Renu Sinha

Evaluation of air-QTM intubating laryngeal airway as a conduit for tracheal intubation in infants – a pilot study

Background:  Air‐QTM intubating laryngeal airway (ILA) has been used successfully as a conduit for tracheal intubation in pediatric difficult airway. However, its use as an airway device and conduit for intubation in infants is not yet evaluated.

Comparison of sub-Tenon's block with i.v. fentanyl for paediatric vitreoretinal surgery

BACKGROUND Vitreoretinal (VR) surgery is associated with moderate to severe pain and significant postoperative nausea and vomiting (PONV). The study aimed to assess the effectiveness of sub-Tenons block for providing perioperative analgesia in children undergoing VR surgery. METHODS In a randomized, observer-blinded trial, after obtaining institutional ethical committee approval and parental consent, 200 ASA grade I-II children aged 5-16 yr were allocated to receive either a sub-Tenons block (Group SB) or 2 microg kg(-1) i.v. fentanyl (Group F) after induction of anaesthesia and topical anaesthesia of the conjunctiva with proparacaine 0.5% drops. Patients in Group F received fentanyl 0.5 microg kg(-1) and those in Group SB were given a corresponding volume of normal saline i.v. every hour from preloaded syringes. Increases in heart rate or mean arterial pressure by more than 20% of baseline were treated with additional 0.5 microg kg(-1) i.v. fentanyl boluses in both groups. The incidence of oculocardiac reflex (OCR), need for additional analgesics, postoperative pain, and PONV were recorded for the first 24 h after surgery. RESULTS More patients in Group F (47.96%) had moderate to severe pain in the first 24 h when compared with Group SB (31.36%) (P=0.023). The need for postoperative ibuprofen was higher in Group F (66.3%) compared with Group SB (47.95%) (P=0.012). The incidence of OCR was significantly higher in Group F (31.6%) compared with Group SB (5.1%) (P<0.001). The incidence of PONV was similar in both groups. CONCLUSIONS Sub-Tenons block provides more effective analgesia than i.v. fentanyl for paediatric VR surgery.

Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns.

Background Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy. Patients and methods The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry. In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered. Results Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 ± 2 to 28 ± 2.7 cmH2O and central venous pressure increased from 12.9 ± 1 to 19.2 ± 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice. Summary Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.

Tumor lysis under anesthesia in a child.

Tumor lysis syndrome (TLS) is a life‐threatening oncologic emergency characterized by metabolic derangements caused by massive lysis and release of cellular components. TLS has been reported to occur under various circumstances. There have however, been only two reports of precipitation of TLS by anesthesia in the current medical literature. We report on the development of TLS in a 7‐year‐old child with a pelvic neuroectodermal tumor following induction of anesthesia and discuss the peri‐operative concerns while dealing with patients with high tumor burdens.

Successful use of C-Mac video laryngoscope in a child with large parapharyngeal mass.

An eleven‐year‐old child presented with a history of gradually increasing left side neck swelling and snoring for the last 6 years. He was initially scheduled for biopsy and on a second occasion for transcervical excision of left parapharyngeal mass under general anesthesia. Examination showed a left lateral pharyngeal and tonsillar mass compressing the oropharyngeal airway. CT neck showed a soft tissue mass (7 × 6 × 9 cm) in the left retropharyngeal space causing a bulge in the oropharynx with lateral deviation of carotid artery and internal jugular vein. During the first anesthesia for the biopsy, oral fiberoptic bronchoscopy (FOB), direct laryngoscopy, and Glidescope video laryngoscopy failed to visualize the glottis and epiglottis. After repeated attempts, intubation was possible with direct laryngoscopic‐guided oral FOB. Fifteen days later, for the definitive surgery, the glottis was visualized at the first attempt using a C‐Mac video laryngoscope and endotracheal intubation was successful at the first attempt after laryngeal manipulation. We discuss the potential causes of failure of intubation with the other airway devices in this child.

Morphine versus Nalbuphine for Open Gynaecological Surgery: A Randomized Controlled Double Blinded Trial.

Introduction. Pain is the commonest morbidity after open surgical procedures. The most effective treatment of postoperative pain is opioid therapy. Morphine, the commonly used opioid, is associated with many side effects including respiratory depression, sedation, postoperative nausea vomiting, and pruritus. Nalbuphine, on the other hand, is known to cause less respiratory depression. Thus this study was undertaken to compare the intraoperative and postoperative analgesic efficacy and side effect profile of the two drugs. Methodology. 60 patients undergoing open gynaecological surgery were randomized to receive either morphine (Group M) or nalbuphine (Group N) in the intraoperative and postoperative period. Intraoperative analgesic efficacy (measured by need for rescue analgesics), postoperative pain by visual analogue scale, and side effects like postoperative nausea, vomiting, sedation, respiratory depression, and pruritus were compared in both groups. Intraoperative and postoperative heart rate and blood pressure were also compared between the groups. Results. Need for intraoperative analgesia was significantly more in Group N (P = 0.023). Postoperative VAS scores were significantly different between the groups at various time points; however, none of the patients required any rescue analgesia. The incidence of various side effects was not significantly different between the groups. The haemodynamic profile of patients was comparable between the groups in both intraoperative and postoperative period. Conclusion. Nalbuphine provides less effective intraoperative analgesia than morphine in patients undergoing open gynaecological surgery under general anaesthesia. Both drugs, however, provided similar postoperative analgesia and had similar haemodynamic and side effect profile.

Perioperative management and post-operative course in preterm infants undergoing vitreo-retinal surgery for retinopathy of prematurity: A retrospective study

Background: Premature infants scheduled for surgery under general anesthesia are more prone to cardio-respiratory complications. Risk factors include post-conception age (PCA), cardiac and respiratory disease, anemia and opioid administration. This retrospective study evaluates the perioperative management and post-operative course (apnea and bradycardia) in premature infants undergoing surgery for retinopathy of prematurity (ROP). Materials and Methods: We analyzed the pre-operative data, anesthesia chart and post-operative course of 52 former premature infants for 56 general anesthesia exposures for ROP surgery. Results: At the time of procedure, median PCA was 51 (36-60) weeks. 71% of the infants were above 46 weeks of PCA. Five infants had cardiac disease and four had a history of convulsion. Four infants had a pre-operative history of apneic spells. The airway was secured with either endotracheal tube (46) or supraglottic device (10). Fentanyl (0.5-1 μg/kg), paracetamol, topical anesthetic drops and/or peribulbar block were administered for analgesia. Extubation was performed in the operating room for 54 cases. Three infants had apnea post-operatively. Seven infants were shifted to neonatal intensive care unit either for observation or due to delayed recovery, persistent apneic spells and pre-existing cardio-respiratory disease. Conclusion: In the present study, intravenous paracetamol and topical anesthetics reduced the total intra-operative opioid requirement, which resulted in low incidence of post-operative apnea. Regional anesthesia may be considered in infants with high risk of post-operative apnea. Infants with PCA > 42 weeks and without any co-morbidity can be managed in post-anesthesia care unit.

Sub-Tenon block does not provide superior postoperative analgesia vs intravenous fentanyl in pediatric squint surgery.

Purpose We evaluated the efficacy of sub-Tenon block in decreasing perioperative pain, incidence of intraoperative oculocardiac reflex (OCR), and postoperative nausea and vomiting (PONV) in pediatric squint surgery. Methods A total of 67 children age 2-12 years, American Society of Anesthesiologists Physical Status 1 and 2, were randomized to receive either sub-Tenon block (ST) in the operative eye or 2 mcg/kg of intravenous fentanyl (F) for squint surgery after induction of general anesthesia in this double-blind study. Postoperative pain was measured by either modified Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) or Visual Analogue Scale (VAS). Pain in the postoperative period (up to 2 hours) was measured as the primary endpoint. Other parameters measured in the groups were intraoperative hemodynamics, postoperative modified CHEOPS or VAS at shifting, 1, 2, 6, 12, and 24 hours after surgery, incidence of intraoperative OCR, and PONV at shifting, 30 minutes, 1, 2, 6, 12, and 24 hours after surgery. Results There was no statistical difference in the postoperative pain scores in the recovery room up to 2 hours after surgery. The VAS and CHEOPS scores were not different in the groups up to 24 hours after surgery. The incidence of OCR was significantly higher in group F than group ST. The incidence of PONV was significantly higher in group F than group ST at 30 minutes and 1 hour after the surgery (41%, 47% vs 19%, 9%, respectively, p<0.05). However, there was no statistically significant difference in intraoperative hemodynamics and PONV scores after 2 hours in the postanesthesia care unit. Conclusions Use of sub-Tenon block does not decrease the incidence of postoperative pain significantly in children undergoing squint surgery. However, it leads to a statistically significant decrease in the incidence of intraoperative OCR and PONV in the early recovery period in these patients.

A randomised comparison of lidocaine 2% gel and proparacaine 0.5% eye drops in paediatric squint surgery

We conducted a randomised trial comparing lidocaine 2% gel with proparacaine 0.5% eye drops in children having elective squint surgery. One hundred and forty children aged between 3 and 14 years were recruited. The requirement for intra‐operative fentanyl and postoperative ibuprofen was significantly less in the lidocaine group compared with the proparacaine group (1 (1.7%) vs 12 (18.5%), p = 0.002 and 16 (27.6%) 38 (58.5%), p = 0.001, respectively). The incidence of postoperative nausea and vomiting was significantly less in the lidocaine group compared with the proparacaine group (6 (10.3%) vs 16 (24.6%), p = 0.04). There were no differences between the groups in terms of incidence and severity of the oculocardiac reflex. We conclude that, compared with proparacaine 0.5% eye drops, a single application of lidocaine 2% gel improves peri‐operative analgesia and reduces the incidence of postoperative nausea and vomiting in elective paediatric squint surgery.

Effect of addition of magnesium to local anesthetics for peribulbar block: A prospective randomized double-blind study

Background: Magnesium sulphate has been used along with local anesthetics in different regional blocks and found to be effective in decreasing the time of onset of the block and increasing the duration of the block. Objective: To evaluate the effect of addition of magnesium sulfate to standard local anesthetics mixture on the time for onset of the globe and lid akinesia for peribulbar block in ophthalmic surgeries. Materials and Methods: Sixty patients with American Society of Anesthesiologists status I to III undergoing ophthalmic surgery under peribulbar block were included in this study. Patients were randomized into two groups. Both the groups received 4.5 ml of 2% lidocaine, 4.5 ml of 0.5% bupivacaine with150 IU hyaluronidase. Group NS received normal saline 1 ml in the peribulbar block and Group MS, magnesium sulfate 50 mg in 1 ml normal saline. The onset of akinesia, satisfactory block and complications were observed by an independent observer. Results: Demographic data was statistically similar. In the Group NS at 3, 5, 10 and 15 min after the block, complete akinesia was seen in 0, 2, 11 and 28 patients respectively. In the Group MS, at 3, 5, 10 and 15 min after the block, complete akinesia was seen in 13, 23, 27 and 28 patients respectively. Patients received magnesium sulfate showed the statistically significant rapid onset of lid and globe akinesia than the control group till 10 min (P < 0.000). None of the patients needed a supplementary block and had complications during the surgery. Conclusion: Addition of 50 mg of magnesium sulfate to the lidocaine-bupivacaine mixture for peribulbar block decreases the onset of akinesia without any obvious side effect.