Dilip Shende

Prophylactic ondansetron in prevention of postoperative nausea and vomiting following pediatric strabismus surgery: a dose-response study.

Background: This study evaluated the antiemetic effectiveness, dose–response, and clinical usefulness of prophylactic ondansetron in the prevention of postoperative nausea and vomiting (PONV) in children undergoing strabismus repair. Method: The authors observed 180 children, American Society of Anesthesiologists physical status I or II, 2–12 yr of age, who were undergoing strabismus repair. After induction of anesthesia with halothane and nitrous oxide in oxygen or intravenous thiopental, children received either placebo (saline) or intravenous ondansetron in doses of 25, 50, 75, 100, and 150 &mgr;g/kg (n = 30). The trachea was intubated and ventilation was controlled. Perioperative analgesic and fluid requirements were standardized. Episodes of nausea and vomiting were recorded for the first 24 h postoperatively. Data such as nonsurrogate (parental satisfaction scores and duration of postanesthesia care unit stay) and therapeutic (numbers needed to prevent and harm) outcome measures were collected. Results: The incidences of PONV in the placebo and 25-, 50-, 75-, 100-, and 150-&mgr;g/kg ondansetron groups were 83, 77, 47, 30, 30, and 27%, respectively. The incidence was less in the 75- (P = 0.002), 100- (P = 0.002), and 150-&mgr;g/kg (P < 0.001) ondansetron groups compared with placebo. Duration of stay in the postanesthesia care unit was shorter in the 75-, 100-, and 150-&mgr;g/kg ondansetron groups (P < 0.002) compared with the placebo group. Parental assessment scores for the child’s perioperative experience and the positive number needed to prevent PONV were also better and favorable in the 75-, 100-, and 150-&mgr;g/kg ondansetron groups compared with the placebo group. The incidence (P > 0.99) and severity (P = 0.63) of PONV were similar in the 75- and 150-&mgr;g/kg ondansetron groups. Surrogate, nonsurrogate, and therapeutic outcome measures revealed that 75 &mgr;g/kg ondansetron provided the same benefits as did 100 and 150 &mgr;g/kg. Conclusion: The routine prophylactic use of ondansetron at a dose of 75 &mgr;g/kg is as effective as 150 &mgr;g/kg in preventing PONV and improving the “true” outcome measures after strabismus repair in children.

A dose response study of clonidine with local anesthetic mixture for peribulbar block: a comparison of three doses.

Clonidine prolongs anesthesia and analgesia of local anesthetics in various neural blocks as well as the duration of retrobulbar block. We assessed the dose-response relationship of clonidine added to lidocaine in peribulbar block. Sixty patients undergoing cataract surgery were given peribulbar block with 7 mL of 2% lidocaine and hyaluronidase with either saline (Control) or clonidine in 0.5-&mgr;g/kg (0.5 Clon), 1.0-&mgr;g/kg (1.0 Clon), or 1.5-&mgr;g/kg (1.5 Clon) doses. The onset and duration of lid and globe akinesia, globe anesthesia and analgesia, postoperative analgesic requirement, and adverse effects (hypotension, bradycardia, hypoxia, sedation, and dizziness) were recorded. The success rate and onset of block were comparable in all groups. The duration of lid and globe akinesia, globe anesthesia and analgesia was significantly (P < 0.01) prolonged in patients receiving 1.0 and 1.5 &mgr;g/kg clonidine as compared with the Control group. Perioperative pain scores and analgesic requirement were significantly less in these groups. 0.5 &mgr;g/kg clonidine did not increase the duration of anesthesia and analgesia significantly. Hypotension and dizziness were observed more in patients receiving 1.5 &mgr;g/kg clonidine as compared with other groups. We conclude that 1.0 &mgr;g/kg clonidine with a mixture of lidocaine (2%) significantly prolonged the duration of anesthesia and analgesia after peribulbar block with limited side effects.

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery.

Methods: Fifty children (age 5–14 years, ASA I–II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique.

Internal jugular vein cannulation: A comparison of three techniques

Context: Ultrasound-guided internal jugular vein (IJV) cannulation is known for increasing success rate and decreasing rate of complications. The ultrasound image can be used as a real time image during cannulation or to prelocate the IJV before attempting cannulation. Aims: This study compares both the ultrasound-guided technique with the classical anatomical landmark technique (central approach) for right IJV cannulation in terms of success rate, complications, and time for cannulation. Settings and Design: A prospective, randomized, observational study was conducted at a tertiary care hospital. Material and Methods: One hundred twenty patients requiring IJV cannulation were included in this study and were randomly allocated in three groups. Number of attempts, success rate, venous access time, catheterization time, and complications were observed in each group. Statistical Analysis Used: Statistical analysis was performed using STATA-9 software. Demographic data were compared using one-way analysis of variance (ANOVA). Nonparametric data were compared using the Kruskall–Wallis test, and multiple comparisons were done applying The Mann–Whitney test for individual pairs of groups. Nominal data were compared by applying the Chi-square test and Fisher exact test. Results: Successful cannulation (≤3 attempt) was achieved in 90.83% of patients without any statistical significant difference between the groups. Venous access time and catheterization time was found to be significantly less in both the ultrasound groups than the anatomical land mark group. Number of attempts and success in first attempt was similar between the groups. Conclusions: Both the ultrasound techniques are found to be better than the anatomical landmark technique. Further, ultrasound-guided prelocation was found to be as effective as ultrasound guided real-time imaging technique for right IJV cannulation.

Comparison of anti-emetic effects of ondansetron and low-dose droperidol in pediatric strabismus surgery.

BACKGROUND AND OBJECTIVE Strabismus surgery is associated with a high incidence of postoperative nausea and vomiting. A dose of 150 microg/kg(-1) of ondansetron has been found to be effective in reducing nausea and vomiting in pediatric patients. However, droperidol (20 to 75 microg/kg(-1)) has shown variable success with various side effects. This randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the efficacy and safety of 25 microg/kg(-1) of droperidol and compare it with that of 150 microg/kg(-1) of ondansetron in pediatric strabismus surgery. PATIENTS AND METHODS After institutional approval and parental informed consent, 120 children aged 1 to 15 years were prospectively randomized into one of three groups. Group 1 received normal saline (placebo), group 2 received 25 microg/kg(-1) of droperidol, and group 3 received 150 microg/kg(-1) of ondansetron after induction of anesthesia. Children were assessed postoperatively for the incidence and severity of vomiting, recovery from anesthesia, and analgesic requirement for 24 hours. RESULTS There was a significant (P < .05) reduction in the incidence of postoperative nausea and vomiting in the ondansetron (37.5%) and droperidol (30%) groups compared with the placebo (62.5%) group. The vomiting was also significantly less severe in these groups. CONCLUSION Doses of 25 microg/kg(-1) of droperidol and 150 microg/kg(-1) of ondansetron administered at induction of anesthesia are equally effective in reducing the incidence and severity of postoperative nausea and vomiting in children undergoing strabismus surgery.

Effect of addition of various doses of fentanyl intrathecally to 0.5% hyperbaric bupivacaine on perioperative analgesia and subarachnoid-block characteristics in lower abdominal surgery: a dose-response study.

Background: The purpose of this randomized, double-blind, placebo-controlled trial is to study the effect of adding various doses of fentanyl to 2.2 mL of bupivacaine (0.5% hyperbaric), for spinal anesthetic in nonobstetric population undergoing superficial lower abdominal surgery (hernia repair). Methods: A population of 60 patients belonging to ASA classes I and II, scheduled for elective inguinal hernia repair, were randomized to receive a spinal anesthetic with 2.2 mL of bupivacaine (0.5% hyperbaric) and saline (control group), or fentanyl 10, 20, 30, or 40 &mgr;g. The volume of injected drug was kept constant at 3 mL by adding preservative-free saline for blinding purposes. Subarachnoid block characteristics, drug-related side effects, and postoperative analgesia requirements were assessed and recorded. Results: Significant improvement in quality and duration of analgesia ocurred in treatment groups (receiving fentanyl and bupivacaine) compared with the control group (saline and bupivacaine) (P < .05). However, no improvement in analgesia occurred when the dose of fentanyl added was increased from 10 to 20, 30, or 40 &mgr;g. Conclusions: The data suggest that in a nonobstetric population receiving spinal anesthetic for superficial lower abdominal surgery (hernia repair), addition of 10 &mgr;g fentanyl to bupivacaine 0.5% (hyperbaric) significantly improves the quality and duration of analgesia. No further advantage occurs if the dose of fentanyl is increased up to 40 &mgr;g.

Successful anesthetic management of a child with blepharophimosis syndrome and atrial septal defect for reconstructive ocular surgery.

Blepharophimosis syndrome is an autosomal dominant disorder characterized by eyelid malformation, involvement of reproductive system and abnormal facial morphology leading to difficult airway. We report a rare association of blepharophimosis syndrome and atrial septal defect in a 10-year-old girl who came for reconstruction surgery of eyelid. The child had dyspnea on exertion. Atrial septal defect was identified preoperatively by clinical examination and echocardiography. Anesthesia management was complicated by failure in laryngeal mask airway placement and Cobra perilaryngeal airway was subsequently used.

Comparison of propofol (1%) with admixture (1:1) of thiopentone (1.25%) and propofol (0.5%) for laryngeal mask airway insertion in children undergoing elective eye surgery: Double-masked randomized clinical trial.

Intravenous propofol 1% has been the preferred agent for Laryngeal Mask Airway (LMA) insertion. Admixture of thiopentone 1.25% and propofol 0.5% (1:1) has been used by various authors for induction as well as insertion of LMA in adults. There is no previous report where this admixture has been used for insertion of LMA in children. This study has been designed to investigate whether this admixture can be a suitable alternative to propofol, in relation to ease of insertion of the LMA, haemodynamic stability, cost containment, pain on injection and recovery in children. In this randomized, double-masked study, 50 ASA grade 1 and 2 patients of age 3 – 15 years and weighing more than 10 kg were included. The patients were divided into two groups; the P group received propofol 1%, while the Ad group received an admixture of thiopentone 1.25% and propofol 0.5% (1:1). All the children were evaluated for incidence of apnoea, pain on injection, jaw relaxation, ease of LMA insertion, coughing, gagging, laryngospasm, involuntary limb movements, incidence of hypotension and recovery. The demographic data, incidence of apnoea, pain on injection, jaw relaxation, ease of LMA insertion, coughing, gagging and involuntary movements were comparable in both groups. In the P group recovery was faster as compared to the Ad group. The admixture was cost effective as compared to Propofol alone [Indian National Rupees (INR) 24.64 ± 7.62 vs. INR 48.75 ± 23.25] (P = 0.001)). Admixture of propofol and thiopentone was a cheap, safe and effective alternative to propofol alone, for LMA insertion in children.

Granisetron versus Granisetron-Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Randomized Double-Blind Trial

Aim. Efficacy of granisetron and combination of granisetron and dexamethasone was evaluated for prevention of postoperative nausea and vomiting (PONV) in children undergoing elective strabismus surgery. Methods. A total of 136 children (1–15 years) were included. Children received either granisetron (40 mcg/kg) [group G] or combination of granisetron (40 mcg/kg) and dexamethasone (150 mcg/kg) [group GD]. Intraoperative fentanyl requirement and incidence and severity of oculocardiac reflex were assessed. PONV severity was assessed for first 24 hours and if score was >2, it was treated with metoclopramide. Postoperative analgesia was administered with intravenous fentanyl and ibuprofen. Results. The demographic profile, muscles operated, and fentanyl requirement were comparable. Complete response to PONV in first 24 hours was observed in 75% (51/68) of children in group G and 76.9% (50/65) of children in group GD, which was comparable statistically (p = 0.96, Fisher exact test; OR 1.11, 95% CI 0.50, 2.46). Incidence of PONV between 0 and 24 hours was comparable. One child in group G required rescue antiemetic in first 24 hours and none of the children had severe PONV in group GD. There was no significant difference in incidence or severity of oculocardiac reflex. Conclusion. Dexamethasone did not increase efficacy of granisetron for prevention of PONV in elective pediatric strabismus surgery. Registration number of clinical trial was CTRI/2009/091/001000.

Anesthetic management of thoracic type of complete ectopia cordis

internal fixation of fracture dislocation of right ankle. Preoperative evaluation revealed a 9-year-old female weighing 25 kg. She and her younger sibling had been diagnosed with Riley-Day syndrome. She was a full term, spontaneous vaginal delivery born to consanguineous parents. Physical examination revealed lack of response to painful stimuli, diminished temperature perception with normal touch and vibration-sensation and diminished deep-tendon reflexes. The patient had Trendelenburg’s gait and shortening of right lower limb along with scoliosis. Oral cavity revealed bifid tongue and absence of most of teeth. She had undergone general anesthesia once in the past for osteotomy of right elbow with no complications and drug allergy. After detailed discussion and obtaining consent from parents, management by spinal anesthesia was chosen. The patient was premedicated with oral midazolam and ranitidine. Preloading with Ringer’s lactate solution was commenced prior to setting-up of the block. A 27 G Quencke’s needle was inserted at L3–4 interspace and spinal block of T10 was established by injecting 7.5 mg of hyperbaric Bupivacaine with 10 mcg of fentanyl. Her preanesthetic blood pressure was 110 ⁄ 70 mmHg with heart rate of 92 bpm. Surgery lasted for 75 min and was monitored with pulse oximeter, ECG, NIBP and peripheral temperature. Intraoperative period was uneventful with systolic BP between 90 and 100 mmHg and heart rate 70–90 bpm with exception to mild hypothermia. She had an uneventful course in the PACU with no complaints of postoperative pain and child discharged on the 10th day. A literature review was carried out prior to anesthesia to provide guidance on potential anesthetic implications especially with regard to autonomic dysfunction. Children with this condition present for a variety of surgical procedures mainly for fundoplication and gastrostomy (4). Despite the apparent insensitivity to pain it is essential to provide adequate anesthesia to reduce surgical stress and dysautonomic events. In most of the cases general anesthetic techniques have been used with varying degrees of success and morbidity (4). Severe hypotension and tachycardia was frequently seen in patients with FD under general anesthesia which was treated by frequent fluid infusions (2). It was concluded that extra attention must be given to intravascular volume status and there was a frequent requirement for prolonged ventilatory support after abdominal surgery or other situations where narcotics are needed to control pain. Epidural anesthesia (3) contributed to the cardiovascular and autonomic stability in three children who required a revision of their anti-reflux procedure. Furthermore, the postoperative pain management was substantially better and respiratory complications were fewer. These children had previously received an opiate-based general anesthetic for the initial surgical procedures that were remarkable for their hemodynamic instability, poor pain control and respiratory complications. In this case as the surgery was on lower limb, we administered spinal anesthesia, weighing risks and benefits. A preloading with crystalloids and low-dose bupivacaine–opioid combination was chosen for the subarachnoid block to ensure a low level of block and to avoid hemodynamic instability. Intraoperative management was directed toward maintaining cardiovascular and temperature stability and prevention of pulmonary aspiration. To conclude, in this case spinal anesthesia is well tolerated with cardiovascular stability and superior intraand postoperative analgesia without episodes of dysautonomic crises and may be indicated for appropriate surgical procedures in patients with Riley-Day syndrome. Better understanding of various manifestations of this rare disorder, close and continuous cardiorespiratory monitoring in the perioperative period is essential for a safe outcome. Nazeer Ahmed K. Mrudula M. Watve Minhaj Ahmed Department of Anesthesiology and Critical Care, Al Ameen Medical College Hospital, Bijapur – 586108, India (email: nazeer8@yahoo.co.in)