Sadik Mohammed

Dexmedetomidine versus midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography: An open-label randomised controlled trial

Background: Traditionally, midazolam has been used for providing conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP). Recently, dexmedetomidine has been tried, but very little evidence exists to support its use. Objective: The primary objective was to compare haemodynamic, respiratory and recovery profile of both drugs. Secondary objective was to compare the degree of comfort experienced by patients and the usefulness of the drug to endoscopist. Study Design: Open-label Randomised Controlled Trial. Methods: Subjects between 18 and 60 years of age with American Society of Anaesthesiologist Grade I-II requiring ERCP were enrolled in two groups (30 each). Both groups received fentanyl 1 μg/kg IV at the beginning of ERCP. Group M received IV midazolam (0.04 mg/kg) and additional 0.5 mg doses until Ramsay Sedation Scale (RSS) score reached 3-4. Group D received dexmedetomidine at loading dose of 1 μg/kg over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4. The vital parameters (heart rate (HR), blood pressure (BP), respiration rate, SpO 2 ), time to achieve RSS 3-4 and facial pain score (FPS) were compared during and after the procedure. In the recovery room, time to reach modified Aldrete score (MAS) 9-10 and patient and surgeon′s satisfaction scores was also recorded and compared. Any complication during or after the procedure were also noted. Results: In Group D, patients had lower HR and FPS at 5, 10 and 15 min following the initiation of sedation (P<0.05). There was no statistically significant difference in BP and respiratory rate. The procedure elicited a gag response in 29 (97%) and 7 (23%) subjects in Group M and Group D respectively (P<0.05). MAS of 9-10 at 5 min during recovery was achieved in 27 (90%) subjects in Group D in contrast to 5 (17%) in Group M (P<0.05). Dexmedetomidine showed higher patient and surgeon satisfaction scores (P<0.05). Conclusion: Dexmedetomidine can be a superior alternative to midazolam for conscious sedation in ERCP.

Comparison of Effect of Epidural Bupivacaine, Epidural Bupivacaine Plus Fentanyl and Epidural Bupivacaine Plus Clonidine on Postoperative Analgesia after Hip Surgery

Background: Management of postoperative pain is one of the most challenging and gratifying domains of anaesthesia. Search for an ideal adjuvant for post operative epidural analgesia still continues. Methods: A total of 75 healthy patients of both sexes in age group 50-80 years belonging to ASA status I and II posted for elective hip surgeries were enrolled and randomly divided into three groups of 25 each - Group B, Group BF and Group BC All the patients in the three groups received 3.5 ml Bupivacaine heavy (0.5%) intrathecally before surgery, followed by epidural bolus postoperatively, at ‘two segment sensory regression’ in following manner: initial bolus made to 10 ml with each group given - 7 ml of 0.125% Bupivacaine and 3 ml distilled water with adjuvant as 50 μg Fentanyl in group BF and 100 μg Clonidine in group BC. Top up of 7 ml was given to each group with 5 ml of 0.125% Bupivacaine and 2 ml distilled water with adjuvant as 50 μg Fentanyl in group BF and 75 μg Clonidine in group BC. Results: There was no statistically significant difference between the demographic profile. VAS scores were found to be better in Group BF and BC at most of the times and these scores were significantly lower than Group B. Rescue analgesia was required in 12% patients in Group B while none of the patients in Group BF or Group BC required rescue analgesia. Nausea, vomiting and pruritus were observed in 52% of the patients in Group BF and in none of the patients in Group BC and Group B.Degree of sedation was significantly more in Group BC when compared with Group BF and Group B. Conclusion: Combination of Bupivacaine-Clonidine was found to be a better option than Bupivacaine-Fentanyl for postoperative epidural analgesia in hip surgery patients.

Efficacy of dexmedetomidine as an adjuvant to ropivacaine in pediatric caudal epidural block

Context: Caudal analgesia is a reliable and an easy method to provide intraoperative and postoperative analgesia for infraumbilical surgeries in pediatric population but with the disadvantage of short duration of action after single injection. Many additives were used in combination with local anesthetics in the caudal block to prolong the postoperative analgesia. Aim: We compared the analgesic effects and side effects of dexmedetomidine added to ropivacaine in pediatric patients undergoing lower abdominal surgeries. Settings and Design: Double-blinded randomized controlled trial. Materials and Methods: Sixty patients (2-10 years) were evenly and randomly assigned into two groups in a double-blinded manner. After sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.25% (1 ml/kg) combined with either dexmedetomidine 2 μg/kg in normal saline 0.5 ml, or corresponding volume of normal saline according to group assignment. Hemodynamic variables, end-tidal sevoflurane, and emergence time were monitored. Postoperative analgesia, requirement of additional analgesic, sedation, and side effects were assessed during the first 24 h. Results: The duration of postoperative analgesia was significantly longer (P = 0.001) and total consumption of rescue analgesic was significantly lower in Group RD compared with Group R (P < 0.05). Group RD have better quality of sleep and prolonged duration of sedation (P = 0.001). No significant difference was observed in the incidence of hemodynamic changes or side effects. Conclusion: Addition of dexmedetomidine to caudal ropivacaine significantly prolongs analgesia in children undergoing lower abdominal surgeries without an increase in the incidence of side effects.

Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature.

Physiological changes of pregnancy imposes higher risk of acute respiratory failure (ARF) with even a slight insult and remains an important cause of maternal and fetal morbidity and mortality. Although pregnant women have different respiratory physiology and different causes of ARF, guidelines specific to ventilatory settings, goals of oxygenation and weaning process could not be framed due to lack of large-scale randomized controlled trials. During the 2009 H1N1 pandemic, pregnant women had higher morbidity and mortality compared to nonpregnant women. During this period, alternative strategies of ventilation such as high-frequency oscillatory ventilation, inhalational of nitric oxide, prone positioning, and extra corporeal membrane oxygenation were increasingly used as a desperate measure to rescue pregnant patients with severe hypoxemia who were not improving with conventional mechanical ventilation. This article highlights the causes of ARF and recent advances in invasive, noninvasive and alternative strategies of ventilation used during pregnancy.

Aseptic handling of ultrasound probe: An easy solution

Sir, Ultrasonography (USG) is nowadays routinely used in anesthesia and critical care practice for nerve blocks, central venous cannulation, and tapping of pleural or pericardial effusions. There have been reports of bacterial infections transmitted through ultrasound probe and coupling gel.[1] To prevent or minimize the risk of infection, USG probe and its cable are generally wrapped in commercially available sterile disposable sleeve. In case of its nonavailability surgical drape, autoclavable sleeves, surgical gloves, or condoms are used. Of these, gloves are the ones majority of USG users are familiar with. The technique includes wearing two pairs of gloves one above another, holding the USG probe having jelly applied over transducer surface with one hand, followed by removing the outer glove inside out over the probe. However, the technique requires multiple maneuvers to fasten the fingers of the glove just above the probe. In addition, some amount of air is invariably left within the glove which affects image quality. In a modified technique to avoid fastening manures, a finger portion of glove is removed aseptically, and the probe with applied coupling gel is advanced through it to cover the probe.[2] Although “sterile glove” technique allows the probe to be used in aseptic condition, the uncovered accompanying cable always carries the risk of contaminating the procedural area during manipulations with the probe.

Airway management in a patient with blunt trauma neck: A concern for anesthesiologist

Abstract Laryngo-tracheal injuries resulting from blunt trauma neck are fortunately rare, but may have dire consequences. A high index of suspicion is required to make the diagnosis. Here we report a case of airway management of a patient with blunt trauma neck with tracheal tear posted for tracheal tear repair under GA. Tracheostomy, FOB guided intubation and direct laryngoscopy are the standard methods used to secure the airway in these patients, but sometimes they may aggravate the underlying injury. Technique of choice depends upon patient’s condition, urgency, and experience of anesthesiologist and surgeon.

Sedation in a child with Klippel-Feil syndrome scheduled for magnetic resonance imaging

imaging (MRI) suites to perform imaging in children and uncooperative adults. The choice of anesthesia may range from moderate sedation to general anesthesia depending on the patient’s characteristics and/or institutional protocols. Due to challenges in accessing patients in the MRI suite, the anesthetic technique should be chosen carefully. This is even more important when the patient has an anticipated difficult airway. A four-year-old male child weighing 14 kg presented with delayed developmental milestones, diminished hearing, and no organized speech. The patient had a diagnosis of Klippel-Feil syndrome (KFS). Ultrasonography of the abdomen and echocardiography ruled out any associated systemic defects and the patient was scheduled for MRI of the brain and cervical spine for further evaluation. After a failed attempt at sedating the patient with oral chloral hydrate in the MRI suite, he was scheduled for MRI under general anesthesia. The pre-anesthetic evaluation showed that the patient had a short webbed neck with limited extension and a low posterior hairline (Fig. 1). Due to an anticipated difficult airway and the diagnostic nature of the procedure, we planned to provide sedation with dexmedetomidine via a backup laryngeal mask airway if required. Intravenous access was obtained with a 22-gauge cannula after application of a eutectic mixture of local anesthetics. Baseline vitals (electrocardiography [ECG], blood pressure, and pulse oxygen saturation [SpO2]) were recorded. A loading dose of 1 μg/kg dexmedetomidine was administered over 10 minutes followed by an infusion of 0.7 μg/kg/h dexmedetomidine. Monitoring of the depth of sedation was performed based on the Ramsay Sedation Score and the patient was moved onto the MRI table once a score of 5 was achieved; following this, ear plugs were applied. Oxygen supplementation was achieved with fraction of inspired oxygen of 0.28 with continuous monitoring of ECG, noninvasive blood pressure, SpO2, and end-tidal carbon dioxide throughout the diagnostic procedure, which lasted approximately 50 minutes. All of the above parameters were within normal limits and no additional intervention was required. At the end of the procedure, dexmedetomidine infusion was stopped and the patient was responsive to verbal stimuli after 7 minutes. The patient was discharged home once the discharge criteria were met. KFS is an inherited condition with the classic triad of a short webbed neck, limited neck movements, and a low posterior hairline [1,2]. KFS may be associated with conductive or sensorineural deafness, congenital heart disease (most commonly a ventricular septal defect), cleft palate, rib defects, and scoliosis. Anesthetic challenges include a difficult airway, cervical spine instability, and associated cardiovascular and genitourinary system abnormalities. There is an increased risk of spinal cord injury during maneuvers such as laryngoscopy, intubation, and placing the patient in an appropriate position for the procedure [3]. Patients with KFS may need to be anesthetized for diagnostic procedures, surgical correction of congenital defects, or any othLetter to the Editor

Air- Q intubating laryngeal airway guided intubation in Morquio syndrome

Mucopolysaccharidoses (MPS) are lysosomal storage disorders caused by the deficiency of enzymes required for the stepwise breakdown of glycosaminoglycans (GAGs), also known as mucopolysaccharides. Patients with MPS may develop complications during general anaesthesia (GA) due to the presence of airway obstruction, excessive secretions, a large tongue and an abnormal airway anatomy. Patients with MPS type IV, also known as Morquio syndrome, pose even greater challenge because of additional problems such as neck instability, restrictive pulmonary disease and end-organ damage.

Comparison of Endotracheal Intubation Through I-gel and Intubating Laryngeal Mask Airway

Received: February 11, 2016 Revised: June 24, 2016 Accepted: June 24, 2016 Abstract: Background: Supraglottic airway devices (SADs) are very useful airway adjunct in managing anticipated and unanticipated difficult airway and can be used as a ventilating aid and as a conduit for tracheal intubation. The new versions of SADs like i-gel and intubating laryngeal mask airway (ILMA), have advantage of hands-free airway maintenance without the need for tracheal intubation, they can be placed easily without direct visualization of the larynx, ensure predictable ventilation and can be used as conduit for tracheal intubation.

Anesthetic concern during cesarean delivery in patient with ruptured cerebral arteriovenous malformation

Vascular malformations of the brain are a rare cause of intracranial hemorrhage during pregnancy. The presentation of arteriovenous malformations during pregnancy is usually a result of hemorrhage following rupture. Once hemorrhage occurs, it accounts for 5–12% of all the maternal deaths and remains the third most common nonobstetric cause of maternal morbidity. Successful anesthetic management during cesarean delivery requires close monitoring to address both the varying maternal and fetal needs. The fundamental aims are to maintain oxygenation and stable systemic, cerebral, and placental hemodynamics and to avoid increase in intracranial pressure.