Raktima Anand

Anesthetic drug wastage in the operation room: A cause for concern

Context: The cost of anesthetic technique has three main components, i.e., disposable supplies, equipments, and anesthetic drugs. Drug budgets are an easily identifiable area for short-term savings. Aim: To assess and estimate the amount of anesthetic drug wastage in the general surgical operation room. Also, to analyze the financial implications to the hospital due to drug wastage and suggest appropriate steps to prevent or minimize this wastage. Settings and Design: A prospective observational study conducted in the general surgical operation room of a tertiary care hospital. Materials and Methods: Drug wastage was considered as the amount of drug left unutilized in the syringes/vials after completion of a case and any ampoule or vial broken while loading. An estimation of the cost of wasted drug was made. Results: Maximal wastage was associated with adrenaline and lignocaine (100% and 93.63%, respectively). The drugs which accounted for maximum wastage due to not being used after loading into a syringe were adrenaline (95.24%), succinylcholine (92.63%), lignocaine (92.51%), mephentermine (83.80%), and atropine (81.82%). The cost of wasted drugs for the study duration was 46.57% (Rs. 16,044.01) of the total cost of drugs issued/loaded (Rs. 34,449.44). Of this, the cost of wastage of propofol was maximum being 56.27% (Rs. 9028.16) of the total wastage cost, followed by rocuronium 17.80% (Rs. 2856), vecuronium 5.23% (Rs. 840), and neostigmine 4.12% (Rs. 661.50). Conclusions: Drug wastage and the ensuing financial loss can be significant during the anesthetic management of surgical cases. Propofol, rocuronium, vecuronium, and neostigmine are the drugs which contribute maximally to the total wastage cost. Judicious use of these and other drugs and appropriate prudent measures as suggested can effectively decrease this cost.

Management of swine-flu patients in the intensive care unit: Our experience

Background: H1N1 pandemic in 2009–2010 created a state of panic not only in India, but in the whole world. The clinical picture seen with H1N1 is different from the seasonal influenza involving healthy young adults. Critical care management of such patients imposes a challenge for anesthesiologist. Materials and Methods: A retrospective analysis of hospitalized positive H1N1 patients was performed from July 2009–June 2010. Those requiring the ventilatory support were included in the study. Result: 54 patients were admitted in the swine-flu ward during the study period out of which 19 required ventilatory support. The average day of presentation to the health care facility was 6th day causing delay in initiation of antiviral therapy and increased severity of the disease. 65% of the ventilated patients were having associated comorbidities. Mortality was 74% among ventilated patients. Conclusion: Positive H1N1 with severe disease profile have a poor outcome. Early identification of high-risk factors and thus early intervention in the form of antiretroviral therapy and respiratory care will help in reducing the overall mortality.

Comparative evaluation of transversus abdominis plane block with transcutaneous electrical nerve stimulation for postoperative analgesia following lower segment caesarean section

Background : Pain relief after caesarean is more compelling than any other surgery. As most commonly used modalities are associated with various side-effects, a multimodal approach is recommended. Transversus abdominis plane (TAP) block and transcutaneous electrical nerve stimulation (TENS) as part of multimodal postoperative analgesia regimes have been shown to be promising following caesarean section. Materials and Methods : 40 patients undergoing caesarean section under spinal anaesthesia were randomly allocated into 2 groups, first group receiving TAP block and second receiving TENS. In postoperative period pain, nausea and vomiting, sedation was recorded at 30 minutes, 2, 4, 6, 12 and 24 hours. Results : Both TAP block and TENS were effective for post caesarean analgesia as a part of multimodal regimen. In both groups VAS was less than 3 at each time interval. None of the patients required rescue analgesia. There was no complication with TAP block. Three patients in TENS group complained of discomfort and apprehension because of tingling sensation of TENS. Conclusion : Both TAP block and TENS as a part of multimodal analgesia are effective following caesarean delivery. Both decrease requirement of opioids and thus associated side effects as a result of which the mother is able to care for baby more effectively.

A randomised trial to compare the effect of addition of clonidine or fentanyl to hyperbaric ropivacaine for spinal anaesthesia for knee arthroscopy

Objectives: To evaluate the clinical effects of hyperbaric ropivacaine alone and with clonidine or fentanyl for spinal anaesthesia for knee arthroscopy. Methods: Sixty ASA I/II patients were randomised to receive spinal anaesthesia with hyperbaric ropivacaine alone (Group R), or with clonidine 15 μg (Group RC) or fentanyl 30 μg (Group RF). The sensory and motor block, time to micturition and side effects were assessed. Results: The three groups were similar in mean time to onset of sensory block at T10, height of block and time to maximum block. Sensory regression to S2 took longer in Groups RF and RC compared with Group R (p = 0.001 and p < 0.01, respectively). Time to requirement of rescue analgesia was longer in Groups RF and RC compared with Group R (p = 0.023 and 0.002, respectively). Time for complete regression of motor block and time to voiding were longer in group RC compared with group R (p = 0.022 and p = 0.013, respectively). Conclusion: The addition of fentanyl 30 μg to hyperbaric ropivacaine may be superior to the addition of clonidine 15 μg for knee arthroscopy as it provides a similar prolongation of sensory block and analgesia without prolonging motor block and time to micturition.

Intrathecal catheterisation for accidental dural puncture: A successful strategy for reducing post-dural puncture headache.

The incidence of accidental dural puncture (ADP) varies from 0.19% to 3.6%[1] during epidural space identification and warrants a prompt response. The possible options include; conversion to spinal anaesthesia by injection of hyperbaric drug through the same epidural needle, placement of the epidural catheter in another interspace, intrathecal catheterisation through the dural hole or less commonly abandoning the procedure.[2,3] Although the first two options may help to tide over the immediate anaesthetic/analgesic requirements, post-dural puncture headache (PDPH) remains a major concern.[1,2]

Avoiding iatrogenic thrombo-embolism: the "KAPLIT" technique

In patients with traumatic injury of an upper limb it is often necessary to both secure intravenous (IV) access and record blood pressure noninvasively in the other upper limb. This may cause intermittent obstruction to the flow of IV fluids during cuff inflation. Also backflow of blood into the IV tubing when the cuff is inflated and the temporary stasis which occurs predisposes to clotting of blood in the IV tubing/catheter. Overenthusiastic efforts to push IV fluids without disconnection and flushing of IV line may pose a possible risk of embolizing the clotted blood thrombus into circulation. We describe a simple technique to prevent backflow of blood into the IV tubing when both intravenous fluid infusion and non-invasive blood pressure cuff are in the same limb. This may prevent clot formation and eliminate the risk of an iatrogenic thrombo-embolism.

Awareness among resident doctors with regards to cardiac defibrillators

Background and Aims: Electrical defibrillation is the most important therapy for patients in cardiac arrest. The audit was aimed to assess awareness among residents with respect to routine preuse checking of cardiac defibrillators. Materials and Methods: The audit was conducted at a multispeciality tertiary care referral and teaching center by means of a printed questionnaire from anaesthesiology residents. A database was prepared and responses were analyzed. Results: Eighty resident doctors participated in the audit. Most (97.8%) of the residents were sure of the presence of a defibrillator in the operation room (OR); 70% of postgraduates (PG)s were aware of the location of the defibrillator in the OR as compared to 83.7% of the senior resident (SRs). Also, 32.1% residents routinely check the availability of a defibrillator. The working condition of the defibrillator was checked by 21.7% of the residents; 25.3% ensured delivery of the set charge. Further, 8.2% of residents ensured availability of both adult and paediatric paddles. About 27.8% of residents ensured the availability of appropriate conducting gel and 53.8% residents were of the opinion that the responsibility of checking the functioning and maintenance of the defibrillators lies with themselves. Some 22% thought that both doctors and technical staff should share the responsibility, while 19.5% opined that it should be the responsibility of the technical staff. Conclusion: All medical equipment is to be tested prior to initial use and periodically thereafter. An extensive, recurring training program, and continued attention to the training of clinical personnel is required to ensure that they are proficient in the operation and testing of specific defibrillator models in their work area. We conclude that apart from awareness of the use of the equipment we are using, its preuse testing is must. All resident doctors should be aware of the presence and adequate functioning of the defibrillator in their ORs and this audit reinforces the need for training of all resident doctors.

Attitude of resident doctors towards intensive care units' alarm settings.

Intensive care unit (ICU) monitors have alarm options to intimate the staff of critical incidents but these alarms needs to be adjusted in every patient. With this objective in mind, this study was done among resident doctors, with the aim of assessing the existing attitude among resident doctors towards ICU alarm settings. This study was conducted among residents working at ICU of a multispeciality centre, with the help of a printed questionnaire. The study involved 80 residents. All residents were in full agreement on routine use of ECG, pulse oximeter, capnograph and NIBP monitoring. 86% residents realised the necessity of monitoring oxygen concentration, apnoea monitoring and expired minute ventilation monitoring. 87% PGs and 70% SRs routinely checked alarm limits for various parameters. 50% PGs and 46.6% SRs set these alarm limits. The initial response to an alarm among all the residents was to disable the alarm temporarily and try to look for a cause. 92% of PGs and 98% of SRs were aware of alarms priority and colour coding. 55% residents believed that the alarm occurred due to patient disturbance, 15% believed that alarm was due to technical problem with monitor/sensor and 30% thought it was truly related to patient’s clinical status. 82% residents set the alarms by themselves, 10% believed that alarms should be adjusted by nurse, 4% believed the technical staff should take responsibility of setting alarm limits and 4% believed that alarm levels should be pre-adjusted by the manufacturer. We conclude that although alarms are an important, indispensable, and lifesaving feature, they can be a nuisance and can compromise quality and safety of care by frequent false positive alarms. We should be familiar of the alarm modes, check and reset the alarm settings at regular interval or after a change in clinical status of the patient.

Anesthetic management of an unusual complication during laser ablation of congenital subglottic hemangioma

Sir, A 3.8-kg, 4-month-old child presented with progressively ensuring satisfactory mask ventilation, suxamethonium 1.5mg/ kg was administered IV to facilitate endotracheal intubation. Laryngoscopy revealed Cormack Lehane grade III. Trachea was intubated with 4.0 mmID uncuffed tube using a stylet and fixed at 13 cm. Fentanyl 5μg was administered for analgesia. Anesthesia was maintained with O2 (40%), N2O, sevoflurane (with cumulative MAC between 1-1.2) and atracurium. IV paracetamol 10mg/kg was administered in the maintenance fluid. The procedure lasted for 2.5 hours and the intraoperative course was uneventful. After the procedure, muscle relaxant was reversed and the trachea was extubated. Postoperative course was uneventful and no episode of aponeic spells was observed in postoperative period.

Selective endobronchial intubation in a child using a rigid bronchoscope

SIR—Several techniques for one lung ventilation (OLV) in pediatric patients have been described (1). The techniques include the use of a double-lumen tube, Univent tube (Fuji Systems, Tokyo, Japan), bronchial blockers, and selective endobronchial intubation. A conventional endotracheal tube (ETT) advanced endobronchially is the simplest means of providing OLV. Although this may be best accomplished using a flexible fiberoptic bronchoscope (FOB), techniques to facilitate blind insertion of the ETT into the endobronchial location have also been described with success rates ranging from 50% to more than 90% (2). We describe the use of a rigid ventilating bronchoscope along with airway exchange catheter (AEC) for achieving successful left endobronchial intubation in a child who presented with major bronchial injury when FOB was not immediately available. An 8-year-old girl weighing 20 kg presented 6 h after having been crushed underneath the carriage of an agricultural tractor trolley in a road accident with steadily increasing dyspnoea and two episodes of hemoptysis. Although she followed verbal commands, but was tachypnoeic (respiratory rate of 60 min). Her heart rate was 130 beats per minute, and peripheral pulses were not palpable. Blood pressure and peripheral oxygen saturation could not be recorded. Absent air entry over the right side of the chest with a resonant percussion note prompted the surgical team to perform a rapid tube thoracostomy that revealed a hemopneumothorax. A continuous air leak and frothing were observed. Even after initial resuscitation with intravenous fluids and blood, general condition failed to improve. A check chest radiograph revealed a right-sided pneumothorax with an intercostal drain in situ. Poor arterial saturation (50% with supplemental oxygen) and continual air leak in the absence of subcutaneous emphysema prompted the suspicion of major tracheobronchial injury, and therefore, a bronchoscopic evaluation was planned in the operating room prior to thoracotomy. Anesthesia was induced with fentanyl and sevoflurane in 100% O2 while assisting spontaneous respiration with bag and mask. Rigid bronchoscopic (Karl Storz size 3.5, 5.0 mm ID, 5.7 mm OD, 26 cm, with a zero degree telescope) examination revealed a tear in the right intermediate bronchus, while the trachea and left main bronchus appeared normal. Massive air leak through the right bronchus mandated a left-sided endoCorrespondence