Ishwar Bhukal

Pre-induction low dose pethidine does not decrease incidence of postoperative shivering in laparoscopic gynecological surgeries.

Objectives: The incidence of shivering in patients undergoing a laparoscopic procedure is stated to be about 40%. A majority of laparoscopic gynecological procedures are taken up on an outpatient basis. Postoperative shivering may delay hospital discharge and is a common cause of discomfort in patients recovering from anesthesia. Aims: To determine the effect of pre-induction, low-dose pethidine on postoperative shivering in patients undergoing laparoscopic gynecological surgeries. Setting and Design: Sixty females between 25 and 35 years of age, of American Society of Anesthesiologists (ASA) class 1 and 2, were randomly divided into three groups of 20 patients each. Group I and II patients received i.v. pethidine 0.3 mg/kg and 0.5 mg/kg, respectively, while Group III received i.v. 0.9% normal saline just before induction of general anesthesia. Temperature of the Operating Room and the Post Anesthesia Care Unit was standardized and all fluids given during the study period were warmed to 37°C. Materials and Methods: Temperature, measured with a tympanic membrane probe, was recorded preoperatively, after induction of anesthesia, on arrival at the Post Anesthesia Care Unit, and postoperatively at 15 minutes and 30 minutes. Shivering was graded (0 – 4 scale) at arrival of the patients to the PACU and every five minutes thereafter, up to 30 minutes. Statistical Analysis: ANOVA, Chi-square test, Kruskal-Wallis ANOVA and Mann-Whitney U tests were used. A P-value of less than 0.05 was considered significant. Results: Core body temperatures were statistically insignificant between groups at pre-induction, post-induction, and in the PACU (P > 0.05). At the end of surgery, shivering was present in 18 patients (30%). In groups I, II, and III, six (30%), three (15%), and nine (45%) patients shivered, respectively. The differences in incidence and grading of shivering among groups was found to be statistically insignificant (P > 0.05). The core body temperature of shiverers and non-shiverers were compared. In the PACU at 0, 15, and 30 minutes, the temperature among shiverers was significantly lower than that in the non-shiverers. Rescue drug i.v. pethidine 20 mg was given to patients with shivering grade ≥2. None of the patients had shivering after 10 minutes. Conclusions: Prophylactic pre-induction, low-dose pethidine does not have major role in preventing postoperative shivering.

Spinal anaesthesia with lidocaine 2% for Caesarean section

Spinal anaesthesia with 2, 2.5 or 3 ml of glucose-free lidocaine 2% was studied in 50 patients undergoing Caesarean section. Onset time, cephalad spread of analgesia, quality of analgesia, muscle relaxation, the cardiovascular effects and duration of analgesia and motor block were assessed. Reliable anaesthesia was provided with 2.5 and 3 ml while 2 ml of 2% lidocaine was insufficient. Onset time varied between 5.5 to 6 min and maximum cephalad spread was achieved in 10–15 min. The mean maximum extent of sensory analgesia was higher after 2.5 ml (T4.1) and 3 ml (T3.6) than after 2 ml (T7) (P < 0.001). Complete motor block was achieved in all the patients. The mean duration of sensory block was 123 ± 6.23 min (2 ml) to 126 ± 7.53 min (2.5 and 3 ml). The mean duration of motor block in 2.5 and 3 ml groups was higher (P < 0.001) than in the 2 ml group and was correlated with the dose of lidocaine (P < 0.05). Hypotension (SBP < 100 mmHg) was noted in 10% (n = 5) of patients in whom the cephalad spread of analgesia was also higher. All the neonates had an apgar score of 7 or more at 1 min. These results suggest that 2.5 to 3 ml of 2% lidocaine provides satisfactory anaesthesia for Caesarean section.RésuméCe travail évalue la qualité de la rachianesthésie réalisée avec de la lidocaine 2% sans glucose chez 50 patientes opérées pour césarienne. La vitesse d’installation, la progression céphalique, la qualité de l’analgésie, la relaxation musculaire, les effets cardiovasculaires et la durée de l’analgésie et du block moteur sont analysés. Une anesthésie efficace est obtenue avec 2,5 et 3 ml contrairement aux 2 ml de lidocaine 2%. La vitesse d’installation varie entre 5,5 et 6 min et la progression maximale est complétée après 10–15 minutes. L’extension maximale moyenne de l’analgésie est plus grande avec 2,5 ml (T4.1) et 3 ml (Ts,6) qu’aprés 2 ml (T7) (P < 0,001). On a obtenue un block moteur complet chez toutes les patientes. La durée moyenne du block sensitif est de 123 ± 6,23 min (2ml) à 126 ± 7,53 min (2,5 et 3 ml). La durée moyenne du block moteur dans les groupes ayant reçu 2,5 et 3 ml est plus longue (P < 0.001) que chez celles qui ont reçu 2 ml avec une corrélation positive pour la posologie (P < 0,05). On a relevé de Vhypotension (PAS < 100 mHg) chez 10% (n = 5) des patientes chez lesquelles la progression céphalique était la plus élevée. Tous les nouveaux-nés cotaient 7 ou plus sur l’échelle d’Apgar à la premiére minute. Ces résultats suggérent que 2,5 à 3 ml de lidocaine 2% procurent une anesthésie satisfaisante pour la césarienne.

Effect of preoperative oral erythromycin, erythromycin-ranitidine, and ranitidine-metoclopramide on gastric fluid pH and volume

STUDY OBJECTIVE To determine whether combining erythromycin with ranitidine is more efficacious than erythromycin or established ranitidine-metoclopramide combination in reducing the volume and acidity of gastric aspirate. DESIGN Randomized, double-blind study. SETTING Operating room complex. PATIENTS Eighty ASA physical status I and II patients. INTERVENTION Patients were divided into 4 groups of 20 patients each. All patients received the study medication (in tablet form) packed in identical gelatin capsules 60 to 90 minutes before surgery in the premedication room. Patients in group PP were given two placebo tablets; group EP received erythromycin 250 mg, and placebo; group ER received erythromycin 250 mg, and ranitidine 150 mg; and group RM was given ranitidine 150 mg, and metoclopramide 10 mg. MEASUREMENTS After tracheal intubation, gastric fluid was aspirated via orogastric tube, and volume and pH of the aspirate were studied. RESULTS Significantly higher gastric volume occurred in group PP than groups EP, ER, or RM (P < 0.001). There were no differences in volumes among groups EP, ER, and RM. Gastric pH was significantly lower (P < 0.001) in groups PP and EP than in groups ER and RM. CONCLUSION Erythromycin and ranitidine combination is more efficacious than erythromycin alone in reducing the acidity and volume of gastric fluid. No difference was found between erythromycin-ranitidine and ranitidine-metoclopramide combination.

Comparison of serum triglyceride levels with propofol in long chain triglyceride and propofol in medium and long chain triglyceride after short term anesthesia in pediatric patients.

Background: Significant increase in serum triglyceride (ST) concentration have been described in adult population after prolonged administration of propofol formulation containing long chain triglyceride (LCT). Though, medium chain triglyceride-LCT (MCT-LCT) propofol when compared with LCT propofol for long-term sedation in adults resulted in identical triglyceride levels, the elimination of triglyceride was faster in patients administered MCT-LCT propofol. Materials and Methods: A total of 40 children were randomized into two groups of 20 each; Group I were induced with 1% LCT propofol (3 mg/kg) and Group II with 1% medium and LCT propofol and maintained with descalating dose of 20.15 and 10 mg/kg/h at 10 min intervals. Blood samples for ST concentration were obtained before induction of anesthesia, at the end of propofol infusion and 4 h after terminating propofol infusion. Results: ST levels were raised significantly above the basal values in both the groups but the rise was significantly higher in Group I (P < 0.05). Four hours after stopping propofol infusion the triglyceride levels were similar to the basal values in Group II, whereas in Group I the values were significantly greater than the baseline (P < 0.05) as well as those of Group II (P < 0.05). No clinically significant adverse effect of hypertriglyceridemia was observed. Conclusion: Even short term anesthesia with LCT and MCT-LCT propofol (1%) leads to elevated ST levels. The increase in ST levels is less with MCT-LCT propofol and elimination of triglyceride is also rapid after terminating MCT-LCT propofol infusion.

Perioperative predictors of morbidity and mortality following cardiac surgery under cardiopulmonary bypass

Background: Prediction of outcome after cardiac surgery is difficult despite a number of models using pre-, intra- and post-operative factors. Ideally, risk factors operating in all three phases of the patients’ stay in the hospital should be incorporated into any outcome prediction model. The aim of the present study was to identify the perioperative risk factors associated with morbidity, mortality and length of stay in the recovery room (LOSR) and length of stay in the hospital (LOSH). Methods: Eighty-eight adults of either sex, patients undergoing elective open cardiac surgery were studied prospectively. The ability of a number of pre-, intra- and post-operative factors to predict outcome in the form of mortality, immediate morbidity (LOSR) and intermediate morbidity (LOSH) was assessed. Results: Factors associated with higher mortality were preoperative prothrombin index (PTI), American Society of Anesthesiology-Physical Status (ASA-PS) grade, Cardiac Anaesthesia Risk Evaluation (CARE) score and New York Heart Association (NYHA) class, intraoperative duration of cardiopulmonary bypass (DCPB), number of inotropes used while coming off cardiopulmonary bypass and postoperatively, Acute Physiology and Chronic Health Evaluation (APACHE) II excluding the Glassgow Comma Scale (GCS) component and the number of inotropes used. Immediate morbidity was associated with preoperative PTI, inotrope usage intra- and post-operatively and the APACHE score. Intermediate morbidity was associated with DCPB and intra- and post-operative inotrope usage. Individual surgeon influenced the LOSR and the LOSH. Conclusion: APACHE score, a general purpose severity of illness score, was relatively ineffective in the postoperative period because of sedation, neuromuscular blockade and elective ventilation used in a number of these patients. The preoperative and intraoperative factors like CARE, ASA-PS grade, NYHA, DCPB and number of inotropes used influencing morbidity and mortality are consistent with the literature, despite the small size of our sample.

Anesthetic management in a patient with Kindler's syndrome

A 35-year-old male with pan-anterior urethral stricture was scheduled to undergo perineal urethrostomy. He was a known case of Kindlers syndrome since infancy. He was having a history of blister formation, extensive poikiloderma and progressive cutaneous atrophy since childhood. He had a tendency of trauma-induced blisters with clear or hemorrhagic contents that healed with scarring. The fingers were sclerodermiform with dystrophic nails and inability to completely clench the fist. Airway examination revealed thyromental distance of 7 cm with limited neck extension, limited mouth opening and mallampatti class III with a fixed large tongue. He was reported as grade IV Cormack and Lehane laryngoscopic on previous anesthesia exposure. We described the anesthetic management of such case on guidelines for epidermolysis bullosa. In the operating room, an 18-G cannula was secured in the right upper limb using Coban™ Wrap. The T-piece of the cannula was than inserted into the slit and the tape was wrapped around the extremity. The ECG electrodes were placed on the limbs and fixed with Coban™. Noninvasive blood pressure cuff was applied over the wrap after wrapping the arm with Webril® cotton. Oral fiberoptic tracheal intubation was done after lubricating the laryngoscope generously with a water-based lubricant with 7-mm endotracheal tube. Surgery proceeded without any complication. After reversing the residual neuromuscular block, trachea was extubated once the patient became awake. He was kept in the postanesthesia care unit for 2 hours and then shifted to urology ward.

Intraoperative localization and monitoring of migrating foreign body using transesophageal echocardiography.

Radiological imaging is often used for the preoperative localization of foreign body following blast injury, but their utility in case of migration during intra-operative period is limited. Transesophageal echocardiography (TEE) has been used for intra-operative localization and removal of intra-cardiac foreign body; however, reports for localization of extracardiac migrating foreign body are few. Preoperative radiological imaging, in a victim of factory blast-injury, suggested foreign body in the posterior mediastinum. However, the intra-operative TEE showed it in the left atrium, which later migrated into the left ventricle necessitating a change in surgical approach for its removal.

A randomized study to compare the efficacy of two intravenous fluid regimens of normal saline on the incidence of postoperative nausea and vomiting

Background: The purpose of this study was to evaluate the effect of two different volume of crystalloid given intraoperatively on postoperative nausea and vomiting (PONV). Materials and Methods: Eighty adult patients of either sex belonging to ASA I and II class undergoing elective surgeries under general anesthesia for 1–2 h were studied in this prospective, randomized double blinded study. First group (group L) (n=40) received normal saline 4 mL/kg and second group (group H) (n=40) received 10 mL/kg of normal saline. This was in excess of the fasting requirement of the patients. No propofol or antiemetic drugs were given. PONV was evaluated by verbal descriptive score (VDS) [0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = unbearable]. Ondansetron (4 mg i.v.) was given if VDS score was 3 or more. Results: The median immediate PONV score was 2 and 1 in group L and H, respectively. The median 2 h PONV score in group L was 3 and in group H was 1. The median 6 h PONV score in group L was 3 and in group H was 1. The 24 h median postoperative PONV score was 1 and 0 in group L and H, respectively. In all these period of time the differences were statistically significant. The incidence of vomiting was more in group L [72.5% (29/40)] than in group H [30% (12/40)]. This was statistically significant (P=0.0003). Conclusion: From the current study it was concluded that patients who received larger volume of crystalloid intraoperatively have lesser incidence of PONV.