Asha Tyagi

Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study.

BACKGROUND Thoracic epidural analgesia (TEA), a commonly used analgesic technique in patients with multiple fractured ribs, is technically demanding and associated with certain side effects or complications. Thoracic paravertebral block (TPVB) is a simple and effective method of providing continuous pain relief in these patients. However, it has never been compared with TEA in terms of efficacy and outcome in patients with fractured ribs. METHODS Thirty adult patients of either sex, having three or more unilateral fractured ribs, were randomized to receive continuous bupivacaine infusion through either thoracic epidural or thoracic paravertebral catheter. Visual Analog Scale scores at rest and on coughing, respiratory rate, peak expiratory flow rate, and PaO2/FIO2 ratio were measured before and after administration of block at regular intervals. Morphine requirement for rescue analgesia, duration of bupivacaine infusion, length of intensive care unit and hospital stay, development of pulmonary complications, and complications of the two techniques were also recorded. RESULTS Both TEA and TPVB provided good pain relief and improved respiratory function, as evident by improvement in Visual Analog Scale scores at rest and on coughing, respiratory rate, and peak expiratory flow rate. However, no significant intergroup differences were found. Duration of bupivacaine infusion, morphine requirement, length of intensive care unit and hospital stay, and incidence of pulmonary complications were also similar in the two groups. Incidence of hypotension was more in TEA group. CONCLUSIONS Continuous bupivacaine infusion through TPVB is as effective as through TEA for pain management in patients with unilateral fractured ribs and the outcome after two techniques is comparable.

Central neuraxial blocks and anticoagulation: a review of current trends

Patients receiving anticoagulants offer a challenge to anaesthesiologists. The issue of spinal haematoma following central neuraxial block in such patients is a contentious issue. Although rare, with an estimated incidence of < 1:150,000 for epidural blocks and 1:220,000 for spinal anaesthetics in patients with normal coagulation status, this is an emergency situation with a potentially grave prognosis. The review presents cases of spinal haematomata that have occurred in the last 5 years, both spontaneously and after central neuraxial blockade. Of the 60 cases reported in the literature, 33% occurred following central neuraxial block and, of these, 55% were associated with concomitant use of anticoagulants. The pharmacology of the newer and older anticoagulants is also described. The variety of risk factors and diverse recommendations that have been described in these patients are reviewed.

Psychological care in trauma patients

The clinician manages trauma patients in the emergency room, operation theatre, intensive care unit and trauma ward with an endeavour to provide best possible treatment for physical injuries. At the same time, it is equally important to give adequate attention to behavioural and psychological aspects associated with the event. Knowledge of the predisposing factors and their management helps the clinician to prevent or manage these psychological problems. Various causes of psychological disturbances in trauma patients have been highlighted. These include pain, the sudden and unexpected nature of events and the procedures and interventions necessary to resuscitate and stabilise the patient. The ICU and trauma ward environment, sleep and sensory deprivation, impact of injury on CNS, medications and associated pre-morbid conditions are also significant factors. Specific problems that concern the traumatised patients are helplessness, humiliation, threat to body image and mental symptoms. The patients react to these stressors by various defence mechanisms like conservation withdrawal, denial, regression, anger, anxiety and depression. Some of them develop delirium or even more severe problems like acute stress disorder or post-traumatic stress disorder. Physical, pharmacological or psychological interventions can be performed to prevent or minimise these problems in trauma patients. These include adequate pain relief, prevention of sensory and sleep deprivation, providing familiar surroundings, careful explanations and reassurance to the patient, psychotherapy and pharmacological treatment whenever required.

Presentation of research in anesthesia: Culmination into publication?

Background: To assess the quality of research presentations made in conferences, its success or failure to be published in a peer-reviewed journal is a well-accepted marker. However, there is no data regarding the publication of research presentations made in Indian conferences of anesthesiology. Objective: The primary objective was to determine publication rate of research presented at the largest and best attended national conference in anesthesiology, the Indian Society of Anaesthesiologists’ Conference (ISACON), and also compare it with the rate from an international conference American Society of Anesthesiologists (ASA annual meeting) held in the same year. Materials and Methods: All 363 abstracts presented as poster or podium presentations at the ISACON, and an equal number of randomly selected abstracts presented at ASA annual meeting were searched on Pubmed and Google Scholar for their full-text publications in peer-reviewed journals using a standardized search strategy. As secondary observations, abstracts were assessed for completeness by noting certain components central to research methodology. Also, changes between abstract of the presentation and published paper were noted with respect to certain components. Results: The publication rate of presentations at ISACON and ASA meetings was 5% and 22%, respectively. The abstracts from ISACON lacked central components of research such as methods and statistical tests. The commonest change in the full-text publications as compared with the original abstract from both conferences was a change in authorship. Conclusion: Steps are required to augment full-text publication of Indian research, including a more rigorous peer review of abstracts submitted to ISACON to ensure their completeness.

Efficacy of dexamethasone pretreatment for alleviation of propofol injection pain

epiglottis/glottis/hypopharynx could not be seen and the straight end of the gum-elastic bougie was directed blindly and without resistance along the right posterior pharyngeal wall until the distal portion was 10 cm beyond the laryngopharynx. A size 5 ProSeal LMA was railroaded into position along its drain tube and the cuff inflated with 20 mL of air. Ventilation, however, was impossible with high airway pressures and airway obstruction. The proposed algorithm was followed, but the mechanical obstruction tests and recommended manoeuvres failed to solve the problem. Remembering that ‘whatever remains, however improbable, must be the truth’, the gum-elastic bougie was advanced and resistance was encountered after approximately 10 cm, indicating tracheal placement. The ProSeal LMA was rapidly exchanged for a tracheal tube, which passed easily along the bougie and provided unobstructed ventilation once the bougie was removed. The lowest SPO2 was 94% and there were no other problems. An alternative solution would have been to reinsert the bougie along the left posterior pharyngeal wall to reposition it in the oesophagus. Based on an audit of our experience with the gum-elastic bougie-guided technique during routine use, we estimate that the frequency of inadvertent tracheal placement is around 1 : 5000. In principle, inadvertent tracheal placement is more likely in the difficult airway scenario, as the hypopharynx may not been seen at laryngoscopy. The proposed algorithm has been modified to accommodate this rare but important scenario (Fig.).

Role of thoracic epidural block in improving post-operative outcome for septic patients: a preliminary report.

Background and objectives Sepsis is considered a relative contraindication for epidural blockade. Recent evidence indicates that thoracic epidural blockade may be of benefit during sepsis by improving gut perfusion. This study was planned to evaluate whether combining thoracic epidural blockade with general anaesthesia could decrease the post-operative mortality and morbidity in patients with sepsis due to perforation peritonitis. Methods This randomised non-blinded study included consenting adult patients of the American Society of Anesthesiologists grade II–III, undergoing emergency laparotomy for small intestinal perforation peritonitis. Severity of illness was evaluated using Mannheim Peritonitis Index, Acute Physiology and Chronic Health Evaluation III score and clinical indicators of systemic inflammatory response syndrome. Patients were randomised into two groups depending on the anaesthetic technique [general anaesthesia combined with thoracic epidural block (group GT) and general anaesthesia (group GA), n = 33 each. The thoracic block was extended from T5 to T10 using 0.125% bupivacaine in aliquots of 2–3 ml, with 50 μg fentanyl. Post-operatively, patients were followed for occurrence of any major morbidity till discharge from hospital, and 30-day mortality. ‘Major morbidity’ included development of organ failure. Post-operative markers for gut motility and perfusion, that is, time to passage of flatus, stools, resumption of oral feeds and occurrence of anastomotic leak were also observed. Sample size was calculated at power of 80% and α error of 0.05, aiming to detect a decrease of 50% in the incidence of post-operative major morbidity or mortality. Results Patients in the two groups were similar with respect to demographic profile and severity of sepsis. The number of patients with major morbidity or 30-day mortality were statistically similar between the two groups (group GT, 0/33; group GA 4/33; P = 0.114). A significantly shorter time to pass stools and resume oral feeds in group GT (4 ± 2 vs. 3 ± 1 days) (P = 0.006 and 0.012, respectively) and lesser incidence of anastomotic leak (0/33 vs. 4/33; P = 0.114) showed earlier recovery of gut motility and perfusion in that group. Conclusion Use of intra-operative segmental thoracic epidural blockade performed in addition to general anaesthesia suggested some benefit in improving post-operative mortality or major morbidity, but the trend was not significant, perhaps due to the small sample size. There was, however, a significantly earlier return of bowel motility and earlier discharge from hospital.

Epidural Volume Extension and Intrathecal Dose Requirement: Plain Versus Hyperbaric Bupivacaine

BACKGROUND: Epidural volume extension leads to an increase in sensory spread of local anesthetic, but whether this translates into lower dose requirements during combined spinal epidural (CSE) remains undetermined. Likewise, the influence of intrathecal drug baricity on the dose-sparing effect of epidural volume extension has not been investigated. We studied the dose-sparing effect of epidural volume extension and its relation to intrathecal drug baricity by comparing the ED50 of plain and hyperbaric bupivacaine with and without epidural volume extension. METHODS: Eighty-eight adult male patients scheduled for lower limb orthopedic surgery under CSE in the sitting position were randomized to four groups (n = 22 each); intrathecal injection was made with plain bupivacaine in groups plain bupivacaine (PB) and plain bupivacaine with epidural volume extension (PBE), and hyperbaric bupivacaine in groups hyperbaric bupivacaine (HB) and hyperbaric bupivacaine with epidural volume extension (HBE). Fentanyl, 25 &mgr;g, was added to the intrathecal drug in all groups. Among these four groups, epidural volume extension was performed with 10 mL normal saline only for groups PBE and HBE. The dose of spinal bupivacaine was varied using the up-and-down sequential allocation method. The first patient of each group received 10 mg bupivacaine. A successful spinal block was defined as attainment of sensory level of at least T10 along with complete motor blockade within 20 min of the intrathecal injection. The dose of bupivacaine was sequentially increased or decreased by 1 mg depending on whether spinal block was a failure or success in the previous patient. RESULTS: The addition of epidural volume extension to plain bupivacaine, i.e., group PBE versus group PB, resulted in a significant decrease in ED50 (relative potency estimate: 1.2, 95% CI: 1.04–1.64) and increase in maximum sensory level (T6 vs T8, respectively, P < 0.05). These differences were not seen with hyperbaric bupivacaine (group HB vs HBE). Independent of the effect of epidural volume extension, the ED50 of plain bupivacaine when compared with hyperbaric bupivacaine was significantly lower (relative potency estimate of group PB vs group HB: 0.78, 95% CI: 0.54–0.93; and for group PBE vs group HBE: 0.68, 95% CI: 0.37–0.87). CONCLUSIONS: Administered with or without epidural volume extension, plain bupivacaine appears to be more effective, requiring a smaller dose and producing a higher sensory block with an earlier onset in comparison to hyperbaric bupivacaine. Epidural volume extension, when applied to intrathecal hyperbaric bupivacaine, fails to decrease the dose or raise the level of block.

Single-shot spinal anaesthesia, combined spinal-epidural and epidural volume extension for elective caesarean section: a randomized comparison

BACKGROUND Single-shot spinal and combined spinal-epidural block, with or without epidural volume extension, can be used for caesarean section. There is no trial comparing their block characteristics and adverse effects under identical conditions. METHODS 60 ASA I or II parturients with gestational age 37 weeks or more, scheduled for elective caesarean section under regional anaesthesia, were included in the trial. Women were randomized to three groups: group SSS: single-shot spinal; group CSE: combined spinal-epidural; group EVE: epidural volume extension of a combined spinal-epidural. Intrathecal injection was identical in the three groups (0.5% hyperbaric bupivacaine 9 mg with fentanyl 10 microg) and was injected via a 25-gauge pencil-point spinal needle, either as a single-shot spinal or through the spinal needle of the needle-through-needle CSE set. In group EVE, 5 mL of normal saline was injected through the epidural catheter. All blocks were performed with the women sitting. Haemodynamic parameters and block characteristics were assessed. RESULTS The onset of maximum sensory and motor block was significantly faster in the SSS group than in the other two. Extent and duration of sensory and motor block and the incidence of adverse effects were similar in the three groups (P>0.05). CONCLUSIONS Intrathecal block is similar in extent and duration whether given as a single-shot spinal or a combined spinal-epidural with or without epidural volume extension when performed for elective caesarean section using hyperbaric bupivacaine in the sitting position.

ED50 of hyperbaric bupivacaine with fentanyl for cesarean delivery under combined spinal epidural in normotensive and preeclamptic patients.

Background and Objectives The use of reduced intrathecal doses is advised for spinal anesthesia during cesarean delivery. However, there are inadequate data regarding the minimum effective dose of intrathecal bupivacaine for cesarean delivery. Preeclampsia is caused by an endothelial dysfunction leading to generalized vasoconstriction. Whether this can offset the pregnancy-induced decrease in intrathecal dose requirement caused by epidural venous dilation and consequent thecal compression is not known. There are no data to evaluate the minimum effective dose of intrathecal drug for cesarean delivery in preeclamptic patients. This study aimed to determine the minimum effective dose represented by the ED50 of intrathecal hyperbaric bupivacaine for normotensive and severely preeclamptic patients undergoing elective cesarean delivery. Methods Combined spinal epidural anesthesia was administered using a standardized technique on 18 consecutively preeclamptic and normotensive patients, each carrying an otherwise uncomplicated singleton pregnancy. The dose of intrathecal hyperbaric bupivacaine was decided by using the up-and-down method with an initial dose of 9 mg and dosing change of 1 mg. All patients received 20 &mgr;g of fentanyl intrathecally with bupivacaine. A successful block was defined as one that resulted in a sensory block to T4 level with modified Bromage score of 1 or 2 within 15 minutes of intrathecal injection. Results ED50 of intrathecal hyperbaric bupivacaine was identical in severely preeclamptic and normotensive parturients undergoing elective cesarean delivery (4.7 mg; 95% confidence interval, 4.5–4.9 mg). Conclusions When a combined-spinal epidural is planned in normotensive or severely preeclamptic patients for an elective cesarean delivery, the ED50 of intrathecal hyperbaric bupivacaine along with 20 &mgr;g of fentanyl is 4.7 mg.

Comparison of combitube, easy tube and tracheal tube for general anesthesia

Background & Aims: The Combitube® and EasyTube™ enable effective ventilation whether placed in the trachea or esophagus and can be used in prehospital settings, as well as in “Cannot Ventilate Cannot Intubate” situations in the operating room. Whether they can be continued to provide general anesthesia, if required, is not established. Thus the efficacy of Combitube and EasyTube was evaluated and compared with the tracheal tube for general anesthesia using controlled ventilation. Materials and Methods: Combitube, EasyTube and tracheal tubes were used in 30 patients each to secure the airway in a randomized controlled manner. Ventilatory parameters were measured along with hemodynamic variables, and characteristics related to device placement. Results: There was no significant difference in the various ventilatory parameters including minute ventilation requirement to maintain eucapnia amongst the three groups at any time point. There was no hypoxia or hypercarbia in any patient at any time. Placement of EasyTube was more difficult (P = 0.01) as compared with both Combitube and tracheal tube. EasyTube and Combitube resulted in higher incidence of minor trauma than with a tracheal tube (P = 0.00). Conclusion: Combitube and EasyTube may be continued for general anesthesia in patients undergoing elective nonlaparoscopic surgeries of moderate duration, if placed for airway maintenance. Given the secondary observations regarding placement characteristics of the airway devices, it, however cannot be concluded that the devices are a substitute for endotracheal tube for airway maintenance per se, unless specifically indicated