R Gopinath

Effect of perineural dexmedetomidine on the quality of supraclavicular brachial plexus block with 0.5% ropivacaine and its interaction with general anaesthesia

Background and Aims: The effect of perineural dexmedetomidine on the time to onset, quality and duration of motor block with ropivacaine has been equivocal and its interaction with general anaesthesia (GA) has not been reported. We assessed the influence of dexmedetomidine added to 0.5% ropivacaine on the characteristics of supraclavicular brachial plexus block and its interaction with GA. Methods: In a randomised, double blind study, 36 patients scheduled for orthopaedic surgery on the upper limb under supraclavicular block and GA were divided into either R group (35 ml of 0.5% ropivacaine with 0.5 ml of normal saline [n - 18]) or RD group (35 mL of 0.5% ropivacaine with 50 μg dexmedetomidine [n - 18]). The onset time and duration of motor and sensory blockade were noted. The requirement of general anaesthetics was recorded. Results: Both the groups were comparable in demographic characteristics. The time of onset of sensory block was not significantly different. The proportion of patients who achieved complete motor blockade was more in the RD group. The onset of motor block was earlier in group RD than group R (P < 0.05). The durations of analgesia, sensory and motor blockade were significantly prolonged in group RD (P < 0.00). The requirement of entropy guided anaesthetic agents was not different in both groups. Conclusions: The addition of dexmedetomidine to 0.5% ropivacaine improved the time of onset, quality and duration of supraclavicular brachial plexus block but did not decrease the requirement of anaesthetic agents during GA.

Anaesthetic management of a patient with deep brain stimulation implant for radical nephrectomy.

A 63-year-old man with severe Parkinson′s disease (PD) who had been implanted with deep brain stimulators into both sides underwent radical nephrectomy under general anaesthesia with standard monitoring. Deep brain stimulation (DBS) is an alternative and effective treatment option for severe and refractory PD and other illnesses such as essential tremor and intractable epilepsy. Anaesthesia in the patients with implanted neurostimulator requires special consideration because of the interaction between neurostimulator and the diathermy. The diathermy can damage the brain tissue at the site of electrode. There are no standard guidelines for the anaesthetic management of a patient with DBS electrode in situ posted for surgery.

Role of Steroids in Prevention of Pain on Propofol Injection

Background and objectives: Pain following intravenous injection of propofol continues to be an intriguing problem. None of the commonly used methods completely attenuate the pain. Inflammatory response to propofol contributes to the pain. Role of hydrocortisone in attenuating pain has not been evaluated. This study was conducted to compare the efficacy of lignocaine and hydrocortisone in attenuation of pain following intravenous injection of propofol. Methods: A prospective randomized double-blind, placebo-controlled study was conducted on 72 adult patients belonging to ASA physical status I or II, scheduled to undergo elective surgery. They were randomly assigned into four groups of 18 each. Group NS, group LG, group HC10, and group HC25, received 2ml normal saline, 2ml 2% lignocaine, 10mg/2ml hydrocortisone and 25mg/2ml hydrocortisone respectively as pretreatment. Propofol was injected 30 sec later. A blinded researcher assessed the patient’s pain level using a four point verbal rating scale. Results: The four groups were comparable in respect to patient’s characteristics. There was no significant difference of haemodynamics changes during propofol induction between all the groups. There was no statistically significant difference in the incidence of pain between patients who received hydrocortisone and the placebo group. The incidence of pain was significantly less in group LG than other 3 groups. Conclusion: Use of intravenous low dose hydrocortisone pretreatment of the vein does not attenuate pain following propofol injection.

Role of hydrocortisone in prevention of pain on propofol injection.

Background and Objectives: Pain following intravenous injection of propofol continues to be an intriguing problem. None of the commonly used methods completely attenuate the pain. Inflammatory response to propofol contributes to the pain. Role of hydrocortisone in attenuating pain has not been evaluated. This study was conducted to compare the efficacy of lignocaine and hydrocortisone in attenuation of pain following intravenous injection of propofol. Materials and Methods: A prospective randomized double-blind, placebo-controlled study was conducted on 72 adult patients belonging to American Society of Anesthesiologists (ASA) physical status I or II, scheduled to undergo elective surgery. They were randomly assigned to four groups of 18 each. Group NS, group LG, group HC10, and group HC25. The groups received 2 ml normal saline, 2 ml 2% lignocaine, 10 mg/2 ml hydrocortisone, and 25 mg/2 ml hydrocortisone, respectively, as pretreatment. Propofol was injected 30 sec later. A blinded researcher assessed the patients pain level using a four point verbal rating scale. Results: The four groups were comparable in respect to patients characteristics. There was no significant difference of hemodynamics changes during propofol induction between all the groups. There was no statistically significant difference in the incidence of pain between patients who received hydrocortisone and the placebo group. The incidence of pain was significantly less in group LG than other three groups. Conclusion: Use of intravenous low dose hydrocortisone pretreatment of the vein does not attenuate pain following propofol injection.

Role of dexmedetomidine and sevoflurane in the intraoperative management of patient undergoing resection of phaeochromocytoma.

Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014 496 tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2:25-28. 3. Soni KD, Gupta B, Agrawal P, D’souza N, Sinha C. An uncommon cause of intraoperative airleak. Indian J Crit Care Med 2011;15:237-8. 4. Fuchs J, Schummer C, Giesser J, Bayer O, Schummer W. Detection of tracheal malpositioning of nasogastric tubes using endotracheal cuff pressure measurement. Acta Anaesthesiol Scand 2007;51:1245-9.

Comparison of nitroglycerine and sodium nitroprusside on serum lactate, mixed venous oxygen saturation and mixed venous and arterial PCO2difference during cardiopulmonary bypass

Background: The primary objective of the study was to evaluate the effect of nitoglycerine (NTG) and sodium nitroprusside (SNP) on serum lactate (S. lactate), mixed venous oxygen saturation (SvO2), and mixed venous arterial carbon dioxide difference (V-ACO2) during cardiopulmonary bypass (CPB). The secondary objectives included the effect on mortality, end organ dysfunction, requirement of vasopressors, duration of mechanical ventilation (MV), intensive care unit (ICU) stay and hospital stay. Materials and Methods: A prospective randomized single blinded study was conducted in 40 patients aged between 20 years and 70 years who underwent cardiac surgery on CPB. The patients were randomly divided into Group N (n = 20) receiving NTG (0.5–2 mic/kg/min) and group S (n = 20) receiving SNP (0.5–2 mic/kg/min) from the commencement of total CPB up to complete rewarming (nasopharyngeal temperature >36.5°C). Arterial blood gases and S. lactate were measured at baseline, after institution of total bypass, after completion of cooling and rewarming, at weaning off CPB and admission to ICU. Venous blood gas (VBG) was sampled from the venous reservoir immediately after institution of total bypass and completion of rewarming. Urine output, dose of rescue vasodilator, use of inotropes and vasopressor after CPB, end organ dysfunction, duration of MV, ICU, and hospital stay were noted. Results: Though the SvO2at the end of CPB decreased significantly from the baseline (P Conclusion: The authors showed that S. lactate increased with CPB and this increase did not correlate with SvO2and V-ACO2. NTG and SNP were comparable in their effect on indices of tissue perfusion.

The effect of different dose regimens of tranexamic acid in reducing blood loss during hip surgery

Background and Aims: Antifibrinolytics may help bleeding in orthopaedic surgeries. The present study was undertaken to compare two dose regimens of tranexamic acid (TA) on perioperative blood loss in patients undergoing hip surgeries. Methods: In a prospective, randomised, controlled study, 59 patients scheduled for hip surgery were divided into Group C: receiving normal saline (n - 20), Group B: receiving single dose of TA (10 mg/kg) (n - 21), and Group I: receiving a bolus (10 mg/kg) plus infusion (1 mg/kg/h) of TA up to 4 h postoperatively (n - 18). Blood loss, haemoglobin and allogeneic blood transfusions were compared between the groups. For parametric data, P was calculated by ANOVA. Intergroup comparison was done by post hoc analysis with Bonferroni test. P < 0.05 was considered significant. Results: The intra-operative blood loss was lower in the patients who received TA (525 ± 150, 456 ± 156 and 400 ± 133 ml in Group C, B and I respectively; P = 0.05). The 6th hourly drain collection in Group I was lower than Group B and C (41 ± 18, 46 ± 14 and 31 ± 14 ml in Group C, B, and I respectively; P = 0.018). The blood loss at 24 h was less in groups receiving TA (146 ± 32, 120 ± 76, 107 ± 37 ml for Group C, B and I, respectively; P = 0.02). The requirement of blood transfusions was lower in Group I. Conclusions: A bolus of tranexamic acid followed by infusion is more useful than a single dose in decreasing perioperative blood loss in patients undergoing hip surgeries. It reduces allogenic blood transfusion without increasing risk of thromboembolic events.

Is visualization of dilator also important in central venous cannulation

an acceptable and preferred access site when the right IJV is not available for central venous catheterization, as was done in our case.[6] USG and color Doppler flow USG are reliable and accurate for the diagnosis of IJV thrombosis. The usual treatment for IJV thrombosis involves anticoagulation and antibiotics. Our patient responded to anticoagulation therapy. After this event, we recommend USG Doppler of neck vessels preoperatively in whom, there is history of long-term catheter in situ for hemodialysis and multiple attempts.

Intrathecal magnesium sulfate as a spinal adjuvant in two different doses, combined with 0.5% heavy bupivacaine for infraumbilical surgeries.

The spinal anesthesia has the definitive advantage that profound nerve block can be produced in a large part of the body by the relatively simple injection of a small amount of local anesthetic. Background and Aims: The use of adjuvant drugs with local anesthetics for spinal is intended to improve the success of regional anesthesia. The present study evaluated magnesium sulfate in two different doses and fentanyl as an adjuvant to bupivacaine for spinal anesthesia. Materials and Methods: Following Institutional Ethical Committee approval and written informed consent, a prospective randomized double-blinded study was conducted in 81 cases. Patients included were of either gender belonging to American Society of Anesthesiology (ASA) I or ASA II status undergoing elective infraumbilical surgeries of <3 h. Patients were randomized into four groups and were administered an intrathecal solution of (1) Group NS: 3 cc of 0.5% bupivacaine + 0.5 cc of NS. (2) Group F: 3 cc of 0.5% bupivacaine + 25 mcg fentanyl (0.5 cc). (3) Group M 50: 3 cc of 0.5% bupivacaine + 50 mg magnesium sulfate diluted to 0.5 cc with NS. (4) Group M 100: 3 cc of 0.5% bupivacaine + 100 mg magnesium sulfate diluted to 0.5 cc with NS. The variables assessed were visual analog pain scale, pruritus, intensity of motor block and somnolence before and after intrathecal injection at 5, 10, 15, 30, 45, and 60 min in the 1st h, at every 30 min in next hour and then hourly thereafter. Results: The mean duration of analgesia in normal saline group, fentanyl group, M 50 and M 100 groups are 272.8 (standard error [S.E.] of mean 22.9), 360.0 (S.E. of mean 28.8), 252.5 (S.E. of mean 15.0), 276.6 (S.E. of mean 29.5) min, respectively. Conclusion: The addition of magnesium sulfate in the two different doses (50, 100 mg) does not affect the quality of block or duration of analgesia. However, M 100 is as effective as fentanyl as far as the duration of analgesia is concerned.

Fractured laryngeal mask airway: Hazards of excessive reuse

Laryngeal mask airway (LMA) is commonly used to secure an airway for day care, and other short duration surgical procedures. A 25-year-old male patient of American Society of Anesthesiologists (ASA) Grade 1 with fracture right side medial malleolus was scheduled to undergo open reduction and internal fixation. As the patient did not give consent for regional anesthesia, surgery was planned under general anesthesia with LMA. Intravenous access secured and standard monitoring were connected. General anesthesia was induced with injection propofol. The LMA size 4 (Intavent Orthofix Ltd., Maidenhead, UK) was inserted into the sniffing position. Anesthesia was maintained with oxygen, N2O, and sevoflurane with patient breathing spontaneously. At the emergence, the sudden disappearance of ETCO2 trace on the monitor was noted. Immediately found that the shaft of LMA was bitten by the patient, and it was completely cut into two pieces. The distal shaft of LMA along with the connector to a breathing circuit fell apart and inflated LMA along with proximal part of the shaft was in the patient’s mouth. Although the patient was breathing spontaneous, and vitals were stable, but still was not responding to calls. The mouth was opened by giving traction to the jaw, and part of LMA left inside the mouth was completely removed after deflation. The patient was oxygenated with face mask till he became completely awake and transported to the recovery room with stable vitals. There was a complete oblique fracture of shaft of LMA [Figure 1]. After checking the records, it was confirmed that the LMA was reused 54 times due to the paucity of supply. Commonly damage to LMA occurs during emergence.[1,2] Retrieval of all the pieces of fractured LMA is very important.