Priyamvada Gupta

Dexmedetomidine as an adjuvant for Hypotensive Anaesthesia during Functional Endoscopic Sinus Surgery (FESS)

Introduction:FESS (Functional Endoscopic Sinus Surgery) is done via endoscope and the area is highly vascular thus it becomes important to minimize bleeding. Hence we require hypotensive anesthesia. Various drugs have been used for the purpose: nitroglycerine (NTG), sodium nitroprusside(SNP),propofol,beta blockers, calcium channel blockers, higher concentrations of inhalational anesthetics etc. Since all these drugs have certain limitations there was a search for safer and more effective drug .Dexmedetomidine, a newer alphaadrenoceptor agonist,fulfills this requirement since it is short acting, has no residual effects, produces sedation and analgesia and reduces mean arterial pressure thereby reducing intraoperative blood loss. Aims: To study the efficacy of dexmedetomidine in providing hypotensive anaesthesia so as to minimize bleeding during endoscopic sinus surgery in a randomized double blind control study. Method:40 patients of ASA grade I/II, aged18-55yrs,scheduled for endoscopic sinus surgery, were randomly allocated into two groups of twenty each by sealed envelope method. Group C: received Normal saline as loading dose of 1mcg/kg intravenously followed by maintenance infusion of 0.6mcg/kg intravenously, Group D: received dexmedetomidine in similar doses. The loading dose was given slowly over 15 minutes. The surgery was started after the loading dose was over. Both the anaesthetist conducting the study and the patient were blinded to the study drug. The amount of blood loss, doses of intravenous& inhalation agents and side effects were studied. Results:The patient characteristics did not differ in bothcontrol(C) and study (D) groups (Table1). Blood losses were lower in group D as compared to group C (p = 0.03).Total dose of fentanyl (p< 0.001),propofol( p <0.001 )and isoflurane ( p =0.04 )were lower in group D as compared to group C. The VAS scores in the immediate postoperative periods were also lower in the group D (p =0.03).The only side effect noted was bradycardia (2patients)which however reverted with discontinuation of the drug.Atropine was not required. Conclusions:Dexmedetomidine is a safe &effective adjuvant for hypotensive anaesthesia to decrease bleeding and thus provide bloodless field during FESS surgery. It also decreases the dose requirements of

Acute cyanide Intoxication: A rare case of survival

A 30-year-old male jewellery factory worker accidentally ingested silver potassium cyanide and was brought to the emergency department in a state of shock and profound metabolic acidosis. This patient was managed hypothetically with use of injection thiopentone sodium intravenously until the antidote was received. Cyanide is a highly cytotoxic poison and it rapidly reacts with the trivalent iron of cytochrome oxidase thus paralysing the aerobic respiration. The result is severe lactic acidosis, profound shock, and its fatal outcome. The patient dies of cardio-respiratory arrest secondary to dysfunction of the medullary centres. It is rapidly absorbed, symptoms begin few seconds after exposure and death usually occurs in <30 min. The average lethal dose for potassium cyanide is about 250 mg. We used repeated doses of thiopentone sodium till the antidote kit was finally in our hands, hypothesising that it contains thiol group similar to the antidote thiosulphate. Moreover, it is an anticonvulsant. We were successful in our attempts and the patient survived though the specific antidotes could be administered after about an hour.

A comparison of Ropivacaine alone and in combination with Fentanyl for caudal analgesia in pediatric patients

Caudal analgesia is a very popular route to provide intraoperative and postoperative analgesia in children because of its simple technique, predictable level of blockade, high success rate and smooth recovery. It can be used mainly for perineal and sub umbilical procedures. Ropivacaine, the S-enantiomer of the amide local anesthetic, produces differential neural blockade, with lesser motor blockade; less cardiovascular and neurological toxicity than bupivacaine, making it suitable for day-care surgery in children. The addition of an adjuvant prolongs and intensifies the sensory blockade caused by local anaesthetic and also reduces the dose of local anaesthetic required to provide desired analgesia. Fentanyl is one of the most commonly used adjuvant with local anesthetics in caudal blocks. The aim of our study was to compare the efficacy of ropivacaine alone and in combination with fentanyl via caudal route for postoperative analgesia in children. The primary end point was duration of sensory and motor blockade. Study Design: Double blind, prospective, randomized .The subjects were 40 children aged 1 - 10 years undergoing perineal and sub umbilical procedures. They were randomly divided in two groups of 20 each using chit in box method. Group R received inj ropivacaine 0.2%, 0.5 ml/kg and Group RF received inj ropivacaine 0.2%,0.5 ml/kg in combination with inj fentanyl 0.5mcg/kg via caudal route just after intubation. GA was induced in the standard manner using propofol. Our study showed that patients in group RF required rescue analgesic 16 - 20 hrs later than patients in group R and the pain scores of group RF were better in the postoperative period. There was no significant motor blockade in both the groups. There was also no significant hemodynamic variation and postoperative complications observed in either group. Thus, addition of fentanyl to ropivacaine as caudal analgesic provides prolonged and more intense postoperative analgesia in children.

A Comparison of Emergence Characteristics with the use of Isoflurane, Sevoflurane and Desflurane in Patients Undergoing Spinal Surgeries under General Anaesthesia

Isoflurane is commonly used agent in neuro anaesthesia. But desflurane has lowest blood gas partition co efficient and has rapid recovery profile. Hence it may have useful role in spine surgeries. There is paucity of data regarding comparison of desflurane, sevoflurane and isoflurane in neuroanaesthesia in adult patients in a single study. Hence the need of present study. Ninety ASA I/II patients aged 20-60 yrs were randomly allocated into three groups of thirty each. Group D, Group S, group I received desflurane, sevoflurane and isoflurane respectively. The primary outcome studied was time to emergence: the time from discontinuation of anaesthetic agents to open eyes either spontaneously or in response to verbal commands. The secondary outcomes studied were time to extubation, time to recovery, haemodyanamic variations and complications if any. Data were analyzed using chi square, student t and ANOVA tests as applicable. p value<0.05 was considered statistically significant.The mean emergence time was shorter in desflurane group (3.32±2.28 min) as compared sevoflurane( 6.13±2.56 min) and isoflurane(7.93±2.02 min) groups (p<0.001) .Similar statistical difference was achieved in extubation and recovery times.Hence desflurane is better suited volatile halogenated agent for adult patients undergoing spine surgeries performed under general anaesthesia.

Role of melatonin in attenuation of haemodynamic responses to laryngoscopy and intubation

Background and Aims: Laryngoscopy and endotracheal intubation are considered as potent stimuli which lead to an increase in heart rate and blood pressure. Melatonin (N-acetyl-5-methoxytryptamine) has been studied for pre-operative anxiolysis and sedation in Intensive Care Unit. We made a hypothesis that melatonin can provide haemodynamic stability during laryngoscopy and intubation when given 120 min before the procedure. Methods: Sixty American Society of Anesthesiologists physical status Grade I and II patients of either gender, 20-45 years old, 40-65 kg body weight, scheduled to undergo elective surgical procedures under general anaesthesia were assigned into two equal groups - Group C (control) and Group M (melatonin). They received oral placebo or melatonin tablets 6 mg, respectively, 120 min before surgery. The haemodynamic parameters were recorded preoperatively, during laryngoscopy and endotracheal intubation and thereafter at 1, 3, 5 and 10 min. Unpaired t-test was used for between-group comparison of ratio and interval scale data. For within-group comparison of ratio and interval scale data, repeated-measures ANOVA and post hoc Bonferroni t-tests were used. Results: It was observed that in the control group, there was a significant increase in heart rate and blood pressure at laryngoscopy and intubation and persisted till 10 min post-intubation. In melatonin group, there was an insignificant increase in heart rate at the time of laryngoscopy and intubation which however settled within 1 min post-intubation. Conclusion: Melatonin is an effective drug for attenuation of cardiovascular responses to laryngoscopy and endotracheal intubation.

Anaesthetic management of a pregnant patient posted for laparoscopic appendectomy in third trimester

1. Parnas M, Sheiner E, Shoham‐Vardi I, Burstein E, Yermiahu T, Levi I, et al. Moderate to severe thrombocytopenia during pregnancy. Eur J Obstet Gynecol Reprod Biol 2006;128:163‐8. 2. Borna S, Borna H, Khazardoost S. Maternal and neonatal outcomes in pregnant women with immune thrombocytopenic purpura. Arch Iran Med 2006;9:115‐8. 3. Devendra K, Koh LP. Pregnancy in women with idiopathic thrombocytopaenic purpura. Ann Acad Med Singapore 2002;31:276‐80. 4. Karne V, Patil M. Severe thrombocytopenia in an immune thrombocytopenic parturient non‐responder to medical line of treatment: Anaesthetic management for splenectomy combined with caesarean section. Indian J Hematol Blood Transfus 2012;28:54‐7. 5. Varghese L, Viswabandya A, Mathew AJ. Dapsone, danazol, and intrapartum splenectomy in refractory ITP complicating pregnancy. Indian J Med Sci 2008;62:452‐5. 6. Tay S, Szabo F, Spain B. Dental extraction in a child with chronic idiopathic thrombocytopenia purpura: Are preoperative platelet transfusions necessary? A A Case Rep 2013;1:3‐4. How to cite this article: Wajekar AS. Anaesthesia management in a patient with severe idiopathic thrombocytopaenia with antepartum haemorrhage for emergency caesarean section. Indian J Anaesth 2015;59:689-90. Access this article online

A comparison of I-gel with the LMA-classic in spontaneously breathing patients

Introduction Laryngeal mask airway (LMA) is a supraglottic airway device (SAD), which was primarily designed to facilitate airway maintenance. Thereafter, many modifications have been made in the SADs, and I-gel is a recent one, which has a unique characteristic of a self-inflatable cuff. It is claimed to be better in terms of ease and success of insertion, risk of complications, etc. Aims and objectives The aim of this study was to investigate and compare the insertion characteristics and complication rate of classic LMA with I-gel. Materials and methods Eighty patients of American Society of Anaesthesiologists I/II, between 16 and 60 years of age, of either sex were randomly divided into two groups of 40 patients each. In respective groups, classic LMA or I-gel were introduced under spontaneous ventilation. Insertion characteristics such as number of attempts at insertion, ease of insertion, better seal, etc. were studied. Proper positioning was confirmed as per fiberoptic view of the glottis. Patients were continuously monitored and hemodynamic variables were studied at frequent intervals. We also recorded the complications at the time of extubation, if any. Data were statistically analyzed using t-test and the χ2 -test. A P value less than 0.05 was considered statistically significant. Results I-gel required less time to insertion (29.32 ± 6.88) compared with cLMA (36.72 ± 7.33 s) (P < 0.05). Airway leak pressure was significantly higher among patients of the I-gel group (26.12 ± 7.41 cm H 2 O) compared with the LMA group (20.77 ± 8.20 cm H 2 O) (P = 0.003). Statistically significant difference was found between the two groups as regards the assessment of patients after removal of the SAD. Fiberoptic view of vocal cords was better in the I-gel group. Conclusion Insertion of I-gel was easier and quicker and proper positioning was achieved in more number of patients as compared with classic LMA. Moreover, there were fewer complications noted at the time of removal of the device.

Comparison of the Effectiveness of Oral Care with Chlorhexidine and Povidone iodine on the Incidence of Ventilator Associated Pneumonia in ICU - A prospective randomized controlled study.

Background: Mechanical ventilation is often required in 10-20% critically ill patients, may be because of respiratory or any other indication. There is always a risk of developing pneumonia in such patients. Any pneumonia developing after 48 hours of commencing mechanical ventilation in a patient with previously non infected lungs is labeled as ventilator associated pneumonia (VAP).It occurs in 9–27% of patients on mechanical ventillation. This study was aimed at comparing the effectiveness of oral care with povidone iodine and chlorhexidine in preventing VAP. Materials and methods: This prospective randomized study included 70 patients in critical care unit requiring mechanical ventilation for more than 72 hrs After obtaining permission from hospital ethical committee and written informed consent from the patients, they were randomly allocated in two groups of 35 each: group I and group II to receive oral care with povidone iodine and chlorhexidine respectively. Development of VAP was recorded on basis of clinical findings, x-ray and tracheal culture. Results &Conclusions: In group receiving oral care with povidone iodine, 6(11.4%) patients developed VAP as compared to chlorhexidine group only 4 (17.1%) patients developed VAP but it did not reach statistical significance. Thus oral care with chlorhexidine is superior in prevention of VAP as compared with povidone iodine mouth wash but more studies need to be done, with larger sample size.

Anesthetic management in a case of congenital sternal cleft diagnosed incidentally on the operating table

Congenital absence of sternum, also known as sternal cleft, is a rare anomaly. It is due to impaired organogenesis leading to nonfusion of sternal bars. It may be of two types- complete or incomplete. It may be associated with other congenital malformations viz., cardiac, anorectal etc., or may be a part of Cantrells pentalogy. Besides cosmetic concerns, mediastinal structures are at increased risk to damage in case of trauma to the anterior chest wall. Due to restricted mediastinal space, there may be restrictive pulmonary dysfunctions and unstable hemodynamics. It usually presents in the neonatal period or early infancy, rarely in adult age. The defect should be surgically closed as early as possible. If cardiac arrest occurs due to any reason, the only option is open cardiac massage. We report a case of complete congenital sternal cleft accidentally diagnosed on the operation table, while preparing the patient for diagnostic laparotomy. The patient was retrospectively assessed for the presence of other congenital malformations.