Madhusudan Upadya

A comparison of midazolam and clonidine as an oral premedication in pediatric patients

Background: To compare oral midazolam (0.5 mg/kg) versus oral clonidine (4 μg/kg) as a premedication in pediatric patients aged between 2-12 years with regard to sedation and anxiolysis. Methods: Sixty pediatric patients belonging to the American Society of Anesthesiologists class I and II between the age group of 2-12 years scheduled for elective surgery were randomly allocated to receive either oral midazolam (group I) 30 min before induction or oral clonidine (group II) 90 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of mask application for induction of anesthesia. Results: After premedication, the percentage of children who were sedated and calm increased in both the groups. The overall level of sedation was better in the children in the clonidine group, but children in the midazolam group had a greater degree of anxiolysis at times of venepuncture and mask application. In addition, midazolam did not cause significant changes in hemodynamics unlike clonidine where a significant fall in blood pressure was noted, after premedication, but preinduction. Conclusion: We conclude that under the conditions of the study, oral midazolam is superior to clonidine as an anxiolytic in pediatric population. Clonidine with its sedative action especially at the time of separation from parents along with its other perioperative benefits cannot be discounted.

Comparative evaluation of midazolam and butorphanol as oral premedication in pediatric patients

Background: To compare oral midazolam (0.5 mg/kg) with oral butorphanol (0.2 mg/kg) as a premedication in 60 pediatric patients with regards to sedation, anxiolysis, rescue analgesic requirement, and recovery profile. Materials and Methods: In a double blinded study design, 60 pediatric patients belonging to ASA class I and II between the age group of 2–12 years scheduled for elective surgery were randomized to receive either oral midazolam (group I) or oral butorphanol (group II) 30 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of facemask application for induction of anesthesia. Rescue analgesic requirement, postoperative recovery, and complications were also recorded. Results: Butorphanol had better sedation potential than oral midazolam with comparable anxiolysis at the time of separation of children from their parents. Midazolam proved to be a better anxiolytic during venepuncture and facemask application. Butorphanol reduced need for supplemental analgesics perioperatively without an increase in side effects such as nausea, vomiting, or unpleasant postoperative recovery. Conclusion: Oral butorphanol is a better premedication than midazolam in children in view of its excellent sedative and analgesic properties. It does not increase side effects significantly.

Submental intubation in patients with panfacial fractures: A prospective study

Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.

Anaesthesia for non-obstetric surgery during pregnancy.

Non-obstetric surgery during pregnancy posts additional concerns to anaesthesiologists. The chief goals are to preserve maternal safety, maintain the pregnant state and achieve the best possible foetal outcome. The choice of anaesthetic technique and the selection of appropriate anaesthetic drugs should be guided by indication for surgery, nature, and site of the surgical procedure. Anaesthesiologist must consider the effects of the disease process itself and inhibit uterine contractions and avoid preterm labour and delivery. Foetal safety requires avoidance of potentially dangerous drugs and assurance of continuation of adequate uteroplacental perfusion. Until date, no anaesthetic drug has been shown to be clearly dangerous to the human foetus. The decision on proceeding with surgery should be made by multidisciplinary team involving anaesthesiologists, obstetricians,surgeons and perinatologists. This review describes the general anaesthetic principles, concerns regarding anaesthetic drugs and outlines some specific conditions of non-obstetric surgeries.

Comparison of the use of McCoy and TruView EVO2 laryngoscopes in patients with cervical spine immobilization

Context: The cervical spine has to be stabilized in patients with suspected cervical spine injury during laryngoscopy and intubation by manual in-line axial stabilization. This has the propensity to increase the difficulty of intubation. An attempt has been made to compare TruView EVO2 and McCoy with cervical spine immobilization, which will aid the clinician in choosing an appropriate device for securing the airway with an endotracheal tube (ETT) in the clinical scenario of trauma. Aims: To compare the effectiveness of TruView EVO2 and McCoy laryngoscopes when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. Settings and design: K. M. C. Hospital, Mangalore, This was a randomized control clinical trial. Methods: Sixty adult patients of either sex of ASA physical status 1 and 2 who were scheduled to undergo general anesthesia with endotracheal intubation were studied. Comparison of intubation difficulty score (IDS), hemodynamic response, Cormack and Lehane grade, duration of the tracheal intubation and rate of successful placement of the ETT in the trachea between TruView EVO2 and McCoy laryngoscopes was performed. Results: The results demonstrated that TruView has a statistically significant less IDS of 0.33 compared with an IDS of 1.2 for McCoy. TruView also had a better Cormack and Lehane glottic view (CL 1 of 77% versus 40%) and less hemodynamic response. Conclusions: The TruView blade is a useful option for tracheal intubation in patients with suspected cervical spine injury.

Comparison of intra-peritoneal bupivacaine and intravenous paracetamol for postoperative pain relief after laparoscopic cholecystectomy

Background: Nonsteroidal anti-inflammatory drugs used for postoperative analgesia have considerable adverse effects, with paracetamol having a different mechanism of action, superior side effect profile and availability in intravenous (IV) form, this study was conducted to compare intra-peritoneal bupivacaine with IV paracetamol for postoperative analgesia following laparoscopic cholecystectomy. Aim: The aim was to compare the efficacy of intra-peritoneal administration of bupivacaine 0.5% and IV acetaminophen for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Settings and Design: Randomized, prospective trial. Materials and Methods: A total of 60 patients of American Society of Anesthesiologists physical Status I and II scheduled for laparoscopic cholecystectomy were enrolled for this study. Group I received 2 mg/kg of 0.5% bupivacaine as local intra-peritoneal application and Group II patients received IV 1 g paracetamol 6 th hourly. Postoperatively, the patients were assessed for pain utilizing Visual Analog Scale (VAS), Visual Rating Prince Henry Scale (VRS), shoulder pain. The total number of patients requiring rescue analgesia and any side-effects were noted. Statistical Analysis: Data analysis was performed using Students unpaired t-test. SPSS version 11.5 was used. Results: The VAS was significantly higher in Group I compared with Group II at 8 th , 12 th and 24 th postoperative hour. At 1 st and 4 th postoperative hours, VAS was comparable between the two groups. Although the VRS was higher in Group I compared with Group II at 12 th and 24 th postoperative hour; the difference was statistically significant only at 24 th postoperative hour. None of the patients in either of the groups had shoulder pain up to 8 h postoperative. The total number of patients requiring analgesics was higher in Group II than Group I at 1 st postoperative hour. Conclusion: Although local anesthetic infiltration and intra-peritoneal administration of 0.5% bupivacaine decreases the severity of incisional, visceral and shoulder pain in the early postoperative period, IV paracetamol provides sustained pain relief for 24 postoperative hours after elective laparoscopic cholecystectomy.

A prospective randomized controlled study comparing intrathecal bupivacaine combined with fentanyl and sufentanil in abdominal and lower limb surgeries.

Background: Hyperbaric bupivacaine along with either fentanyl or sufentanil as additive, has been widely used in spinal anesthesia. In the present study, we compared the analgesic effects of intrathecal fentanyl versus sufentanil combined with bupivacaine for surgical procedures over the abdomen and lower limbs. Settings and Design: This was randomized controlled study conducted in a tertiary care hospital attached to a medical school. Methods: Sixty American Society of Anesthesiologists I and II patients were randomized into three groups by sealed envelope technique. Group 1 was to receive bupivacaine with fentanyl; group 2 to receive bupivacaine with sufentanil and group 3 to receive bupivacaine with saline (control), intrathecally. The parameters checked were hemodynamic changes, onset and duration of sensory block, duration of analgesia and maximal sensory level achieved. Statistical Analysis: The data collected were analyzed using χ2 test and paired Student′s t-test. Results: The time taken for the onset of analgesia was longest in the control group followed by fentanyl group. The earliest onset of action of 9.35 ± 1.92 min was recorded in sufentanil group. Duration of sensory blockade and analgesia was longest for fentanyl group than the other groups. Adverse effects noted were more for sufentanil group but were self-limiting. Conclusion: Fentanyl with bupivacaine produced prolonged analgesia and delayed two-segment regression and demonstrated reduced incidence of complications as compared with intrathecal sufentanil. As the quality of analgesia was complete and comparable, fentanyl emerges as a better option for analgesia and it is much economical too when compared to sufentanil.

A comparison of hypotension and bradycardia following spinal anesthesia in patients on calcium channel blockers and β-blockers

Objectives: Hypotension is a common complication of spinal anesthesia and is frequent in patients with hypertension. Antihypertensive agents decrease this effect by controlling blood pressure. There are conflicting reports on the continuation of antihypertensive drugs on the day of surgery in patients undergoing spinal anesthesia. Sudden hypotension could have detrimental effect on the organ systems. This study was undertaken to compare the variation in blood pressure in hypertensive patients on β-blockers and calcium channel blockers undergoing spinal anesthesia. Materials and Methods: Ninety patients were enrolled for the study, 30 each in the control, β-blocker and the calcium channel blocker groups. Results: The incidence of hypotension was not different among the three groups. However, the number of times mephentermine used to treat hypotension was significant in the patients receiving calcium channel blockers while incidence of bradycardia in patients treated with β-blockers was significant (P<0.001). Conclusion: The incidence of hypotension following spinal anesthesia is not different in patients receiving β-blockers and calcium channel blockers among the three groups.

Effect of different dosages of intravenous midazolam premedication on patients undergoing head and neck surgeries- A double blinded randomized controlled study

INTRODUCTION Benzodiazepines primarily acts on the central nervous system. Most patients are extremely anxious in the pre-operative period. Excessive anxiety adversely influences anaesthetic induction and often leads to functional impairment and poor recovery after surgery. AIM To determine whether amnesia, anxiety, sedation and cardio respiratory symptoms are affected while administering two different doses of intravenous midazolam (0.02 mg/kg & 0.06 mg/kg). MATERIALS AND METHODS Two forty patients posted for head and neck surgeries were involved in this double blinded prospective randomised controlled trial. The patients were randomized into two main groups, Group 1 receiving 0.02 mg/kg and Group 2 receiving 0.06 mg/kg midazolam intravenously as premedication. Visual recognition and recall were tested using eight laminated A4 size posters pre-operatively and four further images were shown at the postoperative interview. Anxiety was evaluated by a Visual Analogue Scale (VAS) and sedation depth was determined by the Observers Assessment of Alertness/Sedation Scale (OAAS) scale. Vital signs including heart rate, respiratory rate, mean blood pressure and arterial oxygen saturation (SpO2) were monitored. Statistical analysis was done using paired Students t-test and Chi-square test. RESULTS VAS scores were lower in Group 2 (0.06 mg/kg) than in Group 1 (0.02 mg/kg) at T15 (15 minutes after the injection of midazolam). Comparison of OAAS scores among Group 1 and Group 2 showed that more patients in Group 1 were alert at T15 compared to Group 2. Recall of events was significantly lower in Group 2 compared to Group 1. There was no significant statistical variation in haemodynamic parameters between the groups except for decreased diastolic blood pressure and room air saturation in Group 2. CONCLUSION A higher dosage of midazolam improves the quality of anxiolysis and sedation with lesser rates of intraoperative recall and maintains haemodynamic stability.

Six percent hetastarch versus lactated Ringer's solution - for preloading before spinal anesthesia for cesarean section.

Background: Regional anesthesia has been the choice of preference for elective cesarean sections. This study was designed to determine whether preoperative administration of 6% hetastarch decreases the incidence of hypotension. Materials and Methods: This study was conducted on 50 nonlaboring American Society of Anesthesiologists class I and II women undergoing elective cesarean section. Patients were randomly divided into two groups and were preloaded either with 1000 ml Ringers lactate (RL) or 500 ml of 6% hetastarch 30 min prior to the surgery. Spinal anesthesia was performed with patients in the left lateral position and 2 cc (10 mg) of 0.5% of bupivacaine injected into subarachnoid space. Hemodynamic variables (heart rate, noninvasive blood pressure, and SpO2) were recorded from prior to preloading until the recovery from the subarachnoid blockade. Results: Our study showed the incidence of hypotension to be 28% in the hetastarch group and 80% in the RL group. Rescue ephedrine requirements for the treatment of hypotension were significantly less in patients who were preloaded with 6% hetastarch prior to cesarean section. The neonatal outcome, as determined by Apgar scores was good and similar in both groups. Conclusion: Hence, we conclude that 6% hydroxyl ethyl starch is more effective than lactated Ringers solution and that its routine use for preloading prior to spinal anesthesia should be considered.