Prakash K. Dubey

Ondansetron Pretreatment to Alleviate Pain on Propofol Injection: A Randomized, Controlled, Double-Blinded Study

We used a randomized, controlled, double-blinded design to study the effect of ondansetron (OND) pretreatment on the pain produced by the IV injection of propofol. Eighty patients were randomly assigned to one of two groups: Group I received 2 mL of IV 0.9% saline pretreatment, and Group II received

Direction of the J-Tip of the Guidewire, in Seldinger Technique, Is a Significant Factor in Misplacement of Subclavian Vein Catheter: A Randomized, Controlled Study

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n = 147) or cephalad in Group 2 (n = 148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P < 0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = < 0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.

Pain on injection of lipid-free propofol and propofol emulsion containing medium-chain triglyceride: a comparative study.

Pain on injection of propofol continues to be a problem for anesthesiologists. A lipid-free formulation of propofol and a propofol emulsion containing medium-chain triglyceride have become available in the Indian market. We performed this study to assess the pain on injection of propofol emulsion containing medium-chain triglyceride as the lipid carrier and lipid-free propofol formulation. One-hundred-thirty adult patients were randomly assigned to one of two groups: Group I received propofol emulsion containing medium-chain triglyceride and Group II received lipid-free propofol. One fourth of the total calculated induction dose was injected over 5 s in the largest vein on the dorsum of a hand. Pain was assessed using verbal response and behavioral signs. Both formulations caused pain on injection. However, the lipid-free propofol solution produced frequent (89%) and severe pain on injection compared with the emulsion containing medium-chain triglyceride (40%).

Internal Jugular Vein Occlusion Test for Rapid Diagnosis of Misplaced Subclavian Vein Catheter into the Internal Jugular Vein

Background During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV). This can be detected by chest radiography. However, after any repositioning of the catheter, subsequent chest radiography is required. In an effort to simplify the detection of a misplaced subclavian vein catheter, the authors assessed a previously published detection method. Methods One hundred adult patients scheduled for subclavian vein cannulation were included in this study. After placement of subclavian vein catheter, chest radiography was performed. While the x-ray film was being processed, the authors performed an IJV occlusion test by applying external pressure on the IJV for approximately 10 s in the supraclavicular area and observed the change in central venous pressure and its waveform pattern. The observations thus obtained were compared with the position of catheter in chest radiographs, and the sensitivity and specificity of this method were evaluated using a 2 × 2 table. Results In 96 patients, subclavian vein cannulation was successfully performed. In four patients, cannulation was unsuccessful; therefore, these patients were excluded from the study. There were six misplacements of venous catheters as detected by radiography. In five (5.2%) patients, the catheter tip was located in the ipsilateral IJV, and in one (1.02%), the catheter tip was located in the contralateral subclavian vein. In the patients who had a misplaced catheter into the IJV, IJV occlusion test results were positive, with an increase of 3–5 mmHg in central venous pressure, whereas the test results were negative in patients who had normally placed catheters or misplacement of a catheter other than in the IJV. There were no false-positive or false-negative test results. Conclusion The IJV occlusion test successfully detects the misplacement of subclavian vein catheter into the IJV. However, it does not detect any other misplacement. The test may allow avoidance of repeated exposure to x-rays after catheter insertion and repositioning.

Venous oxygen embolism due to hydrogen peroxide irrigation during posterior fossa surgery.

Hazards of application of hydrogen peroxide to semiclosed space are well known. We present a case of suspected gas embolism following hydrogen peroxide irrigation of the surgical field during posterior fossa surgery in the prone position. Severe cardiovascular collapse occurred when the wound was irrigated with hydrogen peroxide solution. Generation of pressure gradient leads to absorption of a considerable amount of oxygen giving rise to features of venous gas embolism. Although the case was associated with an uneventful recovery, use of hydrogen peroxide for securing hemostasis should be avoided.

Gabapentin for the treatment of glossodynia due to an unusual cause.

1. Weintraud M, Marhofer P, Bösenberg A, Kapral S, Willschke H, Felfernig M, Kettner S. Ilioinguinal/iliohypogastric blocks in children: where do we administer the local anesthetic without direct visualization? Anesth Analg 2008;106:89–93 2. Marhofer P, Chan VW. Ultrasound-guided regional anesthesia: current concepts and future trends. Anesth Analg 2007;104: 1265–9 3. Bugedo GJ, Cárcamo CR, Mertens RA, Dagnino JA, Muñoz HR. Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine for post-herniorrhaphy pain management in adults. Reg Anesth 1990;15:130–3

Palatal pressure necrosis due to inappropriate size of Guedel's airway?

Sir, n nA 40-year-old male weighing 63 kg presented to Emergency Department with alleged history of road traffic accident 2 days ago with altered sensorium and seizures, referred from a rural hospital. He had a Guedels orophayrngeal airway size 4 (11 cm) (Romsons Scientific and Surgical Industries Pvt. Ltd., Agra, India) in situ firmly fixed with an elastic adhesive bandage. On initial assessment in the emergency scenario, the patient had a Glasgow Coma Score (GCS) of E3 V2 M5 with stable haemodynamics. A noncontrast computed tomography scan brain showed a left fronto-temporo-parietal subdural haematoma with underlying contusion with no mass effect and no evidence of any associated injuries. The patient was immediately shifted to our trauma Intensive Care Unit (ICU) for further management and monitoring. By the time patient reached the ICU, GCS deteriorated to E2 V1 M5 following a brief episode of seizure which lasted for 60 s. Hence, the decision was taken to perform rapid sequence induction using intravenous propofol (2 mg/kg) and injection rocuronium (1.2 mg/kg). On pulling out Guedels airway to perform oral suctioning before intubation, it was noticed that the mucosa of the palatal region had undergone blackish discolouration apparently due to the sustained pressure of the Guedels airway. However, the trachea was easily intubated with the appropriate size of the tracheal tube. n nIn rural set ups such as ours, Guedels airway is commonly available and used as a bite guard as well as for maintaining an open airway and it is made up of elastomeric or plastic material. However, the lack of awareness among primary health care providers can lead to fatal complications during airway management, especially during emergencies. Ideally, an appropriate size airway should relieve/prevent obstruction of the airway by preventing the tongue from falling back. Pressure necrosis of lower lip due to incorrect placement of Guedels airway has also been reported.[1] n nThe best criterion for proper size and position of the airway is an unobstructed gas passage. A method to ascertain the appropriate size of the airway by measuring the distance between the angle of mouth and mandible has been described.[2] Many primary care providers may not be aware of this. We also recommend that the manufacturers provide a diagrammatic depiction showing how to select proper size and insertion technique of airway on the package back cover to prevent such complications. n nIn our case, palatal pressure necrosis may have occurred due to inappropriate size selection, prolonged placement and firm fixation of Guedels airway with a tight elastic adhesive bandage. There is need to emphasize the importance of using proper size of airway devices and teaching the healthcare workers of correct usage of the devices available to them. n nFinancial support and sponsorship nNil. n n nConflicts of interest nThere are no conflicts of interest.

Use of tracheal tube as a splint to prevent intraoperative kinking of gas sampling line.

To JNA Readers: Capnography is an essential monitor during neurosurgery, and kinking of the gas sample line is not unknown, particularly with the side stream analyzer.1 We present a solution that prevents the problem of kinking. A 25-year-old male patient was scheduled to undergo frontal craniotomy and excision of meningioma under general anesthesia. After about 30 minutes from start of surgery, a loss of capnogram was traced to kinking of the gas sampling line at the point connected to the adapter, probably due to the weight of the drapes. To overcome this problem, we took a small length of a nonsiliconised tracheal tube with an ID of 3.0mm. A cut was made in this piece along its long axis, was spread apart, and gently slipped over the sample line near the adapter (Fig.1). This worked as reinforcement over the sample line and prevented kinking at the point of attachment of the line to the adapter. The course of anesthesia was uneventful thereafter. During anesthesia, the gas sampling line is kept vertical to prevent moisture entering the line which also exposes it to the possibility of kinking in certain situations. Mostly kinking occurs near the point where the sampling line is connected to the adapter in the breathing system because of compression by drapes, suction tubing, drill, or the assistant’s hand.2 This can happen more often during prolonged surgeries or when a forced air warming device is being used. Our solution to this problem is simple and quick to perform with the help of easily available resource. Kinking is thus prevented because now the pressure is exerted more proximally on the sample line itself rather than at the junction of the sample line and the adapter. The sample line being high-pressure tubing can withstand this moderate pressure without kinking. Our method can be used to prevent kinking anywhere in the sample line including the end that is attached to the water trap. Care should be taken that the direction of the possible kink in the sample line should not lie against the split side of the reinforcement tube. Or else, a paper tape can be wrapped around the reinforcement tube. One method described to prevent this problem is to loop the sample line; however, this does not prevent lateral kinking.1 Another technique suggests adding a 3-way stop cock to the sampling line near the breathing circuit.2 However, there are concerns of leak, and increase in resistance and efficacy to remove secretions by purging the sample line or increasing the flow rate with this technique. The various manufacturers of the side stream capnograph use different systems at the adapter end. Some have a detachable sample line, and in others, the sample line is fixed to the adapter (Fig.1). Appropriate size of tracheal tube should be selected to ensure a snug fitting over the adapter end of the sample line. Prakash K. Dubey, MD Neeraj Kumar, MD Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, India

Hydrogen peroxide irrigation: avoid it or be prepared for it?

References 1. Nelskylä KA, Yli-Hankala AM, Puro PH, Korttila KT. Sevoflurane titration using bispectral index decreases postoperative vomiting in phase II recovery after ambulatory surgery. Anesth Analg 2001;93:1165–9. 2. Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology 1997;87:842–8. 3. Yli-Hankala A, Vakkuri A, Annila P, Korttila K. EEG bispectral index monitoring in sevoflurane or propofol anesthesia: analysis of direct costs and immediate recovery. Acta Anaesthesiol Scand 1999;43:545–9. 4. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: Conclusions from cross-validations between two centers. Anesthesiology 1999;91:693–700. 5. Apfel CC, Kranke P, Eberhart LHJ, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. Brit J Anaesth 2002;88:234–40.

Internal jugular vein cannulation in neurosurgical patients: a new approach.

A new approach to internal jugular vein (IJV) cannulation with the head and neck placed in the neutral position is described. The junction of the medial two thirds and lateral one third between the angle of the mandible and symphysis menti is identified. A vertical line is drawn from this point to join another line drawn between the mastoid process and the medial end of the clavicle. The junction is the puncture point. In 120 patients studied, the failure rate was 1.66%, and there were no complications. We propose this technique as a safe and reliable alternative in neurosurgical patients.