Neerja Bhardwaj

Comparison of ondansetron with ondansetron and dexamethasone in prevention of PONV in diagnostic laparoscopy.

PurposeTo compare the efficacy of ondansetron-dexamethasone combination with ondansetron alone for prevention of postoperative nausea and vomiting (PONV).MethodsThis double blind, randomized study was carried out in 51 female patients, aged 20–40 yr, ASA-1 physical status undergoing gynecological diagnostic laparoscopy. Group 1 (n = 26) received 4mg ondansetroniv and group 2 (n = 25) received a combination of 4 mg ondansetron and 8 mg dexamethasoneiv soon after induction of anesthesia. Postoperatively patients were assessed hourly for four hours and then at 24 hr for nausea, vomiting, pain and post anesthetic discharge score. Vomiting occurring up to two hours was considered early vomiting and from 2–24 hr as delayed vomiting.ResultsThe postoperative nausea score was lower in patients receiving a combination of ondansetron and dexamethasone (3.76) than ondansetron alone (4.38) at 0 hr (P < 0.01), 2 hr (P < 0.05) and 24 hr (P < 0.01). In group 1, 38.5% of patients had a nausea score of ≥ 5 (major nausea) compared with only 12% of patients in group 2 (P < 0.025). The overall incidence of vomiting was greater in group 1 (35%) than in group 2 (8%) (P < 0.05). The combination group showed better control of delayed vomiting compared with the ondansetron group (4%vs 35%)(P< 0.0l).ConclusionThe combination of ondansetron and dexamethasone provides adequate control of PONV with delayed PONV being better controlled than early PONVRésuméObjectifComparer l’efficacité d’une combinaison d’ondansétron et de dexaméthasone avec l’ondansétron employé seul pour la prévention de nausées et de vomissements postopératoires (NVPO).MéthodeLa présente étude, randomisée et en double aveugle, a été réalisée auprès de 51 patientes, âgées de 20 à 40 ans, d’état physique ASA I qui devaient subir une laparoscopie gynécologique. Le groupe I (n = 26) a reçu 4mg d’ondansétroniv et le groupe 2 (n = 25), une combinaison de 4 mg d’ondansétron et de 8 mg de dexaméthasoneiv peu après l’induction de l’anesthésie. À la suite de l’intervention, on a évalué les nausées, les vomissements, l’échelle de douleur et de congé à chaque heure, pendant quatre heures, et à 24 h. Les vomissements se produisant jusqu’à deux heures après l’intervention étaient considérés comme des vomissements précoces et ceux qui survenaient entre 2 et 24 h, comme des vomissements tardifs.RésultatsLe score des nausées postopératoires était plus bas chez les patientes qui avaient reçu une combinaison d’ondansétron et de dexaméthasone (3,76) plutôt que de l’ondansétron seulement (4,38) à 0 h (P < 0,01), à 2 h (P < 0,05) et à 24 h (P < 0,01). Dans le groupe 1, 38,5 % des patientes ont présenté un score de nausées 5 (nausées importantes) comparativement à 12 % seulement des patientes dans le groupe 2 (P < 0,025). Lincidence totale de vomissements était plus grande dans le groupe 1 (35 %) que dans le groupe 2 (8 %) (P < 0,05). Le groupe ayant reçu une combinaison de médicaments, comparé au groupe qui a reçu de l’ondansétron, a présenté un meilleur contrôle des vomissements tardifs (4 %vs 35 %) (P < 0,01).ConclusionLa combinaison d’ondansétron et de dexaméthasone fournit un bon contrôle des NVPO, meilleur pour les NVPO précoces que pour les NVPO tardifs.

Intrathecal fentanyl added to intrathecal bupivacaine for day case surgery: a randomized study

Background and objective: The implication of intrathecal lidocaine in neurological toxicity has made intrathecal bupivacaine the commonly used drug for local anaesthesia in ambulatory surgery. However, in high doses intrathecal bupivacaine may produce a high level of sensory and motor block, and arterial hypotension; discharge from hospital may be delayed. Intrathecal opioids added to low-dose local anaesthetics produce a synergistic effect without increasing the sympathetic block or delaying discharge. The aim of our study was to identify the minimum effective dose of intrathecal fentanyl that in combination with low-dose intrathecal bupivacaine would provide adequate surgical conditions without prolonging recovery. Methods: A prospective, single, blind, randomized study was conducted in 45 adult males scheduled for minor urological procedures using intrathecal anaesthesia on a day care basis. Patients were randomly assigned to one of three groups (n = 15 each). They received bupivacaine 0.17% 5 mg - with either fentanyl 7.5 μg (fenta-7.5), 10 μg (fenta-10) or 12.5 μg (fenta-12.5) intrathecally in a total volume of 3 mL. The quality of anaesthesia, haemodynamic stability, time to two-segment and S2 regression, time to micturition, and time to discharge were assessed. Results: The time to two-segment regression and S2 regression with fenta-12.5 was significantly longer than with fenta-7.5 and fenta-10 (P < 0.01). Fenta-7.5 had a significantly higher number of failed blocks (four patients) compared with fenta-12.5 (P < 0.05). The time out of bed, time to micturition and time to discharge were significantly longer with fenta-10 and fenta-12.5 compared with fenta-7.5, and also with fenta-12.5 compared with fenta-10 (P < 0.01). Haemodynamic stability did not differ for all the drug combinations. Conclusions: Fentanyl 12.5 μg added to low-dose bupivacaine (5 mg) intrathecally provides better surgical anaesthesia and increased reliability of block than intrathecal fentanyl 7.5 or 10 μg. Haemodynamic stability was the same for all dose combinations used.

Laryngeal mask airway insertion in children: comparison between rotational, lateral and standard technique

Background:  The purpose of the study was to compare the success and ease of insertion of three techniques of laryngeal mask airway (LMA) insertion; the standard Brain technique, a lateral technique with cuff partially inflated and a rotational technique with cuff partially inflated.

CSF p-Tau levels in the prediction of Alzheimer's disease

Summary The two hallmarks of Alzheimers disease (AD) are neurofibrillary tangles and amyloid plaques. Neurofibrillary tangles are formed due to the hyperphosphorylation of tau protein. There is an urgent need to develop a reliable biomarker for the diagnosis of AD. Cerebrospinal fluid (CSF) is surrounding the brain and reflects the major neuropathological features in the AD brain. Diagnosis, disease progression and drug actions rely on the AD biomarkers. Mainly CSF tau and phosphorylated tau (p-Tau) have been observed to serve the purpose for early AD. Keeping in view the early appearance of p-Tau in CSF, we analyzed p-Tau levels in 23 AD, 23 Non AD type dementia (NAD), 23 Neurological control (NC) and 23 Healthy control (HC) North Indian patients. The levels of p-Tau were found to be increased in AD patients (67.87±18.05 pg/ml, SEM 3.76) compared with NAD (47.55±7.85 pg/ml, SEM 1.64), NC (34.42±4.51 pg/ml, SEM 0.94) and HC (27.09±7.18 pg/ml, SEM 1.50). The resulting sensitivity for AD with NAD was 80.27% whereas with respect to the NAD, NC and HC was 85.40%. Therefore elevated levels of p-Tau in AD can be exploited as a predictive biomarker in North Indian AD patients.

Comparison of Ondansetron With Ondansetron Plus Dexamethasone for Antiemetic Prophylaxis in Children Undergoing Strabismus Surgery

BACKGROUND Children undergoing strabismus surgery have a high incidence of postoperative nausea and vomiting. Ondansetron plus dexamethasone is effective in reducing its incidence in many surgical procedures. PURPOSE To examine the efficacy of ondansetron plus dexamethasone in children undergoing strabismus surgery. PATIENTS AND METHODS A randomized, placebo-controlled, double blind study of 100 children 2 to 12 years old, in American Society of Anesthesiologists classes I and II, and undergoing strabismus surgery with the use of general anesthesia was conducted. Children received normal saline (n = 31), an injection of 0.15 mg/kg of ondansetron (n = 39), or an injection of 0.15 mg/kg of ondansetron and 0.2 mg/kg of dexamethasone (n = 30). Postoperatively, children were monitored for the number of emetic episodes, Steward recovery score, and need for a rescue antiemetic. RESULTS The incidence of vomiting was 64.5% in the group receiving saline, 33.3% in the group receiving ondansetron, and 10% in the group receiving ondansetron plus dexamethasone (P < .001). The incidence of early vomiting (0 to 4 hours) and the need for a rescue antiemetic were significantly lower in the groups receiving ondansetron (P < .01) and ondansetron plus dexamethasone (P < .001) compared with the group receiving saline; however, the former two groups were comparable in this regard. In the late postoperative period (4 to 24 hours), the incidence of vomiting and the need for a rescue antiemetic were not significantly different among the groups. Vomiting was significantly more severe in the group receiving saline compared with the groups receiving ondansetron and ondansetron plus dexamethasone at all times (P < .01 and P < .001, respectively). However, the latter two groups were comparable in this regard. CONCLUSION Ondansetron and ondansetron plus dexamethasone were equally effective in preventing early nausea and vomiting in children following strabismus surgery. However, the efficacy of dexamethasone in late postoperative nausea and vomiting could not be demonstrated. Further studies with a large population and different doses of dexamethasone may be warranted.

Efficacy of ketamine and midazolam as co‐induction agents with propofol for laryngeal mask insertion in children

Objectives:  Use of midazolam and ketamine lowers the induction dose of propofol (co‐induction) producing hemodynamic stability.

A comparison of three vasopressors for tight control of maternal blood pressure during cesarean section under spinal anesthesia: Effect on maternal and fetal outcome

Purpose: Maintaining systolic blood pressure (SBP) at 100% of baseline is best for fetal and maternal outcome. We hypothesized that irrespective of the vasopressor used, maintaining SBP at 100% of baseline with phenylephrine (P), metaraminol (M), or ephedrine (E) will produce the best fetal pH after cesarean section (LSCS) under subarachnoid block (SAB). Materials and Methods: Ninety ASA 1 women scheduled for elective LSCS were randomly allocated to receive P, M, or E. SAB was established with patient in left lateral position using 2.5 cc of 0.5% hyperbaric bupivacaine. Immediately following SAB, patients received a bolus of the study drug (E = 5 mg, M = 0.5 mg, P = 30 mcg) followed by infusion (E = 2.5 mg/min, M = 0.25 mg/min, P = 15 mcg/min) to maintain SBP at 100% baseline. Umbilical blood gases, maternal hemodynamic parameters, and complications were recorded. Results: The umbilical pH was comparable in all the three groups (P > 0.05). The mean SBP from spinal block until delivery was similar over time for all the three groups. The incidence of reactive hypertension was more in group M (P < 0.05) than in group E and group P. Total drug consumption to meet target blood pressure till delivery was 39.3 ± 14.6 mg in group E, 1.7 ± 0.9 mg in group M, and 283.6 ± 99.8 mcg in group P. The incidence of nausea and vomiting was comparable in the three groups. Conclusion: All the three vasopressors were equally effective in maintaining maternal blood pressure as well as umbilical pH during spinal anesthesia for cesarean section without any detrimental effects on fetal and maternal outcome.

An evaluation of the retromolar space for oral tracheal tube placement for maxillofacial surgery in children.

BACKGROUND: The eruption of the first and second permanent molar teeth may influence the size of the retromolar space. In this study we evaluated the adequacy of the retromolar space for retromolar intubation and any effect of eruption of the first and second permanent molar teeth on this space in children. METHODS: Children 3–15 yr of age, undergoing surgery other than facial surgery were included for evaluation of the retromolar space. After standard oral tracheal intubation, the endotracheal tube was shifted to the retromolar space and the mandible was slowly closed to achieve centric occlusion. At the same time, any increase in airway resistance or decrease in oxygen saturation was noted. In the second part of the study, the feasibility of retromolar intubation in pediatric patients undergoing maxillofacial surgery with intraoperative maxillomandibular fixation was assessed. RESULTS: There was enough space for endotracheal tube placement in the retromolar region. The eruption of the first and second permanent molar teeth did not affect intubation. It was possible to achieve centric occlusion in 79 of 80 children with the endotracheal tube positioned in the retromolar space. Retromolar intubation was successfully accomplished in six pediatric patients undergoing maxillomandibular fixation and maxillofacial surgery. CONCLUSION: The retromolar space can be safely used for intubation in children when intraoperative maxillomandibular fixation, and simultaneous access to the nose and oral cavity are needed.

A randomized trial of propofol consumption and recovery profile with BIS-guided anesthesia compared to standard practice in children

Aim:  To evaluate the impact of bispectral index (BIS) monitoring on the consumption of propofol and recovery from anesthesia compared to the standard clinical practice in children.

A randomised comparison of the effects of low-dose spinal or general anaesthesia on umbilical cord blood gases during caesarean delivery of growth-restricted foetuses with impaired Doppler flow.

Context Hypotension following spinal anaesthesia for caesarean delivery may decrease uteroplacental perfusion and produce foetal acidosis. The optimal anaesthetic technique for mothers with foetal growth restriction and impaired Doppler flow is unclear. Objective To compare the effects of low-dose spinal anaesthesia and general anaesthesia on neonatal outcome and maternal haemodynamics. Design Prospective, randomised clinical trial. Setting Tertiary care hospital. Patients Forty pregnant women with foetal growth restriction and impaired Doppler flow scheduled for elective caesarean delivery. Interventions The women were allocated randomly to receive a low-dose spinal anaesthetic (8-mg hyperbaric bupivacaine 0.5% with fentanyl 20 &mgr;g) or standard general anaesthesia for elective caesarean delivery. SBP was maintained between 80 and 100% of baseline using bolus doses of phenylephrine. The total duration of hypotension, dose of phenylephrine used and any incidence of hypotension, nausea or vomiting were recorded. Main outcome measures The primary outcome variable was arterial and venous umbilical cord base deficit. Neonatal outcome and maternal haemodynamics were analysed as secondary endpoints. Results The mean umbilical artery pH was significantly lower in the low-dose spinal anaesthesia group than in the general anaesthesia group (7.23 ± 0.06 vs. 7.27 ± 0.04, P = 0.01). Cord base deficit was similar in the two groups. Higher partial pressures of oxygen occurred in the general anaesthesia group (20.9 ± 6.5 kPa) than in the low-dose spinal anaesthesia group (13.6 ± 6.1 kPa, P = 0.001). No difference was observed between groups in 1 and 5-min Apgar scores. There appeared to be a greater need for immediate resuscitation of neonates in the general anaesthesia group, but the difference was not statistically significant (P = 0.51). Low-dose spinal anaesthesia was associated with hypotension of short duration (0.7 ± 1.1 min). Conclusion In this study, there was no difference in umbilical cord base deficit between the groups. Larger studies would be required to assess whether the mode of anaesthesia influences the incidence of clinically important neonatal acidosis in neonates with foetal growth restriction.