Amit Rastogi

Comparison of general anaesthesia versus regional anaesthesia with sedation in selected maxillofacial surgery: a randomized controlled trial.

BACKGROUND The airway is the foremost challenge in maxillofacial surgery. The major concerns are difficulty in managing the patients airway and sharing it between the anaesthetist and surgeons. General anaesthesia, with endotracheal intubation, is the commonly used technique for maxillofacial procedures. We assessed the efficacy and safety of a regional block with sedation technique in certain maxillofacial operations, specifically temporomandibular joint (TMJ) ankylosis and mandibular fracture cases, and compared it with conventional general anaesthesia. We compared the time to discharge from the post anaesthesia care unit (PACU) and the occurrence of side effects, as well as surgeon and patient satisfaction with the anaesthetic technique, between the two groups. MATERIALS & METHODS We enrolled 50 patients of ASA grade 1 or 2, aged 15-50 years, scheduled for maxillofacial surgery (mandibular fracture or TMJ ankylosis). The patients were divided into two groups of 25 each, to receive sedation with a regional block with the use of a peripheral nerve stimulator in group I and general anaesthesia in group II. We observed haemodynamic parameters, intraoperative and postoperative complications and the amount of surgical bleeding in the two groups. Total anaesthesia time, patient and surgeon satisfaction, time to rescue analgesia, the number of rescue doses required, and the time to discharge from the PACU were compared. RESULTS The groups were comparable with respect to demographic profile, intraoperative haemodynamic parameters, surgical time, and amount of blood loss. Postoperative pain was assessed using the visual analogue score (VAS). Patients in group I had lower VAS scores after surgery and remained pain-free for longer than those in group II. The mean pain-free interval in group I was 159.12 ± 43.95 min and in group II was 60.36 ± 19.77 min (p < 0.005). Patients in group I required lower doses of rescue analgesia than those undergoing the surgery under general anaesthesia (p < 0.005). Patients receiving regional blocks also had fewer episodes of postoperative nausea and vomiting (p = 0.005). These results led to earlier discharge of patients in group I from the PACU. CONCLUSIONS Regional block with sedation is a safe alternative technique for patients undergoing surgery for mandible fracture or TMJ ankylosis, with clear advantages over general anaesthesia.

Effect of two different doses of dexmedetomidine on stress response in laparoscopic pyeloplasty: A randomized prospective controlled study

Background: Clonidine, opioids, β-blockers, and dexmedetomidine have been tried to attenuate stress responses during laparoscopic surgery. We evaluated the efficacy of dexmedetomidine in two different doses in attenuating stress responses on patients undergoing laparoscopic pyeloplasty. Subjects and Methods: Ninety patients were assigned to one of the three groups: Group A, Group B, and Group C. Group B received dexmedetomidine 1 mcg/kg as loading dose, followed by 0.7 mcg/kg/h for maintenance; Group C received dexmedetomidine 0.7 mcg/kg as a loading dose, followed by 0.5 mcg/kg/h for maintenance. Group A received normal saline. Stress responses were assessed by the variations in heart rate (HR), mean arterial pressure (MAP), blood glucose levels, and serum cortisol levels. One-way analysis of variance test was applied. Multiple comparisons between groups were done with post hoc Bonferroni test. Results: The HR and MAP were found to be higher in Group A. The difference was statistically significant (P < 0.05) during intubation, carbon dioxide insufflation, and extubation when compared with Groups B and C. Blood glucose levels at postintubation and at extubation were higher in Group A and statistically significant (P < 0.05) when compared with Groups B and C. Serum cortisol levels at postintubation, during midsurgery, and 2 h after extubation were higher in Group A and statistically significant (P < 0.05) when compared with Groups B and C. However, HR, MAP, blood glucose levels, and serum cortisol levels were similar in dexmedetomidine groups. Conclusions: Dexmedetomidine decreases stress response and provides good condition for maintenance of anesthesia. Dexmedetomidine when used in lower dose in Group C decreases stress response comparable to higher dose in Group B.

Valsalva maneuver: Its implications in clinical neurosurgery

Valsalva maneuver is associated with diverse physiological changes. These changes are used in various diagnostic and therapeutic clinical settings. Valsalva maneuver is also employed during various phases of neurosurgical procedures to achieve specific targets and confirm intraoperative findings. In this article, we attempt to describe the various clinical applications of the Valsalva maneuver within the realms of clinical neurosurgery. The associated complications of this act have also been discussed.

Intravenous Lignocaine to Blunt Extubation Responses: A Double-Edged Sword.

Extubation after general anesthetic procedures is often accompanied by transient undesirable responses such as hypertension, tachycardia, coughing, bucking, and raised intracranial and intraocular pressures. In neurosurgical procedures, they need to be stringently controlled to prevent the rise in cerebral blood flow, increase in intracranial pressure, and intracranial bleeding. Intravenous (IV) lignocaine (1-1.5 mg/kg) administration is one such method to blunt extubation responses. We describe a case where IV lignocaine was administered within the recommended doses to inhibit the extubation response, but the same resulted in generalized convulsions because of the clinical and physiological status of the patient at that point of time. Intravenous lignocaine administered to obtund extubation responses can itself manifest in toxic reactions depending on the preexisting clinical and physiological state of the patients. Thus, extreme caution and vigilance is to be maintained whenever IV local anesthetics are used for such purposes.

Aerophagia in a toddler with gastric pull-up: an unusual combination precipitating severe respiratory distress.

Abstract Aerophagia is a common disorder in adults as well as children, which often goes unnoticed. In toddlers, it may lead to acute gastric dilatation, which, if severe enough, may lead to respiratory distress. We hereby report case of a child who had successfully undergone gastric pull-up approximately 18 months before and presented with gradually progressing dyspnea due to aerophagia from excessive crying. Expedient diagnosis from history, examination and x-ray study, and simple treatment by passage of feeding tube and gastric decompression relieved the distress and helped us overcome the acute crisis. Literature search revealed few cases of aerophagia after dissociative anesthesia. Management of aerophagia in children is discussed, and the importance of proper clinical diagnosis to prevent unnecessary interventions in an emergency scenario is highlighted.

Ultrasound guided internal jugular vein cannulation in infants: Comparative evaluation of novel modified short axis out of plane approach with conventional short axis out of plane approach

Background and Aims: Central venous cannulation (CVC) through right internal jugular vein (IJV) route is routinely performed in paediatric patients undergoing major surgery and in those admitted to intensive care units. A novel technique (modified short-axis out-of-plane [MSA-OOP]) to improve first pass success rate of ultrasound-guided IJV CVC in neonates and infants is being compared with conventional SA-OOP method. Methods: A total of 120 patients were enroled in the study over a period of 6 months. All paediatric patients with age <1 year and weight <10 kg who underwent a major surgery requiring CVC were included. Patients were randomised to either of the two approaches of ultrasound-guided IJV cannulation; SA-OOP and modified SA-OOP (MSA-OOP). In modified approach, the midline of probe footprint was marked with a radio-opaque barium wire that casted a central acoustic shadow on ultrasound screen. Results: In MSA-OOP group, 83.1% of patients were cannulated in the first attempt as compared to 49.2% patients in group SA-OOP. Patients in MSA-OOP group required significantly fewer attempts for successful CVC as compared to patients in the SA-OOP group ( MSA-OOP: median = 1, interquartile range [1-1]; SAOOP: median = 2, interquartile range [1-2], P < 0.001, Mann–Whitney U-test). Conclusion: The use of MSA-OOP ultrasound technique for IJV CVC cannulation results in a higher first-attempt success rate and reduces the number of cannulation attempts.

Glomus Jugulare Tumor: Selective Catecholamine Screening–A Golden Miss?

Glomus jugulare tumor is a type of paraganglioma which has an association with catecholamine secretion but only in < 5% of cases. Any such occult or undetected catecholamine-secreting tumor poses anesthetic challenges in the perioperative period. A routine catecholamine assay and rigorous hemodynamic monitoring in such cases minimize perioperative anesthetic complications.

An audit to study pain after laparoscopic cholecystectomy with the use of nonopioid analgesics

Back ground: An Audit to study pain after laparoscopic cholecystectomy with the use of non-opioid analgesics. Patient and Methods: Hundred and nine patients were enrolled in this study that underwent elective laparoscopic cholecystectomy. Aged between 20 – 55 years, patients of either gender were enrolled in this prospective observational study. Seven patients were excluded from the study because of the conversion of laparoscopic procedure to open cholecystectomy and two patients were lost to follow-up. These patients were instructed and taught how to use the Numerical Pain Rating Scale (NPRS) for assessment of pain at rest, during deep breath and on movement. Pain score at rest, deep breath and movement including (Mild, Moderate and Severe pain), dynamic pain, breakthrough episodes of pain and time to discharge post surgery were recorded. Results: We found that none of the patients had severe pain at rest at any time interval. Only 1 patient had severe pain with deep breath at 2 hours and 2 patients had severe pain with deep breath at 6 hours after surgery. 2 patients had severe pain with movement at 2 hours and 6 patients had severe pain with movement at 6 hours after surgery. The dynamic pain was present in 12% patients (12) at 2 hours after surgery, which progressively declined to 4% (4) at 12 hours post surgery. The total number of breakthrough episodes was higher in patients having dynamic-pain at 2 hours. Conclusion: Maximum pain scores were found at 6 hours. Patients having higher dynamic pain score values at 2 hours have frequent breakthrough episodes (p value < 0.05) so an optimal analgesic control is warranted in such subset of patients. The time to discharge of patients was positively correlated to the pain scores of postoperative day 1.

Distributing pulse oximeter: An initiative for improving patient safety and care

Advancements in various surgical techniques may be attributed to advances in the field of anaesthesia, and more so on account of better monitoring techniques.[1-3] In the last 50 years, there has been a significant reduction in anaesthesia-related morbidity and mortality. Patients undergoing surgery in low-income group countries still have 2to 3-fold increased mortality risk in comparison with high-income group countries.[4]

Nil per oral instructions in chronic tobacco chewers: Are they enough?

849 Indian Journal of Anaesthesia | Volume 61 | Issue 10 | October 2017 and the problem was averted. This was discussed in our departmental review meeting, and possible ways to avoid this complication have been implemented. The problem could have been avoided by several things. The person who initiates the machine check should finish it and put the anaesthesia machine in the final pre-use position. Instead of the second reservoir bag, the ‘test lung’ can be used to simulate the lung while checking the ventilator. Anaesthesiologist should be always vigilant to prevent any complications.