Pradeep Bhatia

Dexmedetomidine versus midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography: An open-label randomised controlled trial

Background: Traditionally, midazolam has been used for providing conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP). Recently, dexmedetomidine has been tried, but very little evidence exists to support its use. Objective: The primary objective was to compare haemodynamic, respiratory and recovery profile of both drugs. Secondary objective was to compare the degree of comfort experienced by patients and the usefulness of the drug to endoscopist. Study Design: Open-label Randomised Controlled Trial. Methods: Subjects between 18 and 60 years of age with American Society of Anaesthesiologist Grade I-II requiring ERCP were enrolled in two groups (30 each). Both groups received fentanyl 1 μg/kg IV at the beginning of ERCP. Group M received IV midazolam (0.04 mg/kg) and additional 0.5 mg doses until Ramsay Sedation Scale (RSS) score reached 3-4. Group D received dexmedetomidine at loading dose of 1 μg/kg over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4. The vital parameters (heart rate (HR), blood pressure (BP), respiration rate, SpO 2 ), time to achieve RSS 3-4 and facial pain score (FPS) were compared during and after the procedure. In the recovery room, time to reach modified Aldrete score (MAS) 9-10 and patient and surgeon′s satisfaction scores was also recorded and compared. Any complication during or after the procedure were also noted. Results: In Group D, patients had lower HR and FPS at 5, 10 and 15 min following the initiation of sedation (P<0.05). There was no statistically significant difference in BP and respiratory rate. The procedure elicited a gag response in 29 (97%) and 7 (23%) subjects in Group M and Group D respectively (P<0.05). MAS of 9-10 at 5 min during recovery was achieved in 27 (90%) subjects in Group D in contrast to 5 (17%) in Group M (P<0.05). Dexmedetomidine showed higher patient and surgeon satisfaction scores (P<0.05). Conclusion: Dexmedetomidine can be a superior alternative to midazolam for conscious sedation in ERCP.

Ultrasound measurement of inferior vena cava collapse predicts propofol-induced hypotension

STUDY OBJECTIVES Hypotension is a common side effect of propofol, but there are no reliable methods to determine which patients are at risk for significant propofol-induced hypotension (PIH). Ultrasound has been used to estimate volume status by visualization of inferior vena cava (IVC) collapse. This study explores whether IVC assessment by ultrasound can assist in predicting which patients may experience significant hypotension. METHODS This was a prospective observational study conducted in the operating suite of an urban community hospital. A convenience sample of consenting adults planned to receive propofol for induction of anesthesia during scheduled surgical procedures were enrolled. Bedside ultrasound was used to measure maximum (IVCmax) and minimum (IVCmin) IVC diameters. IVC-CI was calculated as [(IVCmax-IVCmin)/IVCmax × 100%]. The primary outcome was significant hypotension defined as systolic blood pressure (BP) below 90mmHg and/or administration of a vasopressor to increase BP during surgery. RESULTS The study sample comprised 40 patients who met inclusion criteria. Mean age was 55years, (95%CI, 49-60) with 53% female. 55% of patients had significant hypotension after propofol administration. 76% of patients with IVC-CI≥50% had significant hypotension compared to 39% with IVC-CI<50%, P=.02. IVC-CI≥50% had a specificity of 77.27% (95%CI, 64.29%-90.26%) and sensitivity of 66.67% (95%CI, 52.06%-81.28%) in predicting PIH. The odds ratio for PIH in patients with IVC-CI≥50% was 6.9 (95%CI, 1.7-27.5). CONCLUSION Patients with IVC-CI≥50% were more likely to develop significant hypotension from propofol. IVC ultrasound may be a useful tool to predict which patients are at increased risk for PIH.

Middle East respiratory syndrome: A new global threat

The outbreak of Middle East respiratory syndrome (MERS) is reported from Saudi Arabia and the Republic of Korea. It is a respiratory disease caused by coronavirus. Camels are considered as a source for MERS transmission in humans, although the exact source is unknown. Human-to-human transmission is reported in the community with droplet and contact spread being the possible modes. Most patients without any underlying diseases remain asymptomatic or develop mild clinical disease, but some patients require critical care for mechanical ventilation, dialysis and other organ support. MERS is a disease with pandemic potential and awareness, and surveillance can prevent such further outbreaks.

Inadvertent intrathecal injection of labetalol

Labetalol is a combined α and β adrenergic receptor blocker. It is used to treat hypertension, especially in pregnant patients. We report a case of a female patient who was given labetalol intrathecally in place of bupivacaine due to a similar appearance of ampoules which resulted in a drop in blood pressure and pulse rate. The patient responded to fluid resuscitation and there occurred no neurological sequelae.

Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature.

Physiological changes of pregnancy imposes higher risk of acute respiratory failure (ARF) with even a slight insult and remains an important cause of maternal and fetal morbidity and mortality. Although pregnant women have different respiratory physiology and different causes of ARF, guidelines specific to ventilatory settings, goals of oxygenation and weaning process could not be framed due to lack of large-scale randomized controlled trials. During the 2009 H1N1 pandemic, pregnant women had higher morbidity and mortality compared to nonpregnant women. During this period, alternative strategies of ventilation such as high-frequency oscillatory ventilation, inhalational of nitric oxide, prone positioning, and extra corporeal membrane oxygenation were increasingly used as a desperate measure to rescue pregnant patients with severe hypoxemia who were not improving with conventional mechanical ventilation. This article highlights the causes of ARF and recent advances in invasive, noninvasive and alternative strategies of ventilation used during pregnancy.

Aseptic handling of ultrasound probe: An easy solution

Sir, Ultrasonography (USG) is nowadays routinely used in anesthesia and critical care practice for nerve blocks, central venous cannulation, and tapping of pleural or pericardial effusions. There have been reports of bacterial infections transmitted through ultrasound probe and coupling gel.[1] To prevent or minimize the risk of infection, USG probe and its cable are generally wrapped in commercially available sterile disposable sleeve. In case of its nonavailability surgical drape, autoclavable sleeves, surgical gloves, or condoms are used. Of these, gloves are the ones majority of USG users are familiar with. The technique includes wearing two pairs of gloves one above another, holding the USG probe having jelly applied over transducer surface with one hand, followed by removing the outer glove inside out over the probe. However, the technique requires multiple maneuvers to fasten the fingers of the glove just above the probe. In addition, some amount of air is invariably left within the glove which affects image quality. In a modified technique to avoid fastening manures, a finger portion of glove is removed aseptically, and the probe with applied coupling gel is advanced through it to cover the probe.[2] Although “sterile glove” technique allows the probe to be used in aseptic condition, the uncovered accompanying cable always carries the risk of contaminating the procedural area during manipulations with the probe.

Airway management in a patient with blunt trauma neck: A concern for anesthesiologist

Abstract Laryngo-tracheal injuries resulting from blunt trauma neck are fortunately rare, but may have dire consequences. A high index of suspicion is required to make the diagnosis. Here we report a case of airway management of a patient with blunt trauma neck with tracheal tear posted for tracheal tear repair under GA. Tracheostomy, FOB guided intubation and direct laryngoscopy are the standard methods used to secure the airway in these patients, but sometimes they may aggravate the underlying injury. Technique of choice depends upon patient’s condition, urgency, and experience of anesthesiologist and surgeon.

Air- Q intubating laryngeal airway guided intubation in Morquio syndrome

Mucopolysaccharidoses (MPS) are lysosomal storage disorders caused by the deficiency of enzymes required for the stepwise breakdown of glycosaminoglycans (GAGs), also known as mucopolysaccharides. Patients with MPS may develop complications during general anaesthesia (GA) due to the presence of airway obstruction, excessive secretions, a large tongue and an abnormal airway anatomy. Patients with MPS type IV, also known as Morquio syndrome, pose even greater challenge because of additional problems such as neck instability, restrictive pulmonary disease and end-organ damage.

Alternative electrocardiography electrode placement

Continuous real-time ECG monitoring is an essential part of basic intraoperative monitoring guidelines [1, 2]. However, the three-lead ECG electrodes routinely placed in the Mason–Likar (M-L) configuration (i.e. both infraclavicular fossae, and the anterior axillary line midway between the iliac crest and the costal margin) can encroach on the surgical field during anterior chest wall, upper abdominal and shoulder surgery. Further electrode relocation reduces their access by the anaesthetist, and risks misinterpretation [3]. Takuma et al. suggest relocation to the anterior acromial region and anterior superior iliac spines bilaterally, but this is associated with abnormalities in R-wave amplitude (specifically an increase in lead 2) [4]. Instead, we have found that placing electrodes on the left and right sides of the forehead and a third anywhere below neck on the left side improves accessibility without detriment to ECG output morphology (Fig. 3). With minor re-adjustment, this configuration can be used successfully alongside processed electroencephalography electrodes.

The ketamine enigma

Ketamine, first introduced into clinical practice in the 1960s as a general anesthetic, is a noncompetitive antagonist at the glutamate N-methyl-d-aspartate receptor and binds to sites located in the cortex and limbic structures of the brain. This mechanism is believed to be responsible for most of its dissociative effects. It interacts with muscarinic, nicotinic, and cholinergic receptors and inhibits the neuronal uptake of norepinephrine, dopamine, and serotonin resulting in the sympathomimetic effects. At high doses, ketamine binds to mu and sigma opioid receptors, resulting in the loss of consciousness. Ketamine is redistributed from the central nervous system and undergoes hepatic transformation by the cytochrome P450 system into its active metabolite, norketamine. Norketamine has about one-third of the anesthetic potency of ketamine with a half-life of 2.5 h. Ketamine metabolites are mainly excreted in the urine.