Gaurav Jain

Effect of the perioperative infusion of dexmedetomidine on chronic pain after breast surgery.

Background: This prospective double-blind trial was undertaken to analyze the role of perioperatively administered dexmedetomidine on the occurrence of chronic pain in cases undergoing surgery for breast cancer. Subjects and Methods: Eighty-six cases were randomly assigned to two groups to receive either dexmedetomidine (2 μg/ml) in group D or saline in group C, in a loading dose of 0.5 ml/kg, intravenous (IV), 30 min prior to induction, followed by a continuous infusion of 0.25 ml/kg/h IV till the completion of surgery, and then the dose tapered to 0.1 ml/kg/h for up to 24 h. The standardized questionnaires that measured chronic pain (Brief Pain Inventory, BPI; Short Form McGill Pain Questionnaire, SF-MPQ2) and quality of life (Quality of Life Scale, QOLS) were gathered after 3 months of surgery as a primary outcome. Pain (verbal numerical score, VNS), sedation scores (Ramsay scoring), and analgesic requirements were also assessed for 72 h postoperatively. Results: In total, 84 cases (n=42) were analyzed for acute pain and 69 (34 in group D and 35 in group C) for chronic pain. The consumption of isoflurane/fentanyl intra-operatively and paracetamol postoperatively was significantly lower in Group D. The sedation scores were non-significant between the groups. The VNS at rest and after movement was significantly lower in group D at corresponding times (except at 60 min) throughout the assessment period. The BPI and SF-MPQ2 scores were significantly lower in group D in most of the factors. The QOLS score was significantly better in group D in all items except for relationships, friends, and learning. Conclusion: The perioperative infusion of dexmedetomidine has a pivotal role in attenuating the incidence and severity of chronic pain and improving the quality of life in cases undergoing breast cancer surgery.

Comparison of phenylephrine and norepinephrine in the management of dopamine-resistant septic shock.

Introduction: This study aims to compare two vasoconstrictors: – norepinephrine and phenylephrine – in the management of dopamine–resistant septic shock. Materials and Methods: We performed a randomized, prospective, controlled trial in 54 septic shock patients, with persistent hypotension despite adequate volume resuscitation and continued dopamine infusion ~25μg/kg/h. Patients were randomly allocated into two groups to receive either norepinephrine or phenylephrine infusion (n = 27 each) titrated to achieve a target of SBP > 90mm Hg, MAP > 75 mm Hg, SVRI > 1100 dynes.s/cm5m2, CI > 2.8 L/min/m2, DO2I > 550 ml/min/m2, and VO2I > 150 ml/min/m2 for continuous 6 h. All the parameters were recorded every 30 min and increment in dose of studied drug was done in the specified dose range if targets were not achieved. Data from pulmonary arterial and hepatic vein catheterization, thermodilution catheter, blood gas analysis, blood lactate levels, invasive blood pressure, and oxygen transport variables were compared with baseline values after achieving the targets of therapy. Differences within and between groups were analyzed using a one-way analysis of variance test and Fischers exact test. Results: No difference was observed in any of the investigated parameters except for statistically significant reduction of heart rate (HR) (P<0.001) and increase in stroke volume index (SVI) (P<0.001) in phenylephrine group as compared to nonsignificant change in norepinephrine group. Conclusions: Phenylephrine infusion is comparable to norepinephrine in reversing hemodynamic and metabolic abnormalities of sepsis patients, with an additional benefit of decrease in HR and improvement in SVI.

A prospective, randomized, double blind and placebo-control study comparing the additive effect of oral midazolam and clonidine for postoperative nausea and vomiting prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystecomy

Background: Reduction of postoperative nausea and vomiting (PONV) continues to be a major challenge in perioperative care in spite of introduction of newer antiemetics with better efficacy and safety profiles. Therefore, we evaluated the additive effect of oral midazolam and clonidine for PONV prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystectomy. Materials and Methods: In a prospective, randomized fashion, 120 selected cases were randomized into three groups: I, II or III to receive a tablet of midazolam (15 mg, n = 36), clonidine (150 mcg, n = 40), or glucose as placebo (5 g, n = 44) orally, 1 h before anesthesia. Occurrence of PONV along with need for rescue antiemetic during the first postoperative day was compared between groups as a primary outcome. Results: Episodes of PONV reduced significantly in Group II (15%) as compared to group I and III (22.2%, 59%) at various time points during the period of observation (P = 0.002). Need for rescue antiemetic was significantly lower in group I (13.88%) and II (5%) as compared to group III (52.27%, P < 0.001). Conclusion: Oral clonidine is better adjuvant for PONV prophylaxis, as compared to midazolam, in granisetron premedicated patients undergoing laparoscopic cholecystectomy.

Improving neurological outcome after cardiac arrest: Therapeutic hypothermia the best treatment.

Cardiac arrest, irrespective of its etiology, has a high mortality. This event is often associated with brain anoxia which frequently causes severe neurological damage and persistent vegetative state. Only one out of every six patients survives to discharge following in-hospital cardiac arrest, whereas only 2-9% of patients who experience out of hospital cardiac arrest survive to go home. Functional outcomes of survival are variable, but poor quality survival is common, with only 3-7% able to return to their previous level of functioning. Therapeutic hypothermia is an important tool for the treatment of post-anoxic coma after cardiopulmonary resuscitation. It has been shown to reduce mortality and has improved neurological outcomes after cardiac arrest. Nevertheless, hypothermia is underused in critical care units. This manuscript aims to review the mechanism of hypothermia in cardiac arrest survivors and to propose a simple protocol, feasible to be implemented in any critical care unit.

Comparison of three different formulations of local anaesthetics for cervical epidural anaesthesia during thyroid surgery

Background: To compare the efficacy and safety of local anaesthetics under cervical epidural anaesthesia (CEA) using lignocaine (1%), bupivacaine (0.25%) and ropivacaine (0.5%) for thyroid surgery. Methods: In a prospective, randomized fashion, 81 patients were selected for thyroid surgery under CEA. They were assigned to one of three groups: Group L, B and R to receive 10 mL of 1% lignocaine, 0.25% bupivacaine and 0.5% ropivacaine, respectively. We compared their efficacy in terms of pulmonary and haemodynamic parameters, blockade quality and complications. Results: Of the total, 74 patients completed the study successfully. Sensory block attained the median dermatomal range of C2-T4/T5 in all the groups. Motor block was more pronounced in the ropivacaine group. Cardiorespiratory parameters decreased significantly in all the groups; however, none of the patients had any major complications except for bradycardia in two patients. Among the measured variables, the decrease in heart rate and peak expiratory force was more in the lignocaine group while forced vital capacity and forced expiratory volume at 1 sec declined to a greater extent in the ropivacaine group. The lignocaine group required significantly more epidural top-ups compared with the other two groups. Conclusion: We conclude that cervical epidural route can be safely used for surgery on thyroid gland in patients with normal cardiorespiratory reserve, using either of local anaesthetics chosen for our study. Under the selected dose and concentrations, the decrease in cardiorespiratory parameters was lesser with bupivacaine.

Comparison of two different doses of intrathecal dexmedetomidine as adjuvant with isobaric ropivacaine in lower abdominal surgery

Background: To augment the subarachnoid block utility, the efficacy of newer molecules as an adjuvant is investigated constantly. Considering the favorable profile of dexmedetomidine, it could have a potential role as an adjuvant to ropivacaine. Aim: We evaluated the efficacy of two different doses of dexmedetomidine as an adjuvant to isobaric ropivacaine, intrathecally. Methods: Ninety patients scheduled for lower abdominal surgery under spinal anesthesia were randomized into three groups to receive 2.5 ml of isobaric ropivacaine (0.75%, 7.5 mg/ml) added to 5 µg (10 µg/ml) or 10 µg (20 µg/ml) of dexmedetomidine or 0.5 ml of normal saline in group A, B or C, respectively. Block characteristics were compared as a primary outcome. Statistical Analysis: One-way analysis of variance test, Fishers exact test/Chi-square test, whichever appropriate. A P < 0.05 was considered significant. Results: Time to achieve desired block was least in group B and maximum in group C. The sensory-motor blockade remained significantly prolonged in group B compared to other groups. Hemodynamic parameters remained stable in all three groups. Conclusion: Among the investigated doses, dexmedetomidine augments the efficacy of intrathecal ropivacaine in a dose-dependent manner, without any untoward side effects.

Anaesthetic challenges in a patient presenting with huge neck teratoma

Paediatric airway management is a great challenge even for an experienced anaesthesiologist. Difficult airway in huge cervical teratoma further exaggerates the complexity. This case report is intended at describing the intubation difficulties that were confronted during the airway management of a three year old girl presenting with huge neck teratoma and respiratory distress. This patient was successfully intubated with uncuffed endotracheal tubes in second attempt under inhalational anaesthesia with halothane and spontaneous ventilation. This case exemplifies the importance of careful preoperative workup of an anticipated difficult airway in paediatric patients with neck swelling to minimize any perioperative complications.

Comparison of colloid preload versus coload under low dose spinal anesthesia for cesarean delivery

Background: Although fluid bolus is considered as a conventional prophylactic measure to prevent spinal-induced hypotension; vasopressors are nevertheless required. Low dose spinal anesthetics could markedly reduce such episodes of hypotension, by minimizing sympathetic blockade. Aims: We chose to compare the relative efficacy of colloid preload versus coload under low dose spinal anesthesia, for elective cesarean delivery. Settings and Design: A prospective, randomized, double-blinded study. Materials and Methods: In total, 42 parturients were randomized to receive a preload (Group P) of hydroxyl ethyl starch (10 ml/kg) over 20 min before initiation of low dose spinal anesthesia (hyperbaric bupivacaine 5.5 mg with fentanyl 25 μg) or coload (Group C) of an identical fluid over 5 min, starting at the time of identification of cerebrospinal fluid. Our primary outcome included hemodynamic parameters and the incidence of hypotension. The neonatal outcome and side-effects were also monitored. Statistical Analysis: Mann-Whitney U test and Fishers exact/Chi-square test, whichever appropriate. A P < 0.05 was considered to be significant. Results: The incidence of hypotension was lower in Group P (10%) when compared with Group C (25%), though insignificant statistically. The hemodynamic parameters were better in Group P, though intergroup statistical differences were not observed. The time to the first episode of hypotension was longer in the Group P (17 min) as compared with Group C (14 min). No notable side-effects or adverse neonatal outcome was noted. Conclusion: Colloid preload has a clinical advantage over the coload strategy, in reducing hypotensive episodes under low dose spinal anesthesia. Preload is better under large hemodynamic fluctuations while coload is preferable for emergency scenarios.

A modification in the tube guide to facilitate retrograde intubation: A prospective, randomised trial.

Background: The technique of anterograde over a retrograde guide is considered to be more reliable and preferable in comparison to only retrograde one, for improving the success rate of retrograde intubation. As the prior technique requires a lengthy guidewire to negotiate the whole channel of a tube guide, we designed a side eye at one end of tube guide, which obviated the above requirement while maintaining the integrity of the whole channel assembly. The efficacy of this modified technique was compared with the conventional one for retrograde intubation procedure. Methods: In a prospective, randomised fashion, 98 cases posted for surgery of carcinoma buccal mucosa were included in this trial. These cases were randomised to the conventional (Group I) or the modified technique (Group II) for retrograde intubation. Intubation time (first attempt), total number of successful intubations, cause of failures and any associated side effects were recorded and compared between the groups. Results: The total number of successful intubations were significantly higher in group II (95.83%, 46/48 cases) as compared to group I (66.66%, 31/48 cases) (P<0.001). Mean intubation time was 118±22 second in group I versus 124±26 second in group II (P=0.39). The side effects did not differ significantly between the groups. Conclusions: Improvising the tube guide resulted in a significant rise in the number of successful intubations through a modified retrograde intubation technique, with no side effects. This should encourage the use of retrograde intubation technique as a first option for difficult airway management.

Efficacy of ultrasound-guided mandibular block in predicting safer anesthetic induction

Background: Mandibular nerve block reverses the trismus caused by pain and muscle spasm, thereby allowing for selection of a safer intubation technique. Aims: As ultrasonographic imaging has added newer dimensions to clinical anesthesia practice, we utilized this tool in performing mandibular nerve block and evaluated its efficacy in segregating trismus patients on etiological basis, to predict safer anesthetic induction. Settings and Design: Prospective, randomized controlled, outcome assessor blinded trial. Materials and Methods: Sixty-eight patients with unilateral mandibular fracture, acute pain, and trismus were randomized to receive mandibular nerve block by Vazirani-Akinosi approach (Group V) or the ultrasound-guided (USG) technique (Group U) before the general anesthetic induction for corrective surgery. Visual Analog Scale (VAS) score and inter-incisor distance was measured at intervals. Primary outcome measure was blocked failure (continued pain [VAS > 30] after the block procedure). Statistical Analysis Used: Mann–Whitney U-test and Wilcoxon signed rank test. Results: There was a significant decrease in pain score following the block procedure, except for six patients (block failure) in Group V. Inter-incisor distance increased to near-maximal levels after the nerve blockade, except for nine patients in Group V (including all block failures) and four in Group U having continued limited mouth opening. General anesthetic induction increased the inter-incisor gap in block failures (Group V) only. Conclusion: USG mandibular block appears to relieve reversible trismus more reliably, thereby allowing for a precise decision on a safer intubation technique.