Anoop Raj Gogia

Efficacy of three doses of ketamine with bupivacaine for caudal analgesia in pediatric inguinal herniotomy.

Background and Objectives: Ketamine administered systemically is a potent analgesic at subanesthetic plasma concentrations. Addition of ketamine to bupivacaine for caudal epidural block significantly prolongs the duration of postoperative analgesia. The purpose of this prospective, randomized double-blind study is to identify the optimal dose of ketamine that produces the maximum duration of caudal analgesia with minimal adverse effects as an adjuvant to bupivacaine for caudal epidural block. Methods: Sixty children, aged 6 months to 10 years, undergoing inguinal herniotomy were allocated randomly to receive 1 of 3 solutions for caudal epidural block. Group 1 received 0.75 mL/kg of bupivacaine 0.25% with preservative-free ketamine 0.25 mg/kg, group 2 received 0.75 mL/kg of bupivacaine 0.25% with ketamine 0.5 mg/kg, and group 3 received 0.75 mL/kg of bupivacaine 0.25% with ketamine 1 mg/kg. Postoperative pain was assessed using the All India Institute of Medical Sciences pain discomfort scale. Rescue analgesia in the form of pethidine 1 mg/kg intramuscularly was administered when this score exceeded 4. Results: The mean duration of caudal analgesia was 8.8 hours in group 1 compared with 22.1 hours in group 2 (P < .001) and 25.2 hours in group 3 (P < .001). Supplemental analgesia requirements with pethidine were significantly less in group 2 (4 subjects) and group 3 (no subject) when compared with group 1 (18 subjects). There were no differences between the groups in the incidence of motor blockade, urinary retention, emesis, or sedation. Group 3 had a significantly higher incidence of behavioral side effects such as odd behavior, agitation, or restlessness than groups 1 and 2. Conclusions: The optimal dose of ketamine in our study was 0.5 mg/kg added to 0.75 mL/kg bupivacaine 0.25% for caudal epidural block without an increase in side effects.

Comparative Evaluation of the Sniffing Position with Simple Head Extension for Laryngoscopic View and Intubation Difficulty in Adults Undergoing Elective Surgery

The effect of patient position on mask ventilation, laryngoscopic view, intubation difficulty, and the stance adopted by the anesthesiologist during laryngoscopy and tracheal intubation was investigated in 546 anesthetized adults in this prospective, randomized study. Patients were randomly assigned to either the sniffing position group or the simple extension group. The distribution of Cormack grades was comparable between the two groups (P = 0.144). The IDS score [median (IQR)] was 0 (0–2) in the sniffing group and 1 (0–2) in the simple extension group; P = 0.002. There were significant differences between groups with regard to intensity of lifting force, external laryngeal manipulation, alternate techniques used, number of attempts, and the stance adopted by anesthesiologist. We conclude that the sniffing position is superior to simple head extension with regard to ease of intubation as assessed by IDS. An upright stance is adopted by more anesthesiologists performing intubation with patients in the sniffing position.

Comparison of ‘whoosh’ and modified ‘swoosh’ test for identification of the caudal epidural space in children

Background : Caudal analgesia is widely used in pediatric anesthesia practice. The ‘whoosh’ test which uses air to identify the epidural space, has been recommended as a guide for successful needle placement. However, the use of air may be associated with an incidence of neurological complications. The ‘swoosh’ test avoids the injection of air and was originally performed using injection of a local anesthetic solution. A comparison was made between the ‘whoosh’ test and a modified ‘swoosh’ test using saline to identify the caudal epidural space in children.

Stellate ganglion block can relieve symptoms and pain and prevent facial nerve damage

Ramsay hunt syndrome [1] is a varicella zoster virus infection of the geniculate ganglion of the facial nerve. It is typically associated with a red rash and blister (inflamed vesicles or tiny water filled sacks in the skin) in or around the ear and eardrum and sometimes on the roof of the mouth or tongue. Corticosteroid, oral acyclovir, and anticonvulsant are used for treatment of this. In addition to this sympathetic neural blockade via stellate ganglion block is used to prevent facial nerve damage and relieve symptoms. We present a case of Ramsay hunt syndrome in which pain and symptoms are not relieved by oral medication but by daily sittings of stellate ganglion block with local anesthetic and steroid, pain, and other symptoms are relieved, and facial nerve damage is prevented.

Negative-pressure pulmonary oedema in a patient undergoing shoulder arthroscopy.

An 18-year-old ASA-I patient who underwent elective left shoulder arthroscopy developed severe airway obstruction post-extubation due to fluid extravasation from the shoulder joint into the neck and airway tissue. Re-intubation for relief of obstruction resulted in negative-pressure pulmonary oedema. The patient was electively ventilated in the intensive care unit and recovered uneventfully. A high index of suspicion along with monitoring of neck circumference can prevent this kind of complication.

Granisetron versus ondansetron for post-operative nausea and vomiting prophylaxis in elective craniotomies for brain tumors: A randomized controlled double-blind study

Context: Post-operative nausea and vomiting (PONV) pose unique challenges in neurosurgical patients that warrant its study separate from other surgical groups. Setting and Design: This prospective, randomized, double-blind study was carried out to compare and to evaluate the efficacy and safety of three antiemetic combinations for PONV prophylaxis following craniotomy. Materials and Methods: A total of 75 anesthesiologist status I/II patients undergoing elective craniotomy for brain tumors were randomized into three groups, G, O and D, to receive single doses of dexamethasone 8 mg at induction with either granisetron 1 mg, ondansetron 4 mg or normal saline 2 ml at the time of dural closure respectively. Episodes of nausea, retching, vomiting and number of rescue antiemetic (RAE) were noted for 48 h post-operatively. Statistical Analysis: Analysis of variance with post-hoc significance and Chi-square test with fisher exact correction were used for statistical analysis. P <0.05 was considered to be significant and P < 0.001 as highly significant. Results: We found that the incidence and number of vomiting episodes and RAE required were significantly low in Group G and O compared with Group D; P < 0.05. However, incidence of nausea and retching were comparable among all groups. The anti-nausea and anti-retching efficacy of all the three groups was comparable. Conclusions: Single dose administration of granisetron 1 mg or ondansetron 4 mg at the time of dural closure with dexamethasone 8 mg provide an effective and superior prophylaxis against vomiting compared with dexamethasone alone without interfering with post-operative recovery and neurocognitive monitoring and hence important in post-operative neurosurgical care.

Failure of recommended in vitro tests to detect a leak in flexometallic endotracheal tube cuff system: Are we really safe?

I read the editorial by Thrakkal Shamim “Serious thoughts about plagiarism from India.”[1] I strongly object to the word “INDIA” used in the title. Does Dr. Shamim want to convey that India researchers do plagiarism? If his manuscript was copied by some other researcher, Dr. Shamim can blame the researcher and not his nationality. Plagiarism is common worldwide. I would advise Dr. Shamim to read the relevant literature and find out which country is no. 1 in plagiarism. Once again I would emphasize that instead of blaming a country (in the title and content of editorial), the editorial should focus on the menace of plagiarism.