Sushil P. Ambesh

Preemptive gabapentin decreases postoperative pain after lumbar discoidectomy

PurposeWe investigated whether the preemptive use of gabapentin, a structural analogue of gamma amino butyric acid could reduce postoperative pain and fentanyl consumption in patients after single-level lumbar discoidectomy.MethodsFifty-six ASA I and II patients were randomly allocated into two equal groups to receive either gabapentin 300 mg or placebo two hours before surgery. After surgery, the pain was assessed on a visual analogue scale (VAS) at intervals of 0–6, 6–12, 12–18, and 18–24 hr at rest. Total fentanyl consumption in the first 24 hr after surgery was also recorded. Fentanyl 2 μg·kg−1 intravenously was used to treat postoperative pain on patients’ demand.ResultsPatients in the gabapentin group had significantly lower VAS scores at all time intervals of 0–6, 6–12, 12–18,and 18–24 hr than those in the placebo group (3.5 ± 2.3, 3.2 ± 2.1, 1.8 ± 1.7, 1.2 ± 1.3 vs 6.1 ± 1.7, 4.4 ± 1.2, 3.3 ± 1.1, 2.1 ± 1.2; P < 0.05). The total fentanyl consumed after surgery in the first 24 hr in the gabapentin group (233.5 ± 141.9, mean + SD) was significantly less than in the placebo group (359.6 ± 104.1 ; P < 0.05).ConclusionPreemptive gabapentin 300 mg po significantly decreases the severity of pain postoperatively in patients who undergo single-level lumbar discoidectomy.RésuméObjectifVérifier si l’usage préventif de gabapentine, analogue structurel de l’acide gamma amino-butyrique, pouvait réduire la douleur postopératoire et la consommation de fentanyl dans les cas de discectomie lombaire à un seul niveau.MéthodeCinquante-six patients d’état physique ASA I et II, répartis au hasard en deux groupes égaux, ont reçu soit 300 mg de gabapentine, soit un placebo, deux heures avant l’opération. Après l’opération, la douleur a été évaluée selon une échelle visuelle analogique (EVA) de 0–6, 6–12, 12–18 et 18–24 h au repos. La consommation totale de fentanyl pendant les 24 premières heures postopératoires a aussi été notée. Une dose iv de 2 μg·kg−1 de fentanyl a été utilisée pour traiter la douleur postopératoire sur demande.RésultatsLes patients sous gabapentine ont eu des scores significativement plus bas à l’EVA, pour toutes les mesures aux intervalles de 0–6, 6–12, 12–18 et 18–24 h, que ceux du groupe placebo (3,5 ± 2,3 ; 3,2 ±2,1 ; 1,8 ± 1,7 ; 1,2 ± 1,3 vs 6,1 ± 1,7 ; 4,4 ± 1,2 ; 3,3 ± 1,1 ; 2,1 ± 1,2 ; P < 0,05). La consommation postopératoire totale de fentanyl pendant les 24 premières heures a été significativement plus faible avec la gabapentine (233,5 ± 141,9, moyenne + écart type) qu’avec le placebo (359,6 ± 104,1 ; P < 0,05).ConclusionL’administration préventive de 300 mg po de gabapentine diminue significativement la sévérité de la douleur postopératoire chez les patients qui subissent une discectomie lombaire à un seul niveau.

Ondansetron Pretreatment to Alleviate Pain on Propofol Injection: A Randomized, Controlled, Double-Blinded Study

We used a randomized, controlled, double-blinded design to study the effect of ondansetron (OND) pretreatment on the pain produced by the IV injection of propofol. Eighty patients were randomly assigned to one of two groups: Group I received 2 mL of IV 0.9% saline pretreatment, and Group II received

Percutaneous tracheostomy with single dilatation technique: A prospective, randomized comparison of Ciaglia Blue Rhino versus Griggs' guidewire dilating forceps

Percutaneous tracheostomy with single-step dilation technique using Griggs’ guidewire dilating forceps (GWDF) is a well-recognized procedure. Recently, Ciaglia has introduced a one-step dilation technique using a curved, gradually tapered dilator, the Ciaglia Blue Rhino (CBR). In a prospective, randomized study, we performed percutaneous tracheostomy in 60 consecutive patients, using either the CBR or the GWDF technique. Postoperatively, all patients had bronchoscopy by a blinded consultant, and stoma characteristics and injuries to the trachea were studied. Mean tracheostomy time (skin incision to insertion of tracheostomy tube) in the two procedures (CBR 7.5 min versus GWDF 6.5 min) was not different (P > 0.05). The GWDF technique was associated with under-dilation and over-dilation of the tracheal stoma, each in almost one-third of patients. In the CBR group, the procedure was associated with a significant increase in peak airway pressure (P < 0.05) in all patients. There were nine cases of tracheal cartilage rupture, three cases of longitudinal tracheal abrasion, and one pneumothorax. Three patients had tracheal in-drawing at the scar site with huskiness of voice at 8 wk after decannulation; however, none had any breathing difficulty. We conclude that the techniques are equally effective in the formation of percutaneous tracheostomy. However, tracheal stoma over-dilation with GWDF and increase in peak airway pressure and rupture of tracheal rings with CBR remain major concerns.

Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced byiv fentanyl

PurposeFentanyl, a synthetic opioid, is a popular choice amongst anesthesiologists in the operating room. Preinductioniv fentanyl bolus is associated with coughing in 28–45% of patients. Coughing due to fentanyl is not always benign and at times may be explosive requiring immediate intervention. We have studied the role of aerosol inhalation of salbutamol, beclomethasone and sodium chromoglycate in preventing fentanyl induced coughing and have compared their efficacy.MethodsTwo hundred patients aged 18–60 yr, undergoing elective laparoscopic cholecystectomy were randomized into four groups of 50 each. Group I served as control, while Groups II, III and IV received an aerosol inhalation of salbutamol, beclomethasone or sodium chromoglycate 15 min prior to entering the operating room. Followingiv fentanyl (2 μg · kg−1) the incidence of cough was recorded and graded as mild (1–2), moderate (3–5) and severe (> 5) depending on the number of coughs observed. Results were analyzed using‘z’ and Fischer’s Exact test. AP value of < 0.05 was considered significant.ResultsThe incidence of cough was 28% in the control group, 6%, 0% and 4% in the salbutamol, beclomethasone and sodium chromoglycate groups respectively. Occurrence of cough was significantly low (P ≤ 0.05) in the treatment groups, however the difference amongst the groups was not significant (P ≥ 0.05).ConclusionThe use of salbutamol, beclomethasone or sodium chromoglycate aerosol 15 min prior toiv fentanyl administration minimizes fentanyl-induced coughing.ZusammenfassungObjectifLe fentanyl, un opioïde synthétique, est très utilisé par les anesthésiologistes en salle d’opération. L’administration iv d’un bolus de fentanyl avant l’induction de l’anesthésie est associée à de ia toux chez 28–45 % des patients. Cette toux, pas toujours bénigne, peut parfois même être expiosive et nécessiter une intervention immédiate. Nous avons étudié ie rôie de l’inhaiation de salbutamol, de béclométhasone et de chromoglycate de sodium en aérosols dans la prévention de la toux induite par le fentanyl et nous avons comparé leur efficacité.MéthodeDeux cents patients de 18 à 60 ans, devant subir une cholécystectomie laparoscopique réglée ont été répartis au hasard en quatre groupes de 50. Le groupe I a servi de témoin, tandis que les groupes II, III et IV ont inhalé du salbutamol, de la béclométhasone ou du chromoglycate de sodium en aérosol, 15 min avant d’entrer dans la salle d’opération. Après l’administration iv de 2 μg · kg−1 de fentanyl, l’incidence de toux a été enregistrée et cotée comme légère (1–2), modérée (3–5) et sévère (> 5) selon le nombre d’accès de toux observés. Les résultats ont été analysés selon le test“Z” et le test exact de Fischer. Une valeur de P ≤ 0,05 a été considérée significative.RésultatsLincidence de toux a été respectivement de 28 % dans le groupe témoin, 6 %, 0 % et 4 % dans les groupes de salbutamol, béclométhasone et chromoglycate de sodium. L’occurrence de toux a été signifcativement faible (P ≤ 0,05) dans les groupes expérimentaux, même si la différence intergroupe n’a pas été significative (P − > 0,05).ConclusionL’usage de salbutamol, de béclométhasone ou de chromoglycate de sodium en aérosol, 15 min avant l’administration iv de fentanyl, réduit la toux induite par le fentanyl.

Direction of the J-Tip of the Guidewire, in Seldinger Technique, Is a Significant Factor in Misplacement of Subclavian Vein Catheter: A Randomized, Controlled Study

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n = 147) or cephalad in Group 2 (n = 148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P < 0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = < 0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.

Internal Jugular Vein Occlusion Test for Rapid Diagnosis of Misplaced Subclavian Vein Catheter into the Internal Jugular Vein

Background During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV). This can be detected by chest radiography. However, after any repositioning of the catheter, subsequent chest radiography is required. In an effort to simplify the detection of a misplaced subclavian vein catheter, the authors assessed a previously published detection method. Methods One hundred adult patients scheduled for subclavian vein cannulation were included in this study. After placement of subclavian vein catheter, chest radiography was performed. While the x-ray film was being processed, the authors performed an IJV occlusion test by applying external pressure on the IJV for approximately 10 s in the supraclavicular area and observed the change in central venous pressure and its waveform pattern. The observations thus obtained were compared with the position of catheter in chest radiographs, and the sensitivity and specificity of this method were evaluated using a 2 × 2 table. Results In 96 patients, subclavian vein cannulation was successfully performed. In four patients, cannulation was unsuccessful; therefore, these patients were excluded from the study. There were six misplacements of venous catheters as detected by radiography. In five (5.2%) patients, the catheter tip was located in the ipsilateral IJV, and in one (1.02%), the catheter tip was located in the contralateral subclavian vein. In the patients who had a misplaced catheter into the IJV, IJV occlusion test results were positive, with an increase of 3–5 mmHg in central venous pressure, whereas the test results were negative in patients who had normally placed catheters or misplacement of a catheter other than in the IJV. There were no false-positive or false-negative test results. Conclusion The IJV occlusion test successfully detects the misplacement of subclavian vein catheter into the IJV. However, it does not detect any other misplacement. The test may allow avoidance of repeated exposure to x-rays after catheter insertion and repositioning.

Percutaneous dilational tracheostomy : The Ciaglia method versus the Rapitrach method

In a prospective study, we performed percutaneous dilational tracheostomy (PDT) using either the Ciaglia method (gradual dilation) or the Rapitrach method (single dilation) in 80 patients.We encountered difficulty in dilating the tracheal stoma of three (7.5%) patients in the Ciaglia group because of tight pretracheal fascia. It was difficult to insert the tracheostomy tube in four (10%) patients in the Rapitrach group even after appropriate tracheal dilation. However, the tracheal cannulation was successfully completed in all patients in subsequent attempts. The mean time for completion of the procedures, from skin incision to insertion of the tracheostomy tube, was 14 +/- 5.5 min with the Ciaglia method and 6.5 +/- 3.5 min with the Rapitrach method. PDT with either method has not been associated with clinically significant hemorrhage, infection at the stoma site, or cosmetic deformity. In a follow-up period of 9 mo, none of our decannulated patients presented with clinical tracheal stenosis. Our results indicate that PDT with both methods is as safe and easy to organize and perform as a bedside procedure, obviating the need to transport critically ill patients from the critical care unit. Implications: The tracheas of 80 patients were cannulated through an artificial opening using either the Ciaglia (gradual dilation) or the Rapitrach (single dilation) method. Both techniques were successful with no significant complications. After 9 mo of closure of this opening, none of the survivors had significant scarring or narrowing of the trachea. (Anesth Analg 1998;87:556-61)

Efficacy of Ondansetron in Prophylaxis of Postoperative Nausea and Vomiting in Patients Following Infratentorial Surgery: A Placebo-controlled Prospective Double-blind Study

In a prospective double blind placebo-controlled study, 45 patients scheduled for infratentorial surgery were randomly allocated into two groups. Five patients were later excluded from the study because of various reasons. Out of 40 analyzable patients, 20 received IV Ondansetron (4 mg), whereas the other 20 received the matching placebo approximately 1 hour before the skin closure. After conclusion of surgery and tracheal extubation, all patients were monitored in the recovery room for post operative nausea and vomiting (PONV) for 48 hours. The incidence of PONV within the first 24 hours was found to be 50% and 10% in the placebo and ondansetron groups, respectively (p<0.05). After 24 hours, however, both groups were comparable in relation to the incidence of emesis. Rescue antiemetic (RAE) was required in nine (45%) patients in the placebo group and in two (10%) patients in the Ondansetron group (p<0.05). A significantly higher number of patients remained sedated postoperatively in the Ondansetron group than in the placebo group (p<0.05). One patient in the Ondansetron group had protracted diarrhea for 48 hours postoperatively. These results indicate that administration of IV Ondansetron (4 mg) 1 hour before skin closure effectively reduces PONV after infratentorial surgery, and does not have significant adverse effects.

Neuroendoscopic procedures: anesthetic considerations for a growing trend: a review.

The recent trend in neurosurgery is shifting toward further reduction in invasiveness to minimize trauma to the brain. Endoscopy holds the promise of shortened hospital stay with improved postoperative outcome. An important minimally invasive technique is neuroendoscopy. The ventricular system and subarachnoid space of the brain provide suitable conditions for the use of an endoscope. The currently available literature focuses only on recent advances in neuroendoscopy from the surgical perspective. To date, there is paucity of anesthetic literature emphasizing the implications for this growing trend. The surgical technique, instrumentation, anesthetic requirements, potential pitfalls and complications of this technique must be completely understood to ensure a successful outcome. The purpose of this review is to provide knowledge of indications, instrumentation, and anesthetic considerations in anticipation of complications steming from this procedure.

A combination of the modified Mallampati score, thyromental distance, anatomical abnormality, and cervical mobility (M-TAC) predicts difficult laryngoscopy better than Mallampati classification

OBJECTIVE Unanticipated difficult tracheal intubation is a significant source of morbidity and mortality in anesthetized patients. A number of modules have been developed to predict difficult airways, but they are often complex in nature. We combined the modified Mallampati score (M), thyromental distance (T), anatomical abnormality (A), and cervical mobility (C) into a single scoring system with the acronym M-TAC, and evaluated it against Mallampati scoring. METHODS We prospectively analyzed 500 adult patients of the American Society of Anesthesiologists (ASA) class I or II, scheduled for elective surgery under general anesthesia. Preoperative airway assessments using M-TAC were performed, all of which were given a score. Anesthesiologists, blinded to the pre-anesthetic airway assessment, performed laryngoscopy and graded the laryngoscopic view as per Cormack and Lehanes classification. For the study purpose, difficult laryngoscopy was defined as Cormack and Lehane Grade 3 or 4 of laryngoscopic view. RESULTS An M-TAC score ≥ 4 had a significantly higher sensitivity (96% vs. 72%) and specificity (86% vs. 78%) with a high positive predictive value (44% vs. 28%) and a very low false negative value (2% vs. 15%) in comparison with Mallampati scoring (p < 0.05). Analysis of the receiver operating characteristic (ROC) curve for predicting difficult laryngoscopy revealed an area under the curve of 0.83 (95% CI = 0.78-0.88) for Mallampati scoring and 0.94 (95% CI = 0.92-0.96) for M-TAC scoring system. CONCLUSION The M-TAC scoring system has provided a higher sensitivity and specificity in predicting difficult laryngoscopy in comparison with Mallampati classification.