Geetanjali Chilkoti

Technological advances in perioperative monitoring: Current concepts and clinical perspectives

Minimal mandatory monitoring in the perioperative period recommended by Association of Anesthetists of Great Britain and Ireland and American Society of Anesthesiologists are universally acknowledged and has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, transesophageal echocardiography, advanced neurological monitoring, improved alarm system and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, knowledge of technical principle and ability of the convenient routine handling. In this review, we will discuss the new monitoring techniques in anesthesia, their advantages, deficiencies, limitations, their comparison to the conventional methods and their effect on patient outcome, if any.

Current clinical opinions, attitudes and awareness of interns regarding post-operative and cancer pain management in a tertiary care centre

AIM This prospective study was aimed to assess the opinion, awareness and attitude of interns regarding pain assessment, pain management and common barriers in effective pain therapy for patients experiencing pain. MATERIALS AND METHODS A questionnaire including demographic details, knowledge of the tools of pain assessment, choice of drugs used, side effects, lacunae in existing knowledge and barriers in pain management was designed. A total of 160 interns were approached, out of which 149 returned the completed questionnaire. Only a few of them had a chance exposure to cancer pain management but none of them had undergone any formal training, teaching or classes in this field. RESULTS Most respondents knew that the pain can be measured and the ways to do it. A significant number considered morphine as the preferred drug for managing cancer pain and thought morphine is responsible for addiction and respiratory depression. About 72% interns knew about transdermal preparation of fentanyl and its usage in malignancy but only a few were aware of buprenorphine transdermal patch. Though they were enthusiastic about relieving the cancer patients from suffering, they had limited knowledge of how to achieve this. The common barriers identified by them were lack of adequate knowledge and training and limited availability of opioids. CONCLUSIONS The results of this study emphasize the need of special training programs pain management in order to change the current prevailing situation and improve the quality of analgesia provided to the patients.

Anaesthetic concerns of a pregnant patient with Pott's spine for spine surgery in prone position

Sir, Surgical decompression is the treatment of choice in pregnancy complicated by spinal tuberculosis with neurologic deficit.[1] We report the anaesthetic management of a pregnant patient with Potts spine in prone position and discuss the various anaesthetic concerns including haemodynamic instability. A 23-year-old multipara, 17 weeks of gestation, weighing 52 kg, with Potts spine involving T7–T10 segments with progressive neurological deficit was scheduled for decompression and posterior screw fixation. Obstetricians opinion was sought. Preoperative foetal heart rate (FHR) was documented. Anti-aspiration prophylaxis was administered. Her baseline HR was 112/min and blood pressure (BP) was 132/82 mmHg. Invasive arterial BP monitoring could not be done due to the logistic problems. General anaesthesia was induced with propofol and morphine. Endotracheal intubation was facilitated using vecuronium with size 7.0 orotracheal cuffed tube. Injection glycopyrrolate 0.2 mg was administered as anti-sialagogue. Anaesthesia was maintained with isoflurane in 50% nitrous oxide and oxygen mixture. Soon following positioning, patient developed hypotension i.e., more than 20% fall from the baseline systolic BP (SBP). Fluid replacement and pressure-free abdomen were rechecked but the SBP continued to remain between 90 and 100 mmHg. Initially, hydrocortisone 100 mg was administered intravenously. The oozing from the surgical site resolved following injection tranexamic acid 500 mg. Surgery lasted for 5 h but BP persisted in the same aforementioned range. Blood loss was 1000 ml approximately. Haemodynamics and FHR remained stable post-operatively. The anaesthetic concerns related to spine surgery in pregnant patient include both obstetric and surgery-related i.e., prolonged surgery in prone position, major blood loss, relative hypotension and risk of postoperative visual loss.[2] The risk of radiation is of paramount concern due to the inability to use abdominal shield and the proximity of radiation to the foetus. The additional problem with prone position here includes the inability to perform emergent caesarean section. Technical problems may limit the usefulness of continuous FHR monitoring between 16 and 20 weeks and it is recommended to document FHR before and after surgery which was done in our patient. The American College of Obstetricians and Gynaecologists recommends continuous FHR monitoring in non-obstetric surgery from 18 to 20 weeks of gestation, based on the patient and the surgery to be performed.[3] There has been controversy related to the use of controlled hypotension and intraoperative tests/monitoring to detect spinal cord injury during pregnancy. Invasive arterial BP monitoring must be performed, more so, if controlled hypotension is instituted. Various risk factors for haemodynamic instability in these patients include pregnancy-induced aortocaval compression, massive fluid shift, blood loss and prolonged surgery. In addition, autonomic dysfunction has been reported as the cause for high incidence of intraoperative hypotension in adult patients with thoracic spine tuberculosis.[4] In our patient, vasopressor was not considered to treat hypotension:First, because, as the SBP remained in the acceptable range of 90–100 mmHg, and second, its use could have further led to increased blood loss. Since the hypotension occurred soon after positioning, it could be attributed by factors such as pregnancy-induced aortocaval compression, pre-operative hydration status and autonomic neuropathy related to thoracic spine tuberculosis. The initial two factors were ruled out by ensuring adequate fluid replacement and free and hanging abdomen in prone position. It is also reported that prone position in pregnant patient is associated with lesser risk of aortocaval compression than sitting or lateral position.[5] To conclude, intraoperative haemodynamic stability is of paramount anaesthetic concern in pregnant patients with thoracic spine tuberculosis and autonomic dysfunction must be considered as a potential cause for intraoperative hypotension. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Anaesthetic concerns with intramyometrial vasopressin during myomectomy

Vasopressin, a potent vasoconstrictor, has often been used intramyometrially to prevent blood loss during surgical management of uterine myomas. Various lethal complications reported with its use include bradycardia, unmeasurable blood pressure, loss of palpable peripheral pulse, marked pallor, arrhythmia, pulmonary oedema and cardiac arrest. We herein report a case of uterine myomas in which intramyometrial vasopressin-induced complications such as bradycardia, absent pulse and marked pallor were observed with very low dose and concentration (i.e. 1.5 U and 0.1 U/ml). This could be attributed to the coexistence of hypertension in our patient. Here, we discuss the anaesthetic concerns with the use of intramyometrial vasopressin and reinforce the need for dogmatic guidelines envisaging the recommended safe dose and concentrations of intramyometrial vasopressin and proper patient selection.

Randomised double-blind comparison of bolus phenylephrine or ephedrine for treatment of hypotension in women with pre-eclampsia undergoing caesarean section

Treatment of post‐spinal hypotension during caesarean section assumes special concern in pre‐eclamptic patients due to a compromised fetoplacental circulation and increased risk of placental hypoperfusion. Phenylephrine and ephedrine are the most commonly used vasopressors, although the best choice is still not clear. We studied 80 pre‐eclamptic women with a singleton pregnancy who underwent caesarean section with spinal anaesthesia, and who developed hypotension defined as a decrease in systolic arterial pressure ≥ 20% from baseline or absolute value < 100 mmHg. Women were randomly allocated to receive phenylephrine 50 μg or ephedrine 4 mg boluses for treatment of hypotension. Blood pressure changes following vasopressor administration were similar in both groups, but heart rate remained higher after ephedrine at all time‐points. The primary outcome measure of umbilical artery pH was 7.26 (0.11) in the phenylephrine group and 7.25 (0.09) in the ephedrine group (p = 0.86). The incidence of neonatal acidosis (umbilical artery pH < 7.20) was 9 (22.5%) in the phenylephrine group and 11 (27.5%) in the ephedrine group (p = 0.80). Other secondary outcome measures were comparable. In conclusion, phenylephrine 50 μg and ephedrine 4 mg, administered as intravenous boluses to treat post‐spinal hypotension during caesarean section in pre‐eclamptic patients, resulted in similar fetal acid‐base values, were equally effective in treating hypotension and were associated with good maternal and neonatal outcome.

Absent Uvula: What Mallampati Class?

1. Roman SJ, Chong Sit DA, Boureau CM, Auclin FX, Ullern MM. Sub‐Tenon’s anaesthesia: An efficient and safe technique. Br J Ophthalmol 1997;81:673‐6. 2. Kumar CM, Dodds C. Sub‐Tenon’s anesthesia. Ophthalmol Clin North Am 2006;19:209‐19. 3. Kumar CM, Eid H, Dodds C. Sub‐Tenon’s anaesthesia: Complications and their prevention. Eye (Lond) 2011;25:694‐703. 4. Allman KG, Theron AD, Byles DB. A new technique of incisionless minimally invasive Sub‐Tenon’s anaesthesia. Anaesthesia 2008;63:782‐3. 5. Lin S, Ling RH, Allman KG. Real‐time visualisation of anaesthetic fluid localisation following incisionless Sub‐Tenon block. Eye (Lond) 2014;28:497‐8.

Comparison of epidural butorphanol with neostigmine and epidural sufentanyl with neostigmine for first stage of labor analgesia: A randomized controlled trial

Background: Epidural administration of neostigmine appears to be safe in the obstetric population. Recently, few studies have concluded 10 μg sufentanil to be an effective adjuvant with epidural neostigmine in providing labor analgesia. However, no study has evaluated the analgesic effect of epidural butorphanol with neostigmine for the same. Materials and Methods: The parturients were randomly allocated to one of the three study groups - Group A (n = 30) received butorphanol 1 mg and neostigmine 7 μg/kg. Group B (n = 30) received sufentanil 10 μg and neostigmine 7 μg/kg. Group C (n = 30) received neostigmine 7 μg/kg and 0.9% normal saline. Maternal hemodynamic parameters and fetal heart rate (FHR) were continuously monitored. The level of sensory and motor block, and visual analog scale (VAS) pain score were recorded at designated time points. In addition, the total duration of analgesia, duration of labor, mode of delivery, and any maternal or fetal adverse effects were also recorded. Statistical Analysis Used: A one-way analysis of variance (ANOVA) with post hoc Tukeys test was used to compare mean value among the three groups for age, height, weight, gestational age, and cervical dilatation. Repeated measure ANOVA was used to compare mean difference among the time points and also the trend among the various time points for hemodynamic parameters, VAS pain score, and FHR. For inter-group comparison among the groups, post hoc Tukey test was used. Results: There was a statistically significant longer effect of analgesic drug in Group B with respect to Group A and C (P < 0.001); however, the parturient in Group C had minimum duration of analgesia. Epidural neostigmine combined with sufentanil produces effective analgesia in early labor (VAS <30 within 10 min in 63.3% of parturient and within 15 min in 83.3% parturient) with average duration of 111.67 ± 24.51 min without motor block or other side effect in mother and fetus. No significant effect was observed in the duration of labor and mode of delivery in-between the two groups, and none of the patients in any group had any maternal or fetal side effects. Conclusion: Epidural combination of sufentanil with neostigmine provided better pain relief in terms of the total duration of analgesia and the reduction in VAS pain scores at various time points in the initial 30 min of epidural administration of drugs during the first stage of labor in parturient when compared to the epidural combination of butorphanol with neostigmine.

Students' satisfaction to hybrid problem-based learning format for basic life support/advanced cardiac life support teaching

Background and Aims: Students are exposed to basic life support (BLS) and advanced cardiac life support (ACLS) training in the first semester in some medical colleges. The aim of this study was to compare students′ satisfaction between lecture-based traditional method and hybrid problem-based learning (PBL) in BLS/ACLS teaching to undergraduate medical students. Methods: We conducted a questionnaire-based, cross-sectional survey among 118 1 st -year medical students from a university medical college in the city of New Delhi, India. We aimed to assess the students′ satisfaction between lecture-based and hybrid-PBL method in BLS/ACLS teaching. Likert 5-point scale was used to assess students′ satisfaction levels between the two teaching methods. Data were collected and scores regarding the students′ satisfaction levels between these two teaching methods were analysed using a two-sided paired t-test. Results: Most students preferred hybrid-PBL format over traditional lecture-based method in the following four aspects; learning and understanding, interest and motivation, training of personal abilities and being confident and satisfied with the teaching method (P < 0.05). Conclusion: Implementation of hybrid-PBL format along with the lecture-based method in BLS/ACLS teaching provided high satisfaction among undergraduate medical students.

Status of problem based learning in postgraduate anesthesia teaching: A cross-sectional survey

Background: Anesthesia is a specialized branch of medicine with a very narrow margin of error. Incorporation of problem-based learning (PBL) in anesthesia post-graduate (PG) teaching enhances the critical thinking and problem-solving skills. It also helps in developing a broader prospective of clinical case scenarios. Case based discussions (CBD) are most widely practiced out of all PBL methods in anesthesia PG teaching. Materials and Methods: We conducted an anonymous questionnaire based, cross-sectional survey among 62 anesthesia residents from various medical institutions in a city of Delhi, India. We aimed to assess the current status of PBL by assessing the student satisfaction with CBD in anesthesia PG teaching, educational objectives accomplished with CBD and effectiveness of teaching curriculum in PG teaching with suggested modifications, if any. Result and Conclusion: We observed that CBD is lacking in many important key areas of PBL e.g., formulation of objectives, communication on the content and direction of PBL, facilitation skills, supplementation of inadequacies of CBD. However, CBD seems to be a valid method of PBL in terms of the educational objectives accomplished with it but increased motivation for learning is required. Majority of the students felt that PG teaching curriculum should be centralized, with increased emphasis on open interactive sessions regarding its effectiveness.

The big "little problem" with postoperative nausea and vomiting prophylaxis.

Sir, We wish to report a case of severe headache in the immediate post-operative period in 35 years old, 56 kg, smoker, American Society of Anaesthesiologists physical status I, male patient scheduled for fistulectomy for fistula-in-ano. On patients request, general anaesthesia (GA) was administered. Anaesthesia was induced with injection fentanyl 60 μg and propofol 100 mg and maintained with isoflurane to achieve an end tidal concentration of 1.5-2% in an oxygen/nitrous oxide mixture. Proseal® laryngeal mask airway was inserted and surgery was conducted under spontaneous respiration. Injection ondansetron 4 mg was administered for prevention of post-operative nausea and vomiting (PONV). Intraoperatively, approximately 500 ml of Ringer lactate solution was administered. Surgery lasted for 20 min and remained uneventful. In post-operative period, patient complained of severe headache which was more in the frontal area and was not positional. Patient gave no such history of headache in the past. Injection diclofenac 75 mg was given as intravenous (IV) infusion and on follow-up, headache subsided completely in 6 h. Factors that may operate in regard to perioperative headache under GA include cerebral vasodilatation, any history of previous headache and administration of certain drugs. Cerebral vasodilatation may occur due to hypoxia, hypercarbia, dehydration, prolonged fasting period, caffeine withdrawal, hypertension, pre-eclampsia and sepsis.[1] Pre-operative headache and lack of sleep, the previous night are also strong predictors of post-operative headache. None of these factors were present in our patient. Drugs such as antihypertensives (nitrates), steroids, metronidazole, muscle relaxants and 5 HT3 antagonists used in perioperative period can also cause headache in the post-operative period.[1] On retrospective analysis, we speculated the cause of headache to be ondansetron, a 5 HT3 anatagonist in our patient. The recommended prophylactic dose of ondansetron is 4 mg with number needed to treat (NNT) of six for the prevention of vomiting (0-24 h) and NNT of seven for the antinausea effect.[2] However it may be associated with certain side effects e.g. headache, elevated liver enzymes and constipation etc. Headache following use of ondansetron for PONV prophylaxis has been reported earlier in literature.[3] The exact mechanism of this side effect is not known; however, it could be due to weak 5 HT1 antagonistic action. Various tools exist to stratify the risk of developing PONV; however, no uniform and standardised approach has been utilised to evaluate and manage PONV in clinical practice.[4] Apfels simplified risk score includes female sex, prior history of motion sickness or PONV, non-smoking status and the use of post-operative opioids as the independent predictors. The estimated probability of PONV was 10%, 21%, 39%, and 78% with one, two, three, and four risk factors, respectively.[5] Prophylaxis with dexamethasone and serotonin antagonist and use of total IV anaesthetic technique are justified in patients with moderate to high risk (e.g. risk score 2/3/4).[4] However, it may not be warranted in patients at low risk as it may unnecessarily expose the patients to the risk of associated side effects.[6] On retrospective assessment, our patients baseline risk for PONV was found to be very low; hence, PONV prophylaxis was probably not required. We emphasize that Apfel scoring system should be used in all patients receiving GA. Drugs for PONV prophylaxis should be used in minimal effective doses only when the patients individual risk is sufficiently high as we must not forget that each antiemetic has its own side effects.