was elicited, at 4 and 8 h postoperatively when Group BT (bupivacaine-tramadol group) was compared with Group T (tramadol group) or Group B (bupivacaine group) (P < 0.01). There was a significantly lower requirement of analgesics during first 24 h postoperatively in Group BT compared to Group B or T but no significant difference in the intake of analgesics was noted between Groups B Group T. Time to first dose of rescue analgesic was also significantly prolonged in Group BT compared to Group B or T. The incidence of nausea and vomiting was comparable in all the study groups. Conclusions: Intraperitoneal application of bupivacaine with tramadol was a more effective method for postoperative pain control after laparoscopic cholecystectomy compared to intraperitoneal bupivacaine or tramadol alone.
  2,833 514 2
Dexmedetomidine versus midazolam as adjuvants to intrathecal bupivacaine: A clinical comparison
Usha Shukla, Tallamraju Prabhakar, Kiran Malhotra, Dheeraj Srivastava
April-June 2016, 32(2):214-219
DOI:10.4103/0970-9185.182105  PMID:27275052
Background and Aims: Trials are being carried out to identify an adjuvant to intrathecal bupivacaine that preferably potentiates postoperative analgesia .This prospective, randomized, double-blind study was aimed to compare the onset and duration of sensory and motor block, postoperative analgesia and adverse effects of dexmedetomidine or midazolam given with 0.5% hyperbaric bupivacaine for spinal anesthesia. Material and Methods: A total of 80 patients, scheduled for vaginal hysterectomies, were randomly allocated to Group D (n = 40) to receive intrathecally 3.0 mL 0.5% hyperbaric bupivacaine +5 ug dexmedetomidine in 0.5 mL of normal saline; and Group M (n = 40) to receive 3 mL of 0.5% hyperbaric bupivacaine +2 mg midazolam in 0.4 mL (5 mg/mL) +0.1 mL normal saline. The onset, duration of sensory and motor block, time to first postoperative analgesia and side effects were noted. Power and Sample size (PS) version was used for power and sample size calculation. Statistical analysis was performed using Microsoft (MS) Office Excel software with the Student's t-test and Chi-square test (level of significance P = 0.05). Results: Duration of sensory, motor blockade and time to the first requirement of analgesia were significantly higher in Group D. Postoperative visual analog scale was significantly less in Group D than Group M. Both groups were similar with respect to sedation, hemodynamic variables and side-effects. Conclusion: Intrathecal dexmedetomidine was better adjuvant than midazolam as it produces significantly longer duration of sensory block, reduced doses of postoperative analgesic agents with comparable side-effects.
  2,773 574 7
Off-pump awake coronary artery bypass grafting under high thoracic epidural anesthesia
Bharat Paliwal, Manoj Kamal, Dilip Singh Chauhan, Anamika Purohit
April-June 2016, 32(2):261-262
DOI:10.4103/0970-9185.168201  PMID:27275061
Conventionally general anesthesia has been the preferred anesthetic technique for coronary artery bypass grafting (CABG). Ever since the first awake CABG the concept though appearing promising is still being continually evaluated. From the Indian perspective, the practice has been largely limited to certain institutions and seems to be not widely practiced across India. This case reports our experience with this technique from the western part of the country.
  2,725 387 1
Efficacy of intravenous paracetamol on pressor response in patients undergoing cesarean section under general anesthesia
Sanum Kashif, Mohammad Hamid
April-June 2016, 32(2):210-213
DOI:10.4103/0970-9185.173332  PMID:27275051
Background and Aims: Profound hemodynamic alterations due to stress and pain during endotracheal intubation may cause deleterious effects. The purpose of this study was to evaluate the effect of intravenous (IV) paracetamol on hemodynamic changes due to endotracheal intubation during cesarean section under general anesthesia. Material and Methods: Random allocation of one hundred and ten patients in two groups (Group A - placebo and Group B - paracetamol), was achieved as per computer generated table. The placebo (normal saline) and paracetamol solutions looked identical as both were available in 100 ml piggy bags and were labeled as study drug. Infusion of the drug was given 1 h before surgery. Two baseline readings of heart rate, systolic blood pressure (BP), diastolic BP and mean BP were recorded before induction, and these readings were repeated during intubation. Detrimental effect on neonate was evaluated by Apgar score measured at 1 and 5 min after birth. Results: There were no significant demographic differences found between the two groups. Hemodyamic changes during intubation also did not differ between the two groups. Conclusion: Administration of IV paracetamol 1 h before cesarean section has no significant effect in preventing hemodynamic changes at the time of endotracheal intubation.
  2,661 451 1
Comparison of surgical conditions following premedication with oral clonidine versus oral diazepam for endoscopic sinus surgery: A randomized, double-blinded study
Rohini V Bhat Pai, Santhoshi Badiger, Roopa Sachidananda, Santhosh Mysore Chandramouli Basappaji, Raghunath Shanbhag, Raghavendra Rao
April-June 2016, 32(2):250-256
DOI:10.4103/0970-9185.182112  PMID:27275059
Background and Aims: Endoscopic sinus surgery (ESS) provides a challenge and an opportunity to the anesthesiologists to prove their mettle and give the surgeons a surgical field which can make their delicate surgery safer,more precise and faster. The aim of the study was to evaluate the surgical field and the rate of blood loss in patients premedicated with oral clonidine versus oral diazepam for endoscopic sinus surgery. Material and Methods: ASA I or II patients who were scheduled to undergo ESS were randomly allocated to group D (n = 30) or group C (n = 30). The patients' vital parameters, propofol infusion rate, and rate of blood loss were observed and calculated. The surgeon, who was blinded, rated the visibility of the surgical field from grade 0-5. Results: In the clonidine group, the rate of blood loss, the surgical time, propofol infusion rate was found to be statistically lower as compared to the diazepam group. Also a higher number of patients in the clonidine group had a better surgical score (better surgical field) than the diazepam group and vice versa. Conclusions: Premedication with clonidine as compared to diazepam, provides a better surgical field with less blood loss in patients undergoing ESS.
  2,670 397 4
Epidural chloroprocaine bolus in emergency cesarean section-lessons learned from a near mishap
Basavana G Goudra, Preet Mohinder Singh, Maisie Jackson, Ashish C Sinha
April-June 2016, 32(2):263-265
DOI:10.4103/0970-9185.173362  PMID:27275062
Administration of a large bolus of epidural chloroprocaine to hasten the spread of anesthesia is an accepted practice during emergency cesarean section. Occasionally, this practice can result in a very high block that can compromise patient's safety. We describe a case of epidural chloroprocaine administration in a 4 point position resulting in a high dermatomal block requiring respiratory assistance. Events surrounding the case are discussed, with a view to warn the reader about the pitfalls of such a practice.
  2,365 372 -
Spinal anesthesia and direction of spinal needle bevel
Smita Prakash, Parul Mullick
April-June 2016, 32(2):268-269
DOI:10.4103/0970-9185.173360  PMID:27275065
  2,281 375 -
Pneumocephalus after epidural analgesia: Should loss of resistance with air be blown out?
Manish Jagia, Mukul Chandra Kapoor, Pratibha Panjiar
April-June 2016, 32(2):272-273
DOI:10.4103/0970-9185.173399  PMID:27275068
  2,262 358 1
Maximizing organ yield from deceased Lead donors
Noble Gracious
April-June 2016, 32(2):143-143
DOI:10.4103/0970-9185.182083  PMID:27275038
  2,087 369 -
Perioperative problems in patients with brainstem tumors and their influence on patient outcome
Sachidanand J Bharati, Mihir Prakash Pandia, Girija Prasad Rath, Parmod Kumar Bithal, Hari Hara Dash, Surya K Dube
April-June 2016, 32(2):172-176
DOI:10.4103/0970-9185.182102  PMID:27275044
Background and Aims: Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome. Material and Methods: Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated. Results: Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome. Conclusion: Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.
  2,033 378 5
Supraglottic airway and caudal epidural for anesthetic management of a child with Larsen syndrome
Amit Rai, Anjan Trikha, Ashish Kumar, Ravindran Chandran
April-June 2016, 32(2):266-267
DOI:10.4103/0970-9185.173369  PMID:27275063
  1,789 284 -
Anesthetic management of a rare case of Takayasu's arteritis posted for total abdominal hysterectomy
Michell Gulabani, Pavan Gurha, Sabih Ahmad, Prashant Dass
April-June 2016, 32(2):271-272
DOI:10.4103/0970-9185.173326  PMID:27275067
  1,802 234 -
Heparin resistance during pediatric cardiac surgery: An unanticipated challenge for an anesthesiologist
Mohammad Irfan Akhtar, Syed Shabbir Ahmed, Shahid S Sami
April-June 2016, 32(2):273-274
DOI:10.4103/0970-9185.182123  PMID:27275069
  1,735 283 -
Worldwide contribution of Indian authors in various anesthesia-related journals
Indu Kapoor, Hemanshu Prabhakar, Charu Mahajan
April-June 2016, 32(2):276-277
DOI:10.4103/0970-9185.182127  PMID:27275071
  1,739 259 -
Vaporizer interlock malfunctioning
Jeson R Doctor, Sohan Lal Solanki
April-June 2016, 32(2):277-278
DOI:10.4103/0970-9185.173389  PMID:27275072
  1,706 273 -
A case of postpartum lateral sinus thrombosis following cesarean section under spinal anesthesia
Rajat Dadheech, Mamta Khandelwal, Sunil Chauhan, Satya Prakash Sharma
April-June 2016, 32(2):274-275
DOI:10.4103/0970-9185.182125  PMID:27275070
  1,710 268 -
Thoracic combined spinal epidural anesthesia in patient of dilated cardiomyopathy undergoing laparoscopic cholecystectomy
Nandita Mehta, Kuldeep C Gupta, Shikha Sharma, Mohd R Dar
April-June 2016, 32(2):269-270
DOI:10.4103/0970-9185.173321  PMID:27275066
  1,650 304 -
Difficult airway: When deliberate is too close to improvisation
Ruggero M Corso, Davide Cattano
April-June 2016, 32(2):267-268
DOI:10.4103/0970-9185.168170  PMID:27275064
  1,642 258 -