Komal Gandhi

Comparison of Small Dose Ketamine and Dexmedetomidine Infusion for Postoperative Analgesia in Spine Surgery--A Prospective Randomized Double-blind Placebo Controlled Study.

Background: High doses of opioids are frequently used to treat postoperative pain after spine surgery. This leads to opioid-related side effects like nausea, vomiting, respiratory depression, etc. The current study is an attempt to find a safe analgesic adjuvant, which will afford opioid sparing property. Method: Sixty-six patients undergoing spine surgery were randomized into 1 of the 3 groups—group K (ketamine bolus 0.25 mg/kg followed by infusion of 0.25 mg/kg/h with midazolam bolus 10 &mgr;g/kg and infusion of 10 &mgr;g/kg/h mixed in the same infusion pump), group D (dexmedetomidine bolus 0.5 &mgr;g/kg followed by 0.3 &mgr;g/kg/h infusion), and group C (normal saline). Study drugs were started in the postoperative period and continued for 24 hours. Pain-free period, pain scores, rescue analgesic (morphine) requirements, and side effects were noted for 48 hours postoperatively. Result: Mean pain-free periods in the ketamine group (860 min) and the dexmedetomidine group (580 min) were longer than in the saline group (265 min) (P<0.002) during the observation period of 48 hours. There was a significant decrease in the rescue analgesic requirement in both ketamine and dexmedetomidine group (P<0.05) (cumulative morphine requirement at 24 h—group C 15.64±9.31 mg, group D 6.89±5.88 mg, group K 2.45±2.06 mg; at 48 h—group C 21.09±12.88 mg, group D 7.98±7.72 mg, group K 2.59±1.97 mg). Hemodynamics were maintained within normal range in all the groups. Patients in ketamine and dexmedetomidine groups were sedated, but none required assistance for maintaining airway patency. Few patients in the ketamine group had nausea, dizziness, and diplopia, but the difference was insignificant in comparison with other groups (P>0.05). Conclusions: Infusion of low-dose ketamine and dexmedetomidine both provide good postoperative analgesia with minimal side effects. Both of the tested analgesic regimes can be used safely and effectively for postoperative pain relief in patients after spine surgery.

Comparative effectiveness of McCoy laryngoscope and CMAC ® videolaryngoscope in simulated cervical spine injuries

Background: Videolaryngoscopes are increasingly being used in potentially difficult airway. McCoy laryngoscope provides definitive advantage over conventional laryngoscopes in cervical spine patients. The aim of this study was to compare the performance of the CMAC® videolaryngoscope with the McCoy Laryngoscope in patients with a cervical collar. Material and Methods: Sample size of at least 22 patients in each group was calculated using Intubation Difficulty Scale (IDS) score as the primary outcome. 60 American Society of Anesthesiologists I and II patients requiring tracheal intubation for elective surgery were randomly allocated into the McCoy group (n = 30) and the CMAC® videolaryngoscope group (n = 30). Anesthesia was induced with fentanyl 2 mcg/kg, propofol 2-3 mg/kg and rocuronium 0.6 mg/kg. A rigid collar was applied to immobilize the cervical spine. Comparative data on the IDS scale, Cormack-Lehane (CL) laryngoscopic view, time taken for glottis visualization, time taken to pass endotracheal tube, total time to intubate, number of optimizing maneuvers and hemodynamic variables were recorded in the two groups. Results: IDS score was significantly less in the CMAC® group compared to the McCoy group (median [interquartile range (IQR)], 1 [0-1] vs. 4 [3-6], P < 0.05). CMAC® videolaryngoscope required significantly less time for glottic visualization with median (IQR), 5 (5-7) versus 14 (8-15), P = 0.000 in McCoy laryngoscope, 29 (96.7%) patients in the CMAC® group had Modified CL Grade I compared with 16 (53.3%) patients in McCoy group. The hemodynamic variables, number of optimizing maneuvers and incidence of side effects were comparable in the two groups. Conclusion: CMAC® videolaryngoscope forms an effective tool for the airway management of cervical spine patients with a cervical collar.

Evaluation of I-gel™ airway in different head and neck positions in anesthetized paralyzed children

Studies that have compared and quantified the oropharynageal leak pressure (OPLP) and adequacy of ventilation with supraglottic airway devices in different head and neck positions have been done in adult populations. The effects of head–neck position changes on the functioning of I‐gel™ in pediatric population still remain unevaluated.

Intraoperative and Postoperative Administration of Dexmedetomidine Reduces Anesthetic and Postoperative Analgesic Requirements in Patients Undergoing Cervical Spine Surgeries.

Background: Early recovery from anesthesia and avoidance of analgesics with respiratory depressant properties are vital for maintenance of extubated airway in cervical spine surgeries. The current study investigated the role of dexmedetomidine as an anesthetic sparing agent and as a sole postoperative analgesic in these cases. Materials and Methods: Sixty adult patients undergoing cervical spine surgeries were randomized into 2 groups. Group D received intravenous dexmedetomidine infusion 0.5 &mgr;g/kg/h throughout the surgery after a loading dose of 1 &mgr;g/kg over 10 minutes. Postoperatively, dexmedetomidine infusion was continued at 0.2 &mgr;g/kg/h for 24 hours. Group C received a volume-matched bolus and infusion of 0.9% saline. Intraoperative anesthetic requirement, time to recovery, and discharge were recorded. Patients were observed for rescue analgesic requirements for 24 hours after surgery. Hemodynamic stability, sedation scores, and pain scores were assessed for 48 hours after surgery. Results: There was significant reduction in intraoperative anesthetic requirement in group D (P<0.001). Although sedation scores and recovery criteria were comparable, pain scores were significantly lower in group D compared with group C for first 24 hours postoperatively at all corresponding times. The mean pain-free period after surgery was significantly longer in group D (1460.67±517.16 min) with significantly less rescue analgesic requirement during 24-hour postoperative period (P=0.018) compared with group C (98.17±81.20 min). Hemodynamic parameters were maintained within clinically normal range during study period. Conclusions: Dexmedetomidine lowered the anesthetic requirement with clinically permissible hemodynamic variations without undue prolongation of recovery time. Postoperative dexmedetomidine infusion provided effective analgesia without excessive sedation in patients undergoing cervical spine surgeries.

Evaluation of I‐Gel™ size 2 airway in different degrees of neck flexion in anesthetized children – a prospective, self‐controlled trial

A previous study by our group demonstrated an increase in oropharyngeal leak pressures and a deterioration of ventilation in maximum neck flexion with the I‐Gel™. To ascertain the optimal degree of neck flexion which increases OPLP without compromising ventilation we conducted a prospective self‐controlled trial with the I‐Gel™ in different degrees of neck flexion in anesthetized paralyzed children.

Evaluation of weight-adjusted doses of palonosetron for prevention of postoperative nausea and vomiting in day care laparoscopic gynaecological surgery: A dose ranging, randomised controlled trial.

BACKGROUND Palonosetron 75 mcg is being used for the prevention of postoperative nausea and vomiting. However, weight-adjusted doses in laparoscopic surgery are unevaluated. AIM To determine the response to three doses of palonosetron (0.5, 1.0, or 1.5 mcg kg−1) over 72 h in the postoperative period in women undergoing laparoscopic gynaecological procedures. DESIGN A randomised dose–response study. SETTING A tertiary care hospital and research institute in north India from July to December 2014. PATIENTS American society of Anesthesiologists physical status I and II women, from 18 to 60 years old, undergoing laparoscopic gynaecological procedures on a day care basis. METHODS Patients were randomised to receive palonosetron 0.5, 1 and 1.5 mcg kg−1 intravenously before induction of anaesthesia. MAIN OUTCOMES MEASURES The primary outcome was the proportion of patients with a complete response (i.e. who neither vomited nor required additional antiemetic drugs for nausea during the first 72 postoperative hours). The proportion of patients having nausea or emetic episodes and the requirement for rescue antiemetics and analgesics during the 72-h period were recorded as secondary outcomes. RESULTS With palonosetron, there was a significant dose-dependent increase (37.5 vs. 67.5 vs. 75%, P < 0.001) in proportion of patients with a complete response during the 72 h. This was associated with a significant dose-dependent decrease in the proportion of patients with nausea (77.5 vs. 47.5 vs. 35%, P < 0.001) and vomiting (47.5 vs. 32.5 vs. 12.5%, P = 0.003). CONCLUSION Following laparoscopic gynaecological surgery, intravenous palonosetron has a dose-dependent prophylactic effect against postoperative nausea and vomiting during the first 72 postoperative hours. TRIAL REGISTRATION The trial was registered with Clinical trial registry of India(CTRI/2014/09/004987).

Comparison of intubation conditions with CMAC Miller videolaryngoscope and conventional Miller laryngoscope in lateral position in infants: A prospective randomized trial

Endotracheal intubation in lateral position in infants is a challenge. This difficulty may be surmounted to some extent by using videolaryngoscopes but the routine use of these devices as a tool to secure the airway in lateral position remains unevaluated. Therefore, we conducted a prospective, randomized controlled trial to compare the intubation conditions achieved with the CMAC videolaryngoscope and the Miller Laryngoscope in lateral position in infants. We hypothesized that CMAC videolaryngoscope would provide a better laryngoscopic view and reduce the time to intubation compared to the Miller blade.

Comparison of the ProSeal laryngeal mask airway with the I-Gel™ in the different head-and-neck positions in anaesthetised paralysed children: A randomised controlled trial

Background and Aims: Head and neck movements alter the shape of the pharynx, resulting in changes in the oropharyngeal leaking pressures and ventilation with supragottic airway devices. We compared the effect of the different head-and-neck positions on the oropharyngeal leak pressures and ventilation with the I-Gel™ and ProSeal™ laryngeal mask airway (PLMA) in anaesthetised paralysed children. Methods: A total of 70 children were randomly assigned to receive PLMA (n = 35) or I-Gel™ (n = 35) for airway management. Oropharyngeal leak pressure in maximum flexion, maximum extension and the neutral position was taken as the primary outcome. Peak inspiratory pressures (PIPs), expired tidal volume, ventilation score and fibreoptic grading were also assessed. Results: No significant difference was noted in oropharyngeal leak pressures of PLMA and I-Gel™ during neutral (P = 0.34), flexion (P = 0.46) or extension (P = 0.18). PIPs mean (standard deviation [SD]) were significantly higher (17.7 [4.03] vs. 14.6 [2.4] cm H2O, P = 0.002) and expired tidal volume mean [SD] was significantly lower (5.5 [1.6] vs. 6.9 [2] ml/kg, P = 0.0017) with I-Gel™ compared to PLMA. Fibreoptic grading and ventilation score were comparable in both the groups in all the three head-and-neck positions. Conclusion: PLMA and I-Gel™, both recorded similar oropharyngeal leaking pressures in all the three head-and-neck positions. However, higher peak pressures and lower expired tidal volume in maximum flexion of the neck while ventilating with I-Gel may warrant caution and future evaluation.

Reply: Only with an optimal position of the supraglottic airway in situ, valid conclusions can be drawn about oropharyngeal airway pressure

1. Banerjee G, Jain D, Bala I, Gandhi K, Samujh R. Comparison of the ProSeal laryngeal mask airway with the i-gel in the different head-and-neck positions in anaesthetised paralysed children: A randomised controlled trial. Indian J Anaesth 2018;62:103-8. 2. Van Zundert AAJ, Gatt SP, Kumar CM, Van Zundert TCRV. Vision-guided placement of supraglottic airway device prevents airway obstruction: A prospective audit. Br J Anaesth 2017;118:462-3. 3. Okuda K, Inagawa G, Miwa T, Hiroki K. Influence of head and neck position on cuff position and oropharyngeal sealing pressure with the laryngeal mask airway in children. Br J Anaesth 2001;86:122-4. Response to Comments

Effect of intensive education and training of nurses on ventilator-associated pneumonia and central line-associated bloodstream infection incidence in intensive care unit at a tertiary care center in North India

Objective: The aim was to analyze the impact of education and training of nurses on the incidence of ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI). Patients and Methods: A prospective observational study at a tertiary care hospital included adult patients with Intensive Care Unit stay >48 h. The study was done in three phases: in Phase 1, baseline VAP and CLABSI incidence was calculated; in Phase 2, education and training of nurses; and in Phase 3, data were recollected for the incidence of VAP and CLABSI. Results: The baseline incidence of VAP in Phase 1 was 28.86/1000 ventilator days and that of CLABSI was 7.89/1000 central-line days. In Phase 3, the incidence of VAP increased to 35.06 and that of CLABSI decreased significantly, 1.73. Conclusion: Intensive education and training sessions with feedback from nurses over a period of 6 months led to significant reduction in the incidence of CLABSI; however, the incidence of VAP increased.