Akshaya N Shetti

The effectiveness of intravenous dexmedetomidine on perioperative hemodynamics, analgesic requirement, and side effects profile in patients undergoing laparoscopic surgery under general anesthesia

Background: There is an upward surge in the use of laparoscopic surgeries due to various advantages when compared to open surgeries. Major advantages are, due to small incisions which are cosmetically acceptable and most of them are now daycare procedures. Problem of economic burden and hospital bed occupancy has been overcome with laparoscopic surgeries. All these advantages are not free from disadvantages, as hemodynamic changes such as hypertension; tachycardia and other surgical-related complications are commonly observed intraoperatively. Dexmedetomidine is one of the α2agonist drugs which acts at both supraspinal and spinal level and modulate the transmission of nociceptive signals in the central nervous system. The basic effect of dexmedetomidine on the cardiovascular system is to decrease the heart rate and systemic vascular resistance with additional feature of opioid sparing effect. This drug has become an ideal adjuvant during general anesthesia, especially when stress is expected. Hence, the drug was studied in laparoscopic surgeries. Aims and Objectives: (a) To study the effect of dexmedetomidine on hemodynamic parameters during perioperative period in patients undergoing laparoscopic surgery. (b) To study the postoperative sedation score and analgesic requirement. (c) To study the side effect profile of dexmedetomidine. Settings and Design: Randomized double blind controlled trial. Subjects and Methods: After obtaining the Institutional Ethical Clearance, the study was conducted. Forty patients of American Society of Anesthesiologists Class I and II were enrolled in this randomized study. The patients were randomly divided into two groups; group normal saline (NS) and group dexmedetomidine. Patient received either NS or dexmedetomidine in group NS and group dexmedetomidine, respectively, depending upon the allocation. The infusion rate was adjusted according to; loading dose (1 μg/kg) over 10 min and maintenance dose (0.5 μg/kg/h) and perioperative hemodynamics was recorded. Routine general anesthesia was administered in all the patients with conventional technique without deviating from institutional protocols. Postoperatively, Rasmsay sedation score, time taken for request of first analgesic dose, and side effects if any were recorded. Statistical Analysis Used: The categorical factors are represented by the number and frequency (%) of cases. The continuous variables are represented by measures of central frequency and standard deviation. The statistical analysis was done by using unpaired t-test and Chi-square. P < 0.05 was considered statistically significant. Results: Significant hemodynamic changes are observed in NS group during laryngoscopy, intubation, during pneumoperitoneum formation, and during extubation. Hemodynamic stress response in dexmedetomidine group was significantly attenuated. Analgesic requirement during postoperative 24 h were much less in dexmedetomidine group when compared to NS group. No significant side effects were noted except for bradycardia; which was observed in two cases of dexmedetomidine group. Conclusion: Dexmedetomidine infusion in the dose of 1 μg/kg body weight as bolus over 10 min and 0.5 μg/kg/h intraoperatively as maintenance dose controlled the hemodynamic stress response in patients undergoing laparoscopic surgery. Use of dexmedetomidine extends the pain free period postoperatively and thereby reducing total analgesic requirement. Thus, dexmedetomidine can be utilized as an ideal anesthetic adjuvant during laparoscopic surgeries.

Anesthetic management of a patient with Wilms tumor, aniridia, genital anomalies and mental retardation syndrome undergoing right nephrectomy

condition. Associations with craniosynostosis, Crouzon’s syndrome, Apert’s syndrome and Hunter’s syndrome are well documented.[2-4] Therefore, a careful workup is necessary along with necessary planning for anesthesia. Sinus pericranii is compounded by multiplicity, venous channels connecting to the intracranial venous system, and presence of venous lakes in close association with the abnormality. The latter is associated with significant blood loss intraoperatively.[5] Of further concern to anesthesiologist are the following two: hemorrhage and venous air embolism. The potential for blood loss should not be underestimated without disaster, especially in a case with multiplicity. This did occur in our case; however, we were prepared to handle the situation and were therefore able to salvage the situation. Although venous air embolism is another concern, requiring appropriate anticipation, monitoring and management, if it occurs, however did occur in our case. We conclude by stating that sinus pericranii is a rare venous anomaly, and that the above highlighted issues should be considered by the anesthesiologist whilst in preparation for surgery for such a case.

Hazard notice: Blocked oxygen humidifier!!

Oxygen therapy is one of the key components of treatment for patients in high dependency unit or intensive care unit. Different techniques are used for oxygen delivery, and one of the most commonly used methods is by simple mask or Venturi mask. Hence, it is always important to have functioning oxygen humidifier assembly to supply oxygen. Possibility of human errors, malfunctioning of equipment has been reported earlier.[1,2] We report a rare scenario where nozzle of oxygen humidifier was blocked.

Dexmedetomidine with low-dose ketamine for cataract surgery under peribulbar block in a patient with Huntington's chorea.

Huntington′s chorea (HC) is a rare hereditary disorder of the nervous system. It is inherited as an autosomal dominant disorder and is characterized by progressive chorea, dementia, and psychiatric disturbances. There are only a few case reports regarding the anesthetic management of a patient with HC and the best anesthetic technique is yet to be established for those patients which are at higher risk of perioperative complications. We report the anesthetic management of a 64-year-old patient with HC admitted for cataract surgery.

Yet another way to clear water drops from ETCO 2 sampling line

1. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953;39:368-76. 2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33. 3. Bessoud B, de Baere T, Kuoch V, Desruennes E, Cosset MF, Lassau N, et al. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol 2003;180:527-32. 4. Song Y, Messerlian AK, Matevosian R. A potentially hazardous complication during central venous catheterization: Lost guidewire retained in the patient. J Clin Anesth 2012;24: 221-6. 5. Vannucci A, Jeffcoat A, Ifune C, Salinas C, Duncan JR, Wall M. Special article: Retained guidewires after intraoperative placement of central venous catheters. Anesth Analg 2013;117:102-8. 6. Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: Mishap or blunder? Br J Anaesth 2002;88:144-6.

Hazard notice; improper connections and damaged outer tube in oxygen humidifier.

Oxygen has an important role, while treating critically ill patients and also while anesthetizing. One of the modes of delivery of oxygen is by humidification due to its various advantages.[1] Different techniques developed to improve the humidification, but such gadgets are not free from human errors, while using it. In anesthesia practice most of the human errors are commonly seen, while drug administration.[2] Absence of adequate knowledge of proper usage of equipment or negligence is most common cause for such errors. It can be avoided by proper checking of equipment and training.[3] It is also important to note that manufacturing and supply of good quality product in medical field is essential. Here, we report three case scenarios that we observed and highlight the possible cause of errors and help readers to prevent such mishaps.

Anesthetic management of a patient with Holt-Oram syndrome undergoing right radial head excision

Holt-Oram syndrome also known as heart and hand syndrome, first reported in 1960. It is a rare, inherited, an autosomal dominant disorder with mutation in TBX5. As the name suggests, the feature involves skeletal abnormality mainly involving upper limb, that is, upper-extremity malformations involving radial, thenar, or carpal bones; congenital heart diseases like, atrial-septal defect and ventricular septal defect and conduction problems. This syndrome may also involve other part of skeletal structure. We hereby report a case of a patient who was suffering from this syndrome scheduled for right radial head excision.

A superior drug delivery system for peripheral nerve block procedures.

While practicing anesthesia in developing and underdeveloped countries, it is important to consider not only the quality of anesthesia but also the cost-effectiveness. I read the article by Singh et al. where the author mentions cost-effective indigenous drug delivery system for nerve blocks.[1] The mentioned technique is an attempt and concentrated mainly on cost-effectiveness. We do regularly practice peripheral nerve blocks with or without ultrasound guidance. We do take care of cost of each material used. Our technique is more cost-effective, less cumbersome, airtight, easy, takes care of sterility, and is also readily available. We routinely use a male to female pressure monitoring tubing for the delivery of local anesthetic during peripheral nerve block, which is available in various lengths and anesthesiologist can choose depending on comfort. One end of it is connected to needle and the other end to a 20-ml syringe, as shown in the Figure 1. We prime the tubing and needle with local anesthetic before we proceed for the block to remove air. The assistant injects the drug from the syringe after negative aspiration for the blood. The operator can hold the needle with great comfort and can concentrate on locating nerve or plexus. This technique saves time, is sterile, uses less resources, is easy, cost-effective, airtight, and readily available.

A superior indigenous technique for nerve stimulation-assisted peripheral nerve blocks

1. Lang S, Lanigan DT, van der Wal M. Trigeminocardiac reflexes: Maxillary and mandibular variants of the oculocardiac reflex. Can J anaesth 1991;38:757‐60. 2. Lübbers HT, Zweifel D, Grätz KW, Kruse A. Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J oral Maxillofac Surg 2010;68:1317‐21. 3. arasho B, Sandu N, Spiriev t, Prabhakar H, Schaller B. Management of the trigeminocardiac reflex: Facts and own experience. Neurol india 2009;57:375‐80. 4. Schaller B. Trigeminocardiac reflex. A clinical phenomenon or a new physiological entity? J Neurol 2004;251:658‐65. 5. Shearer ES, Wenstone r. Bradycardia during elevation of zygomatic fractures. A variation of the oculocardiac reflex. anaesthesia 1987;42:1207‐8.