Anjan Das

Mechanical bowel preparation versus no preparation before colorectal surgery: A randomized prospective trial in a tertiary care institute.

Background: In the first half of 20th century; mortality from colorectal surgery often exceeded 20%, mainly due to sepsis. Modern surgical techniques and improved perioperative care have significantly lowered the mortality rate. Mechanical bowel preparation (MBP) is aimed at cleansing the large bowel of fecal content thus reducing morbidity and mortality related to colorectal surgery. We carried out a study aimed to investigate the outcomes of colorectal surgery with and without MBPs, to avoid unpleasant side-effects of MBP and also to design a protocol for preparation of a patient for colorectal surgery. Materials and Methods: This was a prospective study over a period of March 2008-May 2010 carried out at Department of General Surgery of our institution. A total of 63 patients were included in this study; among those 32 patients were operated with MBPs and 31 without it; admitted in in-patient department undergoing resection of left colon and rectum for benign and malignant conditions in both emergency and elective conditions. Results: Anastomotic leakage, intra-abdominal collections was detected clinically and radiologically in 2 and 4 patients in each group respectively. P > 0.5 in both situations, indicating statistically no difference between results of two groups. Wound infections were detected in 12 (37.5%) patients with MBP group and 11 (35.48%) patients without MBP. Conclusion: The present results suggest that the omission of MBP does not impair healing of colonic anastomosis; neither increases the risk of leakage.

Emergence agitation prevention in paediatric ambulatory surgery: A comparison between intranasal Dexmedetomidine and Clonidine

Objective: Emergence agitation (EA), a short-lived, self-limiting phenomenon, arises frequently after the use of inhalational agents and hampers the implementation of pediatric ambulatory surgery in spite of using so many drugs with variable efficacy. Methods: In this prospective, double-blinded, parallel group study (2008-2009), 80 children of both sex aged 3-7 years, with American Society of Anesthesiologists (ASA) physical status grade I-II, undergoing sevoflurane-based general anesthesia for elective day care surgery were randomly assigned into groups C or D. Group C received 4 μg/kg intranasal clonidine, whereas group D received 1 μg/kg intranasal dexmedetomidine, 45 min before induction of anesthesia. In postanesthesia care unit (PACU), the incidence of EA was assessed with Aonos four-point scale and the severity of EA was assessed with pediatric anesthesia emergence delirium scale upon admission (T0), after 5 min (T5), 15 min (T15), and 25 min (T25). Extubation time, emergence time, duration of PACU stay, dose and incidence of fentanyl use for pain control were noted. Findings: Based on comparable demographic profiles, the incidence and severity of EA were significantly lower in group D as compared to group C at T0, T5, T15, and T25. But time of regular breathing, awakening, extubation, and emergence were significantly delayed in group D than C. The number and dose of fentanyl used in group C were significantly higher than group D. PACU and hospital stay were quite comparable between groups. Conclusion: Intranasal dexmedetomidine 1 μg/kg was more effective than clonidine 4 μg/kg in decreasing the incidence and severity of EA, when administered 45 min before the induction of anesthesia with sevoflurane for pediatric day care surgery. Dexmedetomidine also significantly reduced fentanyl consumption in PACU.

Effect of dexmedetomidine as adjuvant in ropivacaine-induced supraclavicular brachial plexus block: A prospective, double-blinded and randomized controlled study

Background and Aims: Different additives have been used to prolong brachial plexus block. We evaluated the effect of adding dexmedetomidine to ropivacaine for supraclavicular brachial plexus blockade. The primary endpoints were the onset and duration of sensory and motor block and duration of analgesia. Materials and Methods: A total of 84 patients (20-50 years) posted for elective forearm and hand surgery under supraclavicular brachial plexus block were divided into two equal groups (Group R and RD) in a randomized, double-blind fashion. In group RD (n = 42) 30 ml 0.5% ropivacaine +1 ml (100 μg) of dexmedetomidine and group R (n = 42) 30 ml 0.5% ropivacaine +1 ml normal saline were administered in supraclavicular block. Sensory and motor block onset times and block durations, time to first analgesic use, total analgesic need, postoperative visual analog scale (VAS), hemodynamics and side-effects were recorded for each patient. Results: Though with similar demographic profile in both groups, sensory and motor block in group RD (P < 0.05) was earlier than group R. Sensory and motor block duration and time to first analgesic use were significantly longer and the total need for rescue analgesics was lower in group RD (P < 0.05) than group R. Post-operative VAS value at 12 h were significantly lower in group RD (P < 0.05). Intra-operative hemodynamics were significantly lower in group RD (P < 0.05) without any appreciable side-effects. Conclusion: It can be concluded that adding dexmedetomidine to supraclavicular brachial plexus block increases the sensory and motor block duration and time to first analgesic use, and decreases total analgesic use with no side-effects.

Pain relief after Arthroscopic Knee Surgery: A comparison of intra-articular ropivacaine, fentanyl, and dexmedetomidine: A prospective, double-blinded, randomized controlled study

Background: Postoperative pain is very common distressing symptom after any surgical procedure. Different drugs in different routes have been used for controlling post-arthroscopic pain. No one proved to be ideal. We have compared the analgesic effect of ropivacaine, fentanyl, and dexmedetomidine when administered through the intra-articular route in arthroscopic knee surgery. Materials and Methods: From March 2008 to July 2010, 99 patients undergoing arthroscopic knee surgery were randomly assigned into three groups (A,B,C) in a prospective double-blinded fashion. Group A received 10 ml of 0.75% ropivacaine, where Group B received 50 μg fentanyl, and Group C received 100 μg of dexmedetomidine through the intra-articular route at the end of procedure. Pain assessed using visual analog scale and diclofenac sodium given as rescue analgesia when VAS >4. Time of first analgesia request and total rescue analgesic used in 24 hours were calculated. Results: Demographic profiles are quite comparable among the groups. Time for requirement of first postoperative rescue analgesia in Group A was 380.61 ± 22.973 min, in Group B was 326.82 ± 17.131 min and in Group C was 244.09 ± 20.096 minutes. Total rescue analgesia requirement was less in Group A (1.394 ± 0.496) compared to Group B (1.758 ± 0.435) and Group C (2.546 ± 0.546). Group A had higher mean VAS score at 6th and 24th postoperative hours. No side effects found among the groups. Conclusion: Therefore, it suggests that intra-articular ropivacaine gives better postoperative pain relief, with increased time of first analgesic request and decreased need of total postoperative analgesia compared to fentanyl and dexmedetomidine.

The efficacy of ginger added to ondansetron for preventing postoperative nausea and vomiting in ambulatory surgery

Background: Post-operative nausea and vomiting (PONV) frequently hampers implementation of ambulatory surgery in spite of so many costly antiemetic drugs and regimens. Objective: The study was carried out to compare the efficacy of ginger (Zingiber officinale) added to Ondansetron in preventing PONV after ambulatory surgery. Materials and Methods: It was a prospective, double blinded, and randomized controlled study. From March 2008 to July 2010, 100 adult patients of either sex, aged 20-45, of ASA physical status I and II, scheduled for day care surgery, were randomly allocated into Group A[(n = 50) receiving (IV) Ondansetron (4 mg) and two capsules of placebo] and Group B[(n = 50) receiving IV Ondansetron (4 mg) and two capsules of ginger] simultaneously one hour prior to induction of general anaesthesia (GA) in a double-blind manner. One ginger capsule contains 0.5 gm of ginger powder. Episodes of PONV were noted at 0.5h, 1h, 2h, 4h, 6h, 12h and 18h post- operatively. Statistical Analysis and Results: Statistically significant difference between groups A and B (P < 0.05), was found showing that ginger ondansetron combination was superior to plain Ondansetron as antiemetic regimen for both regarding frequency and severity. Conclusion: Prophylactic administration of ginger and ondansetron significantly reduced the incidence of postoperative nausea and vomiting compared to ondansetron alone in patients undergoing day care surgery under general anaesthesia.

i-gel™ in Ambulatory Surgery: A Comparison with LMA-ProSeal™ in Paralyzed Anaesthetized Patients.

INTRODUCTION Supraglottic devices have mostly eliminated the need of hemodynamically stressful routine endotracheal intubation for ambulatory surgeries. We aimed to compare hemodynamics- like blood pressure (BP) and heart rate (HR) alterations caused by stress response due to i-gel™ and LMA-ProSeal™ usage in Day care surgeries. Secondary outcomes included ease of insertion, time and number of attempts for the placement of devices. MATERIALS AND METHODS From April 2008 to July 2009, Sixty adult ASA I-II patients of either sex, aged 20-30, were randomly allocated into two groups (Group i-gel (n=30) receiving i-gel and Group PLMA (n=30) receiving LMA-ProSeal for airway maintenance) undergoing day care surgical procedures under general anaesthesia (GA).The ease of insertion and time taken for placement of device, postoperative complications were assessed. Haemodynamic parameters (HR, BP) were noted. It was a prospective, double blinded, and randomized controlled study. Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the Chi-square test. Unless otherwise stated, data are presented as mean (+ SD). p <0.05 was considered statistically significant. RESULTS Demographically both the groups were similar. i-gel was more easily inserted than LMA-ProSeal (90% vs. 83.33% respectively). i-gel insertion time was shorter than PLMA (14.9 vs. 20.0 sec respectively) and was statistically significant. Hemodynamics (HR, BP) were less altered in i-gel than PLMA and the results were statistically significant (p <0.05). CONCLUSION i-Gel; a relatively newer and cheap supraglottic device; insertion is easier and quicker as well as hemodynamically less stressful when compared with LMA-ProSeal in a day care setting.

Effect of different doses of dexmedetomidine as adjuvant in bupivacaine -induced subarachnoid block for traumatized lower limb orthopaedic surgery: a prospective, double-blinded and randomized controlled study.

BACKGROUND AND AIMS Improved pain management for blunt trauma to the lower extremity has shown to reduce morbidity, induce early ambulation and improve long-term outcomes. Dexmedetomidine; a selective α-2 agonist; has recently been used intrathecally in different doses to prolong spinal anaesthesia. We evaluated the effect of adding two different doses of dexmedetomidine to hyperbaric bupivacaine for spinal anaesthesia. The primary endpoints were the onset and duration of sensory, motor block and duration of analgesia. MATERIALS AND METHODS Eighty patients, (20-60yrs) posted for elective lower limb orthopedic surgery of traumatic origin under spinal anaesthesia were divided into 2 equal groups (Group D5&D10) in a randomized, double-blind fashion. In this prospective parallel group study, group D5(n=40) 3ml 0.5% hyperbaric bupivacaine+5μg dexmedetomidine in 0.5 ml of normal saline and group D10 (n=40) 3ml 0.5% bupivacaine+10μg dexmedetomidine in 0.5 ml of normal saline were administered intrathecally. Sensory and motor block onset times and block durations, time to first analgesic use, total analgesic need, postoperative VAS, hemodynamics and side effects were recorded for each patient. RESULTS Though with similar demographic profile in both groups, sensory and motor block in group D10(p<0.05) was earlier than group D5. Sensory, motor block duration and time to first analgesic use were significantly longer and the need for rescue analgesics was lower in group D10(p<0.05) than D5. 24 h VAS score was significantly lower in group D10(p<0.05). Intergroup hemodynamics was comparable (p>0.05) without any appreciable side effects. CONCLUSION Spinal dexmedetomidine increases the sensory, motor block duration and time to first analgesic use, and decreases analgesic consumption in a dose-dependent manner.

Does a single loading dose of tranexamic acid reduce perioperative blood loss and transfusion requirements after total knee replacement surgery? A randomized, controlled trial.

Background: Total knee replacement (TKR) is associated with high-perioperative blood loss, which often requires allogenic blood transfusion. Among the many strategies to decrease the need for allogenic transfusion, tranexamic acid (TA) is used systemically in perioperative setting with promising outcome. Here we evaluated the efficacy of single preoperative bolus dose of TA on reduction in blood loss and red blood cell transfusion in patients undergoing unilateral TKR. Materials and Methods: 70, American Society of Anesthesiologists I-II patients scheduled for unilateral TKR were included. Patients were randomly allocated into two groups to receive either TA (Group-TA; 20 mg/kg diluted to 25 cc with normal saline) or an equivalent volume of normal saline (Group P). Hemoglobin concentration, packed cell volume, platelet count, fibrinogen level, D-dimer level was measured preoperatively and at 6th and 24th h postoperative period. Results: In Group P more blood, colloid and crystalloid solutions were used to replace the blood loss. 27 patients in Group TA did not require transfusion of any blood products compared to 6 patients in Group P (P < 0.0001) and only 3 units of blood was transfused in Group TA where as a total of 32 units of blood was transfused in Group P. Despite the more numerous transfusions, Hb% after 6 h and 24 h in Group P were considerably low in comparison with Group TA (P < 0.0001). Conclusion: Tranexamic acid while significantly reducing blood loss caused by TKR surgery collaterally reduced the need for postoperative blood transfusion.

Induced hypotension in ambulatory functional endoscopic sinus surgery: A comparison between dexmedetomidine and clonidine as premedication. A prospective, double-blind, and randomized study

Background: Functional endoscopic sinus surgery (FESS) is the mainstay of a therapeutic technique for nasal pathologies. This study is to compare the ability of preoperative dexmedetomidine versus clonidine for producing controlled hypotensive anesthesia during FESS in adults in an ambulatory care setting. Materials and Methods: Sixty patients (25-50 years) posted for ambulatory FESS procedures under general anesthesia were randomly divided into Group C and D (n = 33 each) receiving dexmedetomidine 1 μg/kg and clonidine 1.5 μg/kg, respectively; both diluted in 100 ml saline solution 15 min before anesthetic induction. Nasal bleeding and surgeon′s satisfaction score; amount and number of patients receiving fentanyl and nitroglycerine for analgesia and deliberate hypotension, duration of hypotension, post anesthesia care unit (PACU) and hospital stay; hemodynamic parameters and side effects were recorded for each patient. Results: Number and dosage of nitroglycerine used was significantly (P = 0.034 and 0.0001 respectively) lower in Group D compared to that in Group C. Similarly, number of patients requiring fentanyl and dosage of same was significantly lower in Group D. But, the duration of controlled hypotension was almost similar in both the groups. Group D patients suffered from significantly less nasal bleeding and surgeon′s satisfaction score was also high in this group. Discharge from PACU was significantly earlier in Group D, but hospital discharge timing was quite comparable among two groups. Intraoperative hemodynamics was significantly lower in Group D (P < 0.05) without any appreciable side effects. Conclusion: Dexmedetomidine found to be providing more effectively controlled hypotension and analgesia, and thus, allowing less nasal bleeding as well as more surgeons′ satisfaction score.

Anti-thyroid peroxidase antibody positivity during early pregnancy is associated with pregnancy complications and maternal morbidity in later life

Aims: We assessed the impact of detecting anti-thyroid peroxidase antibodies (anti-TPO-Ab) in the first trimester of pregnancy on pregnancy outcomes and maternal thyroid function during the postpartum period. Materials and Methods: In a prospective study consisting 400 pregnant women (8-12 weeks pregnant) were screened for their thyroid profile and followed-up to 12 weeks postpartum. Patients with abnormal thyroid function at 12 weeks postpartum were further followed-up with repeated assessment of thyroid stimulating hormone (TSH) and serum-free thyroxine-4 levels at 8 weeks interval up to 12 months postpartum. Results: 11.5% of the subjects were positive for anti-TPO-Ab who had mean TSH level of 2.31 μIU/ml, which was significantly (P- 0.0001) higher than pregnant women negative for anti-TPO-Ab (1.73 μIU/ml). Increased incidence of miscarriage was observed in anti-TPO positive mothers when compared to antibody negative mothers. Postpartum thyroid dysfunction developed in 4.7% cases at 12 weeks, among them antibody positivity was observed in 81.25% of subjects. In 18.75% mothers positive for anti-TPO-Ab, the thyroid dysfunction persisted up to 12 months postpartum. Conclusions: Thyroid antibodies detected in early pregnancy seems to be predicting pregnancy complications and later maternal thyroid disease related morbidity.