Bhawna Rastogi

Palonosetron, Ondansetron, and Granisetron for antiemetic prophylaxis of postoperative nausea and vomiting - A comparative evaluation

Background: Postoperative nausea and vomiting is commonly associated with adverse consequences and hamper the postoperative recovery in spite of the availability of many antiemetic drugs and regimens for its prevention. The study was aimed to compare the prophylactic effects of intravenously administered palonosetron, ondansetron, and granisetron on prevention of postoperative nausea and vomiting after general anesthesia. Materials and Methods: This prospective, double-blind study, comprised 120 adult consented patients of ASA grade I and II of either gender, was carried out after approval of Institutional Ethical Committee. Patients were randomized into three equal groups of 40 patients each in double-blind manner. Group P received inj. palonosetron (0.075 mg), group O received inj. ondansetron (4 mg), and group G received inj. granisetron (2 mg) intravenously five minutes before induction of anesthesia. The need for rescue antiemetic, episode of postoperative nausea and vomiting, and side effects were observed for 12 hours in the post-anesthesia care unit. At the end of study, results were compiled and statistical analysis was done by using ANOVA, Chi-square test, and Kruskal Wallis Test. Value of P < 0.05 was considered significant. Results: The incidence of nausea and vomiting was maximal during the first four hours postoperatively. The complete control of postoperative nausea and vomiting for first 12 hours was achieved in 30% patients of ondansetron group, 55% patients of granisetron group, and 90% patients of palonosetron group. Safety profile was more with palonosetron. Conclusion: Palonosetron was comparatively highly effective to prevent the PONV after anesthesia due to its prolonged duration of action than ondansetron and granisetron.

Submental intubation in panfacial injuries: our experience.

Panfacial fractures present a unique set of problems to the anaesthesiologist and surgeon. Airway management in panfacial fractures is still a challenge to the anaesthesiologist as all modalities available such as orotracheal intubation, nasotracheal intubation, tracheostomy, etc., have their own advantages and disadvantages. When all the conventional modalities to secure airway seem unsuitable then submental route offers an excellent alternative to manage airway in such patients. Here we describe our experience with submental intubation technique in 10 patients with panfacial injuries over a period of two years.

Dexmedetomidine premedication for fiberoptic intubation in patients of temporomandibular joint ankylosis: A randomized clinical trial

Background: Fiberoptic intubation is the gold standard technique for difficult airway management in patients of temporomandibular joint. This study was aimed to evaluate the clinical efficacy and safety of dexmedetomidine as premedication with propofol infusion for fiberoptic intubation. Methods: Consent was obtained from 46 adult patients of temporomandibular joint ankylosis, scheduled for gap arthroplasty. They were enrolled for thisdouble-blind, randomized, prospective clinical trial with two treatment groups – Group D and Group P, of 23 patients each. Group D patients had received premedication of dexmedetomidine 1 μg/kg infused over 10 min followed by sedative propofol infusion and the control Group P patients were given only propofol infusion to achieve sedation. Condition achieved at endoscopy, intubating conditions, hemodynamic changes and postoperative events were evaluated as primary outcome. Results: The fiberoptic intubation was successful with satisfactory endoscopic and intubating condition in all patients. Dexmedetomidine premedication has provided satisfactory conditions for fiberoptic intubation and attenuated the hemodynamic response of fiberoptic intubation than the propofol group. Conclusion: Fiberoptic intubation was found to be easier with dexmedetomidine premedication along with sedative infusion of propofol with complete amnesia of the procedure, hemodynamic stability and preservation of patent airway.

Oral pregabalin premedication for attenuation of haemodynamic pressor response of airway instrumentation during general anaesthesia: A dose response study

Background: The airway instrumentation of direct laryngoscopy and tracheal intubation are powerful noxious stimuli that should be attenuated by appropriate premedication, smooth induction and rapid intubation. The present study evaluated the safe and clinically effective dose of oral pregabalin premedication for attenuation of haemodynamic pressor response of airway instrumentation. Methods: A total of 90 normotensive adult consented patients aged 24–56 years, ASA grade I and II, of both gender were randomized into three treatment groups of 30 patients each. Group I received oral placebo, Group II oral pregabalin 75 mg and Group III oral pregabalin 150 mg 1 h prior to induction. Anaesthetic technique was standardized and all groups were assessed for pre-operative sedation, haemodynamic changes after the premedication, before and after induction, after laryngoscopy and intubation, along with intraoperative haemodynamic stability and post-operative side-effects. Results: Pre-operative sedation levels were higher with pregabalin premedication. Significant increase in heart rate and mean arterial pressure was observed in Groups I and II after airway instrumentation, while statistically significant attenuation of mean arterial pressure was seen in Group III. No significant decrease in heart rate was observed in any group. None of the patient has suffered from any post-operative side-effects, and no significant differences in the parameters of recovery and awakening time were observed. Conclusion: Oral pregabalin premedication has adequately sedated the patients. The haemodynamic pressor response of airway instrumentation was attenuated in a dose-related fashion. The premedicated patients were haemodynamically stable perioperatively without prolongation of recovery time and side-effects.

Electrolyte changes: An indirect method to assess irrigation fluid absorption complications during transurethral resection of prostate: A prospective study

Context: Fluid absorption is inevitable complication of transuretheral resection of prostate and serum electrolytes changes can indirectly assess the irrigation fluid absorption. Aims: To monitor the extent of 1.5% glycineirrigation fluid absorption during transurethral resection of prostate (TURP), by measuring the changes of serum sodium and potassium levels peri-operatively. Settings and Design: This is a randomized prospective cohort observational study. Materials and Methods: The 86 male patients of ASA grades I to III in the age group of 50 to 80 years, scheduled for elective TURP surgery under central neuraxial block, were studied. Their preoperative and post-operative serum sodium, potassium and calcium levels were measured. When duration of surgery exceeds 60 min, serum sodium and potassium levels were done intra-operatively with venous blood samples by using blood gas analyser. The height of irrigation fluid column was kept constant at 60 cm. These changes were correlated with the volume of irrigating fluid used, duration of procedure and the volume of prostate gland resected. Statistical Analysis used: The values of pre and postoperative sodium, potassium and calcium serum levels were compared and statistical significance of the difference in values was assessed using Student’s paired t test. Results: Statistically significant reduction of serum sodium levels (hyponatremia) and elevation of serum potassium levels (hyperkalemia) were observed post-operatively, which was directly proportional to volume of irrigating fluid used, duration of procedure and volume of prostate gland resected. No significant changes in serum calcium level were observed. Conclusions: To measure serum electrolytes changes during TURP surgery, it is simple and economical method for indirect assessment of fluid absorption for early identification of TURP syndrome.

Epidural 0.5% levobupivacaine with dexmedetomidine versus fentanyl for vaginal hysterectomy: A prospective study

Background: Epidural adjuvants enhance the quality and duration of surgical anesthesia. The present study was aimed to compare the hemodynamic, sedative, and analgesia potentiating effects of dexmedetomidine versus fentanyl with epidural 0.5% levobupivacaine for vaginal hysterectomy. Patients and Methods: Sixty consented females of ASA physical status I and II aged 35-65 years weighing 55-75 kg, were double blindly randomized into two treatment groups. Patients received epidural 0.5% levobupivacaine 15 ml either with of 25 μg dexmedetomidine (Group LD) or 50 μg fentanyl (Group LF) and the total volume of study solution was kept 16 ml. Onset of analgesia at T10, sensory and motor block levels and duration of analgesia were observed. Intra-operatively, they were assessed for sedation, hemodynamic changes, respiratory efficiency, and side effects. The data obtained, was compiled systematically and analyzed statistically using Chi-square test and ANOVA. Value of P < 0.05 is considered significant. Result: The demographic profile was comparable between groups. The onset of sensory analgesia at T10 (7.25 ± 2.3 versus 9.27 ± 2.79 min) and time to achieve complete motor blockade (19.27 ± 4.7 versus 22.78 ± 5.57 min) was significantly earlier in patients of LD Group. The intraoperative hemodynamic changes were comparable between groups. Ramsey Sedation score was better in LD group with statistically significance. Postoperative analgesia was significantly prolonged in LD Group. Incidence of nausea, vomiting, and pruritus was high in LF group. Conclusion: Dexmedetomidine was better than fentanyl as an epidural adjuvant for providing early onset of sensory analgesia, adequate sedation with no respiratory depression and prolonged postoperative analgesia.

Efficacy of thoracic epidural anesthesia for laparoscopic cholecystectomy.

Background: Laparoscopic cholecystectomy is performed to minimize the postoperative morbidity and early return to work. This study was planned to evaluate the efficacy and feasibility of thoracic epidural anesthesia for laparoscopic cholecystectomy, so that it can be later used as anesthetic technique in patients when general anesthesia is not feasible. Materials and Methods: Forty-eight adult consented patients of ASA grade I and II of either sex scheduled for elective laparoscopic cholecystectomy were enrolled for thoracic epidural anesthesia with 15 ml of 0.75% ropivacaine and 50 μg fentanyl. Intraoperative hemodynamic parameters and respiratory efficiency were recorded. Intra-operatively patient anxiety, pain, vomiting, hypotension or any other adverse event was managed with appropriate drug regime. Postoperative pain management with epidural analgesia, and bowel recovery were also recorded. Results: The thoracic epidural anesthesia was effective for laparoscopic cholecystectomy in all except in two patients where conversion to general anesthesia was required. The hemodynamic parameters and respiratory efficiency were maintained within physiological limits. Only 4 patients required treatment for hypotension with vasopressor and 15 patients experienced shoulder pain, which was effectively managed with small doses of ketamine. The midazolam was required only in 11 patients for anxiety. The mean surgical time was 56.8±51.6 min. The 24-hour postoperative epidural infusion for analgesia was effective with limited effects on bowel and bladder function. Postoperatively only 3 patients had an episode of vomiting. There was good surgeon and patients satisfaction. Conclusions: The thoracic epidural anesthesia with 0.75% ropivacaine and fentanyl for elective laparoscopic cholecystectomy is efficacious and has preserved ventilation and hemodynamic changes within physiological limits during pneumoperitoneum with minimal treatable side effects.

Premedication with clonidine versus fentanyl for intraoperative hemodynamic stability and recovery outcome during laparoscopic cholecystectomy under general anesthesia

Background: Laparoscopic cholecystectomy under general anesthesia induced intraoperative hemodynamic responses which should be attenuated by appropriate premedication. The present study was aimed to compare the clinical efficacy of clonidine and fentanyl premedication during laparoscopic cholecystectomy for attenuation of hemodynamic responses with postoperative recovery outcome. Subjects and Methods: In this prospective randomized double blind study 64 adult consented patients of either sex with ASA I and II, scheduled for elective laparoscopic cholecystectomy under general anesthesia and met the inclusion criteria, were allocated into two groups of 32 patients. Group C patients have received intravenous clonidine 1μg kg-1 and Group F patients have received intravenous fentanyl 2μg kg-1 5 min before induction. Anesthetic and surgical techniques were standardized. All patients were assessed for intraoperative hemodynamic changes at specific time and postoperative recovery outcome. Results: Premedication with clonidine or fentanyl has attenuated the hemodynamic responses of laryngoscopy and laparoscopy. Clonidine was superior to fentanyl for intraoperative hemodynamic stability. No significant differences in the postoperative recovery outcome were observed between the groups. Nausea, vomiting, shivering and respiratory depression were comparable between groups. Conclusion: Premedication with clonidine or fentanyl has effectively attenuated the intraoperative hemodynamic responses of laparoscopic cholecystectomy.

Hemiarthroplasty in high risk elderly patient under epidural anesthesia with 0.75% ropivacaine-fentanyl versus 0.5% bupivacaine-fentanyl: Clinical trial.

Background: Anesthetic management of elderly patients is a challenge as aging makes them more susceptible to hemodynamic fluctuations during regional anesthesia. This study was aimed to compare the clinical efficacy of epidural 0.75% ropivacaine fentanyl (RF)– with 0.5% bupivacaine–fentanyl (BF) for hemiarthroplasty in high-risk elderly patients. Methods: Sixty elderly consented patients of either sex with American Society of Anesthesiologist ASA II and III, scheduled for elective hemiarthroplasty were randomized into two Groups of 30 patients to receive epidural study solution of 15 mL of 0.75% Ropivacaine or 0.5% Bupivacaine with 1 mL fentanyl (50 μg). The hemodynamic variability with onset and duration of sensory and motor blocks were recorded. The adequacy and quality of surgical anesthesia were assessed. The post-epidural nausea and vomiting, shivering, respiratory parameters, or any other side effects were also recorded. Results: There was no difference in the demographic profile between groups. The mean onset time to achieve sensory block to the T10 dermatome was rapid in the Group BF (12.4±6.9 vs. 17.5±3.7 min in Group RF). The mean time to achieve motor block was 17.5±3.4 min in Group BF versus 21.7±7.8 min in Group RF. The intraoperative hemodynamic fluctuations showed statistically significant differences between groups. The pruritis was observed in five patients but post-epidural shivering, nausea, vomiting, respiratory depression, or urinary retention were not observed in any patient. Conclusion: Epidural 0.75% Ropivacaine with fentanyl showed better clinical profile as compared to 0.5% Bupivacaine with fentanyl for hemiarthroplasty in elderly patients.

Blood glucose estimation as an indirect assessment of modulation of neuroendocrine stress response by dexmedetomidine versus fentanyl premedication during laparoscopic cholecystectomy: A clinical study.

Background: Anesthesia and surgery-induced neuroendocrine stress response can be modulated by appropriate premedication. The present study was designed to assess the clinical efficacy of dexmedetomidine versus fentanyl premedication for modulation of neuroendocrine stress response by analyzing the perioperative variation of blood glucose level during laparoscopic cholecystectomy under general anesthesia. Subjects and Methods: In a prospective randomized double-blind study, 60 adult consented patients of either sex with ASA I and II, scheduled for elective laparoscopic cholecystectomy under general anesthesia and meeting the inclusion criteria, were allocated into two groups. Group D patients (n = 30) were given intravenous dexmedetomidine 1μg/kg and Group F patients (n = 30) received fentanyl 2 μg/kg, given over a 10-min period, before induction of anesthesia. Perioperative blood glucose levels were analyzed preoperatively, at 30 min after beginning of surgery, and 2.5 h after surgery. Anesthetic and surgical techniques were standardized. All patients were also assessed for intraoperative hemodynamic changes of heart rate and mean arterial pressure at specific timings. Results: Blood glucose concentration has shown 20% increase after surgery. The differences between groups were not statistically significant as observed by analyzing the variation of serial perioperative blood glucose estimation. Both premedicants had attenuated the hemodynamic and neuroendocrine stress response of pneumoperitoneum and general anesthesia. The dexmedetomidine group showed more stabilization of intraoperative hemodynamics of mean arterial blood pressure and heart rate when compared to fentanyl group. Conclusion: During the laparoscopic cholecystectomy, dexmedetomidine and fentanyl, both premedicants have effectively modulated the neuroendocrine stress response of general anesthesia as assessed by analysis of perioperative blood glucose variation, but dexmedetomidine was better.