Sanjay Dhiraaj

The efficacy of tolterodine for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study.

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05).

An evaluation of the efficacy of aspirin and benzydamine hydrochloride gargle for attenuating postoperative sore throat: a prospective, randomized, single-blind study.

Postoperative sore throat (POST), although a minor complication, remains a source of postoperative morbidity. We compared the efficacy of dispersible aspirin gargle to benzydamine hydrochloride (a topical nonsteroidal anti inflammatory drug) gargles for prevention of POST. We enrolled 60 consecutive female patients, 16–60 yr of age, ASA physical status I or II, undergoing elective modified radical mastectomy under general anesthesia in this prospective, randomized, placebo-controlled, single-blind study. Patients were randomly divided into 3 groups of 20 subjects each: Group 1 (C) mineral water; Group 2 (AS) tab aspirin 350 mg; and Group 3 (BH) 15 mL of benzydamine hydrochloride (0.15%). All the medications were made into 30 mL of solution. Patients were asked to gargle this mixture for 30 s, 5 min before induction of anesthesia. Grading of POST was done at 0, 2, 4, and 24 h postoperatively on a 4-point scale (0–3). Aspirin gargles reduced the incidence of POST for 4 h whereas benzydamine hydrochloride gargles reduced POST for 24 h. POST was more severe in the control group at 0 and 2 h (P < 0.05). Aspirin and benzydamine hydrochloride gargles significantly reduced the incidence and severity of POST (P < 0.05).

An evaluation of the efficacy of gabapentin for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study.

BACKGROUND:Catheter-related bladder discomfort (CRBD) secondary to catheterization of urinary bladder is distressing. In the present study, we evaluated gabapentin for preventing CRBD. METHODS:One-hundred and eight consecutive adult patients, ASA physical status I and II, of either sex, undergoing elective percutaneous nephrolithotomy were randomized into two groups of 54 each. Group control: placebo and group G gabapentin: gabapentin 600 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL normal saline. In the postanesthesia care unit, the incidence and severity (mild, moderate, and severe) of CRBD were assessed on arrival (0) and at 1, 2, and 6 h. RESULTS:Gabapentin reduced the incidence of CRBD to 50% (27 of 54) compared with 80% (43 of 54) observed in the control group (P < 0.05). Gabapentin also reduced the severity of CRBD and postoperative pain as observed by a reduction in the number of patients requiring any fentanyl and the total fentanyl consumption postoperatively (P < 0.05). CONCLUSION:Gabapentin (600 mg) administered orally 1 h before surgery reduced the incidence and severity of CRBD, postoperative pain, number of patients requiring fentanyl and postoperative total fentanyl requirement.

An evaluation of efficacy of balloon inflation on venous cannulation pain in children: a prospective, randomized, controlled study.

Venipuncture is the most common painful event for a hospitalized child. We evaluated the efficacy of balloon inflation for attenuating venipuncture pain in children. Seventy-five pediatric patients aged 6–12 yr, ASA physical status I–II, of either sex, undergoing elective surgery were included in this prospective and randomized study. Patients were randomly divided into 3 equal groups of 25 each; Group I (control), Group II (distraction) pressed a rubber ball, and Group III (balloon) inflated a balloon. A manual venous occlusion was applied on the forearm and venipuncture was performed with a 22-gauge venous cannula. Pain was self-reported by a pain face scale with a 10-cm visual analog scale (VAS) placed at its back, where 0 = “no pain” and 10 = “worst imaginable pain.” VAS scores of 1-3 were rated as mild, 4–6 as moderate, and >6 as severe. Median (interquartile range) VAS score in the balloon group was 1 (3), which was reduced as compared with 2 (2) and 4 (2) observed in the distraction and control groups, respectively (P < 0.000). Significant reduction in the incidence and severity of venipuncture pain was also observed in the balloon group compared with the other 2 groups (P < 0.05).

Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study.

Pain associated with venous cannula is a distressing symptom. We evaluated the efficacy of the Valsalva maneuver on pain associated with venous cannulation. Seventy-five adults, ASA physical status I and II, either sex, undergoing elective surgery, were included in this study. Patients were randomized into 3 groups of 25 each. Group I (C): control; Group II (V): blew into sphygmomanometer tubing and raised the mercury column up to 30 mm Hg for 20 s; Group III (B): pressed a rubber ball. Twenty seconds later, peripheral venous cannulation was performed. Venous cannulation pain was graded using a 4-point scale: 0–3, where 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain, and visual analog scale of 0–10, where 0 = no pain and 10 = worst imaginable pain. A significant reduction in the incidence of pain was observed in the Valsalva group: 18 of 25 (72%) patients, whereas 25 of 25 (100%) experienced pain in the other two groups (P < 0.001). A significant reduction in the severity of pain, number of patients in whom one needed to make the vein prominent before cannulation, and the time taken for the same were observed in the Valsalva group (P < 0.001).

The Effect of Epidural Bupivacaine on Induction and Maintenance Doses of Propofol (Evaluated by Bispectral Index) and Maintenance Doses of Fentanyl and Vecuronium

The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal, epidural, IV, or IM routes. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation. In this prospective, randomized, double-blind study, we investigated the effect of epidural bupivacaine on the dose requirement of propofol (as evaluated by using the bispectral index [BIS]), fentanyl, and vecuronium for general anesthesia. This study consisted of 30 adults, ASA physical status I and II, undergoing Whipple’s pancreaticoduodenectomy for periampullary carcinoma lasting >4 h. An epidural catheter was placed between T9-10. Depending on the group allocation, 10 mL of the study drug was administered as a bolus followed by an infusion at 6 mL/h via the epidural catheter. Patients were divided into 2 groups of 15 each. Patients in the control group received epidural normal saline whereas those in the bupivacaine group received epidural bupivacaine 0.1%. Induction of anesthesia was performed with IV fentanyl 2 &mgr;g/kg and propofol titrated to achieve BIS between 40–50. Endotracheal intubation was facilitated by the IV administration of vecuronium 0.1 mg/kg and patient’s lungs were ventilated with 66% nitrous oxide in oxygen. After intubation, infusion of propofol 1% was titrated to maintain BIS between 40–50. Inadequate analgesia was defined as an increase in systolic blood pressure and/or heart rate by >20% of baseline values in response to surgical stimulus and was treated with bolus fentanyl 0.5 &mgr;g/kg. Neuromuscular monitoring was used to assess the need for additional doses of vecuronium. Data were analyzed by using the Student’s t-test and P ≤ 0.05 was considered significant. The requirement of propofol for induction and maintenance of anesthesia in the bupivacaine group was 1.3 ± 0.3 mg/kg and 2.4 ± 0.9 mg · kg−1 · h−1, respectively, compared with 2.4 ± 0.6 mg/kg and 4.4 ± 1.6 mg · kg−1 · h−1 observed in the control group (P < 0.05). Significant reduction was also observed in the requirement of vecuronium and fentanyl during maintenance in the bupivacaine group (P < 0.05). We conclude that epidural bupivacaine given before induction of anesthesia reduces the requirement of propofol, fentanyl, and vecuronium during general anesthesia.

Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol

Propofol causes pain or discomfort on injection in 28%–90% of patients. A number of techniques have been tried for minimizing propofol-induced pain with variable results. We compared the efficacy of butorphanol and lidocaine for prevention of propofol-induced pain. One-hundred-fifty ASA I–II adults, undergoing elective surgery were randomly assigned into 3 groups of 50 each. GroupI(NS)receivednormalsaline,GroupII(L)received lidocaine 2% (40 mg), and Group III (B) received butorphanol 2 mg. All patients received pretreatment solutions made in 2 mL with normal saline administered over 5 s. One min after pretreatment patients received one-fourth of the total calculated dose of propofol (2.5 mg/kg) over 5 s. Assessment of pain with IV propofol was done by using a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain and 3 =severe pain at the time of propofol injection. In the control Group 39 (78%) patients had pain during propofol injection as compared to 21 (42%) and 10 (20%) in the lidocaine and butorphanol groups, respectively (P <0.05). Butorphanol was the most effective. We therefore suggest the IV pretreatment with butorphanol 2 mg for attenuation of pain associated with propofol injection.

Rapid preparation of severe uncontrolled thyrotoxicosis due to Graves’ disease with Iopanoic acid — a case report

PurposeTo report the rapid preoperative preparation of a case of thyrotoxicosis due to Graves’ disease resistant to medical treatment.Clinical featuresA 14-yr-old boy presented with a history of progressive swelling in the neck. Signs and symptoms were compatible with hyperthyroidism. Thyroid function tests revealed: serum T4 296.5 nmol· L−1, serum T3 6.06 nmol · L−1 and serum thyroid-stimulating hormone < 0.15 mlU · L−1. The diagnosis of thyrotoxicosis due to Graves’ disease was made. Therapy was instituted with carbimazole 30 mg · day−1 and propranolol 80 mg · day−1, which were gradually increased to carbimazole 80 mg · day−1 and propranolol 120 mg · day−1, without response. Preparation was attempted by adding lopanoic acid 500 mg four times a day and dexamethasone 0.5 mg four times a day in addition to the above drugs for five days. T3 levels declined to 1.8 nmol · L−1, but the serum T4 remained elevated. Symptoms of hyperthyroidism persisted but with decreased intensity. As the patient could not be made euthyroid, surgery was planned to relieve the symptoms. Anesthesia was uneventful except for intraoperative and postoperative tachycardia, which was managed successfully with esmolol.ConclusionIn life threatening thyrotoxicosis refractory to medical treatment, Iopanoic acid may be used as an adjuvant to antithyroid drugs for rapid preparation of the patient prior to surgery.RésuméObjectifPrésenter la préparation préopératoire rapide d’un cas de thyrotoxicose engendrée par une maladie de Graves résistante au traitement médical.Éléments cliniquesUn garçon de 14 ans a consulté pour une tuméfaction progressive au cou. Les signes et les symptômes étaient compatibles avec l’hyperthyroïdie. L’étude de la fonction thyroïdienne a révélé : une T4 sérique de 296,5 nmol · L−1, une T3 sérique de 6,06 nmol · L−1 un taux d’hormone thyréostimuline < 0,15 mUl · L−1. Le diagnostic de thyrotoxicose causée par une maladie de Graves a été établi. Le traitement, amorcé avec 30 mg · jour−1 de carbimazole et 80 mg · jour−1 de propranolol, a été graduellement augmenté à 80 mg · jour−1 de carbimazole et à 120 mg · jour−1 de propranolol, sans résultat. La préparation préopératoire a été tentée avec l’addition, pendant cinq jours, de 500 mg d’acide iopanoïque quatre fois par jour et de 0,5 mg de dexaméthasone quatre fois par jour, en plus des médicaments déjà prescrits. Les niveaux de T3 ont baissé à 1,8 nmol · L−1, mais la T4 sérique est demeurée élevée. Les symptômes d’hyperthyroïdie ont persisté, mais réduits en intensité. Étant donné l’échec à rétablir l’état euthyroïdien du patient, une opération a été planifiée pour soulager les symptômes. L’anesthésie s’est bien déroulée, sauf pour une tachycardie peropératoire et postopératoire traitée à l’esmolol.ConclusionDans un cas de thyrotoxicose réfractaire au traitement médical, l’acide iopanoïque peut compléter le traitement antithyroïdien pour la préparation préopératoire rapide d’un patient.

Is ketamine a safe anesthetic for percutaneous liver biopsy in a liver transplant recipient immunosuppressed with cyclosporine

A 6-yr-old male patient underwent live related left lateral segment liver transplant for cryptogenic cirrhosis with portal hypertension. One month after the liver transplant the patient had an isolated liver transaminases increase. He was posted for percutaneous liver biopsy for suspected graft rejection under general anesthesia. The patient was administered ketamine 7 mg/kg along with glycopyrrolate 0.01 mg/kg IM in the preoperative area. He developed generalized tonic clonic seizures just before the biopsy and was treated with IV midazolam 1 mg and thiopental 60 mg. Percutaneous liver biopsy was obtained once the convulsions subsided. Both ketamine and cyclosporine have been implicated as having proconvulsant properties and may have been responsible for the seizures in our patient. Our experience prompted us to suggest that ketamine in a patient immunosuppressed with cyclosporine may not be safe and that alternative anesthetics may need to be considered for such procedures.

Anesthetic management of a patient with hemophilia A with spontaneous acute subdural hematoma.

Intracranial hemorrhage in patients with hemophilia is associated with high mortality and sequelae. We report the case of 50-year-old man with Hemophilia A, who presented with spontaneous acute subdural hematoma and underwent craniotomy for clot evacuation. The patient received Factor VIII infusions perioperatively along with other measures to decrease blood loss. The patient presented with signs of high intracranial tension and received 3% saline intraoperatively and postoperatively to prevent brain edema. Recommendations for perioperative preparation and management of hemophilia, especially in the setting of emergency major surgery are reviewed.