Indu Kapoor

Propofol as a sole agent for paediatric day care diagnostic ophthalmic procedures: comparison with halothane anaesthesia

Background: Our aim was to study the feasibility of total intravenous anaesthesia with propofol in spontaneously breathing children undergoing ophthalmic procedures.

Intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery: A Cochrane systematic review

Background: Early and rapid emergence from anaesthesia is desirable for most neurosurgical patients. With the availability of newer intravenous and inhalational anaesthetic agents, all of which have inherent advantages and disadvantages, we remain uncertain as to which technique may result in more rapid early recovery from anaesthesia. The objective of this review was to assess the effects of intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 6) in The Cochrane Library, MEDLINE via Ovid SP (1966 to June 2014) and EMBASE via Ovid SP (1980 to June 2014). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct.org and www.clinicaltrials.gov (October 2014). We included randomised controlled trials (RCTs) that compared the use of intravenous anaesthetic agents such as propofol and thiopentone with inhalational anaesthetic agents such as isoflurane and sevoflurane for maintenance of general anaesthesia during brain tumour surgery. Primary outcomes were emergence from anaesthesia (assessed by time to follow verbal commands, in minutes) and adverse events during emergence, such as haemodynamic changes, agitation, desaturation, muscle weakness, nausea and vomiting, shivering and pain. Secondary outcomes were time to eye opening, recovery from anaesthesia using the Aldrete or modified Aldrete score (i.e., time to attain score ≥9, in minutes), opioid consumption, brain relaxation (as assessed by the surgeon on a 4- or 5-point scale) and complications of anaesthetic techniques, such as intraoperative haemodynamic instability in terms of hypotension or hypertension (mmHg), increased or decreased heart rate (beats/min) and brain swelling. We used standardised methods in conducting the systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. We used a fixed-effect model when we found no evidence of significant heterogeneity between studies, and a random-effects model when heterogeneity was likely. Results: We included 15 RCTs with 1833 participants. We determined that none of the RCTs were of high methodological quality. For our primary outcomes, pooled results from two trials suggest that time to emergence from anaesthesia, that is, time needed to follow verbal commands, was longer with isoflurane than with propofol (mean difference [MD] -3.29 min, 95% confidence interval [CI] -5.41--1.18, low-quality evidence), and time to emergence from anaesthesia was not different with sevoflurane compared with propofol (MD 0.28 min slower with sevoflurane, 95% CI - 0.56-1.12, four studies, low-quality evidence). Pooled analyses for adverse events suggest lower risk of nausea and vomiting with propofol than with sevoflurane (risk ratio [RR] 0.68, 95% CI 0.51-0.91, low-quality evidence) or isoflurane (RR 0.45, 95% CI 0.26-0.78) and greater risk of haemodynamic changes with propofol than with sevoflurane (RR 1.85, 95% CI 1.07-3.17), but no differences in the risk of shivering or pain. Pooled analyses for brain relaxation suggest lower risk of tense brain with propofol than with isoflurane (RR 0.88, 95% CI 0.67-1.17, low-quality evidence), but no difference when propofol is compared with sevoflurane. Conclusions: The finding of our review is that the intravenous technique is comparable with the inhalational technique of using sevoflurane to provide early emergence from anaesthesia. Adverse events with both techniques are also comparable. However, we derived evidence of low quality from a limited number of studies. The use of isoflurane delays emergence from anaesthesia. These results should be interpreted with caution. RCTs based on uniform and standard methods are needed.

Effect of nitrous oxide on bispectral index values at equi-minimum alveolar concentrations of sevoflurane and desflurane

Background and Aims: Bispectral index (BIS) values may be anaesthetic agent-specific, depending on their ability to suppress the electroencephalogram (EEG) signals. We carried out a prospective, randomised clinical trial to study the effect of nitrous oxide (N2O) on the BIS values at an equi-minimum alveolar concentration (MAC) of sevoflurane and desflurane. Methods: Sixty adult patients undergoing spine surgery were randomised into two groups; Group S (sevoflurane; n = 30) and Group D (desflurane; n = 30) for the maintenance of anaesthesia in oxygen and air or oxygen and N2O mixture (FiO2-0.4) (Stage 1). BIS and fraction of inspired and end-tidal concentration of agents were noted at 1.0 MAC. In Stage 2, air or N2O was discontinued and the other carrier gas was introduced. At steady state of this carrier gas, values were again noted as in Stage 1. Statistical analysis was performed using two-way analysis of variance followed by Bonferroni correction, and Students t-test for paired data. P<0.05 was considered statistically significant. Results: With air-oxygen as the carrier gas, sevoflurane and desflurane resulted in comparable BIS values (P = 0.44). With addition of 60% N2O, there was a significant increase in BIS values at 1.0 MAC for both the agents. Furthermore, higher BIS values were observed with sevoflurane compared to desflurane (P = 0.01). Conclusion: Sevoflurane and desflurane at equi-MAC concentration exert similar effect on BIS values when used with air-oxygen. N2O results in higher BIS values; this effect is more pronounced in combination with sevoflurane.

Basics of Neuroanesthesia: Anatomy, Physiology, and Pharmacology

The nervous system is a complex network of nerves and cells in the human body that coordinates its actions by transmitting and receiving the signals to and from different parts of the body. The nervous system consists of both the central nervous system [CNS] and peripheral nervous system [PNS]. The PNS contains sensory [afferent] and motor [efferent] nerves which connects the CNS to the body. Afferent nerves carry information from the body to CNS, whereas efferent nerves transmit information from the brain to the rest of the body. The CNS comprises of the brain and spinal cord which connect to each other via the brainstem which is situated at the base of the brain.

Can pediatric bispectral index sensor replace adult bispectral index sensor for depth of anesthesia monitoring

Sir, We report a 53-year-old male with left partial brachial plexus injury posted for exploration and repair under general anesthesia. He was apparently well few days back when he met with an accident following which he developed weakness of the left upper arm. There was no history of loss of consciousness, seizures, nausea, or vomiting. General anesthesia was induced with fentanyl (2 mcg/kg), propofol (2 mg/kg), and rocuronium (1 mg/kg). The airway was secured with laryngeal mask airway size 3. Total intravenous anesthesia (TIVA) was used for maintenance (Propofol @ 100 mcg/kg/min) keeping in mind intraoperative nerve monitoring. Depth of anesthesia was monitored with adult bispectral index (BIS) sensor, applied to the forehead immediately after induction of anesthesia to avoid the incidence of awareness intraoperatively. The monitor displayed a perfect BIS picture with BIS value of 48 with signal quality index (SQI) of 100% and electromyogram (EMG) of 10 decibel (dB) under TIVA. After getting above values, adult BIS sensor was replaced by pediatric sensor on same site under same anesthetic regimen to find out the difference in BIS values between two if any. This time monitor displayed the same BIS value of 48 with SQI of 80% and EMG of 10 dB. Pediatric sensor displayed same BIS value as an adult sensor, but the quality of electroencephalographic (EEG) signals was found to be slightly less compared to an adult. EMG, however, displayed similar value with both sensors.

Enhanced recovery after surgery: Neuroanaesthetic perspective

Enhanced recovery after surgery (ERAS) is a systematic multimodal perioperative care aimed at reducing the immense surgical stress of the patient and thereby facilitating early recovery. This is basically a multidiscipline, multimodal integrated approach in patient care and it integrates the basic knowledge in a more streamlined fashion, which ultimately improves the outcome of surgery. This article reviews the various aspects of ERAS, and its implementation in neurosurgical practice as some concepts of ERAS may not be applicable in the setting of neurosurgery.

Reversal of trend in near infrared spectroscopy [NIRS] values in a patient with carotid artery stenosis

• Near Infrared Spectroscopy (NIRS) monitors continuous non-invasive regional oxygen balance within the frontal cerebral cortex.

Subcutaneous hematoma following subcutaneous emphysema: An occult association

Indian Journal of Critical Care Medicine ¦ Volume 21 ¦ Issue 9 ¦ September 2017 618 Some evidence suggests that lung‐protective mechanical ventilation (MV) with low‐tidal volume ventilation (LTVV) in addition to positive end‐expiratory pressure (PEEP) could prevent PGD‐induced hypoxemia in the recipients of LT. Nevertheless, these suggestions require further validation in prospective clinical studies.[3] In addition, these strategies of MV could not provide sufficient gas exchange in the episode of refractory hypoxemia. Therefore, because of a lack of clear evidence on how to optimally ventilate and manage patients, the current practices of MV strategy following LT are not based on rigorous evidence[1] and need further investigation.

Anesthesia for minimally invasive neurosurgery

Purpose of review With an ultimate aim of improving patients overall outcome and satisfaction, minimally invasive surgical approach is becoming more of a norm. The related anesthetic evidence has not expanded at the same rate as surgical and technological advancement. This article reviews the recent evidence on anesthesia and perioperative concerns for patients undergoing minimally invasive neurosurgery. Recent findings Minimally invasive cranial and spinal surgeries have been made possible only by vast technological development. Points of surgical interest can be precisely located with the help of stereotaxy and neuronavigation and special endoscopes which decrease the tissue trauma. The principles of neuroanethesia remain the same, but few concerns are specific for each technique. Dexmedetomidine has a favorable profile for procedures carried out under sedation technique. As the new surgical techniques are coming up, lesser known anesthetic concerns may also come into light. Summary Over the last year, little new information has been added to existing literature regarding anesthesia for minimally invasive neurosurgeries. Neuroanesthesia goals remain the same and less invasive surgical techniques do not translate into safe anesthesia. Specific concerns for each procedure should be taken into consideration.

Rapid sequence induction with fibrescope: An uncommon practice!

© 2016 Journal of Neuroanaesthesiology and Critical Care | Published by Wolters Kluwer Medknow | fibrescope ready with endotracheal tube railroaded over. Preoxygenation for 5 min was followed by induction with fentanyl 150 mcg and propofol 100 mg via IV route. Following the loss of verbal response, Sellicks manoeuvre was performed by a fellow anaesthesiologist. Succinylcholine 100 mg IV bolus dose was given to facilitate the endotracheal intubation. His trachea was intubated with ease in the first attempt by the aid of fibreoptic bronchoscope (FOB) and tube position was confirmed while removing FOB from the trachea. Once stabilised, his tracheobronchial tree was examined with FOB. A thick mucus plug was noticed over left main bronchus later cleared with suctioning and irrigation with 0.9% normal saline. Subsequent chest X‐ray [Figure 2] and ABG after 2 h of elective Rapid sequence induction with fibrescope: An uncommon practice!