Surendra Kumar Sethi

Efficacy of Low-dose Intravenous Ketamine vs Intravenous Tramadol Infusion for Postcesarean Section Analgesia following Spinal Anesthesia: A Prospective, Randomized, Double-blinded Clinical Study

Background: Postoperative pain is of greatest concern in parturients undergoing cesarean section. Low-dose intravenous (IV) ketamine infusion has been considered to be an effective postoperative analgesia and resurged again as a substitute of opioid analgesics. This study aims to evaluate the efficacy of low dose iv ketamine versus iv tramadol infusion in reducing postoperative pain and rescue analgesic requirements. Materials and methods: This prospective study was conducted on 150 parturients with American Society of Anesthesiologists (ASA) grades I and II, aged 18 to 35 years scheduled to undergo elective or emergency cesarean section under regional anesthesia. All the parturients were randomly allocated into three groups of 50 patients each. Group C (control group) received 5 mL saline; group K (ketamine group) received 5 mL of ketamine (0.05 mg/kg/hour); and group T (tramadol group) received 5 mL of tramadol (120 mg/24 hours) in 500 mL of Ringer’s lactate. Tramadol (1 mg/kg) was given as rescue analgesic. Pain scores, patient satisfaction scores, time to first demand of rescue analgesic, the total number of doses, and total consumption of rescue analgesic along with side effects were recorded. Results: The cumulative visual analog scale (VAS) noted at rest, cough, and movement was significantly less in groups K and T as compared with group C (p < 0.001). The time of requirement of first rescue analgesic dose was significantly prolonged in group K (6.17 ± 3.05 hours) and group T (4.04 ± 1.26 hours) as compared with group C (2.16 ± 0.84 hours) (p < 0.001). The total number of doses of rescue analgesic given in 24 and 48 hours was significantly decreased in groups K and T as compared with group C (p < 0.001). The satisfaction scores were significantly better in groups K and T (p < 0.001). Conclusion: We concluded that low-dose IV ketamine infusion was associated with significantly lower pain scores, reduced rescue analgesic requirement along with better patient satisfaction so that it could be used as a useful adjunct to multimodal postoperative analgesia. 1,4Assistant Professor, 2Senior Professor and Head, 3Senior Professor 1-4Department of Anesthesiology, Jawaharlal Nehru Medical College and Associated Hospitals, Ajmer, Rajasthan, India Corresponding Author: Surendra K Sethi, Assistant Professor Department of Anesthesiology, Jawaharlal Nehru Medical College and Associated Hospitals, Ajmer, Rajasthan, India Phone: +919587150598, e-mail: drsurendrasethi80@gmail.com

A prospective randomized double blind study to compare the effects of dexmedetomidine and fentanyl on intubating conditions during awake fiberoptic bronchoscopy guided intubation

Introduction: Various drugs have been used for sedation to provide adequate intubating conditions during awake fiberoptic intubation (AFOI) but these drugs may cause excessive sedation followed by respiratory depression which is undesirable in these patients.So this study was planned with aim to compare dexmedetomidine with fentanyl for conscious sedation during AFOI in adult patients posted for various elective surgical procedures under general anaesthesia. Materials and Methods: Sixty adult patients were randomly allocated into two groups with 30 patients each. After pre operative evaluation and informed consent, patients were given pre anaesthetic medication followed by airway nerve blocks. Group A (n=30); Dexmedetomidine Group received intravenous (IV) dexmedetomidine 1.5 μg/kg diluted in 100 ml normal saline (NS) over 10 min and Group B (n=30); Fentanyl Group received IV fentanyl 2 μg/kg diluted in 100 ml NS over 10 min. After achieving adequate sedation (RSS ≥ 2), awake fiberoptic bronchoscopy and intubation was done. Intubating conditions, oxygen desaturation caused, tolerance to intubation and haemodynamic changes along with adverse effects were observed and noted in both groups. Results: Cough score and intubation comfort scores were significantly better in Group A when compared to Group B. (P <0.05) The patients in Group A showed less oxygen desaturation as compared to Group B that was statistically significant. (P < 0.05) Post intubation score was also found to be significantly better in Group A. (P <0.05) However, no significant haemodynamic changes and adverse effects were noted in patients of Group A (P >0.05). Conclusion: Dexmedetomidine (1.5 μg/kg) is preferable over fentanyl (2 μg/kg) for conscious sedation during AFOI as it provides more favourable intubating conditions with minimal haemodynamic changes and adverse effects.

Anaesthetic management in a case of large plunging ranula with difficult airway: A case report

Abstract Plunging ranula is a mucous retention cyst found on the floor of mouth which arises from the submandibular and sublingual salivary glands extending to lateral aspect of neck, which may often cause potential airway obstruction leading to difficulty in airway management. A forty year old female patient was admitted to our hospital with large, painless swelling in the floor of mouth extending to the lateral part of body of mandible and neck. This intraoral swelling distorted the normal airway anatomy thus making airway management difficult as the patient was planned for excision of swelling under general anaesthesia. So we present a case of successful management of a difficult airway by using awake fibre optic intubation in a patient posted for excision of a large plunging ranula under general anaesthesia.

Effects of inhaled nitrous oxide on the induction dose and time requirements of propofol: A prospective, randomized, double-blind study

Context: Propofol is a commonly used induction agent during general anesthesia. As a sole agent, it does not provide any strong analgesic effect. The nitrous oxide (N2O) used along with propofol for induction of anesthesia augments the induction characteristics and reduces the dose of propofol. Aims: To study the effects of inhaled N2O on the induction dose and time of propofol during general anesthesia and also its hemodynamic response and adverse effects. Settings and Design: The present research is a prospective, randomized, double-blind comparative study. Subjects and Methods: The study population consisted of eighty patients aged 18–60 years from either sex, American Society of Anesthesiologists physical status 1 and 2 which were scheduled for various elective surgical procedures under general anesthesia. The patients were randomly allocated into two groups comprising forty patients in each group. All patients were premedicated with glycopyrrolate 0.2 mg, ondansetron 4 mg, and fentanyl 1 μg/kg intravenously. Group FN received breathing mixture of gases (67% N2O @ 4 L/min and 33% O2@ 2 L/min), and propofol and Group FO received 100% O2@ 6 L/min and propofol. The different hemodynamic parameters (heart rate, mean arterial pressure, systolic blood pressure, diastolic blood pressure, and SpO2) were measured. Statistical Analysis: All observations were analyzed using Chi-square test, Students t-test, and analysis of variance. Results: The mean induction time and dose were significantly less in Group FN as compared to Group FO (P < 0.05). The mean induction time was 172 ± 32 s in Group FN as compared to 242 ± 43 s in Group FO (P < 001), whereas the mean induction dose was 56.10 ± 13.92 mg in Group FN as compared to 81.67 ± 17.64 mg in Group FO (P < 0.05). The hemodynamic parameters remained stable with no complications. Conclusion: The coadministration of N2O during induction of anesthesia with propofol not only reduced the induction dose of propofol but also reduced induction time significantly. Furthermore, it provided stable hemodynamics without any complications.

A comparative study between ProSeal laryngeal mask airway and endotracheal tube for ease of insertion and haemodynamic changes in patients undergoing laparoscopic cholecystectomy under general anaesthesia

Background: The endotracheal tube is considered a gold standard for providing a safe and effective glottic seal, especially for laparoscopic procedures under general anaesthesia. However, haemodynamic pressor responses associated with its use might be detrimental. The ProSeal LMA minimizes this response without compromising the airway with lesser incidence of complications. The aim of this study was to compare ProSeal LMA and Endotracheal tube with respect to intra-operative haemodynamic responses and ease of insertion of device and nasogastric tube in patients undergoing laparoscopic surgeries under general anaesthesia. Methods: This prospective randomized study was conducted on sixty patients, aged 20-60 years; of ASA grade 1 or 2, 30 in each group, posted for laparoscopic cholecystectomy under general anaesthesia. After induction with propofol and neuromuscular blockade with rocuronium, PLMA or ETT was inserted. The haemodynamic responses and insertion time of device and nasogastric tube were noted. Postoperative complications, if any were also noted. Results: The mean time of insertion of PLMA was 37.40±16.09 seconds and for intubation (ETT) was 31.17±20.89 seconds which was statistically not significant (P >0.05). The mean time of insertion of nasogastric tube was 18.84±6.84 seconds in PLMA group and 73.00±71.06 seconds in the ETT group which was highly significant, (P 0.05). Conclusions: ProSeal LMA proved to be a suitable alternative to endotracheal tube for airway management with stable haemodynamics in patients undergoing laparoscopic cholecystectomy under general anaesthesia.

A comparative study of propofol and N2O versus sevoflurane and N2O with respect to haemodynamic response and ease of laryngeal mask airway insertion: a prospective randomized double blinded study

Background: Laryngeal mask airway (LMA) is an accepted airway device for spontaneous and modest positive pressure ventilation. Propofol is widely used Induction agent. Sevoflurane is a newer pleasant volatile anaesthetic with rapid induction and recovery with stable haemodynamics. The aim of this study was to compare propofol and sevoflurane with respect of haemodynamic changes and conditions for LMA insertion. Methods: This study was done on 60 female patients of ASA I, II grade between 20-60 years of age. Patients were randomized into two groups (n=30). All patients were preoxygenated and received inj. fentanyl 2µg/kg. Induction agent was propofol 2.5mg/kg (group P) or sevoflurane 8% with vital capacity breath (group S). Loss of eyelash reflex was the end point of induction. Induction time, conditions for LMA insertion, number of attempts, time of successful LMA insertion and haemodynamic parameters were noted. Results: time for induction and LMA insertion was significantly faster in propofol group than group S (p<0.05). Successful LMA insertion in first attempt was 100% in group P with excellent conditions (score 18) while in group S, it was 86.7% with excellent to satisfactory conditions (score 16-17). A significant fall in mean arterial pressure (p<0.05) was noted in group P while pulse rates were comparable in both groups. Conclusions: Sevoflurane vital capacity breath inhalational induction can be used as an effective alternative to propofol though it requires greater time for LMA insertion but with better haemodynamic stability.

A prospective randomized study for comparison of haemodynamic changes and recovery characteristics with propofol and sevoflurane anaesthesia during laparoscopic cholecystectomies

Background: Day care laparoscopic surgical procedures are rapidly increasing nowadays. Rapid emergence and early recovery from anaesthesia with minimal complications are desired. Both propofol and sevoflurane meet above criteria and established as agents of choice in laparoscopic surgeries for induction and maintenance of anaesthesia. So this study aimed to compare sevoflurane with propofol for intraoperative haemodynamic changes with postoperative recovery profile in patient’s undergone laparoscopic cholecystectomies under general anaesthesia. Methods: In this prospective randomized study, sixty patients of either sex, 18-60 years with ASA grade 1 and 2 scheduled for laparoscopic cholecystectomies under general anaesthesia were randomly allocated into two groups. In Group S, patients were maintained on sevoflurane anaesthesia (0.5-2.5%) while in Group P, patients were maintained with propofol infusion (75-125 µg/kg/min) along with O 2 (50%) and N 2 O (50%).The intraoperative haemodynamic parameters, recovery characteristics and postoperative nausea and vomiting (PONV) were observed in both groups. Results: The mean baseline haemodynamic parameters (HR, SBP, DBP, MBP, SpO 2 and EtCO 2 ) were comparable in both groups, (P>0.05). No significant difference in HR was at observed any time interval, P>0.05, however, SBP, DBP and MBP were significantly lower in propofol group at different time intervals, P<0.05, but clinically not significant and patients remained haemodynamically stable in both groups. The mean time for all recovery characteristics were significantly shorter in sevoflurane group as compared to propofol group, (P<0.01). However the incidence of PONV was significantly more in sevoflurane group. Conclusions: Sevoflurane can be used as an effective alternative to propofol for maintenance of anaesthesia in day care laparoscopic procedures as it has better recovery profile with stable haemodynamic parameters.

A prospective randomized study for comparison of epidural 0.5% levobupivacaine with 0.5% racemic bupivacaine using fentanyl as common adjuvant in lower limb orthopedic surgeries

Background: Levobupivacaine, an S(-) isomer of bupivacaine, has been shown a lower risk of cardiovascular and central nervous system toxicity than bupivacaine. This study was aimed to compare racemic bupivacaine and levobupivacaine in epidural anesthesia for lower limb orthopedic surgeries using fentanyl as a common adjuvant. Methods and Material: A randomized prospective study was planned on sixty patients of ASA grade I and II who were admitted for elective lower limb orthopedic surgeries under epidural anesthesia. Patients were randomly divided into two Groups, Group B (n=30) received bupivacaine 0.5% (13ml) and fentanyl 100 µg, Group L (n=30) received levobupivacaine 0.5% (13ml) and fentanyl 100 µg. In both the Group’s onset of sensory and motor block, highest level of sensory block, duration of sensory and motor block, degree of motor block and hemodynamic parameters and complications were assessed perioperatively. Results: Mean duration of onset of sensory block was 9.54±1.03 and 9.85±0.97 min for Group B and Group L respectively and onset of motor block for Group B was 19.48±1.58 min and for Group L was 19.01±1.30 min, which were comparable for both Groups (P >0.05). Mean duration of sensory block was 371.33±13.23 min and 366.17±5.83 min in Group B and L respectively and mean duration of motor block was 273.0±11.0 min and 274.9±18.45 min in Group B and L respectively which were comparable in both Groups, (P > 0.05). The degree of motor block assessed by modified bromage scale was higher in Group B than Group L. Hemodynamic changes and complications having no significant differences between two Groups, (P > 0.05). Conclusion: The combination of levobupivacine and fentanyl is equipotent to bupivacaine and fentanyl in epidural anesthesia. Rather it seems to be a better alternative local anesthetic agent in epidural anesthesia for lower limb orthopedic surgeries. Keywords: Bupivacaine, Levobupivacaine, Fentanyl, Epidural, Orthopedic surgeries

Intraoperative wide bore nasogastric tube knotting: A rare incidence

Nasogastric tubes are commonly used in anesthetic practice for gastric decompression in surgical patients intraoperatively. The indications for its use are associated with a number of potential complications. Knotting of small-bore nasogastric tubes is usually common both during insertion and removal as compared to wide bore nasogastric tubes. Knotting of wide bore nasogastric tube is a rare complication and if occurs usually seen in long standing cases. We hereby report a case of incidental knotting of wide bore nasogastric tube that occurred intraoperatively.

Effect of bispectral index versus end-tidal anesthetic gas concentration-guided protocol on time to tracheal extubation for halothane-based general anesthesia

Background and Aims: Early extubation is a desirable goal after general anesthesia. Very few studies have compared the effect of bispectral index (BIS) monitoring versus standard end-tidal anesthetic gas (ETAG) concentration monitoring on tracheal extubation time for halothane-based anesthesia. The aim of this study was to compare the effect of BIS versus ETAG-guided anesthesia on time to tracheal extubation for halothane-based anesthesia in general surgical setting. Methods: This was a randomized, controlled double-blind study. Sixty patients with the American Society of Anesthesiologists physical status Class 1 or 2, receiving halothane-based general anesthesia were randomized to BIS-guided (n = 30) and ETAG-guided anesthesia (n = 30). Time to tracheal extubation was measured. In BIS group, BIS value was kept between 40 and 60 while in ETAG group; ETAG value was kept between 0.7 and 1.3 minimum alveolar concentration. The two groups were compared using Students t-test, and P< 0.05 was considered statistically significant. Data were processed and analyzed using SPSS version 17 software. Results: Mean time to tracheal extubation was significantly longer in BIS group (9.63 ± 3.02 min) as compared to ETAG group (5.29 ± 1.51 min), mean difference 4.34 min with 95% confidence interval (3.106, 5.982) (P < 0.05). Conclusion: In our study, the extubation time was significantly longer in BIS-guided anesthesia as compared to ETAG-guided anesthesia. ETAG monitoring promotes earlier extubation of patients as compared to BIS monitoring during halothane anesthesia.