Neerja Bharti

Paediatric perioperative cardiac arrest and its mortality: database of a 60-month period from a tertiary care paediatric centre.

Background and objective The analysis of perioperative cardiac arrest and mortality remains a potentially valuable method to improve clinical outcome. This survey evaluated the incidence and causes of perioperative cardiac arrests and mortality in a paediatric surgical population over 5 years. Methods All cardiac arrests that occurred between April 2003 and March 2008, during administration of anaesthesia at the paediatric centre of our institute, were recorded from an anaesthesia database and postsurgical ICU census register. All surgery performed under anaesthesia was included whether emergency or elective. All surgical procedures were covered except eye surgery, cardiac surgery and the procedures performed at remote locations. Data collected included patient characteristics, surgical procedures, preoperative physical status and anaesthesia-provider information, immediate cause of cardiac arrest, antecedent events, management and outcome. All cardiac arrests were grouped according to the cause of arrest into one of four groups: totally anaesthesia related, partially anaesthesia related, surgery related or child condition related. Results There were a total of 27 cardiac arrests out of 12 158 procedures. Major risk factors for cardiac arrests were children under 1 year of age (P < 0.05), ASA physical status (ASA-PS) III or more (P < 0.001) and emergency surgery (P < 0.01). There were nine cardiac arrests attributed to anaesthesia, three totally and six partially related to anaesthesia. The main causes of anaesthesia-related cardiac arrest were respiratory events (56%), followed by cardiac events (33%). Anaesthesia-related mortality was 1.2/10 000 anaesthetics in patients with ASA-PS I–II and 7.7/10 000 anaesthetics in patients with ASA-PS III–V with a survival rate of 56%. Conclusion Major risk factors for cardiac arrests were age under 1 year, poor physical status and emergency surgery. Respiratory and cardiovascular-related events accounted for most of all anaesthesia-related cardiac arrests. High ASA-PS was the leading cause of perioperative mortality.

Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial

BACKGROUND Pectoral nerve (PecS) block is a recently introduced technique for providing surgical anaesthesia and postoperative analgesia during breast surgery. The present study was planned to compare the efficacy and safety of ultrasound-guided PecS II block with thoracic paravertebral block (TPVB) for postoperative analgesia after modified radical mastectomy. METHODS Forty adult female patients undergoing radical mastectomy were randomly allocated into two groups. Group 1 patients received a TPVB with ropivacaine 0.5%, 25 ml, whereas Group 2 patents received a PecS II block using same volume of ropivacaine 0.5% before induction of anaesthesia. Patient-controlled morphine analgesia was used for postoperative pain relief. RESULTS The duration of analgesia was significantly prolonged in patients receiving the PecS II block compared with TPVB [mean (sd), 294.5 (52.76) vs 197.5 (31.35) min in the PecS II and TPVB group, respectively; P<0.0001]. The 24 h morphine consumption was also less in the PecS II block group [mean (sd), 3.90 (0.79) vs 5.30 (0.98) mg in PecS II and TPVB group, respectively; P<0.0001]. Postoperative pain scores were lower in the PecS II group compared with the TVPB group in the initial 2 h after surgery [median (IQR), 2 (2-2.5) vs 4 (3-4) in the Pecs II and TPVB group, respectively; P<0.0001]. Seventeen patients in the PecS II block group had T2 dermatomal spread compared with four patients in the TPVB group (P<0.001). No block-related complication was recorded. CONCLUSIONS We found that the PecS II block provided superior postoperative analgesia than the TPVB in patients undergoing modified radical mastectomy without causing any adverse effect. CLINICAL TRIAL REGISTRATION CTRI/2014/06/004692.

Efficacy of Gabapentin for Prevention of Postoperative Catheter-related Bladder Discomfort in Patients Undergoing Transurethral Resection of Bladder Tumor

OBJECTIVE To evaluate the effect of 600 mg and 1200 mg oral gabapentin pretreatment for the prevention of postoperative catheter-related bladder discomfort (CRBD) in patients undergoing catheterization after transurethral resection of bladder tumor (TURBT). MATERIALS AND METHODS One hundred adult patients undergoing elective TURBT under spinal anesthesia were randomly allocated into 3 groups. Group I patients received placebo, group II patients received 600 mg gabapentin, and group III patients received 1200 mg gabapentin 1 hour before surgery. Lumber subarachnoid block was administered with 2.5 mL 0.5% hyperbaric bupivacaine. The patients were observed for the incidence and severity of CRBD in the postoperative period. RESULTS The incidence of CRBD was 90% in group I, 66% in group II, and 26% in group III. The incidence of bladder discomfort was significantly low in group III at all time points compared with group I and at 4, 6, 12, and 24 hours compared with group II. The severity of CRBD was also less in group II and III patients compared with group I. Fifteen patients in group I developed moderate discomfort, whereas 1 patient in group II and none in group III. None of the patient receiving gabapentin had severe discomfort. The duration and level of sensory and motor block was comparable among groups. One patient in group II and 2 patients in group III were complained of dizziness in postoperative period. CONCLUSION Gabapentin 1200 mg administered before surgery is more effective than gabapentin 600 mg in decreasing the incidence of postoperative CRBD.

Comparison of propofol versus propofol-ketamine combination for sedation during spinal anesthesia in children: randomized clinical trial of efficacy and safety

Objectives:  This study was designed to compare the efficacy and safety of propofol vs propofol‐ketamine combination for sedation during pediatric spinal anesthesia.

Minimal effective dose of magnesium sulfate for attenuation of intubation response in hypertensive patients

STUDY OBJECTIVE To study the minimal effective dose of magnesium sulfate to control blood pressure (BP) during intubation in hypertensive patients. DESIGN Prospective, randomized, double-blind study. SETTING Operating room of an academic medical center. PATIENTS 80 adult, ASA physical status 1 and 2, controlled hypertensive patients undergoing elective surgery under general anesthesia and requiring endotracheal intubation. INTERVENTIONS Patients were randomized to 4 groups. Patients in study groups received a magnesium sulfate infusion at a dose of 30 (Group I), 40 (Group II), or 50 mg/kg (Group III) before induction of anesthesia, while patients in control group (Group IV) received a 1.5 mg/kg lidocaine bolus 90 seconds before intubation. Anesthesia was induced and maintained with a propofol infusion. Laryngoscopy and intubation were performed 4 minutes after administration of vecuronium. MEASUREMENTS Heart rate (HR) and BP were recorded before, during, and after endotracheal intubation for 10 minutes. Measures to manage hemodynamic instability were recorded. Serum magnesium levels were also recorded. MAIN RESULTS The changes in HR were comparable among groups. Mean arterial pressure (MAP) was maintained within normal limits in Group I patients while Groups II and III patients showed a significant decrease in MAP (P = 0.01) compared with baseline. A total of 6 patients (30%) in Group II and 10 patients (50%) in Group III required interventions (P = 0.001). No patient in Group I and only one patient (5%) in Group IV required intervention. CONCLUSIONS Magnesium 30 mg/kg is the optimum dose to control BP during intubation in hypertensive patients. A further increase in the dose of magnesium may cause significant hypotension.

Effect of gabapentin pretreatment on propofol consumption, hemodynamic variables, and postoperative pain relief in breast cancer surgery

STUDY OBJECTIVE Gabapentin is an inhibitory neurotransmitter of the central nervous system. This prospective randomized double-blind study was conducted to evaluate the effects of gabapentin on intraoperative propofol requirements, hemodynamic variables, and postoperative pain relief in breast cancer patients. MATERIALS AND METHODS Forty adult females of the American Society of Anesthesiologists (ASA) Grade I-II physical status, undergoing total mastectomy for breast cancer were included. Patients were randomly allocated into two groups. Two hours prior to surgery the gabapentin group received gabapentin 600 mg and the control group received placebo. Anesthesia was induced with intravenous fentanyl, propofol, and vecuronium, and maintained with propofol infusion titrated according to the bispectral index. Postoperative analgesia was provided with intramuscular diclofenac sodium and intravenous morphine on demand. RESULTS The intraoperative propofol consumption was significantly less in the gabapentin group as compared with the control group (p = 0.009), whereas there was no difference in fentanyl and vecuronium requirements. Patients in the gabapentin group had lower pain scores at 30 minutes, 1 hour, and 2 hours postoperatively (p < 0.001). The postoperative morphine consumption was also less in the gabapentin group compared with the control group (p = 0.006). No significant adverse effects were noticeable. CONCLUSION Preoperative administration of gabapentin reduced intraoperative propofol requirements and postoperative analgesic consumption in breast cancer patients undergoing total mastectomy.

Postoperative analgesic effect of intravenous (i.v.) clonidine compared with clonidine administration in wound infiltration for open cholecystectomy

OBJECTIVES This randomized double-blind study was designed to compare the postoperative analgesic effect of clonidine administered intravenously or in wound infiltration with bupivacaine. METHODS Sixty adults of ASA grade I-II undergoing open cholecystectomy were randomly allocated into three groups. Group 1 (control group) patients received wound infiltration with 30 ml of 0.25% bupivacaine at the end of surgery. Group 2 patients received 3 μg kg(-1) clonidine intravenously after resection of gall bladder plus wound infiltration with 30 ml of 0.25% bupivacaine. Group 3 patients received wound infiltration with 3 μg kg(-1) clonidine with 30 ml of 0.25% bupivacaine. A standard general anaesthesia technique was used. Postoperative analgesia was provided with i.v. diclofenac and morphine on demand. Postoperative pain, number of patients requiring rescue analgesia and total morphine consumption during 24 h after operation was recorded. RESULTS Postoperative morphine consumption was significantly less in patients receiving clonidine by either route when compared with the control group (P<0.0001). All patients in the control group required supplemental morphine, with nine patients in the i.v. clonidine group and 11 patients in the wound infiltration group (P<0.002). Pain scores were lower at rest for 12 h and on cough for 6 h in both clonidine groups when compared with the control group (P<0.01). Patients receiving i.v. clonidine had more hypotension (P<0.01) and sedation (P<0.001) compared with other groups. CONCLUSIONS Clonidine 3 μg kg(-1) provided effective postoperative analgesia and reduced morphine requirement when administered intravenously or in wound infiltration with bupivacaine. However, the incidence of complications was less with wound infiltration. CLINICAL TRIAL REGISTRY OF INDIA: (www.ctri.nic.in/), registration number CTRI/2012/12/003258.

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.

A dose-response study of caudal dexmedetomidine with ropivacaine in pediatric day care patients undergoing lower abdominal and perineal surgeries: a randomized controlled trial.

This randomized double‐blind study was conducted to evaluate the analgesic efficacy and safety of addition of three different doses of dexmedetomidine in caudal ropivacaine compared with plain ropivacaine for postoperative analgesia in pediatric day care patients.

Epidural butorphanol-bupivacaine analgesia for postoperative pain relief after abdominal hysterectomy

STUDY OBJECTIVE To determine the efficacy of epidural butorphanol with and without bupivacaine in providing postoperative analgesia following abdominal hysterectomy. DESIGN Randomized, double-blinded study. SETTINGS Postoperative recovery area of a university-affiliated medical center. PATIENTS 60 ASA physical status I and II women, aged 20-65 years, undergoing abdominal hysterectomy. INTERVENTIONS Patients were randomly allocated to three groups during the postoperative period to receive one of three epidural regimens: two mg of butorphanol in 10 mL of normal saline (Group 1), two mg of butorphanol in 10 mL of 0.125% bupivacaine (Group 2), or two mg of butorphanol in 10 mL of 0.25% bupivacaine (Group 3). MEASUREMENTS Onset and duration of analgesia were recorded. Hemodynamic variables, pain scores, sedation scores, and respiratory rate were monitored for 24 hours. Frequency and severity of respiratory depression, sedation, pruritus, nausea, and vomiting were recorded. MAIN RESULTS The addition of butorphanol to bupivacaine resulted in significantly (P < 0.05) faster onset of pain relief. The duration of analgesia was prolonged in patients receiving butorphanol with bupivacaine combination (8.68 +/- 0.82 hrs, 9.82 +/- 0.54 hrs) as compared with butorphanol alone (4.35 +/- 0.66 hrs; P < 0.05). The differences between Groups 2 and 3 were not significant. CONCLUSIONS Addition of two mg of butorphanol to 0.125% of epidural bupivacaine resulted in rapid onset and longer duration of analgesia than did butorphanol alone.