Raminder Sehgal

A prospective randomized study comparing two techniques of perioperative blood conservation: isovolemic hemodilution and hypervolemic hemodilution.

We compared hypervolemic hemodilution (HVH) and isovolemic hemodilution (IVH) as means of perioperative blood conservation under standardized conditions. Thirty ASA status I/II adults slated for orthopedic, ear-nose-throat, or general surgery with expected blood loss of >500 mL underwent either IVH (n = 15) or HVH (n = 15). They were hemodiluted to a hematocrit (Hct) of 25% by blood withdrawal and simultaneous polygeline (Hemaccel®) infusion (IVH) or by infusing polygeline without blood withdrawal, thus creating hypervolemia (HVH). Further blood loss to a Hct of 20% was allowed before autologous/allogeneic blood transfusion to aim for a 24-h postoperative Hct of ≥25%. Systolic blood pressure (P = 0.0107) and central venous pressure (P = 0.0281) were significantly higher during HVH. The mean difference (MD) between the target postdilution Hct of 25% and the Hct achieved was not statistically significant in either group (MD [95% confidence interval; CI], 0% [−0.7% to 0.7%] for IVH and 0.6% [−0.1% to 1.3%] for HVH). The actual amount of allogeneic blood used was similar in the two groups, with an MD (95% CI) of −7 (−326 to 312), and was significantly less than the corresponding projected amount (MD [95% CI], −581 mL [−753 to −409 mL] in IVH; −376 mL [−531 to −221] in HVH). The two techniques were similar in time taken (MD [95% CI] = 7 min [−0.5 to 14.5 min]), cost incurred (MD [95% CI] =

Hemodynamics and early recovery characteristics of desflurane versus sevoflurane in bariatric surgery

1.7 (−

ProSeal TM laryngeal mask airway cuff pressure changes with and without use of nitrous oxide during laparoscopic surgery

4.10 to

ProSeal laryngeal mask airway TM insertion in the prone position: Optimal utilization of operation theatre personnel and time?

7.50]), and volumes of polygeline used (MD [95% CI] = −6 mL/kg body weight [−16 to 4 mL/kg body weight]). This study found IVH and HVH comparable in significantly reducing perioperative allogeneic blood requirements, time needed, and cost incurred. The formula used for achieving the desired HVH appears promising.

LMA Proseal for the surgical procedures in prone positioning - Reply.

Context: Morbidly obese patients are prone for intraoperative hemodynamic disturbances and postoperative airway complications. Aim: Comparison of intraoperative hemodynamics and postoperative recovery characteristics of desflurane versus sevoflurane in morbidly obese patients undergoing laparoscopic bariatric surgery. Settings and Design: Randomized controlled trial Materials and Methods: After institutional ethics committee approval and written informed consent, 40 morbidly obese patients (BMI > 35 kg/m2) were randomized to receive desflurane or sevoflurane as part of a standardized general anesthesia technique. Volatile anesthetic concentration was titrated to maintain electroencephalographic bispectral index score (BIS) in the range of 40-60. Mean arterial pressure (MAP) and heart rate (HR) were recorded preoperatively, at induction and intubation, then at regular intervals. After extubation, early recovery was recorded by time to emergence and orientation to time and place. In post anesthesia care unit, intermediate recovery was assessed by modified Aldrete Score and Digit Symbol Substitution Test (DSST). Results: Intraoperative MAP and HR did not differ between the two groups (P > 0.05). The time to response to painful stimuli, obeying verbal commands and spontaneous eye opening was shorter (P = 0.001) and modified Aldrete Score was higher after desflurane anesthesia than after sevoflurane anesthesia (P = 0.049). DSST also returned towards normal faster after desflurane (28.50 ± 6.30 min vs. 35.0 ± 5.62 min, P = 0.03). Conclusions: Both desflurane and sevoflurane produce similar hemodynamic changes but the immediate and intermediate recovery was significantly faster after desflurane thus contributing to fast tracking and early discharge of patients.

Anaphylaxis during anaesthesia: Indian scenario

Background: The ProSeal™ laryngeal mask (PLMA) is increasingly being used as an airway device for laparoscopic surgery. Its silicone cuff allows diffusion of nitrous oxide, carbon dioxide and other gases with resultant rise in its intracuff pressure during anesthesia. The present study was designed to investigate the intracuff pressure changes during anesthesia with and without nitrous oxide in patients undergoing laparoscopic surgery lasting up to two hours. Materials and Methods: One hundred patients, American Society of Anesthesiologists physical status 2 and 3, undergoing general anesthesia with muscle paralysis, were randomized into two groups of 50 patients each to receive an anesthetic gas mixture containing either oxygen and nitrous oxide (group N) or oxygen and air (group A). Following insertion of an appropriate size PLMA, its cuff was inflated with air to an intracuff pressure of 45 mm Hg. The cuff pressure was measured every 10 minutes for the entire course of anesthesia. The position of the device was also assessed fiberoptically and postoperative airway complications were recorded. Results: The maximum intracuff pressure recorded in group N was 103 ± 4.7 mm Hg vs. 45.5 ± 1.5 mm Hg in group A. The percentage rise in cuff pressure every 10 minutes was also highly significant (P < 0.001) being maximum in first 10 min in group N. The incidence of postoperative airway complications was comparable between the two groups. Conclusion: The results of this study demonstrate that the intracuff pressure of the PLMA increases progressively over time when the breathing gas mixture contains nitrous oxide.

Anaesthetic management of parturient with malaria and thrombocytopaenia

Background: Positioning an anesthetized patient prone is challenging with regard to manpower requirement, time to surgical readiness and airway management. The ProSeal laryngeal mask airway™ (PLMA) is emerging as a suitable alternative, both as a primary and a rescue airway device to the tracheal tube (TT) for patients undergoing surgery in the prone position. Materials and Methods: In this prospective randomized study, 70 patients scheduled to undergo pilonidal sinus excision in prone position were allocated to two groups of 35 patients each, depending on the position of the patient at induction and device placement: Group S (device placed while supine) and Group P (device placed while prone). We compared the manpower requirement, time to surgical readiness, efficacy and safety of the PLMA for airway management in the two groups. Results: The number of personnel [5 (4-6) vs. 3 (3-3); P < 0.001] required for positioning the patient and surgical readiness time (22.1 ± 3 vs. 5.9 ± 0.9 min; P < 0.001) was higher in group S. There was no difference between the two groups with regard to efficacy and safety of the PLMA. Incidence of blood on the PLMA cuff and sore throat was comparable in the two groups (P = 1.000). Conclusion: We conclude that induction and placing the PLMA in the prone position by experienced users require fewer personnel and reduces surgical readiness time.

PLMA vs. I-gel: A comparative evaluation of respiratory mechanics in laparoscopic cholecystectomy

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. and organ distribution of intravenous and oral methylene blue. Propofol‑related urine discoloration in a patient with fatal atypical intracerebral hemorrhage treated with hypothermia. Springerplus 2014;3:551. Sir, We thank the readers for taking keen interest in our study and raising a few safety issues, which need clarification. The rationale for using ProSeal laryngeal mask airway (PLMA: Intravent Orthofix, Maidenhead, UK) in the prone position was not only the accidental extubation in prone position, but the fact that if a technique (PLMA insertion in prone position) has been described for an emergency situation, the same can be used in a controlled elective scenario. Ours is not the first report of the use of PLMA in the prone position. There are several reports of PLMA use in prone position in adults for elective as well as emergency procedures. This technique allows the patient to lie at ease in a position where he/she is most comfortable. Our aim was to see if PLMA insertion in the prone position can reduce the time to surgical readiness and the number of personnel required to position these patients prone. We fully agree that adequate planning and vigilance are cornerstones for prevention of any mishap and ensuring a successful outcome. Some anesthesiologists may never encounter any case of inadvertent extubation of the endotracheal tube in the prone position, but there is no denying of the fact that it does occur. The Fourth National Audit Project of the Royal College of Anesthetists mentions the increased use of the supraglottic airway devices as a primary airway management device for general anesthesia. Any new technique or piece of equipment gradually gains acceptance and with time its scope of applications broadens. Anesthesiologists experienced in the use of PLMA are comfortable using it in different clinical scenarios. We followed all the standard patient safety precautions in the proper prone positioning. There was no abdominal compression and no hyper-abduction of the arms. Adequate padding to the pressure points was provided as mentioned in the manuscript. The image seen in the photographs is the position taken by the patient himself, and the arms were kept above the head with …

Effect of intrathecal midazolam bupivacaine on post operative analgesia.

Background and Aims: Anaphylaxis during anaesthesia is a rare but serious problem. In contrast to the developed countries where databases of perianaesthetic anaphylaxis are preserved, none exist in India. We conducted a survey amongst Indian anaesthesiologists to study the incidence and aetiology of anaphylaxis during anaesthesia in India. Methods: A written questionnaire comprising 20 items was mailed electronically or distributed personally to 600 randomly selected Indian anaesthesiologists. The responses were compiled and analysed. Results: We received responses from 242 anaesthesiologists. One hundred and sixty-two (67%) anaesthesiologists had encountered anaphylaxis during anaesthesia. Anaesthetic drugs led to 40% of reactions, and 60% of reactions were attributed to non-anaesthetic drugs. Opioids were the most common anaesthetic drugs implicated in anaphylaxis during anaesthesia, and non-depolarising muscle relaxants were the second most commonly implicated agents. Colloids, antibiotics and blood transfusion were the common non-anaesthetic agents thought to be responsible for anaphylactic reactions during anaesthesia. There were five deaths due to anaphylaxis during anaesthesia. Only 10% of anaesthesiologists ordered for allergy testing subsequently though 38% of anaesthesiologists had access to allergy testing facilities. Conclusions: Our survey reveals that two-thirds of participating Indian anaesthesiologists had witnessed anaphylaxis during anaesthesia. Commonly implicated anaesthetic drugs were opioids and non-depolarising muscle relaxants while colloids, antibiotics and blood transfusion were the common non-anaesthetic agents causing anaphylactic reactions during anaesthesia. Further, our survey reveals low utilisation and paucity of referral allergy centres to investigate suspected cases of anaphylaxis during anaesthesia.

EFFECT OF INTRATHECAL MIDAZOLAM BUPIVACAINE COMBINATION ON POST OPERATIVE ANALGESIA

Malarial infection during pregnancy is a significant public health problem with substantial risk for the pregnant woman and newborn child. Globally, 125 million women are at risk every year. In Sub-Saharan Africa, 23 million pregnant women are exposed to malarial infection annually and approximately 400,000 pregnant women develop moderate to severe anaemia.[1] We report successful perioperative management of case of Plasmodium vivax infection in full-term parturient who presented with thrombocytopaenia and deep transverse arrest and subsequently developed right occipito-parietal haematoma with mass effect.