Anju R Bhalotra

Anesthetic drug wastage in the operation room: A cause for concern

Context: The cost of anesthetic technique has three main components, i.e., disposable supplies, equipments, and anesthetic drugs. Drug budgets are an easily identifiable area for short-term savings. Aim: To assess and estimate the amount of anesthetic drug wastage in the general surgical operation room. Also, to analyze the financial implications to the hospital due to drug wastage and suggest appropriate steps to prevent or minimize this wastage. Settings and Design: A prospective observational study conducted in the general surgical operation room of a tertiary care hospital. Materials and Methods: Drug wastage was considered as the amount of drug left unutilized in the syringes/vials after completion of a case and any ampoule or vial broken while loading. An estimation of the cost of wasted drug was made. Results: Maximal wastage was associated with adrenaline and lignocaine (100% and 93.63%, respectively). The drugs which accounted for maximum wastage due to not being used after loading into a syringe were adrenaline (95.24%), succinylcholine (92.63%), lignocaine (92.51%), mephentermine (83.80%), and atropine (81.82%). The cost of wasted drugs for the study duration was 46.57% (Rs. 16,044.01) of the total cost of drugs issued/loaded (Rs. 34,449.44). Of this, the cost of wastage of propofol was maximum being 56.27% (Rs. 9028.16) of the total wastage cost, followed by rocuronium 17.80% (Rs. 2856), vecuronium 5.23% (Rs. 840), and neostigmine 4.12% (Rs. 661.50). Conclusions: Drug wastage and the ensuing financial loss can be significant during the anesthetic management of surgical cases. Propofol, rocuronium, vecuronium, and neostigmine are the drugs which contribute maximally to the total wastage cost. Judicious use of these and other drugs and appropriate prudent measures as suggested can effectively decrease this cost.

Should awake caudals and epidurals be used more frequently in neonates and infants

SIR—I read with great interest the review article ‘Awake caudals and epidurals should be used more frequently in neonates and infants’ (1). The authors induced anesthesia with 8 vol% sevoflurane or propofol (up to 4 mg kg ) and spontaneous respiration was maintained and the child placed lateral. Is it then appropriate to say that the block was given with the child awake? The adequacy of respiration was monitored by endtidal CO2 measurement via a Venturi mask throughout the procedure but it is often not possible to measure a reliable endtidal capnogram using a venturi mask in small children. Although the authors recognize that establishment of a pneumoperitoneum during laparoscopic procedures is associated with several cardiopulmonary consequences, such as decrease in the functional residual capacity (FRC) with an increase in ventilation/perfusion mismatch and alveolar deadspace (2) which are more pronounced in small babies than in adults, they still advocate managing the airway without endotracheal intubation. The short neck of infants with a chin tending to meet the chest makes these infants prone to developing upper airway obstruction during sleep. In addition, their upper airway muscles are disproportionately sensitive to the depressant effects of anesthesia and sedation, resulting in pharyngeal airway collapse and obstruction. Their chest is small in relation to the abdomen, which is protuberant with weak abdominal muscles. The rib cage is cartilaginous and the thorax too compliant to resist inward recoil of the lungs. After induction of general anesthesia or deep sedation, the sustained inspiratory muscle tension which maintains the FRC is reduced leading to airway closure, atelectasis, and venous admixture. In addition, due to the reduced FRC and the much higher rate of oxygen consumption in infants, oxygen desaturation is often frighteningly quick. Brenner et al. (3). reported performance of caudal blocks in sedated infants with a high success rate and a low percentage of adverse events in 228 infants. However, all the adverse events were airway related. Comparison of adult and pediatric closed claims reveal a large prevalence of respiratory related damaging events —most frequently related to inadequate ventilation (4). The suggested anesthesia technique is admirable, but it is not clear why the authors so vehemently avoid securing the airway in such small children who are prone to respiratory depression due to both their anatomy and physiology and their response to anesthesia drugs. Placing an infant in the lateral position after induction and during performance of an epidural block without any means to maintain the airway is fraught with dangers of respiratory obstruction, rapid desaturation and bradycardia, laryngospasm, and patient movement, which is unacceptable during placing of a needle in the neuraxis. Many of these problems can be avoided by securing the airway with one of the several supraglottic devices available in pediatric sizes which seem to fill a niche between the facemask and endotracheal tube and are well tolerated at lighter planes of anesthesia. A supraglottic device could be used with the proposed anesthesia technique and would permit the anesthesiologist to maintain airway patency, monitor respiration, and provide IPPV/assisted ventilation/CPAP as required, and minimize the respiratory complications.

A randomised trial to compare the effect of addition of clonidine or fentanyl to hyperbaric ropivacaine for spinal anaesthesia for knee arthroscopy

Objectives: To evaluate the clinical effects of hyperbaric ropivacaine alone and with clonidine or fentanyl for spinal anaesthesia for knee arthroscopy. Methods: Sixty ASA I/II patients were randomised to receive spinal anaesthesia with hyperbaric ropivacaine alone (Group R), or with clonidine 15 μg (Group RC) or fentanyl 30 μg (Group RF). The sensory and motor block, time to micturition and side effects were assessed. Results: The three groups were similar in mean time to onset of sensory block at T10, height of block and time to maximum block. Sensory regression to S2 took longer in Groups RF and RC compared with Group R (p = 0.001 and p < 0.01, respectively). Time to requirement of rescue analgesia was longer in Groups RF and RC compared with Group R (p = 0.023 and 0.002, respectively). Time for complete regression of motor block and time to voiding were longer in group RC compared with group R (p = 0.022 and p = 0.013, respectively). Conclusion: The addition of fentanyl 30 μg to hyperbaric ropivacaine may be superior to the addition of clonidine 15 μg for knee arthroscopy as it provides a similar prolongation of sensory block and analgesia without prolonging motor block and time to micturition.

Assessing the age of deep vein thrombus: A need for future perioperative medicine and anesthesia.

As anesthesiologists and intensivists, we occasionally encounter a patient with deep vein thrombosis (DVT) and immediately the potentially life-threatening complications of thromboembolism come to mind. It is important to recognize the real risks in a specific patient. This editorial intends to focus on the various imaging modalities available to evaluate the entire spectrum of DVT and to develop an algorithmic approach to treat a patient with DVT. The diagnosis of DVT often leads to delays in associated surgical procedures and may lead to the unnecessary use of therapeutic anticoagulation in every patient with a painful swollen limb.

Awareness among resident doctors with regards to cardiac defibrillators

Background and Aims: Electrical defibrillation is the most important therapy for patients in cardiac arrest. The audit was aimed to assess awareness among residents with respect to routine preuse checking of cardiac defibrillators. Materials and Methods: The audit was conducted at a multispeciality tertiary care referral and teaching center by means of a printed questionnaire from anaesthesiology residents. A database was prepared and responses were analyzed. Results: Eighty resident doctors participated in the audit. Most (97.8%) of the residents were sure of the presence of a defibrillator in the operation room (OR); 70% of postgraduates (PG)s were aware of the location of the defibrillator in the OR as compared to 83.7% of the senior resident (SRs). Also, 32.1% residents routinely check the availability of a defibrillator. The working condition of the defibrillator was checked by 21.7% of the residents; 25.3% ensured delivery of the set charge. Further, 8.2% of residents ensured availability of both adult and paediatric paddles. About 27.8% of residents ensured the availability of appropriate conducting gel and 53.8% residents were of the opinion that the responsibility of checking the functioning and maintenance of the defibrillators lies with themselves. Some 22% thought that both doctors and technical staff should share the responsibility, while 19.5% opined that it should be the responsibility of the technical staff. Conclusion: All medical equipment is to be tested prior to initial use and periodically thereafter. An extensive, recurring training program, and continued attention to the training of clinical personnel is required to ensure that they are proficient in the operation and testing of specific defibrillator models in their work area. We conclude that apart from awareness of the use of the equipment we are using, its preuse testing is must. All resident doctors should be aware of the presence and adequate functioning of the defibrillator in their ORs and this audit reinforces the need for training of all resident doctors.

Attitude of resident doctors towards intensive care units' alarm settings.

Intensive care unit (ICU) monitors have alarm options to intimate the staff of critical incidents but these alarms needs to be adjusted in every patient. With this objective in mind, this study was done among resident doctors, with the aim of assessing the existing attitude among resident doctors towards ICU alarm settings. This study was conducted among residents working at ICU of a multispeciality centre, with the help of a printed questionnaire. The study involved 80 residents. All residents were in full agreement on routine use of ECG, pulse oximeter, capnograph and NIBP monitoring. 86% residents realised the necessity of monitoring oxygen concentration, apnoea monitoring and expired minute ventilation monitoring. 87% PGs and 70% SRs routinely checked alarm limits for various parameters. 50% PGs and 46.6% SRs set these alarm limits. The initial response to an alarm among all the residents was to disable the alarm temporarily and try to look for a cause. 92% of PGs and 98% of SRs were aware of alarms priority and colour coding. 55% residents believed that the alarm occurred due to patient disturbance, 15% believed that alarm was due to technical problem with monitor/sensor and 30% thought it was truly related to patient’s clinical status. 82% residents set the alarms by themselves, 10% believed that alarms should be adjusted by nurse, 4% believed the technical staff should take responsibility of setting alarm limits and 4% believed that alarm levels should be pre-adjusted by the manufacturer. We conclude that although alarms are an important, indispensable, and lifesaving feature, they can be a nuisance and can compromise quality and safety of care by frequent false positive alarms. We should be familiar of the alarm modes, check and reset the alarm settings at regular interval or after a change in clinical status of the patient.

Breathing circuit compliance and displayed tidal volume during pressure-controlled ventilation of infants

path toward the glottic opening and may detect any obstruction. It also aids in confirming final placement of the tracheal tube. Ultrasonography identifies esophageal placement, which can help in manipulating the direction of insertion of tube. Capnography is generally available in operation rooms and training in ultrasound for airway management is now widely recommended. We suggest considering this technique in unique situations like this. However, blind nasal intubation takes longer to perform than conventional intubation and it should be undertaken by clinicians familiar with this technique. This technique may lead to complications such as trauma and hemorrhage due to presence of tumor along the nasopharyngeal passage. Fibreoptic bronchoscope, if available must be preferred.

Anesthesia in a patient with Montgomery tube in situ: difficult to easy!

Anesthetic management of a child with a T‐tube in situ poses a great challenge to the anesthesiologist due to the presence of a compromised airway and unfamiliarity with the T‐tube due to rarity of the procedure. The most common type is the Montgomery T‐tube which is a T‐shaped tube with a superior limb, an inferior limb, and an anterior limb projecting out from a tracheotomy site. The tube acts as a stent in a compressed or collapsed airway as well as postlaryngeal reconstruction procedures. The common complications associated with a T‐tube include formation of granulations and crusting which may require urgent removal and replacement of the tube. However, there is a paucity of literature describing the anesthetic management for T‐tube removal in children. There are problems related to both sharing of the airway and loss or occlusion of the airway during T‐tube removal with associated hypoventilation or inability to ventilate and oxygen desaturation. Furthermore, in the pediatric age group, oxygen desaturation is faster than in adults and may be associated with bradycardia and cardiovascular collapse. Wootten et al have discussed various techniques of airway management for patients with T‐tubes in situ. They suggest ventilating the patient with a laryngeal mask airway or face mask with the anterior limb plugged. The anterior extratracheal lumen can be closed with an occluder. There is no standard size connector available for ventilating through the anterior limb of the T‐tube. While ventilating through the anterior limb, gas leak through the mouth and nose will occur which can be prevented by strapping an occluded facemask, using a balloon catheter or laryngeal mask airway to occlude the glottic inlet. The anesthetic management of these patients thus warrants a proper planning, preparation and execution of a meticulous anesthesia technique to avoid disastrous consequences. In our center we are using total intravenous anesthesia with 100% oxygen and spontaneous ventilation through an appropriate size supraglottic airway device for such patients. An endotracheal tube of appropriate size is railroaded over a fiberoptic bronchoscope which is then introduced through the supraglottic airway device with continued assisted spontaneous ventilation through a swivel connector. The bronchoscope is advanced to visualize the carina. If the tracheal lumen is found to be adequate, the fiberscope is withdrawn proximal to the T‐tube and the surgeon is asked to proceed with the removal of the T‐tube. By using this technique, the tracheal lumen is continuously being visualized through the fiberoptic bronchoscope. Once the tube has been removed, the patient is allowed to breathe spontaneously to assess for possible collapse of the trachea during inspiration. In the event of airway collapse, the tracheal tube which has been railroaded over the fiberoptic bronchoscope can be immediately advanced into the trachea over the fiberoptic bronchoscope. Another problem anticipated during this procedure is complete occlusion of the tracheal lumen by infolding of the T‐tube during removal. Use of 100% oxygen prevented desaturation during 90 seconds of complete lumen occlusion in one of our cases. Topical anesthesia has been suggested to decrease the requirement of anesthesia and facilitate direct laryngoscopy in a patient with a T‐ tube in situ. The presence of the fiberscope in the trachea allows the administration of local anesthetic under direct vision by SAYGO (Spray as you go) technique, thus, allowing a decrease in the requirement of intravenous anesthetic agents. This is a safe and simple technique and takes care of most of the problems encountered during removal of a T‐tube and can be recommended for the same.

Ketamine with Propofol for Endoscopic Procedures

propofol alone and in combination with ketamine or fentanyl for sedation during endoscopic ultrasonography. The combination of propofol and ketamine is used to confer advantages such as hemodynamic stability, analgesia, a lower incidence of respiratory depression, and faster recovery. The authors suggest the use of 50 μg fentanyl or 0.5 mg/kg ketamine in a single dose during endoscopic ultrasonography to reduce the dose of propofol required for sedation during the procedure. The dose of propofol administered was significantly higher in the propofol only group than in patients who received either fentanyl or ketamine as an adjuvant. However, in contrast to fentanyl, the use of ketamine prolonged the time to recovery (P < 0.001). The ketamine-propofol combination, also called ketofol, has been used for procedural sedation in several studies in varying ratios. Wang et al. [2] studied the use of the propofol-ketamine combination in varying ratios of 2 : 1, 3 : 1, and 4 : 1 and compared it with the propofol-fentanyl combination and propofol alone. They found that ketofol was as safe and effective as the propofol-fentanyl combination. The level of sedation and recovery based on discharge times for the 3 : 1 and 4 : 1 mixtures of ketofol were comparable to those for the combination of propofol with fentanyl 50 μg and propofol alone. The incidence of respiratory depression and post procedural drowsiness was lower with a 4 : 1 ratio (160 mg propofol and 40 mg ketamine) than with other ratios of ketofol. In another study, Gorji et al. [3] evaluated combinations of propofol with ketamine and fentanyl for endoscopic retrograde cholangiopancreatography. One group received ketamine 0.5 mg/kg, while the other group was administered fentanyl 50–100 μg. All patients received propofol 0.5 mg/kg followed by an infusion of 75 μg/kg/min. The level of sedation was equal in both groups (P > 0.05), while analgesia was better with fentanyl compared to ketamine (P < 0.05). Khajavi et al. [4] enrolled patients undergoing colonoscopy who were administered a combination of either fentanyl 0.5 μg/kg with propofol 0.5 mg/kg or ketamine 0.5 mg/kg with propofol 0.5 mg/kg (1 : 1 ratio). They found that patient satisfaction scores were significantly higher in the ketamine group. The level of sedation, hemodynamic status, oxygen saturation, incidence of nausea and vomiting, and recovery times were similar in both groups. In the study by Singh et al. [1], the dose of propofol administered was significantly higher in the propofol alone group than in patients who received it in combination with ketamine or fentanyl. It seems self-evident that addition of either of these drugs would decrease the requirement for propofol. Patient hemodynamics and oxygenation were well maintained and comparable in all groups; however, the time to achieve a Post Anaesthesia Discharge Score (PADS) [5] of 10 was significantly higher in the ketamine group compared to the other two groups. Intraoperative sedation was titrated using the Ramsay sedation score. Perhaps anesthesia depth monitoring with BIS/entropy could have been used as a more objective measure of the level of sedation; frequent clinical assessment using the Ramsay score entails arousing the patient repeatedly. The ratio of propofol to ketamine used in the study was approximately 15 : 1; hence, it seems surprising that the time to achieve a PADS of 10 was delayed in the ketamine group compared to other groups. Besides, the components of the PADS [5] include vital signs, activity level, nausea and vomiting, pain, and surgical bleeding. Hence, it is surprising that these parameters were affected by a relatively low Letter to the Editor

Let us not discard a preexisting epidural catheter for intrapartum cesarean section yet

epidural surgical anesthesia (ESA) and spinal anesthesia (SA) following epidural labor analgesia (ELA) for intrapartum cesarean section (CS). I also read the accompanying editorial by Kim [2] in which the author raises the question whether a pre-existing epidural catheter should be discarded for an intrapartum CS. Yoon et al. [1] suggest that ESA for CS has been unsuccessful or fails to achieve a satisfactory block in approximately 1.7–38% of cases, depending upon how failure is defined. They compared the rate of pain-free intrapartum CS performed under ESA and SA after ELA. While the failure rate in achieving pain-free surgery was significantly higher in the ESA group than in the SA group (15.3% vs. 2.5%, P < 0.001), there was no statistically significant difference between groups in the rate of conversion to general anesthesia. Yoon et al. [1] excluded patients with less than a 2-hour interval between epidural analgesia top-ups and CS in their study. This implies that when the patients were taken up for CS, the epidural analgesia may have worn off to a large extent. The pre-existing level of sensory block at the start of CS was T10 on assessment by loss of sensation to cold and T12 and L1 respectively, on assessment by pinprick in both the groups. Thus it is likely that the intensity of block was less in the ESA group, making this study more of a comparison of epidural vs. SA for CS rather than extension of ELA to ESA. The use of epidural anesthesia for elective CS is less common, as the resulting block is less reliable than that with SA. Besides, the combined spinal-epidural (CSE) technique offers advantages of rapid onset and the ability to augment or prolong anesthesia as desired. A T10 level of epidural analgesia needs to be extended to T4 level to enable optimal anesthesia to perform CS. This typically requires a volume of 15 to 20 ml of local anesthetic with one or more adjuvants. A fractionated dosing schedule may be used to offer greater hemodynamic stability; this allows assessment of the evolving sensory level prior to administration of the full dose of local anesthetic and minimizes dural sac compression. Besides, it allows early sensory blockade at the incision site, so that surgery can proceed without delay in emergency cases, prior to the establishment of a full T4 level block [3]. In order to reduce the failure rate of an epidural block, meticulous attention must be paid to technical details and a combination of local anesthetic and opioid should be used. Besides, it is important to understand the different characteristics of epidural vs. spinal blockade. It should be explained to the patient that while a sensation of deep pressure and movement may be felt, any discomfort or pain will be addressed promptly. In a review by Lee et al. [4], the predictors of failed ELA for CS included initiation of labor analgesia with plain epidural technique (compared to CSE), two or more episodes of breakthrough pain during labor, and a prolonged duration of neuraxial labor analgesia. Epidural catheters in situ for a longer duration were at higher risk of migration. They suggest that frequent use of CSE analgesia, early replacement of “uncertain” catheters during labor analgesia, and the experience of anesthesia providers may have contributed to their high success rate. Neuraxial anesthesia is preferred wherever possible as the preferred method of providing anesthesia for CS. This is due to the increasing use of epidural techniques for labor analgesia and the ease of rapid augmentation of the block to provide anestheLetter to the Editor